Big Pharma and the Question: Is ADHD Real?

Alan Schwarz's new book is important but off the mark

Posted Aug 23, 2016

In a wise marketing move, Alan Schwarz bows to the current mental health paradigm by opening his new book ADHD Nation: Children, Doctors, Big Pharma and the Making of an American Epidemic with this statement: “Attention deficit hyperactivity is real. Don’t let anyone tell you otherwise.” (The book will be released September 6th- this article draws on the New York Times book review of August 22nd)

However, later on in the book he captures the fallacy of this disease model when he quotes a clinician:

“We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

Contemporary research shows us that efforts to locate a problem either in the child or in the environment are misguided. We now have detailed knowledge of the complex interplay of biology and environment that lead us to a new and different paradigm from the prevailing disease model of mental illness.

Sigmund Freud’s revolutionary ideas emerged out of the darkness of psychiatric care predominated by asylums and mostly ineffective, sometimes bizarre forms of treatment. His original insights, both that symptoms have unconscious meaning and that emotional suffering often has origins in early childhood, led a new generation of clinicians to listen carefully to their patients in the practice of psychoanalysis.

With the advent of the DSM, the so-called "bible of psychiatry" and modern psychopharmacology, the pendulum has swung back to a biological view of mental illness, supported by significant success of pharmacologic intervention. However, an exponential rise in psychiatric diagnoses and prescribing of psychiatric medication in adults and children indicates that a new paradigm is now needed.

Contemporary research validates Freud’s original observations, elucidating not only how adverse early childhood experiences result in long-term negative health consequences, but also the mechanism by which these experiences get into the body and brain. This research is subsumed under a new discipline—infant-parent mental health—that integrates current research at the interface of developmental psychology, genetics, and neuroscience into a model of prevention, intervention, and treatment.

As I present in my forthcoming book The Developmental Science of Early Childhood, the infant mental health paradigm offers a model for understanding human experience from infancy through adulthood. The discipline represents a paradigm shift from treatment of disease to promotion of health and resilience.

The DSM categories represent collections of behaviors or symptoms. While we have some knowledge of genetics and brain structure and function that underlie these behaviors, they are not well-defined biological processes.

Letting go of the need to make a diagnosis is not easy. Our entire system of health care is organized around the diagnostic model. However, as I argue in my book The Silenced Child, in our current climate of mental health care these diagnoses can get in the way of listening to a child’s communication. As we learn more about the developmental science, we increasingly recognize that psychiatric diagnoses as organized by the DSM are constructs in a conceptual framework that is outliving its usefulness.

When seen from this contemporary perspective, ADHD is no more “real” than any other so-called “disorder” described in the DSM.

The latest research by Peter Fonagy, psychoanalyst and director of the Anna Freud Centre in London, leads us to focus not on “what is the disorder” but rather “what makes us well?” In a brilliantly laid out argument, Fonagy and colleagues present the concept of a “p” factor that is common to all forms of mental suffering now categorized under the structure of mental health “disorders.”

Connection is central to our humanity. It regulates our physiology and protects against the harmful effects of stress. Its absence, the profound aloneness that accompanies difficulty in communicating with others, is the common factor underlying all forms of mental distress. As Fonagy writes:

“In that sense, many forms of mental disorder might be considered manifestations of failings in social communication.”

In a questioning of the current paradigm of mental health disorders he continues:

“The p factor concept convincingly explains why, so far, it has proved so difficult to identify isolated causes, consequences, or biomarkers and to develop specific, tailored treatments for individual psychiatric disorders.”

While medication may have role to play in alleviation of symptoms of inattention and hyperactivity, the real solution lies in recognizing our basic human need for connection. We need to shift our attention from diagnosis and treatment of disorders in children to insuring that all children and their parents feel heard and connected to the larger social world.