ADHD: are children diagnosed as hyperactive really hyperactive?

Specialist clinics are overflowing. Parents are panicking. Children are anxious. The French education system has taken up the issue. So what is this ADHD that everyone is talking about? Are the diagnoses being made correctly? An investigation into a disorder that divides opinion.

Source: http://www.psychologies.com/Famille/Enfants/Epanouissement-de-l-enfant/Articles-et-Dossiers/TDA-H-les-enfants-diagnostiques-hyperactifs-le-sont-ils-vraiment/5Revoir-les-modes-de-vie

It is a small booklet from the French Ministry of Education, with a brightly coloured child's drawing. At the bottom, it reads: “Children with attention deficit/hyperactivity disorder and their schooling”. The booklet is meant for teachers, so that they can spot the “ADHD” pupils in their class. These children have “difficulty sustaining [their] attention”, they are “away with the fairies”, they sometimes “speak and act before thinking”, they tend to “talk too much” and to “fidget excessively with their hands and feet”: they are ill! The seven pages of recommendations and descriptions could apply to anyone.

Calming the restless, refocusing the distracted

A thousand psychiatrists, psychoanalysts and child psychiatrists are not very happy with the initiative. In a petition sent in mid-November to Emmanuel Macron and to the French Ministers of Health and Education, they call for the booklet to be withdrawn. Among their arguments: it is not for teachers or school psychologists to suggest psychiatric diagnoses.

Jacques Dayan, a child psychiatrist at Rennes University Hospital and a psychoanalyst, did not start this appeal, but he often sees parents who are convinced that their child has ADHD and who are, in fact, passing on comments from the school. “A great deal has been asked of schools, in particular to take on children with difficulties,” he explains. “Now, with the arrival of the drug treatment offered for ADHD came the possibility for the school system to calm the restless children, and sometimes the distracted ones, whom ordinary teaching was not enough to settle. So we have gradually moved from a tentative request from teachers trying to find out how to deal with difficult children, some of them in great distress, to a demand for a product that calms them down and lets everyone get on with their work. And this satisfies the education world, the parents and even the children, because they can make progress at school and fit in, with a high rate of success.”

Gabriel, 13, was diagnosed with ADHD at 10 after difficulties at school and frequent fights in the playground. He would not dream for a second of stopping his stimulant: “It lets me be a better version of me,” he says. Jacques Dayan recounts what one of his teenage patients told him recently: “With Rιtalin, I can stay seated and get through a whole day of lessons that usually bore me.” Jacques Dayan: “Her deeper relationship with school, which she finds tedious and pointless, has not changed radically, but she manages to put up with it without moving and, as she says, ‘Sometimes I learn a bit.’”

At his Reference Centre for Attention Deficit and Hyperactivity in Bordeaux, Professor Manuel Bouvard¹, a child psychiatrist, sees 1,200 children a year. He is snowed under with requests, first because there are too few specialist clinics, but he also notes “a fashion effect. We are currently seeing overdiagnosis, because ADHD has moved from being a medical status to a social one”.

In a study published in The Lancet last October², German researchers show that over fifty years the number of ADHD diagnoses and of stimulant prescriptions has soared in developed countries, and point to a high likelihood of misdiagnosis.

One disorder can hide another

Jeanne Siaud-Facchin would not disagree. A clinical psychologist who formerly worked in hospitals in Paris and Marseille, she founded psychological consultation centres for children and teenagers. Between January 2005 and 11 September 2017, she saw 25,688 children, 5,500 of them for attention problems. In twelve years, she has not noticed any increase in the number of children with ADHD. It is 5%, no more, she says. The estimated average rate per country ranges from 5% to 7% for children and teenagers³. “Our statistics haven't changed. On the other hand, more and more parents come to us saying: ‘We were told he or she has ADHD’, ‘The school psychologist told us that…’ And our assessments show that the child is no more ADHD than I am a prima ballerina,” she says. In her experience, children are labelled ADHD when they are in fact dyspraxic (they have visual-motor coordination and neurovisual disorders), or “gifted”, or tired (lack of sleep both exhausts and overexcites), or have ODD, oppositional defiant disorder (because they do not feel safe and are under pressure), or else suffer from anxiety. When a young child lacks self-confidence, or is preoccupied by the loss of a pet, the birth of a sister or their parents' divorce, it becomes hard for them to concentrate. “These ‘spinning top’ children move about in all directions to keep their balance. Movement lets them keep thought at a distance. They have genuine attention problems, but they do not have ADHD,” the psychologist concludes. The difficulties can also be linked to age. The diagnosis is often made in the first year of primary school: attention skills differ between a child born at the start of the year and one born in December. Finally, many psychiatrists mention the comorbidity of ADHD, that is, the combination of several conditions: between 57% and 87% of children have an associated disorder⁴ (depression, anxiety, autism…). So making the diagnosis is anything but straightforward.

