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ADHD is best understood as a cultural construct

  • S. Timimi (a1) and E. Taylor (a2)
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Attention-deficit hyperactivity disorder (ADHD) has received significant research attention and is a problem that is rarely out of the news – whether it is concerns about treating children with amphetamines, its over- or underdiagnosis, or the long-term outcomes.

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References
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Barkley, R. A., Cook, E. H. Jr, Diamond, A., et al. (2002) International Consensus Statement on ADHD. Clinical Child and Family Psychology Review, 5, 89111.
Breggin, P. (2002) The Ritalin Fact Book. Cambridge, MA: Perseus Publishing.
Meltzer, H., Gatward, R., Goodman, R., et al (2000) Mental Health of Children and Adolescents in Great Britain. London: Stationery Office.
Moll, G., Hause, S., Ruther, E., et al (2001) Early methylphenidate administration to young rats causes a persistent reduction in the density of striatal dopamine transporters. Journal of Child and Adolescent Psychopharmacology, 11, 1524.
Prout, A. & James, A. (1997) Constructing and Reconstructing Childhood: Contemporary Issues in the Sociological Study of Childhood. London: Falmer Press.
Sayal, K., Taylor, E., Beecham, J., et al (2002) Pathways to care in children at risk of attention-deficit hyperactivity disorder. British Journal of Psychiatry, 181, 4348.
Schachar, R. & Tannock, R. (2002) Syndromes of hyperactivity and attention deficit. In Child and Adolescent Psychiatry (4th edn) (eds Rutter, M. & Taylor, E.), pp. 399418. Oxford: Blackwell.
Sproson, E. J., Chantrey, J., Hollis, C., et al (2001) Effect of repeated methylphenidate administration on presynaptic dopamine and behavior in young adult rats. Journal of Psychopharmacology, 15, 6775.
Taylor, E., Sandberg, S., Thorley, G., et al (1991) The Epidemiology of Childhood Hyperactivity. Maudsley Monograph No. 33. Oxford: Oxford University Press.
Taylor, E., Chadwick, O., Heptinstall, E., et al (1996) Hyperactivity and conduct problems as risk factors for adolescent development. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 12131226.
Timimi, S. (2002) Pathological Child Psychiatry and the Medicalization of Childhood. Hove: Brunner-Routledge.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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ADHD is best understood as a cultural construct

  • S. Timimi (a1) and E. Taylor (a2)
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eLetters

Critique of ADHD as a cultural construct is not "anti-psychatry"

D B Double, Consultant Psychiatrist
16 January 2004

Eric Taylor dismisses Sami Timimi's critique of ADHD as an oversimplified polemic (Timimi & Taylor, 2004). He admits he may have been biased because he viewed it as an anti-psychiatry tract. I find it unfortunate that the threat of "anti-psychiatry" means that a serious attempt does not appear to have been made to resolve the controversy round ADHD (Double, 2002a).Is there a dispute about the facts as well as their interpretation? For example, it is not clear whether brain differences have been shown in unmedicated children, with the protagonists stating opposing views. From the article, it is difficult to see who is correct because Taylor merely quotes the chapter on ADHD from his co-edited textbook (viz. Schachar & Tannock, 2002).Furthermore, Taylor makes various statements, again with the authority of this textbook chapter, which seem to need further clarification. For example, he says there are known physical counterparts of hyperactivity in brain structure and function, and then does not say what these abnormalities are. If we know what they are, they should be stated and we can then debate their role in aetiology. Similarly, he says that some molecular genetic variations have been robustly replicated, but then does not name the genes, except to say they especially affect dopamine systems. If he committed himself, we could then judge whether his claim proves to be fact or speculation.There is surely an onus on Taylor to justify his response to Timimi's challenge that the medical model of ADHD "offers a decontextualised and simplistic idea that leads to all of us - parents, teachers and doctors - disengaging from our social responsibility to raise well-behaved children". Instead, Taylor proposes increased recognition of the disorder, at least in the UK, "because there are several good ways of supporting children with severe hyperactivity". If the central issue is the role of medication in treatment, this is clearly a matter of values (Double, 2002b). The recently published edited collection by Fulford at al (2003) argues that meanings as well as causes are essential to good psychiatric care. One way of viewing the ADHD controversy is that Timimi is more concerned about the meaning rather than the physical cause of the disorder. Such a position should not be dismissed as anti-psychiatry, but acknowledged as a valuable contribution to the debate about the extent to which the use of medication exploits people's emotional problems. Double, D.B. (2002a)The history of anti-psychiatry (An essay review). History of Psychiatry, 13, 231-236Double, D.B. (2002b) The limits of psychiatry. BMJ, 324,900-904 [Full text]Fulford, B., Morris, K., Sadler, J. & Stanhellini, G. (2003) Nature and narrative. An introduction to the new philosophy of psychiatry. Oxford: OUPSchachar, R. & Tannock, R. (2002) Syndromes of hyperactivity and attention deficit. In Child and Adolescent Psychiatry (4th edn) (eds M. Rutter & E. Taylor), pp. 399–418. Oxford: Blackwell.Timimi, S. & Taylor, E. (2004) ADHD is best understood as a cultural construct. British Journal of Psychiatry, 184, 8-9 ... More

Conflict of interest: None Declared

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Over-diagnosis of ADHD: An epidemic or a marker for social intolerance ?

