Why Nicole Arbour is Wrong About ADHD

A recent video called “The Truth about ADD” by Internet celebrity Nicole Arbour in which she denied the existence of ADHD and shamed parents who give evidence-based ADHD treatments to their children. It got close to 6.5 million views within one to two weeks on Facebook and another 70 thousand views on YouTube. About a week later, she posted a much longer follow-up video entitled “Live Debate: Is ADHD real?” that spanned about 35 minutes. Was this an actual debate? No. Instead, she merely recycled her previous claims and added more details, while pausing once in a while to read supporting comments on Facebook or insult her audience. Arbour appears to make controversial and inflammatory videos for views and attention. Previously, she has attacked black people, fat people, feminists and trans people as well as falsely blamed allergies on GMOs and promoting spanking of disobedient children while seemingly aware of the research showing that it is harmful.

Some might say that it is unwise to give her more attention, but her false claims about ADHD need to be debunked and the scientific evidence for ADHD needs more exposure to at least reduce some of her harmful impact on people. In addition, anti-psychiatry nonsense is a pseudoscience that has received relatively little coverage in the wider skeptical community, so there is a need to raise awareness about this form of nonsense. Like many anti-science activists, she uses the deceptive tactic called shotgunning (or the Gish gallop) where she crams as many false claims as possible into as short as time as possible to make it difficult to refute all of her claims. In total, there were over 70 claims in both of her videos (not counting those she read from the comment section). Because covering all of them would take up way too much space, this post will tackle the ten most common claims about ADHD made by Arbour.

Fact #1: ADHD is real

Attention Deficit Hyperactivity Disorder (ADHD) has been known as a clinical condition since at least the early 1900s with earlier suggestive indications tracing back almost a century earlier. A search in the PubMed database over research papers returns over 30 000 articles about ADHD, even when you specifically exclude the alcohol dehydrogenase D that has the same abbreviation. Thus, ADHD is a well-studied psychiatric diagnosis. The early attempts were far from modern scientific knowledge and medical standards, but they (together with modern research) show that ADHD is real and not just something invented by pharmaceutical companies.

The causes behind ADHD are complex and likely a complicated interaction between biological, psychological and social factors. Biological factors include certain genetic variants of neurotransmitter receptors and transporters, variation in executive function connected to memory and attention, and structural and functional neuroimaging differences in many areas. Many of these findings, including findings from animal studies, points to considerable heterogeneity, so there are likely many different subtypes of ADHD that can differ slightly from each other. Future research might be able to provide more insight into these subtypes. The heritability of ADHD ranges from 30-80% depending on which population you look at, what age you look at and what environment they are in and what research methods you use. This suggests that a lot of the variation in ADHD is due to variation in genotype (but this is not a measurement of how important genes are, only the variation in genes). Environmental factors, such as brain injury, premature birth, heavy exposure to lead and other exposures during pregnancy appears linked to certain forms of ADHD.

There are a couple of different positions within the scientific community: some think it is mostly due to biological factors, others think it is a mixture between biological and environmental factors, whereas a third group thinks it is mostly due to environmental factors. There is also a fourth group largely outside of the mainstream scientific community that is mainly composed of anti-psychiatry activists who reject the existence and treatment of psychiatric conditions.

Fact #2: ADHD medications are safe and effective

There are three common treatments for ADHD: medication alone, behavioral therapy alone or a combination of both medication and behavioral therapy. The high-profile Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study found that ADHD medication were reasonably effective and safe. For ADHD specifically, medication and combination treatment are generally considered more effective than behavioral therapy alone or community care control. For other aspects, from social skills, academic performance, anxiety etc. combined treatments are considered more effective than any single treatment alone. A few percent of participants stopped medication due to adverse events, that primarily involved appetite issues, problems sleeping, crying and so on. There was initial concern that the intense medical management group grew slower in height and weight than control, but later studies on larger sample size of participants and some spanning 10 years found that there was no association between ADHD and height or ADHD medication and height.

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Arbour claims that modern ADHD medication is “equal to speed” and that it causes drug abuse. None of this is true.

