Tom, aged 13, has barely made it to the end of the school term. He has been hyperactive all his life, impulsive, poorly organised, forgetful, easily distracted, and struggling to pay attention to his work in school.
He fidgets continuously, wanders out of the classroom and teachers have to follow him to make sure he is safe. His problems wear down his teachers and peers who increasingly reject him. He’s seen as having “behaviour difficulties”, but Tom has ADHD: a neurodevelopmental condition. School exclusion is a significant risk for Tom and in turn is associated with devastating lifelong impacts affecting learning, mental health, risk for imprisonment and shorter life expectancy. There is an exclusion-to-prison pipeline.
The Scottish Government gathers figures on school exclusion. Autism Spectrum Disorder (ASD) is over-represented in exclusions, but there is no data collected for ADHD. Children with ADHD are far more likely to be excluded from school than those without ADHD. But there is a more profound difficulty. Unknown to Tom’s family, they are victims of an ideological struggle that questions the very existence of his underlying problems.
Mainstream scientists have been studying the causes and treatment of ADHD for decades. Clinical guidelines acknowledge ADHD and the World Health Organisation (WHO) has recognised it for decades. The life outcomes for children with untreated versus treated ADHD are poor. ADHD, for many, can be a critical pathway to substance abuse. Yet it is possible to identify very early signs of a whole range of neurodevelopmental disorders. In Scotland, we could be international frontrunners in determining the full range of neurodevelopmental problems far earlier.
Tom could be excluded within days of the new term if he is not treated. Yet there are pharmacological and psychological treatments that would help him. We often forget about the impact children like Tom have on stretched teachers and other children. There has been considerable investment by the Scottish Government into mental health care delivered by Child and Adolescent Mental Health Services (CAHMS) over the years and there is more investment coming to schools soon to help prevent mental health problems, though referrals may be outstripping resources. What Tom experienced is some professionals telling him and his parents that the issues they had worked tirelessly to address do not exist or that labels are stigmatising and dangerous. Service rejection followed.
What’s at the heart of snubbing labels, dismissing diagnosis or questioning the existence of conditions like ADHD? One senior educationalist unashamedly told me, it’s about “radical postmodernism using language to take power and attack the medical model” of mental health. ‘Radical Postmodernists’ reject the concept of there being facts or truth, they tell us science is about a “power discourse”, each person’s “lived experience” is more relevant than scientific knowledge. You have to live in someone’s shoes to truly get their problems.
Really? I have to be depressed to imagine depression. These science saboteurs tell us knowledge from scientific methods is just one story, and there are lots of equally compelling stories. ADHD, in their view, is “made up”, just words and the helpful medication used in ADHD is the way “big pharma” can stay rich.
Yet the evidence is that cognitive behaviour therapy (CBT), parent training and stimulants, sensitively delivered, work for ADHD. One school in Scotland proudly presents its ditching of any limits on children for problematic behaviours and promotion of the idea that all behaviour is communication. In ADHD, children’s brains are fired up, and they often have no idea what their bodies are saying. The idea held by some professionals that “all children need is love” fails to understand the challenges of managing ADHD, where many need clear boundaries and short, simple instructions, for example.
Schools with zero consequences and love only let our children hit the wall of limits in adulthood, a form of slow-motion harshness. Being anti-medication for ADHD is de rigueur despite the excellent evidence for this approach, especially when combining psychological help and pharmacotherapy. I’ve seen stimulants for ADHD literally save children’s education and families.
Radical Postmodernists would deny these interventions. They tie themselves in knots, the label police, choosing which terms are acceptable and which are not: ADHD (no way); Complex Trauma (always); Dyslexia (nope); Attachment (of course); Psychopathy (let’s not go there!). Try describing dyslexia without being allowed to use the term dyslexia and you look ridiculous in the process. What’s more disturbing is who believes they can hold power to decide which labels can and can’t be used?
And if you think this is some deluded ‘narrative’, then you only need to look no further than research studies taking this issue head-on. One critical study found children labelled with “attachment problems” actually had a range of more common disorders: PTSD, social phobia, generalised anxiety, which were missed.
The stakes are high indeed. For Tom, this means repeated referrals for help, some services rejecting the existence of ADHD, others parent-blaming or looking for some early deep-seated trauma, despite the fact his siblings are thriving, and still he does not get the treatment he desperately needs.
Tom’s fraught parents are forced to go private. Gordon Brown, a private ADHD consultant, told me that more parents are choosing to take the private route and, for many, this is something they can ill afford.
Bill Colley, vice-president of the UK ADHD Partnership as well as a trustee of the Scottish ADHD Coalition, tells me Tom’s story is “depressingly familiar”. ADHD parents’ groups highlight the same issues: rejection from services; told ADHD does not exist, that their problems are “behavioural”; lack of understanding of ADHD and its impact. Resources are always an issue, but what money can’t buy is attitudes to real-life, long-term problems like ADHD.
Quick access to thorough, well-structured neuropsychological assessment would allow collaboration with schools to find more individualised support. ADHD should be captured in the school census so that exclusions and outcomes can be tracked.
Another way of thinking of such disorders is that children with ADHD and ASD are neuro-atypical, ie their brains are different, not worse, where people with ASD or ADHD have strengths to build upon: in ADHD, they are spontaneous and energetic, or in ASD: fact-finding, hyper-focused and passionate about specific topics.
If we acknowledge the existence of these neuro-atypical ways of functioning, provide treatment where there are associated problems, accept that jettisoning all diagnostic labels will ultimately lead to a disservice to struggling children in our schools then it would make it easier for affected children to thrive at school and eventually find educational and work opportunities that are a fit for them.
Dr John J Marshall is a consultant clinical & forensic psychologist. Tom is a pseudonym