ADHD: Myth and Reality

BAD TEACHING = HYPERACTIVE KIDS

I met Dr. Sami Timimi in Lincoln, England in the autumn of 2001. He was a psychiatrist working in the Child and Adolescent Mental Health Services (CAMHS). I was doing my child placement there towards a Statement of Equivalence in Clinical Psychology.

Dr. Timimi was a controversial man. My placement supervisor Pete Ludlow had told me that Dr. Timimi did not believe that ADHD was a psychiatric disorder but a behavioral condition. Timimi was, therefore, opposed to medication, which he considered tantamount to poisoning children without delivering any sustainable benefits.

In Ludlow's view, Dr. Timimi's vocal opposition to medication was creating hurdles in the way of appropriate treatment. Pete thought that advising parents against the use of medication did more harm than good and that children were unnecessarily being deprived of evidence-based treatment.

ADHD DIAGNOSIS MAKES KIDS INTO RITALIN JUNKIES

What was the evidence base that Ludlow was talking about? Well, the most common treatment for attention-deficit hyperactivity disorder or ADHD is stimulant medication such as Ritalin. Many psychiatrists recommend combining medication with individual counseling and family therapy. Some studies also claim that ADHD has a neurological basis but the evidence is mixed at best.

I decided to approach Dr. Timimi for a clarification. Why did he not accept the 'neurological evidence' or the evidence base for effectiveness of stimulants. He was kind enough to answer all my questions and also gave me a free copy of his book 'Naughty Boys.'

Let me summarize his arguments: The Western culture is a hyper-masculine culture where mothers are blamed for children's behavior problems. Many mothers are single parents and a majority of teachers are also women. This places a double burden of blame and shame on women, who are relieved when the blame for the boys' misbehavior is shifted from them to the boys' brains.

In pre-modern societies, according to Dr. Timimi, boys' rowdy behavior was dealt with by the fathers with a firm hand. 'Spare the rod, spoil the child' was the motto of the public school headmaster who enforced discipline through an elaborate system of punishments including corporal punishment.

Are you advocating a return to physical punishment? was the logical follow up question to which he replied with an emphatic no. Instead he suggests the following:

-Dietary Interventions

-Family Time

-Fresh Air and Exercise

-Limiting time spent on TV and computer games

-Bedtime routines

-Chores

-Responsibilities, trust and independence

-Emotional Support.

A detailed account of these interventions can be found in his book Misunderstanding ADHD: the complete guide for parents to alternatives to drugs. One may not fully agree with him, but I did finally understand where he was coming from.

ADHD IS NOT A REAL DISORDER

Five years later when I moved to Pakistan, I heard an even more stunning statistic. A survey of school teachers done by the GCU Clinical Psychology department had revealed that nearly 60 percent of the children were considered as having ADHD by the teachers.

It was in 2006, that the Clinical Psychology Unit at GC University Lahore under the leadership of Dr. Zahid Mahmood, conducted a survey of teachers to find out if they thought they had any children with ADHD in their classrooms. The results were shocking.

The teachers reported a very large number, 60 percent, of their students as having symptoms of ADHD. I asked Dr. Mahmood why he thought he got such a result. "They must be filling the forms wrong", he said but wasn't sure what had gone wrong.

This led me to reflect on Sami Timimi's challenge to the notion of ADHD as a neurological/psychiatric disorder. Perhaps the teachers are unable to manage these children well and their incompetence is manifesting itself in over-diagnosis.

In order to understand this argument one needs to know the context in which teaching-learning takes place in Pakistan. Most teachers in the private sector are untrained and are recruited solely based on their ability to speak English fluently. The training given to public school teachers is also of a very low quality and leaves much to be desired.

I came up with a hypothesis: The quality of teaching, lesson planning, and classroom management skills of a teacher are inversely proportional to the number of children identified as having ADHD by the teacher in the classroom. And soon I got the opportunity to test it.

Maria Fatima, a graduate student expressed an interest in doing her M. Phil Thesis on ADHD. I suggested she observe teachers in classrooms and rate them on their teaching skills, lesson planning and classroom management skills. She would then have them fill out Conner's Teacher Rating Scale for children they suspect as having ADHD.

The results were as I had expected. Bad teaching, lack of planning, and poor classroom management meant out of control children. And since that is the norm rather than the exception, a large number of children are diagnosed with ADHD based on teacher's report of their behavior.

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ps. This article combines an earlier 2-part version into a single piece of work.