Sick children or sick society?

Scientific studies show that the treatment of ADHD with so-called methylphenidates such as Ritalin has steadily increased throughout Switzerland over the last 10 to 15 years. A recent study by the Zurich University of Applied Sciences (ZHAW) found that around 2.6 per cent of all schoolchildren in the canton of Zurich were prescribed Ritalin in 2012. This corresponds roughly to the average for Switzerland as a whole (2.4 per cent). The increase primarily took place between 2006 and 2010, after which the figures stabilised.

The increase in the use of Ritalin and the associated suspected increase in ADHD diagnoses repeatedly trigger public concern and criticism. One accusation, for example, is that society has become more intolerant of conspicuous children and that medication is being rashly resorted to in order to tranquilise children.

ADHD is increasingly becoming an «overused» term .

The experts surveyed in the ZHAW study, such as doctors, psychiatrists and educationalists, partly confirm these accusations: ADHD is increasingly an «overused» term. Due to its popularity, there is a danger that children with behavioural problems, nervousness or fidgeting will be diagnosed prematurely and without differentiated consideration.

From the experts' point of view, ADHD is also a fashionable diagnosis under which children's conspicuous behaviour is subsumed without looking closely at what the child is actually suffering from.

A precise differentiation from normal child development or other illnesses, such as depression, is often difficult. However, the experts do not doubt that Ritalin can be used sensibly in carefully diagnosed cases and that those affected can be helped on several levels.

Different perspectives on ADHD

We can only speculate about the increased incidence of ADHD in the public eye and the specific reasons for the increase in ADHD diagnoses. Not only because there is no reliable data on the prevalence of ADHD (diagnoses) in Switzerland, but also because researchers from different disciplines have come to different, sometimes contradictory conclusions about the causes of ADHD.

In the 1990s, psychology officially recognised ADHD as a disorder in the international diagnostic classification systems. ADHD is therefore now considered a recognised mental disorder, whereby the cause lies in the child's psyche and can be traced back to developmental disorders in early childhood. The diagnostic classification systems also define that children with ADHD are unable to concentrate well, are hyperactive and impulsive.

In a person with ADHD, communication between the brain cells is inhibited.

For neurologists, the cause of ADHD lies in brain function, whereby the messenger substance dopamine, which normally transmits information between nerve cells, is unable to pass from one cell to the next.

The reason for this is that the nerve cell captures the dopamine molecules again immediately after releasing them. As a result, communication between the brain cells is inhibited and stimuli and information can no longer be optimally processed. Those affected find it difficult to concentrate, listen to someone or complete a task according to plan.

For geneticists, on the other hand, the roots of ADHD lie hidden in the DNA structures of those affected. From the perspective of genetics, the predisposition to ADHD is innate.

In turn, the sociologists point out that it falls short of the mark to view ADHD as a genetic imprint or purely medical diagnosis. As a central research result, they emphasise that ADHD must be prescribed in the field of tension between child, parents, school and environment.

Sociologists investigate the connection between social structures and ADHD, for example with regard to gender roles, family structures, the social demarcation of those affected or the social pressure to have conspicuous behaviour confirmed by a diagnosis.

ADHD cannot be understood without taking social change into account.

The clinical picture of ADHD is characterised by social norms, such as the pressure to function successfully, i.e. to be able to concentrate at school or to integrate well into a social and school environment. Children with an attention problem are often stigmatised because of their behaviour, and this is often attributed to their parents' allegedly poor parenting.

Such stressful reactions from the child's environment are sometimes the reason why affected families decide in favour of treatment with Ritalin. The ZHAW study came to the conclusion that parents also decide in favour of drug treatment because their children are suffering. Often, other measures have already been tried without success.

One thing is clear: ADHD cannot be understood without taking social change in our society into account. The fact that this is sometimes forgotten in ADHD research is perhaps due to the difficulty of «measuring» social developments.

The social influence on ADHD can be seen in a comparison of countries. For example, there are significantly fewer ADHD diagnoses in children in Italy or France than in Germany or Switzerland. This could be due to cultural differences, for example with regard to school systems or social tolerance towards conspicuous behaviour.

However, there has also been a social change in this country, which has led to changes in the way people deal with and are aware of illnesses and education. The diagnosis of ADHD can therefore not be discussed without taking these changed social conditions into account.

In 2014, the NZZ wrote of a social «fidget spinner's career». This is an allusion to the characters of «Zappelphilipp» and «Hanns Guck-in-die-Luft» described by Heinrich Hoffmann in 1845. Both were characterised by the typical behaviour of children with an attention problem.

These historical figures indicate that «ADHD» already existed back then, just under a different name. What has changed today, however, is the way we look at the phenomenon. Today, people take a closer look: more treatment-orientated, more systematic, more reflective. At the same time, however, people are also more critical, concerned, careless and sometimes overburdened.

The complexity of ADHD

The perspective on the topic of ADHD changes depending on the scientific specialism. While psychological causes are often at the centre of the discussion, social backgrounds are quickly forgotten in ADHD research.

ADHD should always be understood as a phenomenon of various overlapping causes. Psychological, neurobiological, genetic, social, cultural and family circumstances play an equally important role. ADHD is a complex phenomenon and a complex condition for those affected, which can only be successfully treated if the environments in which the children and families live are comprehensively analysed.

Precisely because ADHD affects so many areas - school, family, the world of work - it is important that treating specialists, parents, children and teachers network in order to be able to discuss children's ADHD problems more comprehensively.

Supporting children - an interdisciplinary study on dealing with ADHD

How can and should children with ADHD be supported? In a new research project, researchers from the disciplines of health sciences, psychology, pharmacy, sociology, law and ethics are scrutinising the practice of increased diagnosis and drug treatment of children with attention deficit disorder. The research project is analysing psychological, medical and social factors throughout Switzerland that can lead to an ADHD diagnosis, the selection of support measures and the prescription of medication. Preventive measures and alternative treatment methods will also be observed.

The researchers are advised by experts from the fields of child and adolescent psychiatry, medicine, educational research and school development. The interdisciplinary project is supported by the Mercator Foundation Switzerland.

The study is being conducted by the Institute for Family Research and Counselling (University of Fribourg), the Centre for Health Sciences (ZHAW) and the Collegium Helveticum (ETH/University of Zurich).