What role should psychiatry play in diagnosing and treating ADHD?

In this essay, I draw on anthropology’s claim that all medical systems are cultural systems to argue that psychiatric power over human behaviour should be carefully monitored. The case of ADHD is particularly embedded within the creation of psychiatric drugs and leads us to question the role psychiatry should play in defining this ‘disorder’. The term has now gained social meaning as people reclaim it to describe their realities. How then are we to accurately problematise ADHD? I advocate for the framing of ADHD as enviornmentally-constructed, yet recognise the helpfulness of treatments psychiatry can offer struggling adults.

Over the last 30 years, many books and articles have been published on the phenomenon of “Attention Deficit Hyperactive Disorder”, or ADHD. There has been a long lasting debate among scholars but also in the public opinion about the validity and meaning of this taxonomy, its etiology and how it should be treated. Today ADHD is largely understood to be a neurodevelopmental disorder – present in children but also adults – and has a place in the latest edition of the Diagnostic Standard Manual (DSM) (APA, 2022). Psychiatry makes use of the DSM to separate normal behaviours from "disorders” and recommends treatments to rectify those behaviours. As such psychiatry is a field that should be handled with great care, as social and moral norms are infused in its medical power. In the US, kids as young as 5 are given stimulant drugs daily to help them correct their hyperactive behaviour (Bergey et al., 2018). It is not surprising that anthropology has been a big critic of psychiatry in the past, questioning the validity of psychiatric diagnosis and their pharmaceutical treatments, especially when exported to other cultures.

So, how are we to understand ADHD, and what role should psychiatry play in its treatment? The position I seek to defend is that ADHD should be considered as the behavioural adaptation to a challenging environment. This position ensures that diagnosis draws from ecosocial theory (Krieger, 1994) and accounts for the complex realities of patients and their families when prescribing treatment. I believe the term ADHD carries a lot of social meaning and enables people who are struggling in similar ways to find each other. It also allows them to legitimise and explain their experience to peers and open doors of medical treatment and welfare benefits.

I will argue for a pragmatic use of psychiatric framing when it comes to treatment options: a use that works to help relieve people from their suffering but does not trap them in a medical language; a use that acknowledges the social origins of mood disorders without dismissing helpful drugs. It would be counter productive for applied anthropology to dismiss psychiatry altogether. I believe it is much more practical to recognise its place in our society and the legitimising power it holds, and produce ethnographic work that will nuance it. Psychiatry is not at all a perfect system and its reforms are underway. In the meantime let us not forget the people who suffer and let us think of a way to best support them.

An obscure etiology

ADHD was first described as a hyperkinetic impulse disorder in children at the end of the 50s. In the following decade physician Charles Bradley randomly discovered, as he was trying to cure headaches, that the stimulant drug benzedrine helped with children’s behaviour (Bergey et al., 2018). From this point on, “hyperactivity disorder” began to be widely diagnosed in the US. Its symptoms were numerous and vague, but the drug seemed to alleviate them. In the following years, the name was changed to “minimal brain damage” – later update to “dysfunction” as no proof of physical damage to the brain was found (1963) – “hyperkinetic reaction of childhood” (1968), “attention deficit disorder with or without hyperactivity” (1980) and finally “attention deficit hyperactive disorder” in 1987. These were all understood to be children disorders until the 90s when the etiology was expanded to include ADHD in adults. With an origin story so entangled in drugs, it is hard not to be sceptical of the validity of this disorder… Medical anthropology warns us of the manipulation of diagnostic categories for the profits of pharmaceutical industries. In the case of ADHD, it is difficult to ignore drug companies’ vested interest in the shaping of the ADHD as a disorder and the extension of its “target audience” to now include adults…

