The Other Side of ADHD

The Epidemiologically Based Needs Assessment Reviews, Palliative and Terminal Care - Second Series

Angela Southall, Alison Davies

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781138450769
• eBook ISBN:
  9781315347400
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This is not just another book on ADHD. This book tells the side of the story most of us are otherwise unlikely to hear. ADHD has become a clinical phenomenon, a modern-day epidemic of incredible proportions, unlike any we have seen before. It has swept over us like a tidal wave. "The Other Side of ADHD" brings into sharp focus some of the controversial aspects of ADHD that help maintain its status as the most hotly debated subject in children's mental health. The book draws together the many issues that ADHD raises, clinically, socially, philosophically, ethically and politically. The result is a challenge that goes far beyond this diagnostic label, and reaches into just about every aspect of our lives. Everyone who cares about social issues will want to read this book. This passionate and illuminating work is a clarion call for clinical and educational psychologists and other health and social care professionals including counsellors and therapists. It is a life-line to parents with hyperactive children, and teachers, youth and social workers will also find it invaluable. "ADHD has become a clinical phenomenon, a modern-day epidemic of incredible proportions, unlike any we have seen before. It has swept over us like a tidal wave. I have found myself in a position where I have been at odds with the prevailing view about these children's problems. As the situation has unfolded, it has seemed to me that the subject of ADHD touches on other important issues, some of which are pivotal to our thinking about mental health. It seemed to me that there was a need to pull together the different strands of the debate so that parents and clinicians could build up more of a complete picture and make their own informed decisions." - Angela Southall, in the Introduction.

CHAPTER 1

What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is a diagnostic term that has been used since 1987 to describe a cluster of behaviours associated with inattention, impulsivity and hyperactivity.* Although the term is used increasingly often, there is widespread disagreement about whether it exists at all and whether it is, in fact, a valid diagnostic category. Although its advocates are prone to describing it in certain terms, there has rarely been so much uncertainty and controversy about a diagnosis that is being used extensively to describe children’s behaviour, and which is leading to increases in the prescribing of stimulant medication for children at an unprecedented rate. So high is the degree of concern about the rate of increase in diagnosis and prescribing that enquiries have been initiated in the UK and abroad to try to determine why this is happening.

How are children assessed for ADHD?

There is no single test for ADHD. Most assessments tend to use parent and school reports, combined with ‘checklist’ data (many assessors use only these sources of information). Some (but not all) assessments incorporate additional observational information. After this, a decision is made as to whether or not the child has ADHD.

It will be obvious to any thoughtful reader that this material will be open to interpretation. The interpretation, of course, depends on what we might call the assessor’s frame of reference -the mechanism that they use to understand and interpret what they see. This will have developed over many years and incorporates beliefs, knowledge, prejudices, cultural expectations and experience - it becomes the lens through which they view the world.

In short, ADHD assessment is highly subjective. This is demonstrated by the extreme variation in incidence from country to country and between cities and towns (we shall return to this later in the book). Population data suggest that it is strongly associated with social and psychological factors, such as family income, parental employment status and children’s experiences of stressful family life (e.g. parental separation or family breakdown). For many people who work with children and families, this kind of information adds further impetus to the view that when we give parents and teachers assessment ‘checklists’, we may not be measuring what we think we are measuring.

Incidence

The past decade has witnessed a remarkably steep increase in the number of children diagnosed with ‘ADHD’ in Europe and North America. Reported rates of ADHD in school-age children vary, but most estimates lie between 5% and 10%.’ In the USA, current estimates suggest that as many as 17.8% - almost one in five schoolchildren - have this ‘disorder.’² The trend continues to be an upward one.

In the UK, the figures are lower. Reports suggest a prevalence of between 2% and 5%, depending on which set of diagnostic criteria is applied.³ Although lower, this figure still equates to up to one in 20 children, and will include at least four times as many boys as girls.⁴

Why the increases?

Given these figures, we could be excused for thinking that something strange and unexplained is happening to our children. (After all, this ‘disorder’ didn’t seem to be around earlier, when we were young or when our parents were young. Even ‘hyper-activity’ did not seem to affect anywhere near as many children.) Therefore we might reason that it must be something to do with modern life. Are modern lifestyles making our children ill?

Or is it just the way we think about children’s behaviours nowadays? Are our changed expectations leading us to label some childhood behaviours as problematic, when they might previously have been viewed as normal? Is this the kind of thinking that makes people more likely to look for medical labels for children?

Both of these ideas are important in their own right and have been the subject of much debate among those working with children and families. We shall revisit them later in this book. However, in trying to explain the unprecedented increases in the diagnosis of ADHD and stimulant prescriptions, we need first to look elsewhere. This means focusing on how ADHD has been defined and popularised, and what other factors have been involved in this process.

ADHD as a diagnostic category

The idea of the ‘hyperactive’ child developed in the 1960s, and it is during this period that the first references to hyperactivity (or hyperkinesis) can be found in the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association.

Originally perceived as a research tool, the DSM has developed through a number of revisions into what has often been referred to as the diagnostic ‘bible’ for mental health. Each new edition has been weightier and has included more and more new diagnoses. The DSM has grown longer with each revision (see Box 1.1).

