Why are we failing young patients with ADHD?

Dr Simon Bowers, clinical vice chair of Liverpool CCG, thinks we are "failing young patients with ADHD" (1). That we, as a society, are indeed failing young people on a massive scale, is beyond question. I would take issue, though, with Dr Bowers' rather narrow and distorted use of the term "failure", by which he means, simply, the "failure" to diagnose and treat enough cases of “ADHD”. On the contrary, even the very concept of ADHD is not part of the solution, it's part of the problem.

Ten years ago, in a rare article in the British Journal of Psychiatry, Dr Sami Timimi argued, rightly, that ADHD is best understood as a cultural construct since, for one, "there are no specific cognitive, metabolic, or neurological markers and no medical tests for ADHD" (2). A decade on and this remains the case: ADHD, like most functional psychiatric conditions, is "diagnosed" using behavioural checklist criteria only. The fact that labels like "ADHD" are on this spurious basis then used as independent variables for research purposes, should be an affront to anyone acquainted with the scientific method. Dr Bowers' article even tacitly recognises this, since, he tells us, "in Liverpool last year, new diagnoses rose by 100%". What are we supposed to assume is to account for the sudden doubling in incidence of a purportedly "neurodevelopmental" condition in this way?

Quite clearly, socio-cultural hypotheses provide far more intuitive explanations for the rise of the ADHD phenomenon in recent years than do biologically-reductionist ones. Parents sense this, which probably accounts for the very sensible reluctance amongst many of them to consent to their children being prescribed regular amphetamines, medications which not only have similar effects on children without the ADHD diagnosis - thus raising fundamental questions as to their alleged specificity - but also have been shown to have brain-disabling effects in animal studies (3).

The unavoidable truth is that "ADHD", far from being a "neurodevelopmental disorder", is in fact an artificial construct that simply serves to inappropriately medicalise the increasingly damaging effects of American-style hypercapitalist consumer society on child development. It has long been a cornerstone of attachment theory that less emotionally secure children will often behaviourally "act out" their feelings of anxiety (4). Is it not obvious that the collapse in working class living standards caused by nearly four decades of relentless Thatcherite economic policy will have had a profoundly detrimental effect on many of the most vulnerable children’s sense of emotional security (5,6)? And that the rise of a ubiquitous media culture that celebrates loud, aggressive individualism will have resulted in many children becoming more hyperactive, inattentive, and impulsive (7)? And this is before we have even touched upon such related issues as the selling-off of state school playing fields to private sector developers (8), the increasing preponderance of cheap junk food in children's diets (9), or the stultifying stress-inducing effects of the relentlessly target-driven National Curriculum on children and teachers alike.

Though sociological perspectives such as these intuitively hit the nail on the head about "ADHD", one would be hard-pressed these days to find any such hypothesis in the pages of the leading journals - which instead prefer to investigate ad absurdum the most tenuous associations with genes and various other biological variables. A key reason for this tunnel vision is the pernicious rise over the last 25 years of the corporate management-inspired doctrine of so-called "Evidence-Based Medicine" (EBM) - a strange cocktail of vulgar empiricism and arbitrary "hierarchy of evidence" whose signal achievement has been to convince a generation of doctors to abandon genuinely scientific inductive reasoning in favour of a cargo cult science centred around little more than overcomplicated statistics (10). Since EBM in practise favours, a priori, quantitative evidence over qualitative, there is thus a built-in bias in favour of investigating easy-to-measure biological variables in preference to sociological factors that, by their very nature, tend to be far less amenable to exact measurement. Moreover, EBM's hierarchy of evidence has an irrational favouritism towards randomised controlled trials (RCTs). The huge advantage for the pharmaceutical industry in a research doctrine that bestows official "best evidence" status on trials that tend to presuppose a "diagnose-and-medicate" paradigm through which to view problems like childhood hyperkinetic behaviour as RCTs do, is obvious.

One final point from Dr Bowers' article worthy of particular mention is his praise for "third sector organisations [such as the ADHD Foundation, as]...a fantastic source of best practice knowledge and service provision". The fundamental problem with handing over the running of any health service to a “disease charity” though is the inevitable conflict of interest that arises, as the charity’s continued existence as a going concern depends upon the continued existence of the disease. In the case of ADHD the problem is writ large, since here we have a “disease” whose very conceptualisation as a disease is disputed. The point is not so much about whether a socio-cultural understanding of hyperkinetic behaviour in childhood or a bio-medical conceptualisation of the problem as “ADHD” is correct; the point is rather that if the former view is correct, an ADHD charity’s interests would still lie in promoting the latter, unscientific, biologically-reductionist view.

For doctors, the message is clear: If we genuinely wish to practise medicine rationally, in the best interests of our patients, we simply have to be far more savvy about the philosophy and sociology of scientific knowledge than our profession's spellbound adherence to the corporate edicts of EBM over the past quarter-century suggests we have been. In terms of "ADHD", this means waking up to the fact that the solution to the increasing rates of hyperactivity in children lies not in writing out ever more prescriptions for methylphenidate, but in building a society where all children can grow up safely and securely - free from such social evils as poverty, inequality, family breakdown, and crass consumerism. Put simply, the solution lies not in the inappropriate medicalisation of the political, but in the urgent re-politicisation of the medical.

