Millions of children on stimulants, force-fed drugs at the slightest sign of agitation, at the slightest drop in attention? The last alert was launched last August, on France Inter. According to psychologist and psychoanalyst Caroline Goldman, France is on the verge of joining the United States, where 11% of children are treated with methylphenidate, an amphetamine administered to people with attention deficit disorders with or without hyperactivity ( ADHD).
For Caroline Goldman, the diagnosis of this condition would be too vague, a “catch-all”. We would slide, like the Americans, towards systematic prescription, in search of “rapid drug remedies”. In support of this assertion, a statistic, from a report by the Court of Auditors, published last March: prescriptions jumped by 110%, between 2011 and 2018. The proof, according to many psychoanalysts and doctors of a drift and children in chemical straitjackets.
Just after stating these figures, the Sages of rue Cambon nevertheless recalled: “According to data from the Cnam, the High Authority for Health (HAS), the National Agency for the Safety of Medicines and Health Products (ANSM ) and international work, France still has one of the lowest levels of methylphenidate consumption per child among countries in Europe, North America and Asia.”
All under “school opium”?
When the quantities are low, a few extra boxes are enough to panic the counters: in reality, only 0.2% of French children consume the molecule. And only neurologists and hospital psychiatrists specializing in ADHD can give it, provided they have tried non-drug solutions. Conditions much stricter than in the United States and a panorama far, far away, of a country under the “obedience pill”, “school opium”, addicted to “children’s cocaine”, as it is sometimes presented .
The battle over methylphenidate is just one example of the tensions over ADHD. Long considered the prerogative of lazy people, rude people, or idiots, attention deficit disorders still suffer from numerous stereotypes, fueled by the gray areas left by research. Especially since attention deficit, like depression or autism and many other mental disorders, has no biological markers. No PCR test, no blood test: the door open to all fantasies.
According to some, in the absence of such screening, the disability would not exist. These abnormally agitated children, unable to concentrate, and the exhausted and desperate parents who arrive in medical offices are in reality victims of an “invention of the laboratories”. A “social construction”, “psycho-marketing”, to use the terms of psychiatrist Patrick Landman, critical figure of ADHD. “This disease was born from the thigh of a molecule”, also affirmed Caroline Goldman last year. The psychoanalyst has since repeated that she does not deny the existence of the disorder.
“Born from the thigh of a molecule”
The new enthusiasm around the concept also fuels ambient skepticism. On social networks, the term is taken up, interpreted, caricatured by hundreds of millions of Internet users, in the French-speaking world alone. And, in schoolyards, how many teachers have already been told that the child they are punishing is not “turbulent” but “hyperactive”, without the shadow of a supporting diagnosis? ? Not to mention the screenings that are flourishing online and the apps that promise to improve attention.
This misuse of the term “ADHD” fuels controversy, giving the impression that it is a fad, without much seriousness. The disorder has, however, been recognized as a disability since 2005. And in 2015, the High Authority of Health has published specific recommendations on the subject, to guide general practitioners. A way of dedicating one’s existence even if, in practice, health professionals, the educational institution, and the general public still remain little aware of the problem.
Contrary to popular belief, the concept is neither recent nor the product of generations fed up with screens. “The disorder was first described in 1775 by Melchior Weikard, a German doctor – 169 years before the invention of methylphenidate,” explains Franck Ramus, research director at the CNRS, specialist in cognitive development. In Spain, France and the United Kingdom, some doctors began to speak of “minimal brain dysfunction or disorder”. Then in 1932, two Germans, Franz Kramer and Hans Pollnow, came up with the term “hyperkinesia”. The WHO will make it its name, before abandoning it for ADHD.
Malfunctions, regardless of the context
What concerns specialists is the persistence, intensity and impact of the symptoms. Three criteria on which current diagnoses are based, based on tests, questionnaires and interviews filmed over several weeks. “A child who is not interested in school will not have difficulties in his leisure time,” illustrates Manuel Bouvard, neuropsychiatrist. Just like a forgetful child won’t forget his keys three times a day, every day. A child who needs to exercise is not disorganized. A child disturbed by a tragedy will generally see his condition evolve over time. And trouble is not a sign of a lack of intelligence; of numerous studies detect it in high intelligence quotients.
How then can we explain these “dysfunctions”, the inability to resist distractions, to prioritize, to wait, and the agitation, the disorganization, all these “impediments”, sources of suffering? The clinical picture of ADHD, refined through observations and diagnoses, converges towards a completely different explanation than a problem of education, family environment or socio-economic context: “What links all these manifestations is is a dysfunction of the regulatory processes of cognitive and motor activity in the brain”, summarizes Manuel Bouvard.
