Psychobabble: Leave Them Kids Alone?

By Keir Liddle

ADHD – Attention Deficit Hyperactive Disorder has, since its classification and inclusion in the DSM, been somewhat of a controversial diagnosis. There are those who believe it medicalises normal, though undesirable, childhood behaviour and those who believe it is a real mental health issue that requires treatment often with stimulant medication such as Ritalin. Others believe it is a real mental health issue, but that it may be widely overdiagnosed and that a diagnosis of ADHD may mask other problems such a familial or social factors. It sparks debate both within and without the medical and psychiatric establishments.

The debate recently surfaced again when the BBC website published a recent article where an anonymous head teacher commented on ADHD and her belief that some parents were using their children to gain DLA.

“I think parents are very well aware of how the system works, in terms of obtaining the drugs for their children, and the monetary gains that they get through a diagnosis.”

Not wishing to denigrate the teacher’s standing or expertise as a teacher or school administrator, I wish to take issue with these views.  Firstly, teachers are not trained in the art and science (for arguably, it is both) of psychiatric diagnoses. Are we to believe that they possess greater insight into the mental health of children in their charge than trained and qualified mental health professionals?
It is my contention that many of the mental health issues that can affect children are behavioural in nature, and will likely have come to light through aberrant or unacceptable behaviour in the classroom – particularly in the case of ADHD.  I would also suspect teachers tend to treat children yet to be diagnosed with ADHD the same as those without when they display behavioural issues. I contend that this may lead them to doubt future diagnoses as this may cast their previous treatment of the child in a bad light.

But are there issues with the existence and diagnosis of ADHD? The consensus suggests that ADHD does exist, leaving us with two important issues to consider: is ADHD overdiagnosed and should we be treating children with stimulant medications?

The frequency of occurrence of attention-deficit/hyperactivity disorder (AD/HD) is in dispute, with reported prevalence varying from 1% to 20% among school-aged children. Some epidemiological studies have suggested that between 3-5% of children of school age may be classified as having attention deficit hyperactivity disorder, while others put the highest estimate of the cumulative incidence at age 19 years  at 16.0% (14.7-17.3), with a lower estimate being 7.4% (6.5-8.4). This large variability in reported incidence rates might suggest that there is room for substantial overdiagnosis to exist. However, other research has drawn the opposite conclusions. For ADHD to be overdiagnosed, the rate of false positives (i.e. children inappropriately diagnosed with ADHD) must substantially exceed the number of false negatives (children with ADHD who are not identified or diagnosed) which was not generally found to be the case. Sciutto and Eisenberg found that, despite public perceptions and media coverage to the contrary, the evidence seemed to point towards there being no systematic overdiagnosis of ADHD. Further to this, research undertaken by Byrne reported on the issues arising from underdiagnosis of ADHD for parents and children gaining access to services.  In short, it seems that our perception of ADHD being overdiagnosed and being used as an excuse for unruly children may be ill placed and factually inaccurate.

The prevalence of treatment with stimulant medication in America  is around 86.5% for definite AD/HD, 40.0% for probable AD/HD, 6.6% for questionable AD/HD, and 0.2% for not AD/HD. The use of stimulants varies worldwide—it is estimated to be 10 to 30 times as high in North America as in the United Kingdom. Prescriptions in the United Kingdom rose from 183 000 in 1991 to 1.58 million in 1995.

Should we be medicating children diagnosed with ADHD?

Some believe that a more behavioural, rather than pharmaceutical, approach would be more effective. After all there is some unease about placing children on psychiatric medication. However, research into treatment has shown significantly greater improvement among patient groups that were given medication and a systematic review from McMaster University that reviewed 77 randomised controlled trials concluded that stimulants are effective in the short term, are more effective than placebo, compare well with each other, and seem to be more effective than tricyclics and non-drug treatments. Concerns were however raised about the quality of the intervention studies the pharmacological intervention was being compared with and the lack of good evidence on the long term effects of stimulant medication on children was noted. In answer to our question: it seems that, yes, in the short term stimulant medication can assist children diagnosed with ADHD to a greater extent than behavioural interventions. Yet there appears to be  a strong argument for developing behavioural interventions to avoid potential problems with long term medication use.

I think the above demonstrates that the issues with ADHD may be overstated by the general public, and I suspect there may also be other reasons why teachers may have particular cause to distrust such diagnoses. By and large, teachers are motivated by a desire to educate and inspire (and I have the upmost respect for anyone who joins the profession and copes with the everyday stress involved for the high ideal of education). When confronted with someone who is continually disruptive, it would only be natural that this might wear them down slightly, and cause them to hold negative views about the individual. If it later came to light that this individual had a mental health problem that could explain or mitigate for their poor behaviour, these negative views might be difficult to reconcile with this new information. It might also imply that the teacher’s handling of previous behaviour issues may have been less than perfect, or worse, insensitive towards someone who, rather than just being a “wrong ‘un”, can’t actually help it. It seems plausible that in an effort to reduce this dissonance teachers, who already have an unreasonable amount of stress to deal with, in my opinion, might question the validity of a diagnosis in order not to challenge their self-image.

I want to stress that there will be no intent in this — it’s not a conscious or malicious decision, more a natural doubt that arises due to a clash of old and new information. Teachers should not be in any way vilified or blamed for something we all do.  However, just like everyone else, they should confront their own biases in order to challenge rather than reinforce stigma.