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A Clinician’s Response To The Great ADHD Myth · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: Hello and welcome back to another edition of Inside the Consulting Room with me, Kim Lee, Child and Adolescent Psychotherapist.
• 0:09
  SPEAKER_00: This is an unscheduled podcast that I'm producing today as a consequence of the TV programme last night, the great ADHD myth.
• 0:22
  SPEAKER_00: I've already seen there's a good deal of controversy about this.
• 0:27
  SPEAKER_00: So this is an episode that is intended to provide a take on it, which I hope people will find helpful and reassuring.
• 0:40
  SPEAKER_00: The title of this is The Great ADHD Myth, Where was the Evidence?
• 0:48
  SPEAKER_00: Now I watched this Channel 4 documentary with considerable interest because it does address or addressed questions that I believe should be asked.
• 0:59
  SPEAKER_00: Questions like, are we diagnosing ADHD too readily?
• 1:04
  SPEAKER_00: Are some assessments insufficiently thorough?
• 1:08
  SPEAKER_00: Are children being medicated when their behaviours might better be understood in the context of their relationships, their developmental history, their school environment, or the pressures of contemporary life?
• 1:23
  SPEAKER_00: Are we sometimes locating a problem entirely within a child when at least part of that problem belongs to the world around them?
• 1:33
  SPEAKER_00: Now these these are legitimate questions.
• 1:35
  SPEAKER_00: And as a child and adolescent psychotherapist, I've long been concerned by any approach that takes complicated behavior and attaches a diagnostic label to it without first trying to understand what that behavior means.
• 1:51
  SPEAKER_00: And this is a theme throughout all of my work and has been for many years.
• 1:57
  SPEAKER_00: And let me just say that inattention is not an explanation, impulsivity isn't an explanation, and neither is hyperactivity.
• 2:07
  SPEAKER_00: These are descriptions of behavior.
• 2:10
  SPEAKER_00: And the clinical task is to understand why this particular child is inattentive, impulsive, or hyperactive, why the difficulties occur in some settings more than others, when they begin, what makes them better or worse, and how they're connected to the child's development, relationships, emotional life, and constitutional characteristics.
• 2:33
  SPEAKER_00: Therefore, I didn't approach the program from a position of believing that the diagnosis of ADHD must be defended at all costs.
• 2:43
  SPEAKER_00: But nor do I believe that medication should ever be used simply to make a child quieter, more compliant, or easier for adults to manage.
• 2:56
  SPEAKER_00: But the program went considerably further than questioning the quality of diagnosis or the use of medication.
• 3:03
  SPEAKER_00: And its central question was whether ADHD is a genuine neurodevelopmental disorder or whether it is largely a social construct, an environmentally produced collection of behaviours that medicine has chosen to characterize or to categorize as a disorder.
• 3:23
  SPEAKER_00: But that's a different question.
• 3:26
  SPEAKER_00: And if a national television program intends to challenge the neurodevelopmental status of ADHD, it must accept a substantial evidential burden.
• 3:37
  SPEAKER_00: It's not enough to gather together a number of sceptical opinions.
• 3:41
  SPEAKER_00: It's not enough to demonstrate that modern childhood can be unhealthy.
• 3:46
  SPEAKER_00: And it's not enough to show that some assessments are inadequate.
• 3:50
  SPEAKER_00: And it's certainly not enough to follow one child through a short period of medication or medication withdrawal and lifestyle change.
• 3:59
  SPEAKER_00: The fundamental question I was left asking was very simple.
• 4:04
  SPEAKER_00: Where was the research evidence?
• 4:06
  SPEAKER_00: And so several different questions become one.
• 4:11
  SPEAKER_00: Now the program appeared to bring together several concerns.
• 4:15
  SPEAKER_00: The first was whether ADHD is sometimes diagnosed too readily.
• 4:20
  SPEAKER_00: The second was whether private assessment services may have lowered the threshold for diagnosis.
• 4:26
  SPEAKER_00: And the third was whether the behaviors associated with the condition are intensified by screens, poor diet, lack of exercise, and inflexible schools.
• 4:36
  SPEAKER_00: And the fourth was whether stimulant medication is sometimes prescribed inappropriately or at a dose that suppresses the child's personality.
