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We should be treating the societal, not biological cause of ADHD

Dr Des Spence argues that the way we currently treat ADHD is not evidence-based and should be changed

The current paradigm of mental health is flawed. The diagnostic criteria within the mental health bible, the DSM, are treated as absolute in fact, however they constantly change. For example, in the 1970s the DSM once deemed homosexuality a disorder [1]. The reality is most of these conditions are merely the ‘opinion’ of a few distant academics. And 70% of these academics have financial links to Big Pharma [2]. Today mental health has become the biggest billion dollar business in healthcare, based on the idea of a ‘chemical imbalance’ biological model that can be ‘treated’ with medication.

Modern society considers these normal characteristics problematic

Questioning this current biological model can lead to accusations of being dismissive of mental illness and a tirade of abuse on today’s illiberal social media platforms. There is no proper debate or challenge of this biological model. But this label gun approach and medication for all is causing real harm. We are witnessing persistent disease creep, with 25% of the population now reportedly having a mental illness on a yearly basis [3]. But such numbers surely means normal mental experience is being medicalised?

For example, in ADHD, I have witnessed ever growing numbers of children labelled as having the disorder, the vast majority of who are boys. This is reflected in a 50% rise in stimulant prescriptions in the last five years in England, to 1.2 million scripts a year [4]. Also I have witnessed a significant increase in drug seeking behaviours, dependence and withdrawal reactions to these stimulant medications [5]. Yet there remains the fundamental question - do the diagnostic criteria for ADHD hold up to scrutiny? Is there a biological basis for this condition or is it behavioural?

Let’s scrutinise the diagnostic criteria. I have done an online self-testing questionnaire [6] and even at 50 I still tick many of these boxes! The criteria include ‘fidgets’, ‘runs about or climbs’, ‘on the go’, interrupts’, ‘does not seem to listen’,’ does not give close attention to details’, ‘loses thing’, ‘easily distracted’. This gives a flavour of the non-specific meaningless diagnostic criteria. These are common and normal male traits. For ADHD is a male problem: hyperactive, impulsive, inattentive and prone to risk taking. But through the eons hasn’t risk taking and impulsiveness been a major part of the engine of human development?

Modern society considers these normal characteristics problematic. Today we expect boys to sit in the classroom for six hours a day, dutiful and quietly completing Maths, English and colouring in. Today’s parents are older, have few children, lack parenting experience and have a blinding obsession with schooling. Modern society has different expectations of boys than in the past. And instead of recognising this as a cultural issue, we have found it easier to medicalise these non-complaint behaviours as an ‘illness’. In the USA this is epidemic, with 15% of children labelled with ADHD, and one in 20 medicated [7]. Yet there is no evidence this is biological problem. The rise of ADHD does not reflect a change in boys but a change in societies attitudes towards boys. Medicine is aiding and abetting the marginalisation of boys.

This is accompanied by medication of the ‘biological’ disease. Dr Camilla Groth who authored a recent Cochrane review concluded, ‘this review shows limited quality evidence for the effects of methylphenidate on children and adolescents with ADHD’ [8]. But this doesn’t stop big business, with prescriptions in the US worth about $13bn and set to grow. [9]

We need new thinking. Exercise and sports improve conduction [10, 11, 12], family therapy works [13], poor behaviours are linked to poor sleep patterns [14] and high technology usage [15]. Children need consistent and set boundaries. Anyone with boys will know that this is all intuitively true. We need behavioural solutions to behavioural problems presenting in ADHD. Big Pharma and psychiatry’s current biological model of ADHD is simplistic, reductionist, unscientific, illogical and defies common sense. Schools and society are failing boys and boys should be free from the growing threat of a childhood chemical cosh. Let’s make this a mental health priority.

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow 

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Readers' comments (14)

  • Is this a rehash? - feels like an article I've read before.

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  • Thought provoking article. Big pharmacy have a lot to answer to- just look at diabetes meds in the last 10 years!

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  • Excellent piece,well written
    Like 8 am I feel there is a wealth of evidence out there to support this point of view
    Shabi big pharma only have to answer to shareholders, noone else
    The accusations of disease mongering, data manipulation, and market manipulation have been well made by: marcia angell,margaret mcartney,malcolm kendrick,all produced excellently written,authoritative and highly readable accounts.
    Like Shabi all miss the point,
    to accuse pharma, in this way, is to accuse the all blacks of being unfair, because they run faster,it's their job
    The question Shabi and all similar authors fail to address, is why is it so easy to fool gp's?
    Why are we so gullible?
    What is wrong with the education system?
    Why is a system dominated by the college producing such nieve practitioners?
    The college is the source of the problem, not big pharma.

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  • This article is an almost exact statement of my views on the matter and I suspect the views many experienced GPs.

    We - or at least a vocal subset of the profession- have medicalised ordinary life to an extraordinary extent. Any attempt to put forward an alternative view is denigrated as a 'Victorian approach' or a failure to 'fully recognise the patient's very real problems'.

    The benefits system now worsens problems. The PIP criteria (written with the best of intentions to help the psychotic) actively reward lifestyles of isolation, withdrawal and dependency in those who are at risk of failing to move forward from the adjustments of adolescence. As this article suggests this group is largely male.

    Forty years ago Ivan Illich warned that medical hubris would inevitably lead to a medical nemesis. We are well along the predicted road.

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  • Great article. ADHD is just part of the list of medicalising wider societal problems
    How many consultations and sick notes signed for stress, ME / CFS, alcohol dependency, depression, chronic pain and even type 2 diabetes.
    There is no doubt these people are suffering real problems, but sick role doesn't seem the best way to help? Just seems to reinforces the helplessness "you are ill, and illness is not your fault".
    There must be better solutions. Hopefully it isnt all resilience training.

