In this podcast (episode #449) and blog, I talk to child and adolescent psychiatrist, psychotherapist, professor, mental health advocate and author Sami Timimi about the dangers of pathologizing childhood, the myths surrounding ADHD, a better way to approach children’s mental health, and more. This is part 2 of a series I did with Dr. Timimi, so if you haven’t listened to part 1 yet, we recommend doing so before listening to this podcast.
Dr. Sami Timimi has been a Consultant Child and Adolescent Psychiatrist since 1997. He is also an experienced psychotherapist and he currently works and lives in the UK. He qualified as a doctor from Dundee University in 1988 and became a Member of the UK Royal College of Psychiatrists in 1992, becoming a Fellow of the college in 2012. He has been a Visiting Professor of Child Psychiatry and Mental Health Improvement at the University of Lincoln, UK, for many years. He is also an author who writes from a critical psychiatry perspective on topics relating to mental health, and he has published over 130 articles and dozens of chapters on many subjects including childhood, psychotherapy, behavioral disorders and cross-cultural psychiatry. He has authored five books, including Naughty Boys: Anti-Social Behaviour and ADHD and the Role of Culture, co-edited four books, including Libratory Psychiatry: Philosophy, Politics and Mental Health with Carl Cohen, and co-authored two others, including The Myth of Autism: Medicalising Men’s and Boys’ Social and Emotional Competence with Neil Gardiner and Brian McCabe. His latest book, Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them, is available in serialised form on the Mad in America website.
As Dr. Timimi pointed out in last week’s podcast, much of the existing research surrounding ADHD started with the assumption that certain behaviors are indicative of some sort of medical condition. This was eventually called a near-developmental disorder, and became a diagnosis that was made independent of someone’s history and context through asking questions (mainly of people who care for that person and not the person themselves) and, occasionally, some observation. It is an incredibly subjective diagnosis, as it is totally dependent on a description that generally starts with the word “often” and is followed by a subjective observation of behavior like fidgeting.
This is why Dr. Timimi calls ADHD a “manufactured” diagnosis in his book Insane Medicine. As he notes, “there was an assumption that ADHD exists as a ‘thing’ and that this thing had a concrete reality that meant you could make authoritative statements about its features, implications, causes, prevalence, treatment, and so on.”
According to Dr. Timimi, the reality is different. “There has been a failure to find any specific and/or characteristic biological abnormality such as characteristic neuroanatomical, genetic, or neurotransmitter abnormalities [related to ADHD]. Unlike the myths that have been spread to spur an ADHD industry on, the scientific reality is that we have a cupboard empty of confirming evidence and full instead of ‘junk’ scientism.” This is a system of knowledge that is built on faulty assumptions and that relies almost entirely on the subjectivity of the person doing the diagnosing and the systems we have created, which are far from the scientific method and evidence-based medicine.
As Dr. Timimi points out, “the behaviours that are said to make up the diagnosis of ADHD did not make up ADHD until it was imagined in that way. Literally: There was no ADHD until someone called it ADHD (or its precursor names). There has never been any basis in scientific discovery before ADHD was invented (or since) that has shown that what we call ADHD is the result of a known abnormality or difference sufficiently characteristic to think of it as a natural kind—a thing that occurs in an identifiable way in nature, just like pneumonia or diabetes.”
Unlike the accepted approach to the scientific method, where you start with a null hypothesis (do not assume that your hypothesis is true) and work to discover a possible cause or causes of what you are studying, much of the research and work behind issues like ADHD is based on the assumption that there is a biological cause or causes (such as a genetic component), which is not supported by the evidence we have to date. This kind of thinking has resulted in what Dr. Timimi calls the “biologization of childhood”, which has had many repercussions for the way we treat children today.
It is important to understand that when it comes to behavioral issues and subjective experiences like mood, it is almost impossible to disentangle nature and nurture, environmental and biological causes. Even with advances in molecular genetic research, we have yet to find a solid evidence base for the “genetic roots” of ADHD. As Dr. Timimi notes, “The only way to reliably evidence a specific genetic contribution to ADHD is through molecular genetic studies. Since faster and cheaper whole genome scans have become available, the molecular genetic evidence has been accumulating. This increasingly large volume of ADHD genetic research is not showing any particular findings, whether in relation to abnormal genes or consistent genetic associations.”
Dr. Timimi goes on to explain that “because [many researchers] assume ADHD must be genetic, they imagine the genetic problems must be there somewhere; it’s just that we haven’t found it yet. The most likely reason for the ‘missing heritability’ is, of course, that it was never there in the first place. Scientifically speaking, we have to assume then that with regards to genetics, the cupboard is empty and the null hypothesis stands: There is no characteristic identifiable genetic abnormality/profile associated with ADHD.”
