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• Where did your interest in ADHD start?
  I vividly remember a lot of noise about this new ‘disorder’ when ADHD (attention deficit hyperactivity disorder) started to be talked about, and I was fascinated to know what it was all about. Having been a children’s psychologist for many years, and having seen the other side of children’s problems, it didn’t take long for me to notice a mismatch between what I was hearing about these children and the ‘disorder’ they were supposed to have. Much of the literature states categorically that ADHD is a neurobiological disorder with a strong genetic component, and that the most successful treatment is stimulant medication, usually Ritalin. At the same time, however, there is no debate, no other ideas on the issue. Look at all the different aspects of these children’s lives and then ask yourself: has this idea of ADHD being a mental disease got any credibility?

  So there are two camps – the medical model that sees ADHD as a mental disease and the psychosocial perspective that sees the problem in broader terms. Can you say more about the first perspective?
  In the last 10 years, the medical model has become the dominant view. In my early years as a clinical psychologist, things felt much more psychosocial. Since then the pharmaceutical industry has grown at a phenomenal rate and I’ve been astonished at how it has become an accepted part of every aspect of healthcare, from research and education right through to treatment. Also, a lot of emphasis on the physiological aspects of people’s difficulties has come about through new technology – brain scans and imaging – but it’s been totally misused and misunderstood; they’re looking for physical evidence of mental distress, which straight away sounds like an impossible search.

  In terms of evidence of ADHD as a brain disease, their search hasn’t yielded any unequivocal results, and we’re no further forward with finding any kind of physical correlates for ADHD, which is interesting because it’s not a view the general public has. A lot of people believe that we’ve found these physical proofs for ADHD and that it’s a mental disease. And this message has gone out primarily from the drug companies and other big pro-ADHD figures such as Russell Barkley, who together with his colleagues published an International Consensus Statement¹ signed by various international scientists who claim that ADHD is a recognised medical disorder.

  This statement has been widely criticised and I agree totally with the psychiatrist Joanna Moncrieff who called it an explicit attempt to cut short debate². But the media gets very excited with new scientific ideas. They come up with headlines telling us they’ve found some link to something and they don’t unpack it properly. It’s not willful – we all want to have faith in science because it’s a very simple solution to life.

  Are we in denial when we ignore the lack of evidence and the known side-effects of Ritalin and still agree to a medical approach?
  Yes. If we acknowledge it’s the way we organise society and what we do to our children that creates these difficulties, we start to feel guilt – and it’s a huge problem for most people to think about. It makes us responsible rather than the person with the symptoms, and it’s much easier to say it’s inside the child because then it can be dealt with.

  A lot of the ADHD propaganda has bought into parents’ guilt and it’s almost impossible to be a parent and not feel guilty about everything you do. So if somebody says, ‘Well actually it’s not your fault your child has this disease,’ then people find it reassuring. Personally I wouldn’t find it reassuring at all.

  What about the psychosocial perspective on ADHD?
  The psychosocial context is so important for any psychological or emotional difficulty. Where children are concerned, those most likely to attract a label of ADHD are children who have certain characteristics in common – and it’s very much to do with the lives they and their families are living. For instance, many of the children have experience of broken attachments, they’ve undergone considerable trauma, and they will go on to be at risk of acquiring not only ADHD labels but other psychiatric labels too.

  You could, for example, be describing a child who’s been in a state of chronic stress for years. When you look at the characteristics of such a child, they almost always tick the ADHD boxes of hyperactivity, impulsiveness, distractibility, disorganisation, forgetfulness etc. I think we’re talking mostly about children who have suffered deprivation of various sorts. But I’m also aware of children who on the face of it have had a fairly stable, privileged environment, but who have come under considerable stress as well. They might have parents with mental health problems, mums with serious postnatal depression, things like that, so that the children have grown up in a very stressful situation. So all children are at risk but those most likely to be labelled ADHD are those who have suffered deprivation in some way, which is a psychosocial issue with psychosocial solutions. Relational and environmental factors across generations make us who we are and are extremely important factors in child development, and it’s not the same as something being genetic or having a biological basis.