First of all, ADHD medication does not increase the risk for drug abuse. Instead, it appears that some people with ADHD who do not get treatment may engage in self-medication for their symptoms or be at increased risk from drug abuse due to having to repeat grades or drop out of school. Some studies even conclude that ADHD medication reduces risk for subsequent drug abuse, but others find no impact on drug abuse risk whatsoever. Treatment with ADHD medication also appears to reduce risk of criminal behavior, presumably for similar mechanisms.

Second, ADHD medication such as Ritalin (methylphenidate) and methamphetamine (“speed”) are both stimulants, but they differ in chemical structure, mode of administration, time it takes to have a biological effect, time it takes for it to clear from the brain, dosage used and many other areas. It is a false comparison that is often used by anti-psychiatry activists for shock value, but it cannot be considered a scientifically accurate description.

Fact #3: “Grandfather of ADHD” never rejected existence of ADHD

Another flawed claim made by Arbour that she repeats over and over again is that ADHD does not exist because the grandfather of ADHD supposedly rejected the condition. This is false in three different ways.

First, this trope refers to the child psychiatrist Leon Eisenberg who made great contributions to understanding behavioral conditions in children, but is not the father of ADHD. The first person to describe ADHD-like symptoms in a scientific manner was George Still in 1902, not Eisenberg (who would not even be born for another two decades). It should be pointed out that Still’s characterization had several flaws and modern research has updated and refined considerably since then.

Second, this is a quotation taken out of context. The fact-checking organization Snopes covered this in some detail in an article back in 2013. They went back to the original interview and analyzed the context. They found a 2012 article (cache) in the German newspaper Der Spiegel that discussed Eisenberg’s last interview. Here is the original German from Der Spiegel:

Ein großer, hagerer Mann mit Brille und Hosenträgern öffnete 2009 die Tür zu seiner Wohnung am Harvard Square, lud an den Küchentisch und schenkte Kaffee aus. Niemals hätte er gedacht, erzählte er, dass seine Erfindung einmal derart populär würde. “ADHS ist ein Paradebeispiel für eine fabrizierte Erkrankung”, sagte Eisenberg. “Die genetische Veranlagung für ADHS wird vollkommen überschätzt.”

Stattdessen sollten Kinderpsychiater viel gründlicher die psychosozialen Gründe ermitteln, die zu Verhaltensauffälligkeiten führen können, sagte Eisenberg. Gibt es Kämpfe mit den Eltern, leben Mutter und Vater zusammen, gibt es Probleme in der Familie? Solche Fragen seien wichtig, aber sie nähmen viel Zeit in Anspruch, sagte Eisenberg und fügte seufzend hinzu: “Eine Pille verschreibt sich dagegen ganz schnell.”

Here is the English translation provided by the Snopes article (my bold):

A tall, thin man with glasses and suspenders opened the door to his apartment in Harvard Square in 2009, invited me to the kitchen table, and poured coffee. He said that he never would have thought his discovery would someday become so popular. “ADHD is a prime example of a fabricated disorder,” Eisenberg said. “The genetic predisposition to ADHD is completely overrated.”

Instead, child psychiatrists should more thoroughly determine the psychosocial reasons that can lead to behavioral problems, Eisenberg said. Are there fights with parents, are there are problems in the family? Such questions are important, but they take a lot of time, Eisenberg said, adding with a sigh: “Prescribe a pill for it very quickly.”

In other words, when read in context, Eisenberg is not claiming that ADHD does not exist, merely that he considers psychosocial factors more important in the cause of ADHD. Eisenberg might be categorized into the third position described above that favors primarily social and environmental factors in ADHD.

Third, even if Eisenberg (or even Still) had said that ADHD did not exist at all, it would not have mattered that much. This is because scientific and medical facts are decided by scientific research, not by the say-so of a single individual, no matter how well-respected.

Fact #4: Sugar consumption is not linked to ADHD

In one of her many ironic contradictions, Arbour claims that ADHD “isn’t a thing”, but that symptoms are real. She then attributes these symptoms to a wide range of alleged environmental causes, from food allergy to bad eye sight. While complaining about how the American public has been sold out by GMOs and food additives, she puts forward about a dozen or so causes of ADHD, which she also says does not exist. She appears to have some weird hybrid belief between the idea that ADHD is purely caused by environmental factors and the more weaponized pseudoscience that ADHD does not exist.