• 4:47
  SPEAKER_00: The fifth, and the most profound, was whether ADHD is a neurodevelopmental disorder at all.
• 4:54
  SPEAKER_00: And the problem is that these questions aren't interchangeable.
• 4:58
  SPEAKER_00: If an assessment is poor, that tells us something about the assessment.
• 5:03
  SPEAKER_00: It doesn't establish that the condition being assessed doesn't exist.
• 5:09
  SPEAKER_00: If some people are incorrectly diagnosed, that raises questions about diagnostic practice.
• 5:16
  SPEAKER_00: It doesn't mean everybody with the diagnosis has been incorrectly diagnosed.
• 5:21
  SPEAKER_00: Now, if medication causes emotional flattening or loss of spontaneity in a particular child, that may indicate that the medication, the dose or the treatment plan needs to be reconsidered.
• 5:36
  SPEAKER_00: It doesn't establish that the child's underlying difficulties are imaginary.
• 5:42
  SPEAKER_00: Now, if exercise, reduced screen use, and greater parental involvement help a child to regulate themselves, that demonstrates that environment matters.
• 5:54
  SPEAKER_00: It does not establish that the original difficulty was caused by the environment.
• 6:00
  SPEAKER_00: Now the program repeatedly moved between these different propositions as though evidence for one supported all the others, and of course it doesn't.
• 6:09
  SPEAKER_00: Now what the current evidence tells us, and this is the scientific understanding of ADHD, doesn't rest upon a single study or one brain scan or the claims of pharmaceutical companies.
• 6:21
  SPEAKER_00: It rests upon converging research from multiple fields: developmental psychology, genetics, epidemiology, neuroscience, family and twin studies, longitudinal research, neuropsychology, and controlled treatment trials.
• 6:40
  SPEAKER_00: In 2021, the World Federation of ADHD published an international consensus statement containing 208 evidence-based conclusions.
• 6:52
  SPEAKER_00: So this wasn't an opinion of one doctor or one research team.
• 6:57
  SPEAKER_00: It brought together findings supported by meta-analysis and large replicated studies.
• 7:04
  SPEAKER_00: 80 authors from the 27 countries contributed to it.
• 7:09
  SPEAKER_00: That doesn't mean that every aspect of ADHD is settled, and it doesn't mean that the diagnosis is always applied correctly.
• 7:16
  SPEAKER_00: And it doesn't mean that every person diagnosed with ADHD has the same underlying difficulties.
• 7:23
  SPEAKER_00: But it does mean that any program proposing that ADHD may not be a neurodevelopmental disorder has to engage seriously with it this substantial body of evidence.
• 7:35
  SPEAKER_00: I didn't see that engagement.
• 7:37
  SPEAKER_00: Genetics research, for example, indicates that ADHD has a strong inherited component.
• 7:44
  SPEAKER_00: Now this doesn't mean that there is one ADH gene or that somebody's destiny is genetically predetermined.
• 7:53
  SPEAKER_00: ADHD is understood as polygenic, which means many genetic variations may be carrying a very small effect combined to influence vulnerability.
• 8:07
  SPEAKER_00: Now a major genome-wide study published in 2023 compared tens of thousands of people with ADHD with a much larger control group, and it identified 27 significant genetic locations and a number of potential risk genes, many of which are particularly relevant to early brain development.
• 8:30
  SPEAKER_00: Now, that evidence doesn't eliminate environmental influence, and it's not intended to.
• 8:37
  SPEAKER_00: Genes and environment do not occupy separate worlds.
• 8:42
  SPEAKER_00: Development emerges through their interaction.
• 8:46
  SPEAKER_00: But the genetic evidence is very difficult to reconcile with the proposition that ADHD is simply created by screens, processed food, schooling, or contemporary social expectations.
• 9:02
  SPEAKER_00: It's nonsense.
• 9:04
  SPEAKER_00: Now the program placed considerable emphasis upon the question of whether people with ADHD have identifiably different brains.
• 9:14
  SPEAKER_00: Now this requires quite careful language because there's no brain scan at all that can diagnose ADHD in an individual person.
• 9:23
  SPEAKER_00: If somebody placed two scans in front of a clinician, one person, or one from a person diagnosed with ADHD, and one from somebody without the diagnosis, the clinician couldn't reliably identify which was which.
