Adhd: disease or cultural phenomenon?

Three to five percent of all children in Germany have attention deficit hyperactivity syndrome. Does this disease really exist? Or is it just a cultural phenomenon? We asked Professor Leuzinger-Bohleber, director of the Frankfurt Sigmund Freud Institute and professor of psychoanalytic psychology at the University of Kassel. One of her research interests is the developmental psychology of childhood and adolescence.

> What do you think about the thesis that ADHD is rather an environmental behavioral disorder, which is "image" driven? of a disease has been given to psychiatry and the pharmaceutical industry in order to attract new "customers" to be delivered?

In this context, it must be remembered that the pharmaceutical industry makes a lot of money from Ritalin. There are authors who therefore argue that the interests of the pharmaceutical industry are creating a diagnosis, for example ADHD, and thus a new market for Ritalin. This is one reason for the enormous increase in the use of medication.

In any case, a careful clarification by a specialist must take place before a child is diagnosed with ADHD. Not every child who is inattentive and fidgety has ADHD.

I’m not against medications in principle: Sometimes they are a kind of acute aid to de-escalate a social situation. But only in very few cases do they really solve the problems that these children have.

Precisely because the drugs are highly effective, they mask the social causes, such as trauma or early neglect, that cause some children to be unable to concentrate or sit still. Such children need educational or psychotherapeutic care, which really helps them to deal with their problems better in the long term. them as "sick" labeling them instead of offering them social support is convenient and problematic, and can also stigmatize the children. This is especially true for very young children. Therefore, in some countries it is forbidden to give Ritalin to children under the age of six.

> Does ADHD exist in primitive peoples??

In Africa, for example, where children in some areas grow up in a loose association with other children in a village community, the diagnosis is unknown. These children do not have to sit for hours on a school bench while concentrating. From this point of view, it is a cultural phenomenon. Here in Europe, too, the problem of the fidgety child has only arisen since children had to go to school.

> Where to draw the line between sick and healthy (norm variant)? Are there smooth transitions?

The two classification systems DSM 4 and ICD 10 are used. These specify exactly what behaviors must be present for a child to be diagnosed as having ADHD. Precisely because cultural differences play a role, these classification systems try to standardize this diagnosis.

Very often, however, the diagnosis is made without a thorough clarification. A pediatrician needs ca. five hours before he can make the diagnosis. Very often, however, the diagnosis is made by non-specialists, sometimes by doctors who cannot devote so much time to an individual child.

The line between "temperamental and "hyperactive is not quite sharp. All experts agree on this. A boy who is considered to be striking in northern Germany would tend to be a relatively quiet boy in southern Italy. On the one hand the cultural factor plays a role, on the other hand also the perception, for example of teachers. Some can cope well with active children, others feel disturbed right away. These are personal variations.

Overall, it is perhaps less crucial to "pigeonhole" the child stuck with a particular diagnosis, but rather how to help the child deal well with himself and the social situation. It is known, for example, that even children with a clear ADHD diagnosis can sit still and concentrate in certain learning situations in which they are really interested in a subject.

> What are the dangers of a wrongly indicated Ritalin therapy??

First, there is an influence at the psychological level. The child receives the message that he or she is ill. This is a massive intervention for the child’s self-concept. It then defines itself, for example, not as a particularly temperamental child, but as a sick child.

On the other hand, very little is known about the long-term effects. In any case, it must be remembered that the drugs are highly effective and influence the development of the child’s brain. The brain could be deprived of the possibility to practice compensatory control functions, i.e. to use its adaptive abilities to constructively compensate for certain weaknesses in self-regulation.

The brain can develop enormously through new relationship experiences and thus learn to cope with certain difficulties. This is where psychotherapies come in. The child is taught that it can learn to deal with hyperactivity socially and psychologically.

> How does ADHD develop?? Do external influences play a role?

There is a controversial debate about this. There are very different explanatory models about the emergence of this disease.

On the one hand, there is the neurobiological hypothesis. This is based on the assumption that there is a disturbance in the neurotransmitter system.

On the other hand, earlier relationship experiences can be a cause for later ADHD. These help the children, for example due to difficult life events of the family, insufficiently to deal with their affects in a regulating way.

