Mr Rudin, you say that ADHD is not an illness, but a social construct. You'll have to explain that.
From a medical perspective, the term «illness» refers to a disorder or impairment of physiological functions that can be objectively verified. It is clear to see whether an arm is broken or an infection is present. ADHD, on the other hand, describes a deviation from a norm that is in turn shaped by social expectations.
Our view of children is deficit-oriented. We focus too much on what needs to be optimised.
It's about children who are fidgety, inattentive and impulsive.
Exactly – or rather , behaviours that are considered inappropriate or conspicuous in certain social contexts. The way we classify childish behaviour depends heavily on cultural, institutional and social factors. ADHD is therefore a socially constructed phenomenon, not a disease in the classical sense. There are no blood tests or imaging techniques that can conclusively diagnose ADHD.
This is the case with most psychiatric diagnoses. Do you therefore also question the existence of personality disorders or schizophrenia?
The psyche is so complex that we will probably never be able to break it down into objectively measurable values. I am not criticising psychiatric diagnoses per se – it is the social discourse surrounding them that gives me pause for thought. This is particularly true in relation to ADHD: highly complex issues are often interpreted, abbreviated and simplified at will. Scientific findings do not support the idea that we should treat ADHD «like a broken leg», as some voices demand. There are also a few important aspects that show that the ADHD debate differs from society's approach to other psychiatric diagnoses.
Namely?
Firstly, the majority of ADHD diagnoses concern children who are in a sensitive phase of development. Secondly, expectations regarding academic performance and behaviours that are considered desirable in a school context play a key role in the diagnostic criteria. Thirdly, ADHD is treated relatively quickly with medication rather than psychotherapy. In some cantons, almost 20 per cent of boys between the ages of 11 and 15 receive psychostimulants. I think it is time to question what standards are being used as a benchmark here.
Where do you think the problem lies?
From my perspective as a sociologist, ADHD is more than just an individual disorder. It is an expression of how we as a society deal with diversity and define normality – of the expectations we place on children. Tolerance for deviation is becoming increasingly rare, and the pressure to conform is growing. All of this leads to a deficit-oriented view of children. We focus too much on what needs to be optimised. This also applies to our school system, which plays a central role in the emergence and reproduction of the ADHD discourse.
In what way?
Our schools are geared towards standardisation and performance. Children who are different are expected to perform in the same way. The famous animal metaphor illustrates the problem well: if the duck always has to practise climbing because it is worse at climbing trees than the monkey, it will eventually only be a mediocre swimmer – and still be bad at climbing.
Instead of understanding the child in a social context, the cause is sought in neural structures or genetic dispositions. In my view, this is a problematic simplification.
If only certain skills are considered valuable, children who have other strengths are turned into losers. A resource-oriented school would have to recognise and promote diversity and adequately address children's basic needs for meaning, participation and so on.
Instead, children are expected to sit quietly and function. Those who are not so good at this are considered disruptive. Added to this is economic pressure: childcare facilities must work efficiently, and teachers must teach large classes.
Well, back when ADHD wasn't an issue, schools probably had higher expectations of children: discipline and order were the norm, and teacher-centred teaching was the rule, as were classes with over 30 children.
And children who were loud or boisterous were punished. I am not claiming that school was better in the past, nor do I want to deny that change has taken place. Moreover, it would be too simplistic to focus solely on ADHD discourse at school – but it does play an important role. School is an expression of a social value system that is constantly changing. Today, there is broad consensus that corporal punishment is a no-go as a means of education – but we can still critically question the extent to which the position of children has improved. To answer this, I need to back up a little.
Please.
Our view of children, the way we interpret their behaviour and respond to it, has changed over time. In the 19th century, children who misbehaved were considered morally misguided. It was assumed that they needed to be brought back onto the right path through corporal punishment.
With the advent of psychoanalysis, this way of thinking changed: now the mother was responsible for the child's misbehaviour. Later, this view broadened somewhat, with causes increasingly being sought in family dynamics. We evolved from a morally influenced world view that saw the fault in the child to a psychosocial approach that highlighted environmental factors. This is now increasingly being replaced by a medically and biologically oriented world view.
