|Dr Simon Bowers, clinical vice chair of Liverpool CCG, thinks we are “failing young patients with ADHD”. 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 construct 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, consultant child and adolescent psychiatrist in Lincolnshire, 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”.
A decade on and this remains the case: ADHD – like most functional psychiatric conditions, in the conspicuous absence of anything more concrete to go on – 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 even vaguely acquainted with the most basic philosophical underpinnings of the scientific method. Dr Bowers’ article even tacitly recognises this, since, he tells us, “in Liverpool last year, new diagnoses rose by 100 percent”.
What are we supposed to assume is to account for the sudden doubling in incidence of a purportedly ‘neurodevelopmental’ condition from one year to the next in this way? Presumably, though, we are expected to conveniently ignore one obvious explanation that comes to mind with Dr Bowers’ mention of “embattled community paediatricians find[ing] themselves morphing into neurodevelopmental specialists by default” ...
Quite clearly, to anyone prepared to engage their critical faculties, socio-cultural hypotheses provide far more intuitive explanations for the rise of the ADHD phenomenon in recent years than do biologically-, neurologically- and pharmacologically-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.
The uncomfortable, but in the end unavoidable, truth is that ‘ADHD’, far from being a ‘neurodevelopmental disorder’, the recent rise in reported incidence for which is supposedly accounted for by the helpfully self-congratulatory notion that “we are getting better and better at recognising it”, is in fact an artificial construct that simply serves to inappropriately medicalise and therefore fundamentally misattribute the increasingly damaging effects of American-style hyper-capitalist 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. Is it really all that difficult to see that, in a society where working-class living standards have declined over the past four decades, and indeed have outright collapsed over the past four years, with all of the social breakdown this inevitably entails, many of the most vulnerable children’s sense of emotional security will obviously have been profoundly compromised?
Is it really all that difficult to see that a society in which both parents have to work longer and longer hours for lower and lower wages, with less and less time to spend with their children, will obviously have a negative impact on those parents’ ability to parent as effectively as they would like?
Is it really all that difficult to see that a society in which an all-pervasive corporate media bombards children with relentless advertisements and a way of being that celebrates loud, aggressive individualism will obviously result in a general tendency for many children to become more hyperactive, inattentive, and impulsive?
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, the increasing preponderance of cheap junk food in children’s diets, 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 medical and psychiatric 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 the genuinely scientific inductive reasoning in which they have been trained in favour of an ‘Emperor’s New Clothes’ cargo-cult science centred around little more than overcomplicated statistics.
Since EBM in practise favours, a priori, quantitative evidence over qualitative, there is thus a built-in bias in favour of investigating easy-to-define, easy-to-measure biological variables in preference to sociological factors that, by their very nature, tend to be far more complex, far more nuanced, and therefore far less amenable to exact measurement.
Moreover, as EBM’s hierarchy of evidence automatically favours interventional studies over observational ones, randomised controlled trials (RCTs) that lend themselves to conceptualising behavioural phenomena as wholly biological ‘medical model’ diagnoses, the solution for which is assumed to be some drug or other (such as methylphenidate for ‘ADHD’), in that they are assumed by EBM to provide ‘gold-standard’ evidence, therefore presuppose a similarly ‘gold-standard’ level of credibility in the medical model itself – a level of credibility to which it is not in fact entitled.
The huge benefits to the pharmaceutical industry of a research doctrine that officially bestows ‘best evidence’ status on trials that presuppose a ‘diagnose-and-medicate’ paradigm through which to view problems like hyperkinetic behaviour in childhood, as EBM does, are obvious.
The degradation of research quality brought about through the rise of EBM has parallels in the corporate managerialisation of medical training in recent years. With the advent in 2007 of the Modernising Medical Careers (MMC) programme, audit and research were made preconditions of passing the Annual Review of Competence Progression (ARCP) for doctors in higher training posts.
With this imperative to ‘publish or be damned’, it is entirely understandable that doctors in training have increasingly come to view research not as something to be pursued as an intellectual challenge in the interests of furthering scientific knowledge, but rather as simply yet another box to be ticked in order to avoid getting kicked off the training programme.
Hence there is now a built-in pressure to churn out a steady flow of easy, unchallenging, samey, uncontroversial material, as opposed to the sort of inspired, leftfield, innovative, creative research that would tend to require a good deal more time, thought, and effort – and, indeed, has always been the stuff of which real scientific discovery is made.
So for something like ‘ADHD’, it is now a much safer bet for a young doctor to produce a piece of research that simply has lots of quantifiable (and therefore almost certainly biological) data, lots of statistics, is safely bio-reductionist in its assumptions, and above all is of a similar style to the many other publications on the topic, than it is to risk finding him- or herself out on a limb ARCP-wise by asking unconventional questions – however genuinely illuminating such questions might well be.
Thus MMC can be seen in the context of broader managerial trends in recent decades, whereby steps have been taken to disincentivise intellectuals from speaking out against corporate power (or from ‘acting unprofessionally’, as managers would put it) by systematically undermining their economic security – as in the Education Reform Act of 1988, which abolished academic tenure, for example.
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”. With all due respect to many of those well-meaning and hardworking people often involved with such ‘third-sector organisations’, the fact is that these organisations are private enterprises in all but name, just as the process of awarding them huge numbers of NHS and Social Care contracts over recent years has indeed been privatisation in all but name.
In fact, in a good many instances, the only meaningful features that distinguish ‘third-sector organisations’ from fully-fledged private businesses are the lucrative tax breaks and freedom to hire unpaid ‘volunteer’ labour afforded to the former on account of their ‘charitable’ status.
The fundamental problem with handing over the running of any health service to a charity, of course, is the inevitable conflict of interest that arises.
Consider, for example, a disease, ‘Syndrome Q’, the sufferers of which are cared for by a fully publicly-run health service. That health service’s only interest is to provide the best possible care, which might well include curing Syndrome Q outright, if that were feasible.
If all Syndrome Q sufferers were cured, the health service would not lose out, as the consequent savings could simply be redeployed elsewhere. If, on the other hand, the Syndrome Q service were privatised, and the contract awarded to a charity, the ‘Syndrome Q Association’ say, a conflict of interest arises, since that charity’s very existence as a going concern depends upon the continued existence of Syndrome Q: while diagnosis is good for business, a cure would ultimately be ruinous.
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 so-called Evidence-Based Medicine 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, inattention, and impulsivity in children lies not in writing out ever more prescriptions for methylphenidate, but in setting about 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.
1. ‘Why are we failing young patients with ADHD?’ by S Bowers, British Medical Journal, 2014, 349:g608
2. ‘ADHD is best understood as a cultural construct’ by S Timimi and E Taylor, British Journal of Psychiatry, 2004, 184:8-9
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