The most common myth in this category is that excessive sugar consumption causes ADHD, but this has been refuted by several studies. Even more interestingly, it looks like this notion arose due to parental expectations, because when mothers are told that their allegedly sugar sensitive children got a high dose of sugar (when they just got non-sugar placebo), they still believed that their children where hyperactive as a response to the sugar they never actually got.

Fact #5: Spanking is ineffective for ADHD symptoms

Arbour is a long-time defender of spanking misbehaving children. In a video entitled WHY TO SPANK KIDS (all caps in original) posted on March 17, 2016 on her YouTube channel, she advocates spanking because she thinks that the current generation is too spoiled. Despite acknowledging that researchers have concluded that spanking is harmful, she insists that children cannot be reasoned with, but learn from positive punishment. However, if children cannot understand some simple stuff about not misbehaving, they likely cannot understand why you are hitting them either or what they should do instead. She dismisses scientific findings by stating that “so adulting is hard for them too?” and that increase in sending naked pictures on the Internet and vile YouTube comments is a result of less spanking. Of course, she provides no reason to reject the research and does not provide any studies supporting her claims. Currently, the video has about four times as many dislikes as likes.

In her second video, she goes so far as to advocate spanking for children with ADHD:

“Hypnotherapy is a great alternative for children with behavioral issues.”

Cool, do that. Also, so is spanking. Just putting that out there. Yeah.

This has been disproved by five decades worth of research on over 160 000 children that measured over 111 unique metrics recorded. The research found that spanking was associated with “low moral internalization, aggression, antisocial behavior, externalizing behavior problems, internalizing behavior problems, mental health problems, negative parent–child relationships, impaired cognitive ability, low self-esteem, and risk of physical abuse from parents” among children and ” adult antisocial behavior, adult mental health problems” in adulthood. Spanking is harmful.

Furthermore, spanking is not even effective. Besides being associated with lower moral internalization (i.e. being bad at understanding and accepting reasons for why bad behavior is bad) and higher aggression and antisocial behavior, an earlier meta-analysis found that spanking does not even produce better immediate or long-term compliance compared with non-spanking. Why? The researchers suggest that spanking does not teach children why the behavior was wrong or what they should do instead. Instead, it teaches that violence is part of a loving relationship, which likely perpetuates the cycle of violence. Even more confusingly, it involves a role model punishing aggression with aggression, which can seem confusing and hypocritical to the child.

Before pro-spanking activists insists that this is just a correlation and that the causation is actually reversed (i.e. more aggression causes more spanking), the researchers used many independent techniques to rule this out, such as cross-lagged studies, adjusting for baseline level of aggression and interventions to reduce spanking. The result? Spanking causes negative outcomes and does not work.

Fact #6: Psychiatrists are “real doctors”

Arbour claims that psychiatrists are not “real doctors” and only became “real doctors” only when pharmaceutical companies invented prescription medication. In reality, psychiatry is a medical specialty among others such as cardiology or oncology.

What is required for becoming a psychiatrists? In the United States, you need to complete four years of medical school and then at least four years of residency in psychiatry. In the United Kingdom, you need to complete five years of medical school, spend two years on foundation training and then another six years of specialty training. In total, psychiatrists in the US have at least 8 years of training, and psychiatrists in the UK have 13 years of education and training. Psychiatrists are real doctors.

Fact #7: Doctors are more qualified than Internet celebrities

Arbour spends a lot of time in her second video on bashing medical doctors, insisting that they do not have some “magical powers” that others do not have. While this is trivially true, doctors do have extensive medical knowledge and training that most people, including Arbour, do not have. She dismisses this by asserting that doctors just “read some books” and “went to some lectures”. She insists that all doctors screw up all the time, that doctors are bought and paid for by the pharmaceutical companies and that their “opinions are worth bullshit”. One cannot help but wonder what research that Arbour has carried out on ADHD. Presumably, she has primarily read conspiracy blog posts and watched YouTube videos, but that is not actually research.