What does that mean?
We are dealing with increasing medicalisation, the tendency to interpret difficult behaviours, stressful emotional states or problems that are simply part of human reality and human experience in medical terms and classify them as requiring treatment.
The threshold for diagnosing ADHD is so low today that it hardly distinguishes between developmental variance and a disorder requiring treatment.
When children's behaviour raises questions, we increasingly look to neuroscience for answers. Abnormalities are located in the brain, complex life situations are translated into illnesses. Instead of understanding the child in a social context, we look for the cause in neural structures or genetic dispositions. In my view, this is a problematic simplification that ignores social responsibility.
So you consider ADHD to be a zeitgeist phenomenon, while research results suggest that it is a neurobiological disorder?
I do not dispute the existence of this disorder. But I repeat: there is no medical procedure that can clearly identify it – which, in my view, would at least call for a more cautious approach. Researchers are always cautious in their statements and never as categorical as the media in their reporting of the facts. Vague indications are quickly turned into causal relationships, and even minimal differences in imaging procedures are presented as neurobiological facts, even when they lack statistical significance. It is understandable that people are receptive to this.
What do you mean by that?
We live in a world that promotes efficiency, self-optimisation and competition, and shifts the responsibility for failure onto the individual. In addition to the pressure to perform, which parents are subject to even more because they are expected to prepare their children for a performance-oriented society, there is the economisation of the healthcare system, the influence of digital media, the tight schedule of school requirements, overworked teachers and a school system that links help to diagnoses. This development increasingly shifts structural problems onto the individual – the child is the problem – and obscures the view of underlying grievances. As a result, we are faced with diagnostic inflation.
Medical professionals dispute this: they continue to assume that 5 per cent of people worldwide are affected and attribute the increase in ADHD diagnoses to improved education, awareness and diagnostics.
I am familiar with this argument. Of course, increased awareness can lead to more diagnoses, but that alone does not explain the significant regional differences. When diagnosis rates vary greatly between countries, and even within Switzerland, it shows that this is not a biologically determined factor, but rather a socially constructed assessment pattern that determines whether a child is considered to have ADHD or not. Technically, the frequently cited prevalence rate of 5 per cent, i.e. the proportion of those affected, is based on statistical methods in which international prevalence values – which vary between 1 and almost 18 per cent – were modelled to an average value. However, there are good reasons to question this value.
I do not deny the suffering of children. I just want people to ask the right questions.
Why?
A prevalence rate of 5 per cent is a grotesque understatement given that more than one in ten boys aged between 11 and 15 in Switzerland already take ADHD medication. In the canton of Neuchâtel, as I said, the figure is almost 20 per cent of boys in this age group. In my view, this undermines the idea of normality in child development. The amount of ADHD medication prescribed in Switzerland is rising steadily – by 10 per cent annually since 2021. Of course, we do not know whether these medications are actually being taken. But even taking this uncertainty into account, such figures are well above what doctors have considered reasonable for decades.
Namely?
It was always assumed that around half of the 5 per cent of children with ADHD would require medication. We have long since exceeded this figure: around 4 per cent of all Swiss schoolchildren – 5.5 per cent of boys – receive ADHD medication through basic insurance, and there are also cases where the costs are covered by disability insurance. This increase is now being justified by the fact that full coverage has not yet been achieved and there is a need to catch up due to underdiagnosis. At the same time, the prevalence rate of 5 per cent is repeatedly cited as apparent evidence that everything is running smoothly. Ten years ago, the UN Committee on the Rights of the Child criticised Switzerland for diagnosing ADHD in children too frequently and too superficially.
«Too superficial»: What does that mean?