  How does the British view of ADHD compare with other countries?
  The big Ritalin users are the USA, Canada and Australia – over 90 per cent of the world’s Ritalin is going to children in the USA – but a lot of Europe is now marching towards this same view that certain children need to be medicated. And the subtext of that is that some children can’t be helped by conventional means. In my book, The Other Side of ADHD, I compare France and Canada, which have similar-sized populations and the cultures are not too different – yet the Canadians medicate much, much more. On the face of it, it doesn’t make sense but when you look at the way children’s problems are thought about in the two countries, you find the medical model predominates in Canada, whereas the French approach to children’s mental health still has much more of an educative and social focus.

  The idea that we can medicate children when there isn’t an actual identifiable problem is really quite shocking. It’s the first time in my lifetime – and one of the reasons I am so incensed by what’s happening – that we’ve come up with a new disorder in children that people are saying can’t be cured and has to be treated with medicine, the long-term effects of which are simply not known. The impact of that for our generation is serious. The fact is that, despite years of searching and a tremendous amount of money spent on the search, there is still no evidence for the existence of ADHD as any kind of brain disorder. We willfully ignore that, and the drug companies are desperately peddling the opposite point of view. Unfortunately, it’s them we’re listening to.

  You’re talking vested financial interests here, aren’t you – an economic cycle that’s feeding on itself?
  Basically, yes. There are a lot of people making a lot of money out of ADHD. Research funded by the drug companies is being selectively published to support certain views held by them, and also to support the continuing biological model of mental health. They also fund research to ‘discover’ new disorders, in order to give them a rationale to provide more treatments. Then there are the user groups that have been set up to promote ADHD – CHADD in the USA (Children and Adults with Attention- Deficit/Hyperactivity Disorder) and ADDISS (Attention Deficit Disorder Information and Support Service) in the UK – and they, too, receive funding from drug companies. The most obvious professionals targeted here are psychiatrists, who do the prescribing, so they’re part of this cycle as well. I don’t want to be rude about them because there are some very brave ones who have banded together in the Critical Psychiatry Network and who actively promote the opposite view.

  What has this conflict looked like in your own patch?
  If we backtrack some years, national ADHD clinics were set up and psychiatrists got very excited; here was something they could do. A lot of these clinics were set up, and my part of Staffordshire was no different. Children were often fast-tracked to these clinics from the GP’s referral letter, which might read, ‘I think this child has ADHD’ or ‘This child can’t sit still in class’ and the child would go straight to the ADHD clinic. What happened as a result is that we had a lot of children being put on medication and little else.

  Then some of the psychiatrists realised that this wasn’t a solution and that they were inheriting loads of children on medication who were coming back endlessly. They weren’t getting better. I knew several newly qualified psychiatrists who inherited a Ritalin clinic and despaired because it’s a heart-sink situation. The problem is that the medication looks as though it ‘works’, and it does work in the sense that it subdues the child, but nothing else changes. The kids are still difficult kids and simply become difficult kids who are on medication. The underlying problems are not addressed. And, as the saying goes, the pill doesn’t cure the ill and it certainly doesn’t teach the skill.

  So you’ve got a superficial change because the child is medicated, and that, to some people, resolves the problem.
  But in all fairness to the people who are in the opposite camp to me, they did start to do different things, such as introduce parenting programmes, acknowledging that parent management was something to do with this. The difficulty, I guess, is that if your view is that there is something fundamentally wrong with the child and the problem is inside her, then whatever you do is going to be based on this view, that it’s the child who is the problem.

  But there were those of us who were very sceptical about the whole philosophy of ADHD in the first place, and we ignored the comments about ADHD in the referral letters and saw children as we always have done. That means that whichever child comes through the door, you have to have a really good look, often with the family, and together you decide on a plan of action. And obviously, if attention, concentration and motivation were a problem, we would also go into schools and talk to the teaching staff and maybe spend a day there looking at what was going on. But we wouldn’t rush into this ‘Ritalin clinic’ mentality. And the interesting thing we found was that we never actually got to that point. We resolved the problem doing what we always did. We’ve had GPs who couldn’t understand it at all. No matter who goes out and talks to them – and I’ve done it myself very often – they still have a feeling you’re depriving their patients of their Ritalin.