BOX 1.1 The growth of the DSM since first publication

DSM	1952	100 pages (containing about 60 disorders)
DSM-II	1968	150 pages
DSM-III	1980	500 pages
DSM-III-R	1987	567 pages
DSM-IV	1994	900 pages

On the basis of the above, the DSM-V, expected in 2011, has been predicted to have 1,256 pages and to contain 1,800 diagnostic criteria, generating US$ 80 million in revenue for the American Psychiatric Association.⁵

The 1980 edition (DSM-III) saw the first appearance of the term ‘attention deficit disorder’, which significantly expanded the definition of its predecessor, ‘hyperkinetic reaction of childhood.’ By 1987 (in the DSM-III-R), this had become the by now familiar term attention deficit hyperactivity disorder (ADHD). There were still more developments in 1994 with the DSM-IV. In this edition, two categories of symptoms are listed, namely ‘inattentive’ and ‘hyperactive/impulsive’, and three types of disorder, namely ‘ADHD, primarily inattentive’, ‘ADHD, primarily hyperactive’ and ‘ADHD, combined type.’

Following the broadening of diagnostic criteria in 1991, the numbers of children diagnosed with ADHD shot up by approximately 60%.⁶ In short, definitions of ADHD have come to include more and more children.⁷ As a result, ADHD is often held up as an example of ‘diagnostic spread’, where ever broader definitions of ‘disorders’ mean that more and more people are caught in the diagnostic ‘net.’ Critics suggest that categories have now become so wide that we risk labelling normal childhood behaviour ‘disordered.’

Decide for yourself. The DSM-IV criteria for ADHD are listed in Box 1.2.

BOX 1.2 DSM-IV diagnostic criteria for ADHD

A. Either 1 or 2

1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

1. Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).
5. Often has difficulty organising tasks and activities.
6. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
7. Often loses things necessary for tasks and activities (e.g. toys, school assignments, pencils, books or tools).
8. Is often easily distracted by extraneous stimuli.
9. Is often forgetful in daily activities.

2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

1. Often fidgets with hands or feet, or squirms in seat.
2. Often leaves seat in classroom or in other situations in which remaining in seat is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
4. Often has difficulty playing or engaging in leisure activities quietly.
5. Is often ‘on the go’ and often acts ‘as if driven by a motor.’
6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been completed.
2. Often has difficulty awaiting turn.
3. Often interrupts or intrudes on others (e.g. butts into conversations or games).

A. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.

B. Some impairment from the symptoms is present in two or more settings (e.g. at school or work, or at home).

C. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.

D. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder, and are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder or personality disorder).

It is possible, of course, that some readers of this book might have children who do not display these ‘symptoms.’ If so, I would say they are highly unusual. That is the first problem with this list of behaviours - it describes things that all children do. Secondly, there is a reliance on opinion that is rather too subjective. For example, at what stage does ‘fidgeting’ or ‘not listening’ - surely very ordinary behaviour in children - reach the clinical threshold? Who decides when something is too much (or not enough)? After all, parents, teachers and doctors vary enormously in what they are prepared to tolerate as ‘normal.’ The over-inclusiveness of the criteria, together with their reliance on subjectivity, has led to much criticism. Indeed, some have alleged that the criteria are pretty meaningless. Among these critics is psychiatrist Peter Breggin, who suggests that the DSM criteria are nothing but lists of behaviours that need more attention from the teacher.⁸

Breggin is one of many children’s specialists who have expressed concern. On the face of it, it seems that there is indeed cause for concern. Not just our children but also the adult population seems to be more and more prone to mental illness these days. As we can see by the steady growth of the DSM, more disorders are being ‘discovered’ year on year. Their increasing number and the broadening of some, such as ADHD, make it imperative that we step back and ask ourselves what this kind of mental health classification really means.

How ‘real’ are diagnostic categories?

It is important to recognise that the system of classification of mental illness was originally set up for research purposes and that it is subjective. That is, like any system it is a product of professional, social, cultural and political thinking during a particular period in time. To appreciate this, we only have to remind ourselves that until 1973 homosexuality was still classified as a mental disorder and appeared in the DSM under the category of ‘sociopathic personality disturbance.’ Homosexuals were no different in 1973 than in 1972. They had not suddenly changed their sexual preferences and practices. What had changed was the way in which homosexuality was classifie...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• About the author
• Acknowledgements
• Author’s note
• Introduction: Why I’ve written this book
• 1 What is ADHD?
• 2 The psychopharmacology of ADHD
• 3 The drug companies
• 4 The rise and rise of biological psychiatry
• 5 What’s happening to our children?
• 6 The lost boys
• 7 Why do children really have attentional difficulties?
• 8 A bit about the brain
• 9 Choice for children?
• 10 Social and political issues
• 11 Where do we go from here?
• Epilogue Looking after our children
• Appendix 1: Peter Breggin’s critique of the MTA study
• Appendix 2: Comparison of 1997 Labour Party Manifesto with position and plans in 2006
• References
• Index