Soumitra Shankar Datta, Observer/Clinical Attachment
16 January 2004

I read with interest the interesting debate regarding the cultural construct of ADHD (1). As highlighted by the authors, it is time that we remind ourselves about the ill effects of diagnosing ADHD too often, when the child gets a label for his or her life. As a consultant psychiatrist who was working in India, I have often felt that the diagnosis of ADHD hasincreased with the advent of stimulants. This seems to be a world wide trend (2). There have been studies from the Indian subcontinent reporting prevalence rate of ADHD as high as 29.2% amongst children, aged between 11and 12 years (3). Other concerns being raised were regarding the increasing rate of diagnosis with the female gender in one of the studies (2). The above findings should all be viewed with caution in the light of the increased pressure on the parents to bring up their children in the very individual oriented social system. There has been likely decrease in tolerance for even transient non-adaptive behaviour for the parents and teachers. In the Indian subcontinent the progressive decadence of the extended family support might have contributed to the issue. Because of the medicalisation of the child’s distress or the ‘psychological state’ many of the treating physicians are under the stress of ‘prescribing’.

References:

1. Timmi, S., Taylor,E. (2004) ADHD is best understood as a cultural construct. British Journal of Psychiatry, 184, 8 –9.

2. Robison, L.M., Skaer, T.L., et al (2002) Is attention deficit hyperactivity disorder increasing among girls in the US? Trends in diagnosis and the prescribing of stimulants. CNS Drugs 16(2), 129 – 37.

3. Bhatia, M. S., Nigam, V.R. et al (1991) Attention deficit disorderwith hyperactivity among paediatric outpatients. Journal of Child Psychology and Psychiatry 32(2), 297-306.
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Conflict of interest: None Declared

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ADHD: Is it really explained only by cultural factors?

Dr.Naseem A. Qureshi
16 January 2004

We have reviewed the relevant literature on ADHD and found that, unlike Western world this syndrome is underdiagnosed, underreported and undertreated in the developing world (Al-Ghamdy & Qureshi, 2001).We also observed that this disorder, after introduction of its DSM-IV criteria and 3 common types its prevalence has increased considerably in the developed world including the USA, which is reported to be 3% to 17%. Likewise, there was also increased use of drugs in particular stimulants in the developed world. Furthermore, researches on ADHD were more sophisticated and revealing supporting phenomenology, genetic etiology, pathophysiological mechanisms, and treatment modalities. Many studies havealso explored environmental contribution to the etiology of ADHD. Recently, in an editorial, in light of three studies (Linnet et al, 2003; Ernst et al, 2003; Olfson et al, 2003) Volkmar has highlighted changing perspectives on ADHD (Volkmar 2003). The raised critical questions were about this disorder, i.e, its increased prevalence, basic mechanisms, genetic vulnerabilities, environmental contribution and course. Volkmar also suggested avenues for pursuing future research on ADHD.

In an extensive review, maternal smoking during pregnancy was found to have strong relation with ADHD or ADHD-like behaviors in children. Conversely, exposure to alcohol, caffeine and stress during pregnancy was reported to have equivocal results (Linnet et al 2003). In another study, adults with ADHD were found to differ in decision making as compared to normal control and this was attributed to the activation of neural circuits during the task performance (Ernst et al, 2003), which has some implications including specific drug development for the treatment of ADHD. Furthermore, Olfson reported national trends in service utilization by patients with ADHD.

Overall, the literature comprising of human and animal studies on ADHD is replete, which certainly supports its diagnostic entity together with its biological underpinnings. At present, it is premature to say thatADHD is best understood as a cultural construct. It might result in premature closure of research on biological aspects of ADHD.

Declaration of interest: none

References

Al-Ghamdy YS, Qureshi N A. Attention deficit hyperactivity Disorder: etiological, pathophysiological and treatment perspectives. Saudi Med J 2001; 22: 666-673.

Ernst M, Kimes AS, London ED et al. Neural substrates of decision making in adults with attention deficit hyperactivity disorder. Am J Psychiatry 2003;160:1061-1070

Linnet KM, Dalsgaard S, Obel C et al. Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence.Am J Psychiatry 2003; 160: 1028-1040

Olfson M, Gameroff MJ, Marcus SC et al.National trends in the treatment of attention deficit hyperactivity disorder.Am J Psychiatry 2003;160:1071-1077

Timimi S,Taylor E.ADHD is best understood as a cultural construct.Br J Psychiatry 2004; 184: 8-9

Volkmar FR. Changing perspectives on ADHD. Am J Psychiatry 2003; 160:1025-1027

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