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Tuesday, May 21, 2013

Point/Counterpoint: Why French Kids Don't Have ADHD, and....

From the Scientific American Blog "Suffer the Children"

By Marilyn Wedge, Ph.D.
March 8, 2012

The case against labeling and medicating children, and effective alternatives for treating them.

French children don't need medications to control their behavior.

In the United States, at least 9% of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5%. How come the epidemic of ADHD—which has become firmly established in the United States—has almost completely passed over children in France?

Is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the United States. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological--psycho stimulant medications such as Ritalin and Adderall.

French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs,

French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child's brain.

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Related Article

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French child psychiatrists don't use the same system of classification of childhood emotional problems as American psychiatrists. They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM. According to Sociologist Manuel Vallee, the French Federation of Psychiatry developed an alternative classification system as a resistance to the influence of the DSM-3.

This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983, and updated in 1988 and 2000.

The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding the best pharmacological bandaids with which to mask symptoms.

To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis.

Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior.

The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.

The French holistic, psycho-social approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child's problem.

In the United States, the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.

And then, of course, there are the vastly different philosophies of child-rearing in the United States and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé.

I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the United States.

From the time their children are born, French parents provide them with a firm cadre—the word means "frame" or "structure." Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it.

French babies, too, are expected to conform to limits set by parents and not by their crying selves. French parents let their babies "cry it out" if they are not sleeping through the night at the age of four months.

French parents, Druckerman observes, love their children just as much as American parents. They give them piano lessons, take them to sports practice, and encourage them to make the most of their talents. But French parents have a different philosophy of disciplinine.

Consistently enforced limits, in the French view, make children feel safe and secure. Clear limits, they believe, actually make a child feel happier and safer—something that is congruent with my own experience as both a therapist and a parent.

Finally, French parents believe that hearing the word "no" rescues children from the "tyranny of their own desires." And spanking, when used judiciously, is not considered child abuse in France.

As a therapist who works with children, it makes perfect sense to me that French children don't need medications to control their behavior because they learn self-control early in their lives. The children grow up in families in which the rules are well-understood, and a clear family hierarchy is firmly in place. In French families, as Druckerman describes them, parents are firmly in charge of their kids—instead of the American family style, in which the situation is all too often vice versa.

Marilyn Wedge is the author of Pills are not for Preschoolers: A Drug-Free Approach for Troubled Kids

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And a Rebuttal...

French Kids Do Have ADHD

An Interview with Elias Sarkis M.D.

September 22, 2012

Moliere described ADHD in his play L'Étourdi ou Les Contretemps (The Blunderer) in 1655. However, the concept of ADHD, or "Trouble déficit de l’attention/hyperactivité" (TDAH), as a serious disorder is still not fully accepted in France.

However, ADHD impacts the functioning of 3.5% of the population of France (Lecendreux, et al. 2011). In addition, ADHD is just as prevalent in other countries as it is in the U.S. (Faraone, et al. 2003).

I interviewed Elias Sarkis M.D., a board-certified child and adolescent psychiatrist and Distinguished Fellow of the American Psychiatric Assocation, to learn more about the prevalence of ADHD in France. Dr. Sarkis lived in France for 10 years, and graduated from medical school at Universite de Lille in Lille, France. He is now the medical director of Sarkis Family Psychiatry and Sarkis Clinical Trials in Gainesville, Florida.

Dr. Sarkis returns to France on a regular basis. He said that ADHD does most certainly exist in France. Not only are there clinical studies showing the prevalence of ADHD in France, but Dr. Sarkis also has a friend, a psychiatrist, whose child has ADHD. His friend's daughter had lifelong difficulties in school, had an unplanned pregnancy, and then dropped out of school. Her mother is now watching her child so she can return to school. 

Dr. Sarkis said that in France there is a "strong negative cultural belief against medication" for children with psychiatric disorders. However, he said, children with ADHD continue to suffer the consequences of the disorder.

Regarding the impact of undiagnosed and unmedicated ADHD in France, Dr. Sarkis said, "the reality is that there are French kids in prison, a high rate of tobacco use, and kids dropping out of school".

Dr. Sarkis said said that if a French child with ADHD receives "excellent parenting, high structure, and clear expectations from parents" it can mitigate behaviors, However, it is "at the price of the child experiencing increased anxiety and internalizing problems".

For those children who are not able to receive excellent parenting and high structure, ADHD behaviors can be extremely impairing.

In France it is difficult for parents to get an evaluation and treatment for their ADHD child. It takes 8 months for a child to get an appointment with a specialist, and it can take another 8 months before a child is prescribed medication (Getin, 2011).

Fortunately, Dr. Sarkis said, the concept of ADHD as a serious, treatable disorder is gaining strength in France. Parents are learning more about ADHD via the Internet, and there are more centers being established to help treat this debiliating disorder.

References

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