ADHD – Mismatch or Illness?

At 6, Lilly was in lots of trouble.  She and her family had been referred to family therapy by the school who had become exhausted by her inattention, distractibility, and violence towards other children.

In the first session attended by the whole family it became clear that there was much that could not be openly discussed, and that the reality presented did not match the facts. Later it was disclosed that Lilly had been born into a frightening world of addiction, violence and instability punctuated by police and legal involvement which resulted in her father’s disappearance explained as ‘Dad working away from home’. Throughout the first visit of an hour and a half Lilly played quietly and intently with her younger siblings, clearly listening but not interrupting. Seen alone for the next session she was co-operative and attentive especially as she spoke about her fears that both parents may die, and she would be responsible to care for the young ones. At our third session a very different child appeared. Lethargic and disinterested she spent the bulk of the session with head on arms leaning on the sofa. Her mother explained that school could no longer tolerate her behaviour and had suggested she was suffering ADHD and referred them to a pediatrician who prescribed medication. The school, her mother reported was well pleased with the result.

It is many years since meeting Lilly, but she came vividly to mind on reading a paper by biological anthropologists Syme and Hagen (2020) who challenge traditional psychiatric approaches, noting that. ‘Scientists understand little about the etiology of mental disorders, however, and many of the most popular psychopharmacological treatments, such as antidepressants and antipsychotics, have only moderate-to-weak efficacy in treating symptoms and fail to target biological systems that correspond to discrete psychiatric syndromes’. Their analysis of ADHD was particularly striking where they suggest that it may be ‘a harmful (but not dysfunctional) mismatch between highly structured modern environments and less structured ancestral ones’. With low hereditability and high population prevalence it is characterized by symptoms specific to ‘contexts requiring sustained attention and behavioral restraint such as the classroom or the workplace, and it is not clear how problematic this phenotype is in less structured environments. It may be that this ‘disorder’ is a result of a ‘mismatch between normal child development and classroom environments’. Their final word on this subject was particularly poignant given my clinical experience ‘ADHD is perhaps another example in which the illness label serves the interests of the powerful (e.g., teachers, parents) at the expense of the powerless (e.g., children). It is far easier to control rambunctious and inattentive children using medication than it is to restructure the school environment to accommodate normal variation in development.’ One could add that it is also easier to medicate a child than face the distressing chaos of the world in which they reside.

Syme KL, Hagen EH. Mental health is biological health: Why tackling “diseases of the mind” is an imperative for biological anthropology in the 21st century. Yearbook Phys Anthropol. 2020;171(Suppl. 70):87–117

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