The same can be said for ADHD brain imaging studies (neuroanatomy). As Dr. Timimi notes in chapter 3 of his book Insane Medicine, “the picture that emerges is of consistently inconsistent findings, which are statistical deviations (the brains would not be recognised by radiologists as being clinically abnormal), come from small sample size studies, don’t always accurately match for age (and you’ll see why this important when I comment on birthdate research below) and typically don’t control for IQ level, or for the possible effects of medication. One research team finds one bit of the brain smaller than ‘healthy’ controls and the next one doesn’t, or even finds that bit is a little larger.”
This kind of research always starts with the assumption that there is something there, which is not evidence based medicine. As mentioned above, the scientist’s responsibility is to assume the null hypothesis: that what they assume is not true, and only change their mind when the evidence shows as much—it is not scientific to assume the biological cause there but we “just haven’t found it yet”.
Similarly, the chemical imbalance hypothesis behind ADHD comes up short. As Dr. Timimi notes, “this idea is based solely on the perceived finding that drugs (like Ritalin) that act to stimulate the release of dopamine, and therefore increase its levels in brain synapses, appear to improve the “symptoms” of ADHD (more on that later).” Yet, as research done by psychiatrist Dr. Joanna Moncrieff, Dr. Timimi and others have shown, the relationship between the chemical imbalance theory and mental health diagnoses fails in so many ways, most notably when it comes to actually understanding how drugs like Ritalin, which are used to “treat” ADHD, work. As Dr. Timimi points out, “stimulants like Ritalin act on the nervous system in almost identical ways to cocaine. Most stimulant medications are analogues of amphetamine and indeed some are amphetamine derivatives. Amphetamines are widely used illegally because they give you a kind of a tunnel vision, making you highly absorbed in what you are doing; thus, as well as taking them for their recreational effects, they are also used as exam study aids as they increase concentration and keep you awake. Like all other drugs we use in psychiatry, they have general effects on everybody. They do not correct any disease based ‘chemical imbalances’.”
It is easy to become dependent on these drugs, and the person using them over the long term will need to take more and more to get the same effect as the brain adjusts. They can also be incredibly hard to withdraw from, alongside the many side effects that they have on the brain and body. This is why we need to be super careful giving these drugs to children, especially as their brains are still developing. We need to have clear short and long term evidence that there is a definite benefit to taking these drugs compared with not taking them, which we simply do not have. In fact, there are no recognizable or measurable long term benefits to children taking these drugs academically, behaviorally, or relationally, while children who do not take these medications appear to fare better than their counterparts in the long term.
These drugs cross the blood-brain barrier and can have a significant and quick effect on the brain, which may lead someone to believe they are working. But, as Dr. Joanna Moncrieff notes, this is the same as saying alcohol cures social anxiety because it makes someone less upset in social situations, which is simply not the case. These drugs are psychoactive, which means they will influence the brain. If we take these drugs, we will experience similar effects, even if we do not have a diagnosis. The fact that they are psychoactive doesn’t mean that they are curing someone’s disorder.*
*It is however important to remember that DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process. There are thousands of patient-run sites on withdrawal from psychoactive substances on the Internet, and many books available in stores and online. There are also great sources of information like Mad in America, Rxisk, ISEPP and other patient-run websites (like the kind Mark mentions) that seek to provide people with helpful information.
As Dr. Timimi notes, “whatever you might think are the perceived merits of constructing ADHD as a ‘diagnosis’ that has biological origins and can be ‘treated’ with medication, the scientific truth is that it cannot be thought of as a valid scientific entity and the current recommendation for its treatment that usually prioritizes medication without time limits is not evidence based.”
When we start seeing behaviors as symptoms, we fail to address the full picture of what is going on in a child’s life. From a medical perspective of diagnosis, the goal is reduced to controlling or getting rid of these symptoms with medication, which overlooks the child’s environment and what is happening in their lives. We do not fully think about or try to understand what that person is thinking or experiencing therapeutically. We do not look at ways we can improve or widen our perspective to help the child in question. This is disempowering for both the child and their parents, as it seems like there is nothing they can do to remedy the situation and they just must just trust the professionals and experts.
The thing to remember is that there is always hope. If you or someone you know has been diagnosed with ADHD or another mental health label, remember that these are just words. There is nothing wrong with or in you. You are not broken, and you are not disordered. When you understand this, you will rediscover hope: life is as much open to you as anyone else. You are more amazing and more resilient than you think, and your capacity to withstand and get through challenges is incredible. Remind yourself of this daily.
For more on mental health, ADHD and the failure of our current mental healthcare system, listen to my podcast with Dr. Sami Timimi (episode #449) and check out his incredible work. If you enjoy listening to my podcast, please consider leaving a 5-star review and subscribing. And keep sharing episodes with friends and family and on social media. (Don’t forget to tag me so I can see your posts!).
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2:38 The manufacture of ADHD
7:50, 10:00 The genetic myths surrounding ADHD
9:47 Behavioral issues & the impossibility of disentangling nature and nurture
26:18 The failure of ADHD brain imaging studies
31:00 Where brain scans fall short: the debate between trait or state of mind
37:00, 51:30 The chemical imbalance myth & ADHD
57:00 There is hope!
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