A control tower asleep

There is a great deal of uncertainty around how to identify a disorder that remains rather mysterious. It is the fault of “the criteria defined by the psychiatric manuals we use,” says Louis Véra⁵, a child psychiatrist who specialises in treating ADHD. “They were cobbled together by people who lack an in-depth view. True ADHD is the result of a disturbance in the executive functions.” To explain to parents what their child has, Professor Bouvard uses the metaphor of the control tower: “Imagine an airport. The planes arriving are the information we receive from outside. The ones leaving are the behaviour we adopt. ADHD is a control tower problem: it isn't working. This attention problem affects learning, organisation, and how they regulate their relationships and emotions. It is as if the control tower were asleep. That is why stimulant drugs can work.”

Marc always knew his daughter Lola had attention problems. At 4 months, she couldn't keep still: “We had to change her position every ten minutes. Later, when I read her stories, she turned the pages very quickly. The restlessness disappeared as she grew up, but the attention problems remained and the trouble at school began.” At 7, in her second year of primary school, on the teacher's advice, her parents took her to a psychomotor therapist. She carried out an assessment, then referred them to an expensive handwriting therapist, far from home, who told them she would treat their child with massage and reiki. “We ran!” says Marc. “Catherine Vanier, a psychoanalyst, got us out of that vicious circle. She wondered whether Lola's anxiety was the cause or the consequence of her attention problems. Since then, we have been following a care pathway. She has been diagnosed with ADD without hyperactivity. We are trying to avoid Rιtalin.” For now, the little girl is doing “cognitive remediation”, a programme that helps build concentration skills. Between the tests, assessments and specialist appointments, Lola's parents have spent nearly a thousand euros. A thousand euros to name, and try to ease, a child's suffering that is as undeniable as it is complex. Because ADHD cannot be detected physiologically. Brain imaging cannot identify it: “A slight reduction in grey matter in certain areas of the brain and a slight change in the neural pathways linking the deep nuclei with the prefrontal cortex have been found, but individual variation and comorbidity are very significant,” says Jacques Dayan. “It is impossible to tell, by looking at a human brain, whether its owner has ADHD or not.”

Rethinking our lifestyles

Clinicians lean towards a multifactorial origin. Manuel Bouvard is “convinced that regulation of behaviour, attention and mental cognitive activity is acquired more slowly, or with more difficulty, in ADHD, because the neural networks underlying these processes mature more slowly or are damaged. But neural networks are only mechanisms. The causes can be many: severe emotional or physical deprivation, disturbing events, but also pesticides and endocrine disruptors that may have hindered the baby's development during pregnancy… The environment plays a key role in the emergence of these disorders, but it can also regulate them”.

The plasticity of the brain, its ability to change according to the environment we live in, is not a myth, points out Sarah Stern, a psychiatrist and psychoanalyst who does not believe in the ADHD diagnosis: “A child with deficits in one area can recover the functions of that area through other routes. Of course some areas of the brain are more or less involved in particular tasks, but the connections are not the same for everyone, and new paths and routes can form from one region to another. And the way our thought processes are broken down into separate operations for ADHD does not match reality: none of these operations is independent of the others. Yet that is what the diagnosis is based on!”

Naming, classifying and making sense of ailments that are hard to pin down is what the clinical study of mental illness strives to do. The line between normal and pathological is not always clear-cut. Words are solid, while mental conditions are shifting and fluid, which is why we find it hard to capture them in language. But these disorders often reflect their time. “Today's lifestyles contribute to attention problems in children,” believes Marie-France Le Heuzey⁶, a psychiatrist at the Robert-Debré hospital in Paris. “Children and adults juggle several tasks and several screens at once. I remember a boy in a consultation who told me: ‘I don't like school because I can't change channel on the teacher.’” It may be no coincidence that our brains are starting to channel-hop too.

What is ADHD?

The term “attention deficit disorder with or without hyperactivity” (ADHD) appeared in 1980 in the DSM-III, the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. It is based on three lists of symptoms: attention difficulties (the child cannot sustain attention), impulsivity (inability to wait…) and, in some cases, hyperactivity (difficulty keeping still…). The diagnosis is generally made at around 6. Complex assessments are needed. The condition is thought to fade as children grow up, but it can also persist into adulthood.

Jacques Dayan, a child psychiatrist and psychoanalyst, explains that “it is not an illness that ‘really’ exists, in the same way as flu does. It is what is called a ‘construct’. Its manifestations, or some of them, have been recognised since the 19^th century, and it has been suggested, in different ways at different times, to group some of them together as coherently and precisely as possible to create this diagnosis”.

Since the brain changes that have been observed may be correlates as much as causes, the diagnosis can be called into question for as long as the facts and causes have not been clearly established.

Rιtalin… or not

Methylphenidate, the active substance in Rιtalin, is an amphetamine derivative that is “much less powerful”, according to Professor Manuel Bouvard, a child psychiatrist who does not prescribe it before the age of 7. The risk of side effects is a concern: loss of sleep and appetite, growth problems and sometimes dark thoughts. But according to Jacques Dayan, a child psychiatrist and psychoanalyst, “in some severe cases of ADHD, the balance of risks and benefits is clearly in favour of the drug”. Children are said to catch up on growth once they stop the medication, and while Rιtalin does not cure, its supporters say it trains children to concentrate. Specialists say they prescribe it as a last resort, and support through alternative therapies is booming: behaviour management (working on shorter periods of concentration, on judging time…), attention training with computer-based “cognitive remediation”, and emotional regulation.