So, what causes ADHD? Currently, ADHD is described as a neurodevelopmental disorder by the ICD-10 and the DSM-5-TR (World Health Organisation, 1993; APA, 2022). Activists also use this definition to raise awareness and help people navigate their ADHD symptoms. Dr Samantha Hiew, founder of ADHD Girls in the UK, tells her audience that their brain is different: they have “an entirely different neurobiology”; multiple parts of their brain activates at the same time which makes it difficult to focus on what people are saying and make a decision (2023). She says the “thinking brain is inhibited” and that “reduced signalling” leads to impulsivity. In short, she summarises the struggles of the ADHD community by saying that they receive more sensory input from the world, creating a “feel first brain” (Hiew, 2023). Indeed, pathophysiological differences in the prefrontal cortex, the cerebellum and dopaminergic pathways have been observed by neuroscientists; however they are not able to conclude whether these neurobiological differences are the cause or consequence of ADHD, shining little light on its etiology (Mehta et al., 2019). On the genetic research front, twin studies findings are also inconclusive as they encounter a lot of limitations: the assessment of ADHD is biased when the raters know two people are twins, samples all come from the same families and there is a huge amount of co-morbidities (Faraone and Larsson, 2019).

Ethnographic evidence that symptoms of ADHD vary drastically across the world further supports the idea that the etiology of ADHD is not biological, but rather socio-cultural. In their book Global Perspectives on ADHD, multiple anthropologists from around the world take turns to describe the ADHD landscape in their countries (Bergey et al., 2018). And the findings are shockingly cultural: in England, ADHD is understood as an anger management problem, “kids are naughty” (Singh, 2018), whereas in the US the emphasis is put on kids being unable to focus (Bergey & Conrad, 2018). Furthermore, it seems the diagnosis of conduct disorders like ADHD is very correlated to class in the UK: kids from a lower social class are three times more likely to be diagnosed with ADHD than upper class kids. Indeed, many studies have shown correlations between poverty and ADHD, and have reached the conclusions that “an improved socio-economic environment may significantly improve the overall outcome of childhood ADHD” (Singh, 2018).

As such, a group of anthropologists are arguing that ADHD is a myth and should be understood as the medicalisation of normative values. That is the case of Sami Timimi, Joanna Moncreiff and Peter Conrad, all members of the Critical Psychiatry Network. They argue that behaviours are classified as disorderly not on medical grounds but on the basis of social and moral norms.

Who is diagnosed with ADHD?

Medical anthropology has a long and tumultuous relationship with psychiatry. Founded by two psychiatrists – Arthur Kleinman and Roland Littlewood – medical anthropology is critical of psychiatry for its tendencies to universalise, individualise and medicalise mental health. Due to its complex nature as the intersection of social behaviour and medicine, psychiatry can easily be seen through a Foucauldian dystopic lens as a way for the state to control its people – and with a Marxist turn – for the good of healthy capitalistic growth. This is the argument that Moncrieff defends in her recent piece published in Frontiers in Sociology (2022). A psychiatrist herself, she disagrees with the way mental health is currently being framed through psychiatry. She draws on Marxist literature to place the mental health issue back in its socio-political space. As Neoliberalism grew with its capitalistic goals, the responsibility of caring for people became privatised. In this ideology, people are considered as individual (free) agents. However these agents are easily replaceable by companies if they are no longer productive or healthy; and in the most neoliberal system, there are very little welfare benefits. As mental ill-health has been growing in the general population, psychiatry has provided a convenient framework for reading it not as a result of the unhealthy structure of neoliberalism, but as an individual problem which can be solved by taking drugs. She concludes that psychiatry today participates in the continuation of neoliberalism even in the face of rising mental ill-health. Since the first cited adverse effect of ADHD is often “academic impact” for children or “decrease in productivity” for adults it is interesting to take into account what the ADHD diagnosis reflects about the pressure to contribute to capitalistic growth.

Psychologist Jessica Taylor is working to change the way psychiatric disorders are perceived, not as disorderly behaviour but rather as completely normal reactions to trauma. For instance women who suffer from PTSD after having been raped are not suffering from disordered behaviour, they are suffering from having been raped. She has taken on the task to reorganise DSM categories into an alternative she calls the Indicative Trauma Impact Manual (I-TIM), just released this month. She argues against the need for diagnostic categories but rather for a language of trauma impact, which ensures socio-cultural context is taken into account (Taylor & Shrive, 2023). Her goals with the I-TIM are to free people of psychiatry but also of the guilt and isolation they feel, and to highlight the responsibility of our society in the reproduction of certain trauma (rape culture for instance).

