Magnus Betnér is a Swedish stand-up comedian that now has his own TV show called Betnér Direkt. His style is strongly reminiscent of giants like George Carlin and Bill Maher, but he is bald, brutal and takes no prisoners in his social criticisms of things like anti-immigration, religious and social conservatism and general societal wrongdoings. He almost always push the envelope, making volatile sex jokes and is one of the first Swedish comedians who has taken support of feminism to an art form.
However, just like George Carlin and Bill Maher, he sometimes stays from the path of evidence-based reason. In his later years, George Carlin gave partial support for 9/11 truth ideas and Bill Maher has issues with vaccines and the germ theory of disease. To be fair, both George Carlin and Bill Maher has strongly criticized anti-science sentiments as well. Mill Maher personally help threw out 9/11 truthers that disrupted his shown and George Carlin often made fun of creationists. Betnér has also mocked creationists and poked fun at supporters of Zeitgeist, so what I will be discussion below maybe be a rare exception, but statements that I think should be challenged.
In the latest episode of Betnér Direkt (episode 7 of the first season), in the segment called Betnérs bud (a monologue at the end of the program), Betnér makes the following claims (2:27 ->, my translation):
We must stop diagnosing our children. A study revealed that it is more common with ADHD the later in the year you are born. Among reasons to get the diagnoses, “run around and climb on things” and that “they do not like school or homework” is mentioned. I see. You mean that what it takes to get the diagnosis is that you are a child! And stop calling that which you get for ADHD medicine. The medicine that the government prescribes is amphetamine. That is not medicine, that is breakfast [picture of a Swedish celebrity that has been in the news for taking drugs eating white powder as breakfast cereal]. It is fucking obvious that children become more effective if they get amphetamine! Do you know who also gets more effective if they get amphetamine? Everyone!
In other words, Betnér makes the central claims that (1) ADHD is an invalid diagnosis and that (2) medical treatment for ADHD is amphetamine, not medicine. These are fairly common claims in the anti-psychiatry play book and I will be discussing them each in turn.
ADHD is a legitimate and science-based condition
Singh (2008) outlines the major positions that exists with respect to ADHD. The first is the notion that ADHD is primarily caused by interacting biological factors. This means that medical treatment is reasonable as it attempts to adjust for the neurological issues facing individuals with ADHD. The second is the position that both biological and social factors are important in explaining the cause of ADHD. From this perspective, the diagnosis does not yet capture the full range of heterogeneity or complexity of the condition and so medication is accepted, but it also emphasizes behavioral therapies. The third perspective is that the primary factors influencing the development of ADHD is environmental factors and support preventative interventions, rather than psychotropic drugs. While all of these three scientific positions accepted that ADHD is a valid diagnosis, there is a fourth position which rejects it all together. The main proponents of this fourth perspective are scientologists and certain sophisticated sociologists.
Before looking at the evidence for the validity of the ADHD diagnosis, it is worth clarifying a number of points. It is important to separate the two different questions of “whether” and “how”. To take an example, there is currently a legitimate scientific controversy regarding exactly how certain species are related by evolutionary common descent as the precise relationship between various taxa are still being investigated. That is, how certain species are related is controversial, but it is not controversial whether all species are related by common descent. We can apply this thinking to psychiatric diagnosis as well. As we saw above, the main scientific controversy lies in what factors influence the development of ADHD, not whether the mental condition exists. This is no different from any other psychiatric condition. The existence of depression, for instance, is not really controversial in science, but scientists are still working on finding out the risk factors associated with the development of depression, which range from biological factors such as genetic vulnerability, psychological factors such as negative thought patterns and social factors such as previous life experiences of loss and rejection or decrease in social support.
So what is the evidence for the validity of the ADHD diagnosis? Generally speaking, three important categories are (1) reliability, (2) neurobiological findings such as decrease in executive function and (3) efficacy of treatment.
The two most important diagnostic manuals in use in psychiatry is DSM-IV-TR and ICD-10. The United States uses the former, whereas Europe primarily uses the latter. Both are reliable in the sense that if you subject, say, 100 children to psychiatric investigation, psychiatrists working independently of each other will very often reach the same conclusions for any given child. ICD-10 requires more diagnostic criteria than does DSM-IV-TR, and it also focuses more on impairment. To be diagnosed with ADHD using ICD-10, you need all three major behavioral symptoms need to be met: hyperactivity, inattention and impulsivity and it has to impair function more than transiently. The fact that some children sometimes display this symptoms transiently does not mean that ADHD is an invalid diagnosis, just like the fact that some people may be sad on occasion means that depression does not exist. If ADHD was not a legitimate diagnosis, it is hard to see why the reliability would be so high. This alone does not conclusively demonstrate the validity, but certainly points in the direction. More convincing evidence has emerged from neurobiological research.
