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For some specialists, it’s a neurological disease, for others a purely social construct. Here are some explanations.

Hugo, 7 years old, can’t keep still. In class, he chatters, laughs abruptly, turns around, stands up, calls out to another child, taps his pen on the edge of the table, chews on the tab of his pencil case… His teacher is distraught, his classmates annoyed. Hugo has been diagnosed as hyperactive. Or, more precisely, ADHD (Attention Deficit Hyperactivity Disorder). A common disorder, yet little-known, even by doctors. Even more disconcerting: for some specialists, it simply doesn’t exist. Hyperactivity exists, not ADHD, » insists psychiatrist and psychoanalyst Patrick Landman in Tous hyperactifs (Albin Michel).

An overestimated prevalence

ADHD first appeared under this name in 1987 in the DSM (the Diagnostic and Statistical Manual of Mental Disorders, a reference work for psychiatrists). Today, according to the only existing study, between 3.5% and 5.6% of French children suffer from this disorder. A range obtained by questioning families by telephone. « This is not a scientific diagnostic approach. What’s more, this study was financed by Shire, the pharmaceutical company that markets methylphenidate, a molecule prescribed to so-called hyperactive children », comments neurobiologist François Gonon, CNRS research director and researcher at Bordeaux University. In the United States, the proportion of children affected has reached record levels: 19% of boys and 10% of girls aged 14 to 17 have been diagnosed as hyperactive, an increase of 53% in 10 years. « By contrast, in Lombardy (Italy), the prevalence, calculated using a network of 18 diagnostic centers, is 0.5% », adds François Gonon.

A controversial diagnosis

The discrepancy stems from the definition of the disorder. A child with ADHD suffers from 3 symptoms (see box): excessive impulsivity, attention deficit and motor hyperactivity of varying degrees. But there are no neurological or physical signs specific to the disorder, making it difficult for doctors to diagnose. According to Bruno Harlé, child psychiatrist at the Centre Hospitalier Le Vinatier in Bron, Lyon, « the name ADHD implies that children’s agitation is the result of attentional difficulties. However, not all ADHD children suffer from attention problems. Some of them show a greater lack of motivation and ability to delay gratification ». Another pitfall is that the signs suggestive of ADHD resemble those of other disorders, such as learning disabilities, behavioral disorders, intellectual precocity, anxiety disorders and so on. Finally, some children are diagnosed with ADHD because of their age-related immaturity. According to a study by Canadian Richard Morrow, who analysed the files of a million children in British Columbia, girls born in December are 70% more likely to be diagnosed than those born in January of the same year. Boys are 30% more likely.

Brain or environment? The origin remains unclear

Controversy also surrounds the origin of the disease. A number of studies have demonstrated minimal brain lesions in hyperactive children, or the over- or under-activation of certain brain areas. « These changes visible on brain imaging do not prove the existence of ADHD, but only correlations between brain changes and behavioral symptoms, » writes Patrick Landman. For the moment, ADHD exists as a symptom but not as a neurological disease, » adds François Gonon. Over the past 20 years, the more studies we’ve carried out, the more we’ve realized that the role of genetics remains minimal. So why is this disorder more common in certain families? » There are many diseases with a strong genetic component, but where the environment also plays a role. For example, tuberculosis, an infectious disease, has a high genetic heritability, » points out Bruno Harlé, a child psychiatrist at the Centre Hospitalier Le Vinatier in Bron, Lyon. The environment plays a vital role in the development of a child’s attentional capacity.

The environment in question

According to François Gonon, the explosion in attention disorders can be explained by changes in society: « Since the work of Françoise Dolto in particular, babies have been considered as people in the making, which represents considerable progress. But parents seem to find it harder to set limits for their children. In fact, single-parent families have more ADHD children than others. Screens are also blamed for impoverishing children’s attention spans. According to a study published in Pediatrics in 2007, a child who watches an hour of television a day is twice as likely to develop an attention deficit disorder in elementary school. This is because the screen over-stimulates the involuntary attention system, to the detriment of the voluntary attention system (oriented towards the page of a book, the line of a notebook…), which is invaluable for learning.

Impact on family and school life

Whatever the origin of hyperactivity, it often causes great suffering. Despite their good will, children quickly lose control of their behavior. « These children are rarely invited by their school friends or taken to the mall by their parents, because of their incessant restlessness. Having a hyperactive child disrupts the family and plunges it into a vicious circle, in which overexcited parents can resort to psychological abuse, which they bitterly reproach themselves for, » stresses François Bange, psychiatrist, attached practitioner at Robert Debré and Sainte-Anne hospitals, and author of L’Aide-mémoire de l’hyperactivité, enfants, adolescents et adultes (Dunod). At a loss, parents don’t always know how to react. Nor do teachers. Hélène Ducret, co-President of Aspedah, the French-speaking Swiss association of parents of children and adults affected by ADHD (aspedah.ch), explains: « Many families consult us when their child starts school, when they take their first exams, or when they move up to a higher level. « Kindergarten teachers tolerate a certain amount of agitation on the part of pupils, but this is no longer the case in primary school, » stresses François Bange. In Veyrier, Switzerland, an elementary school excluded a hyperactive child and placed him in a medical-pedagogical center, believing that the mainstream school was unable to accommodate him. In France, public schools are supposed to deal with disorders. « These children need to move to learn. Why not let them turn around their table or swing on their chair to memorize their poetry? » asks Hélène Ducret. »

