France Is Great, But Their Kids Have ADHD Too

According to Dr. Berezin, ADHD can’t be real because kids in France aren’t diagnosed with it.

Where do you start with something like this? Maybe, at first, with a compliment. Dr. Berezin certainly brings up some valid concerns regarding the perennial debate over ADHD and its treatment (see my previous post on the subject). The increase in the rate at which this diagnosis is being applied is quite startling and research has shown both that there are many children who don’t meet criteria who are being treated and that there are many children who do meet criteria who aren’t. People spend a lot of energy condemning one side of this equation, but for many of us who actually do this work and see these children and their families, our objective is to get this right on both sides.

It is also a legitimate criticism, in my view, to claim that psychiatric medications are being too heavily emphasized at the expense of non-pharmacological interventions. However, many of people now leading the charge to bring things back into balance are also psychiatrists, and Dr. Berezin’s blanket contempt for all of psychiatry is misguided and uninformed. Maybe he has given up on his own field, but the rest of us certainly have not.

So before you decide to move your family to France, it might be worth examining some of the fantastically misleading errors that are contained in this blog post.

1. “ADHD doesn’t exist in France.” I know people love this fantasy, but it just isn’t true. Yes it may be the case that French doctors diagnose ADHD much less than American doctors, but that is certainly not because kids there are all beautifully behaved due to their superior parenting skills, as the post asserts. A very important study (Rescorla et al., 2012) examined the level of child behavioral problem across 44 different societies, all using the same rating scale that measured emotional-behavioral problems quantitatively and without assigning any diagnosis to them. The total score across all behavioral problems (including attention problems) for American kids was 24. Where was France? Right next to the United States with the exact same score. France is also well known as a place where Freudian based psychoanalytic theory continues to thrive. That means that if you did a survey of American versus French psychiatrists on the state of their country’s children, you’d likely hear about fewer kids in France with ADHD, but a lot more with unresolved Oedipus complexes.
2. “Active children are not a disease; many of these kids of this temperament become great athletes and leaders.” I agree. We do not want our kids to feel defective or damaged because they are highly active or struggle to focus during quiet activities. These qualities, as the post suggests, can be very positive in many ways and help children be successful in certain areas. However, to whitewash the very real struggles that these children experience when they spend two hours to complete a 20 minute homework assignment or when they are ostracized by their peers because of their impulsivity does them no service. Yes we need to celebrate and adapt to temperamental diversity as best we can, but there is a real world here in which attention is important, and we cannot pretend that there is not genuine suffering that needs to be addressed with a balanced approach.
3. “Yes there can be symptoms of hyperactivity and concentration. But it is created by psychological causes, not biological ones.” Nearly 400 years ago, René Descartes popularized the idea that the mind was a nonphysical entity and therefore quite different from the rest of the body. That theory has been, of course, thoroughly debunked, although you’d never know it from reading Dr. Berezin’s post. In reality, however, we have come to appreciate that forces like genetics can cause certain environments to become more likely to occur and environmental forces can have biological effects by changing brain function, structure, and even gene expression. I mean, really, how else did we think it was supposed to work?

Further, to ignore the genetic influence on ADHD means conveniently ignoring literally dozens of studies conducted with twins that are raised in the same household. It is true that there is no single gene mutation that leads to ADHD. It also appears true that ADHD behaviors exist on a general continuum that encompasses the full temperamental spectrum of traits like activity level and attention span. In this way, one could certainly conclude that ADHD is not a disease like pneumonia in which you have it or you don’t. At the same time, it is important to remember we have yet to find “the gene” for some of the most genetically influenced properties we know of, like height. In addition, some of the most common non-psychiatric conditions that exist, such as hypertension, diabetes, and high cholesterol, also exist in dimensional form.

As for the lack of a concrete test for ADHD, fair enough. But if you are prepared to disqualify as “not real” anything that you can’t point to on a lab test or scan, then be ready to write off everything from physical pain to autism.

To be sure, these challenges makes ADHD a difficult and more subjective diagnosis to make. However, denying decades of science to mount a parent-blaming argument for ADHD behaviors not only is factually wrong but a true disservice to the vast majority of hard-working parents.

Reference

Recorla L, et al. International epidemiology of child and adolescent psychopathology II: Integration and applications of dimensional findings from 44 societies. Journal of the American Academy of Child and Adolescent Psychiatry 2012; 51:1273-1283.

@copyright by David Rettew, MD

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.