• 9:38
  SPEAKER_00: And the differences found in research are group level differences, they are averages and they're generally small.
• 9:45
  SPEAKER_00: And there's a considerable overlap between people with ADHD and people without it.
• 9:51
  SPEAKER_00: And these limitations are important because the absence of an individual diagnostic scan is not evidence that ADHD has no neurodevelopmental basis.
• 10:04
  SPEAKER_00: We're not far enough along, I think, to really see these things.
• 10:09
  SPEAKER_00: But large international neuroimaging studies have identified statistically significant average differences in a number of brain regions, particularly among children.
• 10:22
  SPEAKER_00: Other studies have found differences in what's called cortical development and in networks associated with attention, inhibition, and executive functioning.
• 10:33
  SPEAKER_00: Once again, these findings do not reveal a single uniform ADHD brain, nor should they be used to reduce a child to a neurological abnormality.
• 10:47
  SPEAKER_00: But it's it's mis it's misleading to move from we can't diagnose ADHD using a brain scan to there is no evidence of neurodevelopmental difference.
• 10:58
  SPEAKER_00: That's just once again nonsense.
• 11:01
  SPEAKER_00: It's not that those those are not the same statement.
• 11:04
  SPEAKER_00: There are many recognized conditions which no individual diagnostic scan or for which no scan exists.
• 11:12
  SPEAKER_00: And the clinical reality of a condition does not depend upon being able to point to a single visible abnormality.
• 11:22
  SPEAKER_00: Now, one of the program's strongest arguments was that modern environment environment may be profoundly unhelpful to children.
• 11:31
  SPEAKER_00: Well, as it happens, that's not news.
• 11:33
  SPEAKER_00: And I do agree, many children spend far too much time using screens, some sleep badly, exercise too little, and have limited opportunities for unstructured play.
• 11:45
  SPEAKER_00: Yes, diet can affect energy, sleep, and general well-being.
• 11:49
  SPEAKER_00: Schools can be overly regulated and intolerant of children whose developmental needs do not fit within the timetable.
• 11:59
  SPEAKER_00: Some children are expected to sit still for periods, of course, and developmentally, or rather, that for certain children, this is developmentally unreasonable.
• 12:09
  SPEAKER_00: You know, behavior generated by anxiety, trauma, family conflict, sensory difficulties or learning problems may be interpreted as evidence of ADHD.
• 12:21
  SPEAKER_00: But there is also a risk that diagnostic language can close down curiosity.
• 12:26
  SPEAKER_00: Once a child has been explained as ADHD, adults may stop asking what else has happened?
• 12:32
  SPEAKER_00: What has the child experienced?
• 12:34
  SPEAKER_00: What is the child trying to communicate?
• 12:37
  SPEAKER_00: Is the restlessness associated with anxiety?
• 12:40
  SPEAKER_00: Does the child become inattentive when emotionally overwhelmed?
• 12:45
  SPEAKER_00: Are there attachment disruptions?
• 12:47
  SPEAKER_00: Is the child preoccupied by conflict at home?
• 12:52
  SPEAKER_00: And the sorts of questions that I ask where every child is concerned.
• 12:58
  SPEAKER_00: Because what I want to understand is the context and what I want to see is is there evidence that might support whatever clinical opinion I finally form?
• 13:12
  SPEAKER_00: And this is not in any way restricted to ADHD and the subcategories of attentional difficulties.
• 13:22
  SPEAKER_00: There are lots of explanations.
• 13:24
  SPEAKER_00: And I very often say when parents bring children to me saying, I think they have ADHD, what they might do, but that is not a diagnosis that you can reasonably rely upon by using Google.
• 13:41
  SPEAKER_00: And that that that sounds a little bit critical, but but actually what it does is to say, look, we have to have a much bigger frame through which we examine what is what is happening.
• 13:52
  SPEAKER_00: And there may be other there may be other difficulties, but one thing is true, your child is suffering and you're doing your best.
• 14:01
  SPEAKER_00: A child may have a constitutional vulnerability that becomes disabling in one environment and manageable in another.