In people diagnosed, medical imaging shows a maturation deficit in the prefrontal cortex, the control tower of our mental and motor activity. “We have the airport, the planes, but the air traffic controllers are asleep,” explains Manuel Bouvard, as if he were speaking to one of his little patients. Hence this paradox: prescribing anxiolytics or sedatives to hyperactive people does not calm them down. Because what poses a problem is not the activity but the control of the activity. Conversely, although we do not yet know exactly how it acts, methylphenidate stimulates the prefrontal cortex and thus allows focus.
ADHD in the brain
As part of a study published in 2019 in the journal Jama Psychiatry, 94 children presenting behavioral disorders at 7 years old underwent a scanner. The brain structures obtained made it possible to predict which children would, at age 11, develop attention disorders, or present anxiety or depressive disorders. Published in Brain in 2014, a controlled study, carried out on 56 people, sixteen years after their first diagnosis, showed significant brain differences between those who had nothing, those whose symptoms had reduced, and those still affected.
In 2021, 79 neurologists and psychiatrists specializing in the study and treatment of ADHD signed a consensus statement, published in the scientific journal Neuroscience and Behavioral Reviews. These experts reviewed population studies involving more than 2,000 participants and meta-analyses bringing together more than five studies. The researchers draw “208 conclusions” supported by scientific literature. Among them: “Imaging shows brain differences between people with and without ADHD.”
To explain what is happening, several avenues are emerging: “Most cases seem to be explained by the combination of genetic factors and environmental risks,” details the international consensus. These could be, for example, injuries linked to accidents during pregnancy, intrauterine exposure to substances such as alcohol or even premature birth. Another hypothesis: genetic mutations cause abnormalities in the transport of dopamine or norepinephrine, hormones essential respectively for motivation and arousal, participating in attention.
In the genes, and during pregnancy
A controlled study published in January 2023 in Nature Genetics and carried out on more than 38,000 cases, notably highlighted 76 genes at risk of causing the disorder, if an abnormal mutation were to occur. It must be confirmed. Other work, carried out by Hugo Peyre, psychiatrist at Montpellier University Hospital, and published in Journal of Child Psychology and Psychiatry in 2021, show genetic factors common to autism; these two families of disorders could have common roots. “When one member of a sibling is often affected, the others also have one,” summarizes the researcher, who with others, launched a large cohort study in France, to clarify the links between the different neurodevelopmental disorders.
Faced with so many elements, the recurring questions annoy Christine Gétin, president ofHyperSupers ADHD, the main association in France. “If the problem doesn’t exist, that’s fine with me. I close up shop, I rest. It would be much better that way,” grumbles this mother, one of whose children suffers from ADHD. At each controversy, she publishes notes on her site, linking to the latest research articles. “A lot of people think that ADHDers should just try harder. That’s the problem, they can’t do it, no matter how hard they try. And punishing them doesn’t help, quite the contrary.”
Often, undiagnosed people think they are to blame for their failures. This was the case of Benjamin Laurent, journalist and producer. At 25, he went to a conference on the subject for his work. Faced with the clinical picture drawn up by a specialist, the young man suddenly became aware: “I had the impression that my life was being described.” Suddenly, everything made sense: his chaotic school career, his difficulties in following classes, listening to his friends debate without interrupting them, the subways that he often takes in the wrong direction…
A pill to avoid the powder?
Now in his thirties, diagnosed, Benjamin Laurent cringes when reading the debates in the newspapers: “I want to give my life to them, to those who don’t believe in it! Instead of fighting over the numbers and the names Instead, let’s find school arrangements, human parental postures or molecules, to prevent these people from sinking.” According to different estimates, approximately 5% of children carry this disorder. 65% of children diagnosed still present symptoms at the age of 25, according to a study published in May 2005, in Psychological Medicine.
In people with ADHD, the suicide rate is higher than in the rest of the population. Up to four times more, depending on Danish health statistics. The risk of falling into alcohol or drugs is three times higher, according to a study carried out on half a million Swedes in 2015. If methylphenidate does not provide a cure, and if we do not know what long-term consumption entails, the molecule has shown its effectiveness. Taking it would even reduce the risks of later becoming addicted to prohibited substances, according to a study published by Harvard researchers, in Journal of Attention Disorders, in 2016.