The primary neurobiological explanatory model for ADHD revolves around deficiencies in executive function (EF). I will let neurologist Steven Novella explain:
But there are some consistent themes that have emerged. The most prominent theory of ADHD at this time is that it is mostly a deficiency in executive function (EF). EF is a function of the frontal lobes that allows us to focus our attention, to be goal-oriented, and to consider long-term strategies and consequences of our behaviors. Diminished EF explains many of the features of ADHD and the demonstrable harm that those with an ADHD diagnosis suffer. In one 2005 systematic review the authors concluded that there is robust evidence for EF disorder in those with ADHD, but that EF dysfunction is not a universal or required condition for ADHD. Therefore, “Difficulties with EF appear to be one important component of the complex neuropsychology of ADHD.” Other reviews agree, citing evidence for EF dysfunction in ADHD but pointing out that ADHD is a heterogeneous disorder and needs more study to define its subtypes.
If you read this study, and many others like it, you do not find the evasion and vague nonsense of a pseudoscience, but rather the process of legitimate science earnestly exploring a complex disorder, considering alternatives, probing for weaknesses in the data, etc. It does not, in other words, resemble the straw man that mental illness deniers attack.
So why is a child more likely to be diagnosed with ADHD the later in the year they are born? This is probably do to the fact that teachers are not controlling for relative age when they are deciding which children should be investigated for ADHD. In any given class, children may be as much as 11 months apart in age, and so when a teacher compares children born early in the year with those born later, he or she may hold up children born later in the year to the same behavioral requirements as those born later in the year, despite there being substantial difference in age. Needless to say, a larger proportion of children born later in the year may fail these behavioral requirements because of their younger age (almost a full year) and therefore be selected for ADHD screening. Finally, it is important to not over-interpret a single correlational study. At best, this study suggests that teachers need to take into account age differences better, not that ADHD is an invalid diagnosis.
Medical treatment for ADHD
When it comes to medical treatment, dose is a very important factor to remember. Any substance in a high enough dose will be toxic or even lethal. Water is necessary for human life to exist, yet consuming too much water will lead to water intoxication. What happens is that the water makes electrolytes in the extracellular fluid more dilute, which forces water into the cells (since the concentration of solutes is higher inside than outside). This leads first to increased intracranial pressure and then, as the cell swells, to cerebral edema and pressure of the brain stem. The end result can be brain damage or death.
Ritalin, a popular medical treatment for ADHD, is chemically similar to amphetamine. But the dose is so much lower that it does not produce a high, withdrawal or tolerance in the same way that occurs in drug users that take much larger doses of amphetamine. To be sure, there will always be a problem with parents using off-label medications and safety testing for long-term effects will always be needed. However, there is another side to the story. Children who do not get medical treatment (or any treatment) may start self-medicating. So one also has to look at the risk of not using the treatment. What if it is worse? I will finish this blog post with a longer quote from Singh (2008) and a personal word of advice to Betnér.
Childhood is frequently depicted as an ideal state of innocence and freedom, with children as passive subjects in need of protection. Stimulant drugs are seen as potential threats to children’s right to this particular experience of childhood. The protective intuition of nurture–neuroethics arguments is valuable and relevant in the context of drug interventions for children. However, in the case of stimulant drugs it may encourage overemphasis on the harms of diagnosis and drug intervention, and a superficial understanding of the benefits. evidence from two small in-depth studies into the social and ethical implications of psychotropic drug treatment suggest that children with ADHD express desire for psychotropic drugs; they successfully negotiate the stigma around drug treatment and they tend not to believe that the medication threatens their capacity to originate and direct actions for given purposes. ADHD diagnosis and stimulant drug use have been shown to affect children’s concepts of identity and personal authenticity, but the available evidence suggests that these effects are largely positive for most children, at least until they reach adolescence.
Spreading pseudoscience and moral responsibility
As a TV host, social commentator and comedian, Magnus Betnér enjoys a strong and broad support in Sweden. He has the ability to influence literally hundreds of thousands of people. With this, comes a moral responsibility. If Betnér is genuinely interested in combating other forms of pseudoscience than just creationism and anti-immigration, I suggest doing additional research before making broad, sweeping statements about things like psychiatry.
References and further reading
Singh, I. (2008). Beyond polemics: science and ethics of ADHD. Nat Rev Neurosci, 9(12), 957-964.
Categories: Debunking Anti-Psychiatry