• 14:09
  SPEAKER_00: What we also have to understand is that some presentations are have a situational quality, basically one behavior in one environment, one in another.
• 14:20
  SPEAKER_00: Now, a highly structured classroom may expose difficulties that are barely visible when the same child is moving freely outdoors, not always.
• 14:29
  SPEAKER_00: A calm, predictable home may reduce symptoms, while a chaotic or frightening environment amplifies them.
• 14:36
  SPEAKER_00: We call these aggravating factors.
• 14:39
  SPEAKER_00: So it could very well be that the child, the diagnosis is absolutely right, but the environment aggravates the symptoms, or it supports the symptoms and we see a reduction.
• 14:50
  SPEAKER_00: So when I see children who have been diagnosed in this way, their symptoms in the consulting room are low.
• 14:57
  SPEAKER_00: And I I'm not surprised because the the environment doesn't aggravate the symptoms.
• 15:05
  SPEAKER_00: Now, and that's the true of it of all psychological functioning.
• 15:10
  SPEAKER_00: You know, human beings respond to their environments.
• 15:13
  SPEAKER_00: The fact that a person improves when the environment improves does not mean that the original vulnerability never existed.
• 15:22
  SPEAKER_00: Now I want to turn to the case of Mason, because he was the emotional center of the documentary, ten-year-old boy.
• 15:32
  SPEAKER_00: And Mason had taken ADHD medication for approximately two years.
• 15:38
  SPEAKER_00: And he described the medication as taking away his funness.
• 15:42
  SPEAKER_00: Now that statement deserves to be heard because a child should never be expected to surrender his vitality or sense of self merely to become easier to teach.
• 15:54
  SPEAKER_00: Medication must benefit the child, not simply the adults around them.
• 15:59
  SPEAKER_00: And during the program, he stopped taking his myth.
• 16:03
  SPEAKER_00: And at the same time, his family introduced several lifestyle changes.
• 16:07
  SPEAKER_00: So screens and ganging were removed or greatly reduced, his diet changed, you know, uh ultra-processed foods and sugary products were restricted, exercise and yoga introduced as were creative experiences.
• 16:23
  SPEAKER_00: He also received more structured involvement and attention from his family and from the professionals working with the program.
• 16:32
  SPEAKER_00: His mother experienced him as happier, funnier, and more fully himself.
• 16:37
  SPEAKER_00: This was meaningful.
• 16:38
  SPEAKER_00: But what did it establish scientifically?
• 16:42
  SPEAKER_00: Very little.
• 16:43
  SPEAKER_00: Medication was withdrawn at the same time as numerous other changes were introduced.
• 16:48
  SPEAKER_00: It was therefore possible, sorry, impossible, to know which intervention produced which effect.
• 16:55
  SPEAKER_00: Mason was happier because the medication had been removed.
• 16:59
  SPEAKER_00: Was it because of exercise, less time gaining, gaining more parental attention?
• 17:06
  SPEAKER_00: Was it because the family had entered an unusually highly focused period in which coaches, nutritionists, and a television crew were interested in it?
• 17:17
  SPEAKER_00: Was it the combination of all these things?
• 17:19
  SPEAKER_00: There was no control group, no binding, blinding, sorry, no independent experimental structure and no way of separating the variables.
• 17:28
  SPEAKER_00: It wasn't a scientific experiment, it was a single case film for television.
• 17:34
  SPEAKER_00: There was another difficulty.
• 17:36
  SPEAKER_00: Although Mason appeared happier and more animated, reports from school indicated that he also became more talkative, more fidgety, more disruptive, and less able to complete work he'd managed.
• 17:50
  SPEAKER_00: That's not evidence that the medication withdrawal failed, and it doesn't prove that medication was necessary.
• 17:57
  SPEAKER_00: But the best answer for him, perhaps, but it demonstrates that the outcome was mixed.
• 18:02
  SPEAKER_00: Some aspects improved, others deteriorated.
• 18:06
  SPEAKER_00: Now, the program's closing credits disclosed that he subsequently resumed medication after experiencing poor examination results.
• 18:17
  SPEAKER_00: Now, if you want to shoot yourself in the foot with a documentary, that's a really good way to do it.
• 18:23
  SPEAKER_00: It could be interpreted in several ways.