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  • Take a look at the symptoms of aluminium poisoning and ADHD and other learning disorders....
    Then think about all the ways we are now exposed to free aluminium.
    So many medicines now contain them from antacids to asprin to vaccines. Then you will start to understand the problem being faced and unfortunately we are playing our part in it.

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  • Despite your erudition, Des you are obsessed about the evils of "Big Pharma" your bete noir during your time as a BMJ columnist. Drugs work brilliantly in ADHD -ask the relatives and so called Big Pharma is dont forget the jewel in the crown of British Industry.

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  • @ GP Partner14 Jul 2016 3:03pm

    Please educate yourself for the sake of your patients. Recent trials have shown that CFS/ME patients have a clinically significant response to B-cell depletion using the monoclonal anti-CD20 antibody rituximab. CFS/ME is most likely an autoimmune disease.

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  • This article looks at the past with rose-tinted glasses and fails to convey the reality of our educational structures.

    In the past, all children were expected to sit quietly and listen to the teacher. If they didn't, the teacher could physically abuse them or threaten them with violence. Nowadays, teachers aren't allowed to beat up the kids in their charge (which is a good thing).

    There was never a golden age where boys could fidget and mess around. To sit still, listen to the teacher and be a good pupil isn't some "different expectation" of boys. It was ever thus.

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  • It seems that Dr Spence would have us lump most if not all childhood ADHD sufferers into the category of " boys will be boys." Moreover, and despite all the accumulated evidence concerning the functioning of the dopamine system in the brain and the drugs modifying it, he questions the biological and genetic basis of the disorder. As ADHD isn't primarily a behavioural disorder, behaviour therapy, even when combined with the mush vaunted physical exercise, has offered little to ameliorate it.(see link below for a recent paper.)

    There is a large body of evidence showing that methylphenidate and its derivatives, used appropriately and combined with pyschological and social support, have benefited many ADHD patients, allowing them to develop their true potential and live stable lives.

    Until something better comes along, most likely from the much maligned drug industry, it would be foolish if not negligent to abandon tried and tested treatment in the faint hope of some unstated societal change which will somehow abolish- Dr Spence doesn't say how- ADHD.

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  • I shall just run this past the 21 year old lad who lives next door to me. Diagnosed with ADHD he is awake for days, sleeps little, cannot build relationships with young men his age successfully. He has huge flares of temper and cannot work because (due to all of the above and the fallout thereof) cannot study or work - not necessarily through choice but because he is just unacceptable for the work place.

    He reminds me much of my dad - emothionally immature he became a violent drunk who could not relate to my brothers when they reached early adulthood. He almost murdered my mother. There was a strong thread of mental illness in his family, one of his brothers committed suicide and my own children suffer (and myself) to varying degrees do or have suffered with anxiety and depression. Medical or not, genetic possibly, these problems are real and if they can be treated successfully that's a huge plus.

    Before we talk about non-medical problems being medicalised, perhaps we should look at what would have happened to these kids 50 or so years ago - borstal, prison, suicide perhaps?

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  • There is a need to look at environmental factors and parentally inflicted symptoms.

    Many children I see whose parents come in with ??ADHD are filling them with additives and food full of sugar and artificial ingredients.

    Often just removing these from their diets results if actually done completely can change children back into 'Normal' behaviour.

    There clearly will always be those outside the 2 standard deviations expected, but many of those closer would benefit from tighter boundaries and parents who pay more attention to their children as opposed to leaving them in front of TVs and iPads all day.

    The small remaining numbers would benefit from expert assessment after consideration from their schools and perhaps even medication, but would be a fraction of the scripts currently expected/requested.

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  • Totally agree with everything in this article. Treating depression with SSRI tablets (as useless as these stimulant drugs are in ADHD) is a waste of time. Why do we do it? We do it because the opinion leaders tell us to. Who are the opinion leaders? They are the doctors who do the research. How do they have the time to do all this research? Big pharma help them!The whole system it biased in favour of prescribing to the core. Read Bad Pharma by Ben Goldacre. There is no mystery to this. All the answers to your questions are contained within.

    Step one - convince doctors that the illness exists - media, pharma sponsored mags etc.

    Step two - convince them that the disease is has a biological cause eg - low serotonin in depression. no decent scientific evidence for this as far as I am aware.

    Step three - invent a drug to correct the biological issue.

    Step four - publicise faulty trial data to doctors and patients (the latter done through the media )

    Step five - get the opinion leaders to write the protocols that we all love to chase as doctors - especially if we get points and cash.

    There you have it - a corrupt system with badly educated doctors prescribing drugs with flimsy benefits.

    Diabetes is an even worse scandal. Drug reps now only have to tell us that their drug will lower HBA1C and they know we will be excited. Ask a colleague or a drug rep to quantify the benefits of such a reduction - you won't get a clear answer - the overall main benefit being a reduction in eye referrals for laser treatment. No reduction in blindness end stage renal disease strokes fatal heart attacks.

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  • Wholly endorse the views expressed. Sometimes a look and observation of the parents and their history is evidence enough that the child has lacked proper parenting and that TLC that is so essential in child's social skills and psychological development.
    Kids given ADHD medicines bloat; have tachycardia and are walking zombies though more docile. The intelligent parents give medication only when the child is symptomatic and I have a case where mother finds the behaviour of child is great during vacation and does not give medication. This one child is developing a lot better than those on regular meds.

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