Valuable educational strategies

Learning to learn is one of the most effective strategies for supporting a hyperactive child. « It’s important to help parents adapt their educational practices, » points out François Bange. They can draw on parenting skills training programs, such as the one developed by Canadian Russel Barkley. The aim? Accompany the child and find the keys to avoiding a never-ending power struggle. Barkley’s techniques include setting aside a special time each day for the child to do what he wants, alone with his parents; giving simple, effective orders; and paying attention to (and praising) the child when he’s not disturbing them. Another tip: a system of tokens or stickers that reward pre-scheduled actions (getting into pyjamas alone, setting the table) when they are carried out. The French Ministry of Education, for its part, offers a range of teaching aids adapted to children with attention and concentration difficulties. For example, the child answers only 5 out of 7 questions, or the teacher ignores spelling mistakes.

Psychostimulants as a last resort

What about medication? The French National Authority for Health recommends that behavioral and cognitive therapies be preferred, and that psychostimulants only be used when the situation becomes unbearable. Methylphenidate, betterknown as Ritalin, is the subject of much debate, not least because of its side effects (loss of appetite, insomnia, headaches, stunted growth, etc.). While parents speak of a « miracle » in that their child is making better progress at school, many doctors criticize the systematic prescription of Ritalin. Under psychostimulant conditions, children are better able to maintain their attention on boring, repetitive tasks, » explains François Gonon. On the other hand, the quality of the work produced is no better. Researchers at the University of Toronto and Princeton have followed children treated for 10 years. As a result, school performance did not improve over the long term. The researchers also noted harmful emotional side-effects, such as misunderstandings with parents, especially in girls.

Ritalin consumption on the rise

Yet Ritalin consumption continues to rise. According to the Celtipharm research laboratory, 3% to 4% of boys and 1% of girls of school age take it, and the number of boxes sold has risen by 70% in 5 years. For Patrick Landman, it’s the product that makes the disease. Clearly, the clustering of the 3 symptoms that make up ADHD coincided with the launch of Ritalin, which treats precisely these 3 symptoms. According to the psychoanalyst, in addition to the pharmaceutical laboratories, of course, families also play a part in this « social construction ». Indeed, a diagnosis of the disease and the appropriate treatment can bring them relief after years of trying, more or less unsuccessfully, to help their child.

For his part, François Bange regrets the bad image that hyperactives suffer from. « Hyperactives are full of energy. Once they’ve found a path they’re passionate about, they can invest it in very positive ways ». Sadly, these assets are rarely promoted at school. « It’s important to reassure parents that their child’s future is not blocked – quite the contrary.

Symptoms to watch out for

According to the DSM-V (psychiatrists’ controversial reference manual on mental disorders and illnesses), ADHD should be considered when 6 out of 9 symptoms persist for at least 6 months and have a direct, negative impact on social and school activities. Only a specialized doctor (usually in hospital) can diagnose the disorder.

Inattention

– The child makes many careless mistakes and does not pay attention to details.

– Easily distracted, has difficulty sustaining attention

– He is unable to successfully complete tests requiring intense concentration.

Hyperactivity

– He often flails his arms, legs, feet and hands, can’t keep still and is always impatient.

– He stands up and/or moves around in an environment where he should remain seated (in class, in a restaurant, at a show…).

– He often talks too much, irrepressibly

Impulsivity

– He answers questions before they are asked of him

– He can hardly wait his turn

– He often interrupts those around him during an activity, game or conversation.

A lifelong disorder for a third of children

In 2013, William Barbaresi’s team (Boston Hospital) examined the medical records of 5,718 adults born between 1976 and 1982. 367 had been diagnosed with ADHD as children, and 232 of them were still being monitored. Results: 29% of adults diagnosed with ADHD as children still have the disorder. And among them, 81% were affected by another psychiatric disorder (personality disorder, depression, anxiety), compared with 47% of those no longer ADHD and 35% of the general population. With age, the disorder changes. Adults are much better at controlling their agitation. But attention deficit and excessive impulsivity remain. Across the Atlantic, they are referred to as ADD ( Attention Deficit Disorder). As François Bange points out, these adults make many decisions on the spur of the moment, living in the moment. Because of their difficulty in managing time, they can devote a great deal of energy to secondary tasks, and often find it difficult to keep their affairs in order. A 2006 meta-analysis also estimated the excess risk of being involved in a car accident at between 54% and 88%. As with children, behavioral and cognitive therapies can often help to implement strategies for better organization.