The Question of ADHD
Is ADHD really biologically based, or a socially constructed disorder?
Posted Jun 22, 2017
It can be challenging to write an article such as this, because, as in politics where passions flare vehemently, so too do they in the ADHD debate. Is it genetic? Is it socially constructed? Does it even exist? But after recently attending an excellent lecture on non-medicated treatment options for children and teens with ADHD and then completing Marilyn Wedge’s phenomenal must-read book, A Disease Called Childhood: Why ADHD Became an American Epidemic, the reality is that the conversation must be continued.
In her highly thought-provoking book, Wedge beautifully and very thoroughly lays out what every parent should know before accepting an ADHD diagnosis for their child. She explores how the diagnosis itself stemmed from the merging of “hyperkinetic reaction to childhood” and “organic brain syndrome,” essentially a mild form of brain damage, to create a new disorder, now called ADHD.
The new ADHD appeared with the publication of DSM-III in 1980. At the time, eight symptoms were required to meet diagnostic criteria. With the publication of DSM-5 in 2013, this was reduced to six symptoms, making it even easier to meet criteria. The age of onset was even changed to allow more youth to make the cut. Instead of needing to meet criteria by age 7, this was raised to age 12, and teens only need to meet five criteria to qualify. Sound like when statisticians play with data to make things “statistically significant”? It should. And there are many reasons why this is so. In fact, they can be easily summed up by two-word terms such as Big Pharma and corporate America.
Known widely for her article, “Why French Kids Don’t Have ADHD," Wedge posits that while Americans are quick to adopt a biological explanation for ADHD, the French attribute ADHD to psychosocial and situational factors. Having casually observed French children on a trip to Paris myself one year, I couldn’t help but remark at how well-behaved, orderly and courteous a massive group of young children were. Anecdote indeed, but I was not surprised in the least.
What’s most disturbing about Wedge’s research is the blatant misrepresentation of expertise abused by professionals paid off by drug companies. While I consider myself somewhat of a skeptic already, reading about ghostwriters publishing in respected medical journals stopped me in my tracks. Wedge writes, “the practice of drug companies ghost writing articles in medical journals dates back to the 1950s (p. 77).” Most recently, this occurred in 2002 with the marketing of the drug Ritalin-LA. One report she cites finds 11% of articles published in prestigious medical journals, including the Journal of the American Medical Association were written by ghostwriters hired by drug companies.
She also discusses how many of the early studies indicating efficacy of drugs or attempting to establish genetic bases for ADHD were published in the big name journals, while the follow-ups negating these very findings only made their way into esoteric, less known publications. She shares that even the most well-meaning prescribers today don’t often have time or access to the latest updates in medical research. They may recall a study from the New England Journal of Medicine calling a certain medication efficacious and never look back again. Furthermore, she reports many of the psychiatrists who made strong claims about medications are now back-pedaling out of their statements, even though the damage has already been done. Finally, Wedge shares that some acclaimed ADHD experts who travel the country giving talks to other professionals about the biological basis of ADHD are actually funded by drug companies upwards of six figures annually. With the conversation on ADHD being so highly controlled by pharmaceutical companies, it should come as no surprise that “the United States consumes 70 percent of the world’s stimulant drugs, though it represents only 4 percent of the world’s population" (p. 21).
In addition to providing a strong foundation for understanding the history and background of how ADHD came to be as it is in the U.S., Wedge also explores global approaches to education. She discusses our uniquely American pressure for children to learn to read early, while in Finland, putting children into school too early is thought of as robbing them of their human right to freedom and play. Indeed, the academic environment is a high stakes game in the United States.
As a practitioner in an affluent area where nearly everyone has a 4.0 GPA or higher in addition to being an athlete, I know that anything that can give a student an edge is explored. While many of my clients are very bright, they nearly all have 504 plans to provide accommodations. They must be willingly labeled as “disabled” in order to qualify for extra time on tests, a quiet setting or any other number of aids that would help anyone! Wedge discusses the Finnish model, where students can access teams to make sure they stay on track and are provided a quality education. Meanwhile, I assist my clients in moving to alternative and online schools to keep them from drowning under the piles of busy work that, Wedge shares, is a very American form of education. As a therapist, I see how damaging this practice is to my clients who are now labeled with a disorder even though it is our culture that is ailing.
When I was an intern at UC Berkeley, part of my training involved ADHD assessments. A six-hour battery, three testing sessions, and a 12-page report later, I usually broke the news to my disappointed students that no, they did not have ADHD. They needed to work on study skills, creating a quiet study environment and pushing past the complete boredom of homework which was what was often really underlying the distractibility (because let’s be honest, who wouldn’t space out trying to solve calculus problems?). There were two particularly striking things about this experience. First, the athletes that came to me because essentially their coaches wanted them on a stimulant. This rings true to one of the most provocative quotes from Wedge’s book; when she discusses how competitive the academic arena has become and how normative ADHD medications are, she shares “like doping in professional sports, you need a performance enhancer if you want to compete" (p. xvi). In this case, I had athletes looking for performance enhancement in the form of ADHD drugs.
The second striking part of my ADHD assessment training was how high I scored on the batteries. My parents had always noted I was a fidgety child, easy to distract, and very energetic with a capital E. While many of my own classmates were medicated for far less disruptive behaviors, at the end of the day through my parents limiting my sugar intake and lots of love and discipline, nothing more came of it. I could have been an ADHD child, but either way it’s irrelevant. Had I been labeled, told I needed extra help, or that my brain worked differently than other kids, I don’t know that I would be where I ended up today.
While Wedge positions herself on the side of believing ADHD to be more socially constructed, I would say I’m somewhere in the middle. It is hard to say because I believe families are well-meaning and come seeking genuine help. But often times the problems do stem from too much screen time, action-packed movies with quick screen changes, video games and little discipline. It is hard to parse out true ADHD (which I think could exist in a very small percentage of children) with so many other factors masking whether or not a real problem exists. It is also difficult and a tough pill for parents to swallow when they are told that they may be a big part of the problem.
I’ve had clinical supervisors share that ADHD runs in families, thereby indicating a genetic component to ADHD. But what about modeling and learned behaviors? If a child observes a disorganized and frantic father, won’t they be more likely to pick up these very behaviors themselves? In her book, Wedge discusses the enfant roi, or child king concept. I can tell you confidently I’ve met hoards of them who call the shots at home, and as they grow older, the problems just escalate.
Indeed, family therapy is critical here—too many times have parents handed over their children to me, identifying them as the sole problem and removing any blame from themselves. In addition to family therapy, important factors also include discipline, unconditional love, and creating a positive, structured, and chaos-free environment for the child. Of course, this does not solve the much larger societal problems of demanding schools and an over-medicated society. But parents can also choose to make their own voices heard and advocate for their children in schools and pediatrician’s offices, locally in their communities, and nationally with their votes.
In the second of this two-part article, I will elucidate some of the non-medicated alternatives to ADHD for children and teens. Some are common sense, others are more recent phenomenon. Whether you believe strongly in ADHD, are on the fence, or otherwise, at the end of the day most honest psychologists will tell you ours is an imperfect science. There is no conclusive test, no agreed upon clinical parameters and there are certainly no magic pills for ADHD. We have a world that is more complex by the day, and learning to cope with it is enough to make any of us distracted and disoriented at best.
Wedge, M. (2016). A Disease Called Childhood: Why ADHD Became an American Epidemic. New York: Avery.