ADHD mystery: Claims of no attention deficit disorder in France challenged

Adorable 3 year old boy covered in bright paint.
Adorable 3 year old boy covered in bright paint.

It’s been a puzzle. As psychiatrists began to better understand what is now called attention deficit-hyperactivity disorder (ADHD), the rates among children (around 5 percent) seemed steady in nearly every country worldwide. Except a few in Europe, France in particular.

In 2012, American psychologist Marilyn Wedge addressed the issue in an article in Psychology Today, “Why French kids don’t have ADHD” : Nine percent of U.S. children are diagnosed with ADHD, compared to only 0.5 percent of French children, she noted. “Is ADHD a biological-neurological disorder?” she asked in the article, to which she answered “no.”

Wedge looked at how French psychiatrists look at ADHD, and presented a case for upbringing. Specifically, she said that French doctors look at social contexts and connections as opposed to dysfunctions in the brain. She pointed to what she characterized as stricter family rules and structures in France, so that “French children are generally better-behaved than their American counterparts.” Somehow, then, she speculated, this upbringing explained low rates of ADHD among the French.

Psychological French twist

Wedge’s article created quite a storm. Since it appeared, it’s had more than 13 million hits. Some bloggers and writers embraced the idea that simply raising kids strictly like the French do will eliminate ADHD. Others aren’t as enthusiastic. On Reddit, one critical writer responded recently:

As a French person with ADHD, I’ll tell you the real reason French kids don’t “have” ADHD: that’s because of the sorry state of psychiatry in my country, where the b–ls–t that is called psychoanalysis, which has been debunked 50 years ago, is still prominent in psychiatry and psychology here. It’s disgusting. Medical malpractice on a national scale.

Wedge’s article created a platform from which to observe how differently mental health experts can view a disease, and how complex biology, the brain, the mind and the environment truly are.

DSM versus CFTMEA—Oui or “no way”?

For decades, much of the mental health profession has relied on the Diagnostic and Statistical Manual of Diseases, a tome updated periodically by the American Psychiatric Association. The latest three versions (DSM-III through DSM-V) zeroed in on what constitutes ADHD. French guidelines do not follow the DSMs, instead hewing to the Classification Francaise des Troubles Mentaux de l’Enfant et de L’Adolescent, or CFTMEA.

In France, CFTMEA guidelines require a much longer time to diagnose ADHD, and take in family and social issues that have had a role in the child’s life. After interviewing teachers, school officials, family members and the child, they’ll make a diagnosis. Often two years later.

In the United States, usually a single psychiatrist or psychologist makes a much faster diagnosis (about six months), after some input from teachers and others, but usually based on the psychologist’s impression.

While French psychiatrists do tend to look more for social context, it’s also illegal in France to prescribe stimulants (the main drug intervention in the US) to any child under 6 years old. Meanwhile, American physicians have been accused of overmedicating patients, particularly children and particularly children with ADHD.

Over doping versus over-talking

This is not the first time ADHD diagnostic discrepancies have appeared worldwide. More than 10 years ago, a group of Harvard University psychiatrists decided to look into what were up to 20-fold higher rates of ADHD diagnosis in North America compared to England. But once they got into the data, most of these discrepancies faded away in the wake of incomparable studies, incomplete data from certain countries and research foci of the studies that really didn’t allow for these kinds of comparisons.

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More recently, one of the original Harvard group members led another study (using US DSM guidelines) that uncovered rates of ADHD in France of 3.5 to 5 percent, more aligned with the rest of the world.

In Europe, several parent groups have taken political action to create a different way to treat ADHD. One group, ADHDEurope, describing ADHD as “among mental disorders…one of the most neglected and misunderstood in Europe,” has been urging the European Parliament to improve and increase treatments for ADHD.

The consequences of having ADHD is a problem in France, as it is elsewhere. Researchers who looked at the outcomes of those diagnosed with ADHD in Europe and the U.S. found that “Adults with ADHD in both regions were generally less likely to be married, employed, or rate their health as good/very good/excellent and were more likely to smoke, have experienced alcoholism, have other mental health conditions, have work productivity/activity impairments, and use healthcare resources.” Another group of French researchers, using American-style DSM criteria, found that 43 percent of prisoners in a Bordeaux prison were diagnosable for ADHD.

But the DSM isn’t off the hook, either. Some researchers have found that DSM categories have limitations and cultural biases. Others have found that European doctors did not have fully successful results using American-style stimulant therapy.

State of ADHD genetics

Like that of many mental disorders, the genetics of ADHD is very complicated. The definition of the disease took a very long time to solidify (and some have maintained it still hasn’t). Twin studies show a possible heritability of 70-80 percent, as well as a number of genes that may carry the risk of ADHD. But environmental influences can inflate heritability figures, and the candidate genes known so far only seem to explain less than 5 percent of variation in ADHD.

In the last 20 years or so, scientist have begun to deconstruct the symptoms of ADHD, and looking at “multiple pathway models,” in which impairments in attention and issues with motivation eventually can come together to create ADHD. Researchers also have looked at whether ADHD is more than one syndrome, and in reality a hodgepodge (for now) of similar symptoms and have yet to be parsed.

It has yet to be made clear, whether in France, the U.S. or the rest of the world, where the boundaries lie between “normal” and ADHD, and even within the definitions of ADHD. Perhaps if nothing else, the revisions of the DSM, and the French approach, call for a meeting of minds.

Andrew Porterfield is a writer, editor and communications consultant for academic institutions, companies and non-profits in the life sciences. He is based in Camarillo, California. Follow @AMPorterfield on Twitter.

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