  Can you give an example of psychosocial help for children with ADHD symptoms?
  Typically these kids need help in a number of areas – home, school, friendships, managing their emotions, and so on. They also need help managing their tendencies not to think and have usually developed some quite destructive strategies to achieve this. I would always seek to involve parents and carers in the work because there is usually a mismatch between how they are trying to manage the child and what the child needs. With the parents, it’s important to find a way of dealing with this that they’re at peace with. And it’s remarkable when change comes, what that change is really about.

  For instance, one of our services for under-fives has looked at a whole range of measures with parents before they get support from the team and then again afterwards. This is work undertaken by specialist health visitors who are skilled at working with mums in particular, and one thing they found early on was that the number of problems these children had didn’t really change that much, according to how their parents rated them at the end of their involvement with the team. The change that came about through concerted support of the right type – going out with them, spending time with them – was that parents changed their views of the problems and could report a qualitative change in the relationship with their children. So the behaviours themselves didn’t change much, but parents were coping with them so much better, and these were parents whose stress levels beforehand had been off the scale.

  In general, the kind of kids we see present in very irritated, irritable, hypervigilant ways and it’s important to find out what is contributing to these characteristics, which are only symptoms of something else going on. Lots of things can contribute to children behaving like that, such as bullying, poor environments, developmental delays etc.
  Usually when you can get together with children and parents and anyone else involved and really get down to the problems, you’re half way to solving them. The thing is that people don’t spend time doing this. They leap into a medical explanation far too quickly.

  How far do you think modern childhood is a contributory factor to the problem?
  Modern life generally makes us all inattentive. It isn’t only children who are not able to think. Adults find it difficult too. I’ve become more worried over the last few years that people are objectively finding it very difficult to reason things out.
  It’s not because anything is wrong with them, but the way we live our lives now is in fast soundbites. There is no requirement to think things through because it’s all done for you, and it’s almost as if things are packaged up and fed back to you in a way that doesn’t need much processing. The way we live our lives today affects everyone, but I think children are really struggling, and people from quite disparate areas are ringing alarm bells and saying this environment is not good for children.

  Children are sitting in front of screens and not being given the opportunity to play or work things out for themselves. There is very little family life or time for it and we are all under pressure to do as much as possible. That militates against reflection and learning to process and listen, yet that’s how we develop skills in self-regulation. Children don’t learn these any more, partly because of outside things and how we live our lives but also because of internal things resulting from trauma, and influences on them that don’t allow them to learn those skills. And self-regulation is crucial to controlling the symptoms of ADHD. We live in a contradictory society, expecting them to learn selfregulation while telling them what to do. And boys in particular find that hard.

  You say in your book that boys fare badly in our society. How so?
  I think girls do better than boys in an environment that requires them to selfregulate. The ratio of boys to girls labelled as having ADHD is about four to one. And that’s primarily to do with how we socialise boys – to show their aggression, to behave in physically active and dominant ways and do ‘boy things’, and then effectively we punish them for that in class. We’re creating a real quandary for boys. Not only that, but a lot of boys don’t have the support and role models they need – the ones I see in my area of practice often don’t have any role models at all, or, if the role models are there, they’re very negative or pro-criminal. It used to be that mums got blamed for everything, but it’s high time we looked at the role of fathers.

  What skills do your staff team have that enable them to deal with these symptoms psychosocially?
  A combination. Many CAMHS teams in the UK are heavy on medical personnel and subsumed into the medical culture. The team I led for a number of years had a very big solution focus, which is enormously helpful to families who perhaps feel wary of coming to see professionals and being blamed for the problem. So developing a culture that’s welcoming and an approach that people feel comfortable with is helpful. We had counsellors who were very skilled in systemic work. Between us we had a good range of psychological skills and a solid understanding of child development that comes from psychological training.

  That helps massively; it’s very important to know the ‘normal’ trajectory. And one of the commonalities that our team had was a very normal model of child development. But if you’re looking at a team that’s made up of psychiatrists etc – without wanting to be too stereotypical here – they have a medical model, they deal with the abnormal. So having people with that ‘normal’ model and an approach that’s built on strengths is really important.

  I’m fortunate to have some teachers in my service too – having an educational focus is very helpful. One of my colleagues specialises in autism, and her model is much more educational than clinical. So we have people who are unusual in areas like CAMHS. One of our team was a couple counsellor who then trained in solution focused therapy. The stuff she was able to deal with between the parents was phenomenal. I guess it’s especially the non-traditional staff that I have found so valuable, and that definitely includes the counselling staff, as they are not often there in traditional teams.