In the case of ADHD, Sami Timimi highlights the role that culture plays in shaping kids with ADHD, and specifically boys (Timimi, 2005). Indeed, boys are on average three times more likely than girls to be diagnosed with ADHD in the UK (NICE, 2018). Timimi describes how girls are socialised at a much younger age to be “well-behaved” whereas “boys will be boys” remains the main mentality in the Western world. Obtaining an ADHD diagnosis can be a way for parents to reject the responsibility for their kids behaviour. Indeed in Chile, Navarro describes how ADHD “medication allowed avoiding questioning about parenting styles” (Navarro, Rojas and Ochoa, 2018, p. 314). Similarly, Singh describes how British parents try not to "make a fuss” in school (2018). Timimi’s argument in the book is that not only is diagnosis of ADHD informed by cultural values and preferences, but hyperactive disordered behaviour in boys is also a product of our society (2005).

According to the National Institute for Care and Excellence (NICE) an ADHD diagnosis can be given by a healthcare professional with training and expertise on ADHD and should not rely solely on ADHD rating scales (NICE, 2018). This is interesting since the availability of online tests keep growing and the lockdown period has seen a 3200% increase in women self-diagnosing with ADHD through them (Hiew, 2023). Since symptoms are very varied and the demand for ADHD diagnosis is on the rise, NICE published last month a review of a new computerised technology for the assessment of ADHD. The goals of those QbTests are to replace a clinician visit – therefore saving time and money – and produce objective measures of this neurodevelopmental disorder (NICE, 2023a). Right away it is easy to see that this technology fails to acknowledge the complex etiology of ADHD and how those tests will only reinforce health inequalities as they will most likely not be accessible to all.

In addition, looking for an ADHD diagnosis can be a strategic move on the part of parents when there are welfare benefits associated with it: this is the case in the US where children with ADHD are eligible for free schooling programmes (Bergey & Conrad, 2018, p.13). In a culture where tuition is so expensive and state benefits are sparse, it becomes immediately clearer why there are about twice more children diagnosed with ADHD than in the rest of the world (Bergey et al., 2018). Individuals make use of their agency as they navigate the political, economic and social systems they inhabit, and medicine is no exception.  

So, if ADHD has no biological etiology (yet), and its understanding is socially and politically constructed in a culturally-variable manner, should treatment include the administration of stimulant drugs to children?

To drug or not to drug children?

For all categories of people with ADHD and since 2018, stimulant drugs are no longer the first line of treatment: instead, NICE recommends prioritising “environmental modifications” (NICE, 2018). They also recommend that parents of children and young adults attend “parent-training programmes” – a form of behavioural therapy training – before being given the option of medication. The guidelines also advocate for “multidisciplinary specialist ADHD teams” to support people with ADHD in the management of their symptoms; and for families to be involved and consider their own mental health assessments. Medication is to be prescribed to children under 5 only if there is a second specialist opinion on the diagnosis, and to children over 5, young adults and adults only after environmental modifications have been put in place and failed to reduce symptoms. The guidelines stress the importance of a baseline assessment before the start of ADHD (stimulant) medication with the exception of an electrocardiogram which they deem unnecessary unless the patient has a cardiac medical history. A variety of molecules are listed to be used first or as replacement in the case of adverse effects: methyphenidate – the molecule in Ritalin – is the first line pharmacological treatment recommended for all age groups. The American drug Adderall is not approved by the NHS in the management of ADHD symptoms, yet Singh points out that dexamfetamine – it’s main molecule – is heavily prescribed by British private health care, highlighting the weight of economic resources in ADHD management (2018).