• 18:26
  SPEAKER_00: It might indicate excessive academic pressure, but that's an aggravating factor.
• 18:31
  SPEAKER_00: It might demonstrate that the school environment couldn't accommodate him without medication, another aggravating factor.
• 18:38
  SPEAKER_00: It might also indicate that the medication had been helping with genuine attentional and regulatory difficulties as a supportive factor.
• 18:50
  SPEAKER_00: You know, a forensic examination would have retained all of these possibilities, but the program appeared to favour only one.
• 18:58
  SPEAKER_00: In a forensic investigation would ask questions.
• 19:04
  SPEAKER_00: I'd begin by asking precisely what the program was seeking to prove.
• 19:10
  SPEAKER_00: Was it claiming that ADHD doesn't exist, that it's misdiagnosed, the criteria's too broad, medication is over-prescribed, and so on.
• 19:20
  SPEAKER_00: Or that environmental factors can aggravate attentional and behavioural difficulties.
• 19:27
  SPEAKER_00: But each proposition requires different evidence.
• 19:30
  SPEAKER_00: And I then ask what evidence could potentially disprove the program's preferred hypothesis?
• 19:37
  SPEAKER_00: And this is crucial because a proper investigation doesn't simply collect material supporting the position it wishes to explore.
• 19:45
  SPEAKER_00: That's like coming to a conclusion and then searching for the evidence that proves the position.
• 19:54
  SPEAKER_00: Where was the detailed consideration of genetic research?
• 19:57
  SPEAKER_00: Where were the twin and family studies?
• 20:00
  SPEAKER_00: Where was the international consensus evidence, longitudinal studies, which are within a few weeks?
• 20:08
  SPEAKER_00: Where was the discussion of children who show significant impairment across multiple environments, despite good parenting, healthy diets, limited screen use, and supported supportive schools?
• 20:21
  SPEAKER_00: And where were the distinction between the causes of ADHD and factors that influenced the severity of its presentation?
• 20:32
  SPEAKER_00: There was no evidence that really supported these things.
• 20:37
  SPEAKER_00: There was no systematic evaluation of medication research, including both adverse effects and demonstrated benefits.
• 20:45
  SPEAKER_00: And why was a single uncontrolled case given such prominence in answering a population-level scientific questions?
• 20:55
  SPEAKER_00: The program was appropriately cautious about treating associations found in brain research as proof of causation, but the same caution wasn't consistently applied to its environmental argument.
• 21:11
  SPEAKER_00: Research may find that children with ADHD symptoms more spend more time using screens.
• 21:18
  SPEAKER_00: That doesn't establish that screens cause the symptoms.
• 21:22
  SPEAKER_00: Many children with ADHD, and I have a caseload to refer to, use screens because they have a regulating factor and they make a connection with a part of the brain that needs regulating.
• 21:37
  SPEAKER_00: It also results in the production of dopamine and serotonin, in some instances, oxytocin, all of which may benefit mood and behaviour.
• 21:53
  SPEAKER_00: Medication does deserve scrutiny, and I think it was right for the documentary to examine medication.
• 22:01
  SPEAKER_00: Stimulant medication produces side effects, and these may include reduced appetite, sleep disturbance, emotional numbing, and a whole lot of other things.
• 22:11
  SPEAKER_00: And some children benefit greatly.
• 22:14
  SPEAKER_00: Others benefit only partially.
• 22:16
  SPEAKER_00: Some dislike how the medication makes them feel.
• 22:20
  SPEAKER_00: Some do better with a different dose or different preparation.
• 22:23
  SPEAKER_00: Some just don't want to take it.
• 22:25
  SPEAKER_00: And I can understand that.
• 22:27
  SPEAKER_00: Now we can recognize, we can recognise that medication has a role to play.
• 22:32
  SPEAKER_00: It is not a silver bullet, and it's not relevant to all children.
• 22:36
  SPEAKER_00: Because for some children, other methods may be sufficient, and this sort of more holistic approach is something I fully support.
• 22:45
  SPEAKER_00: But I think what I want to really conclude with is that the approach to this disorder and its subcategories has no single cause and it has no single treatment.
• 23:02
  SPEAKER_00: When I work with patients who have a significant history of attentional disorder, I also have to look at so many other factors.