NOTES

(1) Bowers S. Why are we failing young patients with ADHD? BMJ 2014;349:g6082.

(2) Timimi S, Taylor E. ADHD is best understood as a cultural construct. BJP 2004, 184:8-9.

(3) ibid.

(4) Bowlby J. The Making and Breaking of Affectional Bonds. London: Tavistock Publications Limited; 1979.

(5) Davies N. Dark Heart: The Shocking Truth About Hidden Britain. London: Vintage; 1998.

(6) Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin Books; 2010.

(7) Timimi S. Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture. Basingstoke, Hants: Palgrave Macmillan; 2005.

(8) Monbiot G. Captive State: The Corporate Takeover of Britain. London: Pan Books; 2001.

(9) Schlosser E. Fast Food Nation: What The All-American Meal is Doing to the World. New York: Harper Perennial; 2002.

(10) Hickey S, Roberts H. Tarnished Gold: The Sickness of Evidence-based Medicine. CreateSpace; 2011.

The views expressed above are my own and do not necessarily reflect those of my employer or Deanery.

Ian McClure's response to me suggests that there is a greater need for more research and understaning of what we are actually referring to when we say ADHD. One needs to read with caution Ian McClure's claim that 'ADHD is not life-threatening '.

Simon Bowers correctly states that few geographical areas offer clinical pathways that include holistic interventions for ADHD (1). He argues for ‘a definitive diagnosis’ and ‘evidence based treatments’ from the outset, but the reality is that ADHD is such a confused, over-simplistic and, consequently, over-diagnosed disorder, that it cannot deliver the certainty that health managers understandably expect on behalf of tax payers.

Instead, the failure of ADHD research to deliver a valid and reliable concept of impairment within the condition, means that, all too often, children diagnosed with ADHD are prescribed stimulant medication from the outset, whether their condition is severe, moderate or mild (2,3). In all likelihood, these patients, once prescribed stimulant medication, will continue to take it throughout their primary and early secondary school years, with increasing numbers remaining on it into adulthood. Because of the increasing pressure on doctors in community paediatric and child psychiatric clinics, many of these patients will not receive a 'drug holiday' from this medication throughout these years, despite the advice of guidelines (2). This situation contrasts starkly with mainstream general adult psychiatric practice, regarding antidepressants or antipsychotics, in which doctors expect to at least attempt a withdrawal of such medications, once the patient has remained clinically well for several months.

One of the anomalies of ADHD compared to other psychiatric conditions, is that it appears to offer no recovery concept, except stabilisation on medication. Why is this? Usually, such a scenario only arises in those child patients who have life-threatening conditions, such as asthma, epilepsy or cystic fibrosis. Yet we know that ADHD is not life-threatening and that there is no evidence that stimulants reduce the long term problems associated with the severe form of the condition, let alone the milder forms (2,3).

The current, apparently inevitable trajectory of ADHD diagnosis and consequent long-term medication for moderate, or even mild cases, accretes associated issues, such as disability and carer benefits, which gain supertanker momentum. Given the pressure which doctors are under to accommodate this powerful system, services fail to develop the alternative strategies which Simon Bowers is asking for. Even if Clinical Commissioning Groups do have the transformational clout to look at this situation with ‘a fresh perspective and a determination to do things differently’ (1), are there sufficient numbers of qualified (and, more importantly, motivated) clinicians who can run psychological group treatment programmes (which is what NICE recommends should be the first line treatment for moderate ADHD(4))?

To really tackle this problem, we need to completely dismantle the ADHD concept and generate something which more accurately describes children and adolescents, their thoughts, feelings and behaviour, the families they live in and the social systems around them, all within a nurture, as opposed to a disorder, concept.

At the very least, clinicians, health managers and guideline bodies such as NICE and SIGN should challenge the ADHD industry (academic and pharmacological) to produce a disease concept which accurately describes levels of severity (which, for example, autism science has achieved). Only if such evidence emerges, will health and local authority managers be able to attempt to develop multi-agency pathways which accurately meet the needs of these vulnerable children and young people.

However, given that the drug industry for ADHD in the USA alone was worth $9 billion annually in 2012 (and continues to increase) (5) any such progress seems a distant prospect. Perhaps the best way to get full value out of the Liverpool pound is to withhold it.

References:

1. Why are we failing young patients with ADHD? Bowers, S. BMJ 2014;349:g6082

2. Prescribing methylphenidate for moderate ADHD. McClure, I. BMJ 2013;347:f6216

3. Attention-deficit/hyperactivity disorder: are we helping or harming? Thomas, R, Mitchell, GK, Batstra, L. BMJ 2013;347:f6172

4. National Institute for Health and Care Excellence. attention deficit hyperactivity disorder. QS39. 2013. http://publications.nice.org.uk/attention-deficit-hyperactivitydisorder-....

5. http://mobile.nytimes.com/2013/12/15/health/the-selling-of-attention-def...