Although you can certainly find examples of pharmaceutical companies and doctors misbehaving, there are strict federal laws in place to prevent that kind of manipulation and distortion:

False Claims Act (FCA): it is illegal to submit fake claims to medicaid and medicare.
Anti-Kickback Statute (AKS): it is illegal to pay for referrals in federal health care programs (this includes kickbacks from pharmaceutical or medical device companies).
Physician Self-Referral Law (Stark law): it is illegal to refer patients to someplace that benefit yourself.
Exclusion Authorities: it is illegal to participate in Federal health care programs if they have committed one of several criminal offenses and it is also illegal to work with any such person within the same contexts.

Fact #8: There is ADHD in France

Arbour repeats the common myth that there is supposedly no ADHD in France. This was promoted by family therapist Marilyn Wedge, who attributed it to structure, spanking and better food.

In reality, there is certainly ADHD in France. A 2011 study found that ADHD prevalence in France was somewhere between 3.5%-5.6%.

Fact #9: Rates partially depend on differences in diagnostic systems

A common claim is that there is a massive overdiagnosis of ADHD in the United States and that there are so many more children with ADHD in the United States than elsewhere and Arbour repeats this latter claim in her second video.

Although there are some geographical differences between countries, there is no radical difference between the United States and other countries.

The global prevalence of ADHD ranges from 5.3%-7.2%. An earlier study from 2003 found that ADHD rates are similar in both United States and other countries when the same diagnostic criteria are used. Thus, the claim that ADHD is just an American phenomena is simply not true.

So where did this notion that there is a ton of ADHD in the United States, but very low elsewhere? It turns out that this is the result of comparing rates from different diagnostic systems. In the United States, the primary diagnostic manual for mental conditions is the Diagnostic and Statistical Manual (DSM) from the American Psychiatric Association, currently in its fifth edition. In most of Europe, the diagnostic manual used in health care generally is the ICD-10 from WHO. The criteria for ADHD (DSM-5) and hyperkinetic disorder (ICD-10) differ in such a way as to impact rates.

In ICD-10, a child needs sufficient number of diagnostic criteria from all three categories of inattention, hyperactivity and impulsivity for at least 6 months that “has persisted for at least 6 months, to a degree that is maladaptive and inconsistent with the developmental level of the child”. In DSM-5, a child needs to have sufficient symptoms in either the category of inattention or hyperactivity/impulsivity with the same persistence and degree as ICD-10.

Fact #10: There is no “Big Pharma” ADHD conspiracy

It is popular for various anti-science activists to push conspiracy theories about pharmaceutical companies. While it is true that some pharmaceutical companies have sometimes behaved unethically (and have been prosecuted for it), it is both unnecessary and unreasonable to promote batshit conspiracy theories. There are many reasons why they fail.

If ADHD was a pharmaceutical conspiracy, there would have to be so many people involved (from parents, teachers, doctors and researchers) that it could never work without massive leaks. The NSA could not keep global mass surveillance a secret, the military could not keep hundreds of thousands of Army documents and diplomatic cables from being leaked and the former U. S. President Bill Clinton could not even keep his affair secret. What chances would a pharmaceutical conspiracy involving literally thousands of people have? It is also unclear how pharmaceutical companies could have so much money, power and influence to keep such a global conspiracy from crashing without having enough power to take down some YouTube video or Facebook post exposing them.

Conclusion

ADHD is real. There are clear biological and environmental risk factors for the condition that has been demonstrated in the scientific literature. ADHD medications are safe and effective, and will not make a child become a drug addict, but might reduce the risk of abuse and criminality. Leon Eisenberg never claimed that ADHD did not exist, merely expressed a strong preference for social and environmental causes. Excess sugar consumption does not cause ADHD and spanking will not treat it. Psychiatrists are real doctors and have medical training for around a decade and they are certainly more qualified than Internet celebrities. Contrary to popular belief, there is ADHD in France and the ADHD rates are comparable between the United States and other countries when the same diagnostic system is used.