• 23:12
  SPEAKER_00: And one of those, alongside medication, is the role of psychoeducational psychotherapy.
• 23:19
  SPEAKER_00: That means working with the child and with the family, helping them to understand all of these different factors and how to manage them differently.
• 23:28
  SPEAKER_00: But I can assure you that trying to work with children who are really finding it incredibly hard to manage symptoms, those symptoms are not sufficiently restrained, so to speak, find it incredibly hard to access a psychoeduc or therapy more generally, because their brains just can't cope.
• 23:59
  SPEAKER_00: So we have to consider a contrasting a range of approaches.
• 24:06
  SPEAKER_00: And we have to include parents, we have to help parents, and we have to teach parents.
• 24:11
  SPEAKER_00: And you know, we we we we don't do anybody any favours by saying you're being a bad parent.
• 24:17
  SPEAKER_00: It's just nonsense.
• 24:19
  SPEAKER_00: So I guess where I finally arrived was that, okay, the program had made a credible case against careless diagnosis, simplistic explanation, and unreflexive prescribing.
• 24:32
  SPEAKER_00: But that's not news.
• 24:34
  SPEAKER_00: I really don't believe there's anything uh remarkable about that.
• 24:40
  SPEAKER_00: I didn't believe that it had made a credible case that ADHD is not a neurodevelopmental disorder.
• 24:47
  SPEAKER_00: It showed that children are affected by their environments, but we already knew that.
• 24:53
  SPEAKER_00: It showed that diet, exercise, play, relationships, and reduce screen exposure will very probably improve well-being and regulation.
• 25:03
  SPEAKER_00: But we knew that too.
• 25:05
  SPEAKER_00: It showed that medication can affect a child's personality and subjective experience and must therefore be prescribed carefully.
• 25:15
  SPEAKER_00: Now that's important, but I think the people who prescribe know that as well.
• 25:20
  SPEAKER_00: But it didn't demonstrate that modern environments cause ADHD.
• 25:26
  SPEAKER_00: It didn't adequately engage with so many studies, whether they were genetic, developmental, epidemiological, or neurological, and it attempted to illustrate and illuminate a population-level scientific question through the experience of one child undergoing several simultaneous changes over a few weeks.
• 25:50
  SPEAKER_00: The program's failure wasn't that it questioned ADHD.
• 25:54
  SPEAKER_00: You know, we should question certain things, but we have to do it in a manner which gives us substantial answers.
• 26:03
  SPEAKER_00: And if we ask a scientific question, we must be prepared to follow the evidence.
• 26:08
  SPEAKER_00: Even when that evidence complicates the story we hope to tell, or actually shatters the story.
• 26:15
  SPEAKER_00: ADHD, like any other diagnostic term, should not become a convenient label that prevents us from understanding the whole child.
• 26:25
  SPEAKER_00: The appropriate question is not: does the child have ADHD?
• 26:31
  SPEAKER_00: It is what combination of constitutional, developmental, remote relational, emotional, and environmental factors is producing these difficulties in this child in these circumstances at this time.
• 26:49
  SPEAKER_00: The question doesn't diminish the child to a diagnosis and it doesn't deny a neurodevelopment.
• 26:56
  SPEAKER_00: It requires us to think about the whole child.
• 27:01
  SPEAKER_00: And that is the level of forensic and clinical inquiry that the great ADHD myth promised, but it didn't deliver.
• 27:12
  SPEAKER_00: It was even the even the title, I think, was very misleading because it oriented viewers towards the idea that there was mythology associated with a diagnosis, which I think is very laden, and it's unsurprising that the reactions have been so mixed.
• 27:38
  SPEAKER_00: I do have great sympathy for parents who watched the program and who have a child with a diagnosis, because unfortunately, that may compound already existing, an already existing sense of guilt and failure.
• 27:57
  SPEAKER_00: From my position as a clinician with a good deal of experience in this area, I can assure you that this podcast comes not from a position of seeking to promote an argument one way or another.
• 28:13
  SPEAKER_00: It is simply to help listeners understand this is that this is a big area and it deserved a far better, a far more forensic and a far more informed presentation.
• 28:29
  SPEAKER_00: Thank you for listening.