  Another much overlooked need in the team is having a common philosophy that people are signed up to. If you’re not signed up around a model, you can come unstuck. In our team, we were absolutely clear in having a psychosocial model and what that meant for us and the families we worked with. Like most teams, we used a range of different approaches, depending on the situation. But we were also clear about having a multi-systemic framework for the work.

  
  You believe that cost isn’t the issue in providing this kind of psychosocial help. So what is the issue?
  Politics. I firmly believe this is a political issue. Everything we do is political. It would be naïve to say otherwise.

  Are you saying there isn’t the will in the country to change this state of affairs?
  Yes. The problem for people like me – and there are a few of us who have been battling this ADHD thing for a number of years – is that we are not only a minority but also a powerless minority, because unfortunately all of the power (and money) is put behind the medical model, and that’s the political issue. And all the changes that have come about in the NHS in recent years have actually strengthened that dichotomy. We have a situation here where debate isn’t encouraged, it’s stamped on, and I always wonder why it is so difficult for us to speak out. Even within traditional teams, you have a whole range of professionals who must have a different view or they wouldn’t be practising as they do, so why is it so difficult for them to speak out?

  What do you think we should be doing so that children can get the help they need?
  There is a huge responsibility on those of us who practise in this way, and have evidence, to write up that evidence and share it. It’s unfortunate that the onus is on us to show we can do these things, but just because medical people can’t do these things is no reason to write these children off, to pretend skilled practitioners who actually do this work every day can’t help them. Ensuring we write up our case studies is imperative, and starting some communication with the media too.

  What is your opinion of the recent NICE report on the diagnosis and management of ADHD in children, young people and adults?
  I am deeply concerned that NICE is taking it as read that this is a bona fide disorder when there is no evidence. The philosophy is the same: this child has something wrong inside her and therefore has to be medicated. And that’s why I have been critical over the years about the concept that it’s a both/and situation. I don’t think it can ever be that. If you are challenging the view of physiology underlying children’s distress, then you can’t keep everybody happy by saying, ‘Well, okay, it’s a bit of that.’ It’s very dishonest. The fact that you can help a young person to overcome their difficulties using psychosocial interventions, what does that say about the idea that there is something physiologically wrong with them? I’d say it disproves it. Unfortunately we do not speak with the same authority as those in the medical camp.

  What kind of things would you want to see in trainings for counsellors who might work in multidisciplinary teams with children?
  Knowledge of a normal trajectory is really important. And also something about the context the child is in – an understanding of the different systems and of systemic working. I do think that one of the most important things is to learn about attachment. Trauma in children would be important too. I would like to see a foundation in working with children in any training course. I do some training with psychiatrists and they don’t even know that ADHD is a controversial area. So they don’t know there’s another view. With dedicated professional trainings you don’t get this wider view. These dilemmas need to be presented in training because they’re going to be out there.
  Otherwise, it can be difficult working in multidisciplinary teams.

  So what is the thing that annoys you most about the present ADHD debate?
  People think they know about ADHD – it’s taken as a given that it exists. And nothing could be further from the truth.

• Angela Southall is a consultant clinical child psychologist and has been Head of Specialist Children’s Services for South Staffordshire and Shropshire NHS Foundation Trust for 11 years. She is author of several books, including The Other Side of ADHD: Attention Deficit Hyperactivity Disorder Exposed and Explained. Email angela.southall@tiscali.co.uk.

  This is an edited version of an interview first published in the September 2008 issue of Counselling for Children and Young People, the quarterly journal of CCYP, a division of BACP. For more information about the division, or to subscribe to Counselling for Children and Young People, contact Julie Camfield, Divisional Administrator, tel 01455 883381, email julie.camfield@bacp.co.uk

• References:
  

  1. Barkley R, Cook EH, Dulcan M et al. International Consensus Statement on ADHD. www.addwarehouse.com
  2. Moncrieff J. Is psychiatry for sale? London: Institute of Psychiatry; 2003. Also see www.critpsynet.freeuk.com/pharmaceuticalindustry.htm