Meanwhile, doctors with whom I am in contact through my work in the ADHD expert group of the Federal Office of Public Health are increasingly complaining that things are getting out of hand. I hear of cases where assessments were made during a single consultation and diagnoses were made on the basis of a brief conversation and standardised questionnaires. I criticise the fact that no psychiatric expertise is required for this – even paediatricians and general practitioners without the relevant specialisation can diagnose ADHD.
In addition, the diagnostic criteria in psychiatric classification systems such as DSM-5 have been continuously expanded. The threshold for diagnosis is now so low that it hardly distinguishes between developmental variance and disorders requiring treatment. There is a lot of room for interpretation.
Can you give an example of this?
Previously, a diagnosis of ADHD required significant impairment in several areas of life. Today, according to DSM-5, six out of nine very general symptoms such as «often loses things», «has difficulty playing quietly», «is easily distracted» or «often has difficulty waiting» are sufficient.
In the past, symptoms had to be acute for at least a year, but today ADHD can be diagnosed after six months. We run the risk of equating the diagnosis with a checklist assessment, regardless of whether a disorder actually exists – especially since conflicts and grief can also cause children to be impulsive, inattentive or indignant. A multi-perspective diagnosis is needed that also takes educational, family and social factors into account. Only then can we develop meaningful support.
You are receiving a lot of criticism for your statements. You are being accused of doubting the existence of a neurobiological disorder and thus denying the suffering of affected children.
I take the suffering of children and their families very seriously. That is precisely why I criticise hasty pathologisation. A diagnosis can stigmatise, it can obscure the view of social causes and lead to treatments that are not always helpful. My aim is to broaden our perspective – to look at the environment, social conditions and the responsibility we bear as a community. Anyone who interprets this as trivialisation has misunderstood my point. I am not denying the suffering or that children in this case need support. I just want people to ask the right questions.
I consider administering medication without accompanying discussions, school intervention and therapeutic involvement of the family to be irresponsible.
And doesn't prescribe any medication?
I am not opposed to Ritalin and similar drugs. In certain cases, they can be a useful part of treatment, provided that their use is carefully justified, regularly reviewed and critically questioned. The problem is the almost reflexive prescribing of medication without first exhausting or considering other measures. I consider it irresponsible to administer medication without accompanying discussions, school intervention and therapeutic involvement of the family. It is not a question of whether, but under what conditions Ritalin is prescribed. Or else society decides to change course and consciously adopts a scattergun approach.
What do you mean by that?
The family doctor of a family I worked with as a social worker once said that many more children could benefit from methylphenidate – the active ingredient in ADHD medication – and, in fact, should benefit from it, given that environmental demands are becoming increasingly complex. If there is a tool that can give them more stamina and concentration, why not use it? Methylphenidate has a high response rate; many people respond well to it.
In the professional world, the performance-enhancing effects of Ritalin and similar drugs are already being exploited, and it is well known that more and more students are resorting to them in order to perform better during exam periods. The question is: do we want to establish neuroenhancement, i.e. the enhancement of mental performance through psychoactive substances, in children as well? We need to address these issues. Throwing up our hands in horror is not a solution when, depending on the region, as many as one in ten or one in eight children are already taking such substances.
Nowhere else in Switzerland are so many children prescribed ADHD medication as in the canton of Neuchâtel. Why is that?
It is impossible to say for certain, but there are indications: a stronger orientation towards the French healthcare system, which generally shows a greater tendency towards medicalisation, or a traditionally closer link between medical diagnosis and educational support.
In contrast, Ticino is very cautious: only 0.8 per cent of schoolchildren are prescribed ADHD medication.
Ticino is an exciting example of how things can be done differently. On the one hand, the canton is influenced by its southern neighbour Italy, where there is great scepticism about Ritalin and its prescription was even banned for a long time. On the other hand, Ticino has traditionally been more oriented towards educational and social solutions. The education system is generally more permeable, less influenced by early selection, and the approach to childhood restlessness is often less deficit-oriented. Medical practices also seem to be more cautious with diagnoses and medication. This shows that ADHD is not a scientifically clear-cut phenomenon, but highly culturally malleable.