A month ago, NICE has reviewed and authorised further research on the use of electrical stimulation of the trigeminal nerve in children for the treatment of ADHD (NICE, 2023b). A patch of two electrodes on the forehead is to be worn during the night for 8 hours over the course of 4 weeks, a posology based on “a mechanism of action [that] is not completely understood” (NICE, 2023b)… Upon reviewing the evidence myself, I found that the 3 pieces of evidence cited are in fact a pilot trial, a 4-week trial and a secondary analysis done by the same team of American scientists which includes the Senior Vice President of a company called NeuroSigma … who makes the trigeminal nerve stimulation technology! The NICE Interventional Procedure Guidance explicitly states that “patient commentary was sought but none was received”, meaning no qualitative assessment of the impact of such technology on children has been conducted (2023b). Although this evidence presents clear conflicts of interest and unclear mechanisms of action, this technology is attractive to Public Health England because it is more scaleable and therefore more cost-effective than parent-training programmes and other behavioural therapies. Indeed, the NICE-mandated cost-effectiveness analysis of parent-training programmes already finds them to be too expensive (NICE, 2018, appendix 1). Yet medical anthropology knows that "innovation solutions” fail to work in the long-term as they do not address the socio-cultural realities. They reinforce the idea that health can be individualised, universalised and medicalised; even in the case of ADHD which has yet to prove its biological origin.

The etiology of ADHD could be best understood through Turkheimer’s terms of “weak” and “strong” biologism (Schleim, 2022). ADHD is a brain disorder in the weak biologic sense because the brain is a plastic organ that adapts itself to its environment. ADHD is not a brain disorder in the strong biologism sense as it is not caused by a brain lesion, as was previously thought in the 50s. Schleim argues that “biology is not the suitable taxonomic basis for psychiatry” because it tends to fix symptoms and diagnosis to a person, without taking into account their capacity for change and the importance of their environment. That is why I believe that conceptions of ADHD should be moulded on a bioecological model of development, such as the one created by Urie Bronfenbrenner in 1979. This psychological model traces how people develop through time from interactions with several layers of society he calls microsystem, mesosystem and exosystem. It parallels Nancy Krieger’s ecosocial theory (1994) which describes the embodiment pathways of disease, taking into account biological and social components of health. Both of these frameworks value social factors in the etiology of disorder or disease, allowing for variation across individuals and cultures, and would be relevant in the ADHD discourse.

Indeed, in his 2019 book Problematising Young People, Marley emphasises the importance of considering the phenomenon of ADHD to be situated in particular contexts and not to be a universal truth; a position that can be extended to mental health more generally. His ethnographic case study approach highlights Krieger’s ecosocial theory in that it connects social actions with policy factors and medical diagnosis to better understand the experience of children with ADHD in Scotland. This approach would be beneficial in explaining the high rates of co-morbidities associated with ADHD: it seems that about 50 to 70% of people with autism are also diagnosed with ADHD (Hours, Recasens and Baleyte, 2022).

Conclusion

Scientists have found a pathophysiology for ADHD. The question remains: quid of its etiology and its place in the psychiatric landscape? Thanks to ethnographic accounts and anthropological theory, and in light of the lack of proof of a biological etiology, it seems that psychiatry might not be the right language in which to speak about ADHD. Indeed, “conduct disorders” exist in specific social, cultural and moral contexts. Children build themselves in reaction to their environments and their brains adapt as such. ADHD should be considered of social and environmental origin, and even maybe through the lens of morality according to Timimi (2005).

Nevertheless, I do not think it would be productive to take an anti-psychiatry stance either. From an Applied Anthropology perspective I think it much more pragmatic to work with the psychiatric system. The ADHD diagnosis is meaningful to people: it enables them to find each other, explain their experience to their social circles, and access welfare benefits where available. The fact that psychiatry holds the power to legitimise an individual’s experience in the eyes of the state is a problem in itself. But when it comes to helping people with ADHD navigate their symptoms and suffer less, I believe psychiatry can be used carefully.

Finally, Public Health England should fund research efforts that focus on identifying the social etiology of ADHD, as well as appropriate environmental modifications. It should use the methods of anthropology such as rapid ethnography in schools. Innovation solutions such as nerve stimulation and neurobiological research should not receive any more funding as they further individualise and universalise a very socio-culturally particular experience. In parallel, the impact of psychiatry on mental health should be revised, and alternatives to the DSM such as Taylor’s I-TIM given more attention.

References:

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