All in all, we assume a complex interaction of a genetically inherited vulnerability and early environmental influences.

> Is ADHD a fashionable disease? Does the overstimulation play a role in today’s society??

It must be assumed that ADHD is a fashionable diagnosis. The fact that this diagnosis is made much more frequently today cannot only be due to the fact that it was not recognized in the past. That is why it is so important to make the right diagnosis.

In pedagogy, there is much discussion that symptoms such as lack of concentration and "fidgetiness" are a cause of the disorder also have to do with environmental factors such as stimulus overload. Many children have problems with overstimulation if they are not helped to cope with it. But this does not mean that these children automatically have ADHD.

> Has the disease really become more frequent over time, or is it just diagnosed more often nowadays??

It is very difficult to determine scientifically. The diagnostic criteria that are used nowadays have not existed for very long. Already in the fifties one spoke of hyperactivity, later, for example in Switzerland of psycho-organic syndrome. MCD, minimal cerebral dysfunction, also belongs to similar disorders. From today’s point of view, however, it is difficult to say whether the disease has increased. It is assumed, but it cannot be scientifically proven.

> How is it justified that ADHD is called a disease??

This is a big discussion in social psychology. It is a general problem in medicine, for which one needs the exact description of a disease and the distinction to the healthy one. This is not only the case with ADHD. It can be said that a diagnosis is necessary in order to be able to help the child and his family in a targeted way. Such children but simply as "sick" is usually not very helpful, although at first it seems to be relieving for the parents.

> Is there an imaging "substrate" found in ADHD?? Is this necessarily proof of the disease value??

First examinations show that abnormalities can be detected in the MRI. It is therefore quite possible that in a child who has developed too few internal regulatory mechanisms, the flooding of feelings and stimuli has an effect on the functioning of the brain. But the question of the chicken and the egg remains. Social experiences are also reflected in the brain and are then visible in the MRI. For example, even severely traumatized refugee children show changes in the MRI.

> In the USA, more than six million children are given Ritalin. Do you believe that this practice is always based on a clean indication?

Unfortunately, the medication is very often prescribed without a consultation with a specialist. However, there must always be a thorough clarification beforehand.

> Are there therapy alternatives?

There are pedagogical possibilities to help the child to cope with his difficulties. The earlier you start, the better. Psychotherapeutic measures are another therapy option. There is currently a study underway that demonstrates the lasting effects of these therapeutic approaches. With the help of alternative therapy options, the child can learn to cope with social situations even without medication.

> Are there studies that provide information on whether a "Ritalin child" is a "Ritalin child" or a "Ritalin child"? More likely to become addicted in the long term?

This is a thesis that is discussed in the literature, but is not yet sufficiently covered empirically. Psychologically it can be explained. The child makes the experience of needing a drug in order to be loved, in order to function. It stands to reason that people also turn to drugs later on in difficult situations to cope with their problems.

> Are there suitable preventive measures?

There are studies that show a high correlation between "Schreibabies" and ADHD and later ADHD children show. If you understand why a child cries in certain situations, you can usually help the families to calm down the children within a short time. The "writing baby should then be given a structure that it learns not to slip into these states of despair. This is a very efficient prevention of ADHD.

In the Frankfurt prevention study, in which children from several daycare centers participated, we were also able to empirically prove that with educational measures, the aggressiveness of the children decreased.

> How do I know if my child has ADHD??

Most often, it is a disorder that occurs either in kindergarten or at school. Often teachers approach parents and complain about the child not being able to sit still and concentrate. The most important thing is not to make a hasty diagnosis, but to go to a reputable pediatrician, pediatric therapist or pediatric psychologist and have the disorder clarified in detail, and then to consider together how the child can best be helped.

> What must I, as a parent of an affected child, pay attention to/avoid??

Parents should take it seriously in the first place if their child has problems. You should make an effort to work carefully with teachers and educators to find an individual solution for your protege. However, many children have normal problems adapting to the school situation when they start school. Only a few, ca. three to five percent, really suffer from ADHD. These children should then be given the educational and therapeutic help they need as early as possible.

There are many courses of events in which the children then develop quite normally. So one must neither dramatize nor trivialize.

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