Still not fully recognized in France, incorrectly seen as a social issue, masked by the simplified term “hyperactivity,” ADHD remains difficult to diagnose. Its medical treatment is a subject of intense debate.
1 “Too restless,” “Never stops chattering,” “A little more concentration wouldn’t go amiss,” “Constantly daydreaming,” “Always forgetting his belongings.” As long as there has been school, there have been schoolchildren who receive such reports. But. . . what if they can’t help it? What if they can’t stop themselves? What if it’s not their fault?
2 At home, the parents are fully aware that their second oldest is a real tearaway, more so than his brother: he never sits still, doesn’t listen, acts without thinking, has inexplicable meltdowns—they’ve even given him the nickname “Twister”! Another set of parents have noticed that their youngest, who is constantly biting her nails, always has her head in the clouds; that she can’t sleep at night—because her head is buzzing, she says—and that in the morning it’s impossible to get her moving. On top of that, she forgets everything—her keys, her sports kit—exasperating those around her. The parents often get annoyed, sometimes they crack, but still, that’s how their kid is and, so long as school goes okay, then everything is okay—even if they are always being told that their child is too unstable, badly raised, or even that they, the parents, are not consistent enough.
3 But as they grow up, these children don’t get any calmer, nothing changes, school grades plummet, they are no longer so happy, can’t manage to keep friends, are constantly being scolded and punished, become anxious and sometimes aggressive, making those around them uneasy at school, in leisure time, and at home, without anyone being able to link this behavior to any particular event.
Genetic and Environmental Factors
4 As specialists explain, making the link to what the DSM  calls attention- deficit/hyperactivity disorder (ADHD) is no simple matter: the very term “hyperactivity” can contribute to trivializing the symptoms, since it poses the risk that every restless child will be diagnosed as hyperactive. There are many possible reasons that might lead to daydreaming, being restless, distracted, or anxious.
5 The number of children with ADHD is said to be around 5%. They are far from all being diagnosed, since France lags behind somewhat in awareness and treatment of the condition. This is why, last February, the French National Authority for Health (Haute Autorité de Santé, HAS) issued a recommendation on the issue to family doctors and schools, in order to make it better known.
6 The fact is that certain children have difficulty in focusing their attention, and are constantly distracted. And it is this attention deficit (some prefer the term attention dysfunction) that is the primary symptom of ADHD.
7 “We are talking about a neurodevelopmental problem, which is something quite different from a simple psycho-emotional problem (even if the two may be linked), because it affects the neurological development of the brain,” explains pediatric psychiatrist Jean Chambry, who led the recommendation. “Neuro-imaging reveals an underactivation of the prefrontal cortex, the part of the brain responsible for processing and sorting information. We also see a delay in the maturation of the brain.”
8 “The condition has a multifactorial origin, and today we talk about it in terms of an interaction of genetic and environmental factors: studies have highlighted the role played by intrauterine perturbations linked to prematurity and to smoking. But one thing is certain, ADHD is not simply a social issue, caused by perpetual zapping and the overstimulating environment in which all of today’s children are immersed—even if this environment can help exacerbate the symptom,” he adds.
A Delicate Diagnosis
9 The condition is far more subtle and difficult to grasp than it may seem. The diagnosis is not simple because, taken separately, the symptoms can seem unremarkable: attentional difficulties, agitation, and impulsivity, combined and in varying degrees. It is therefore difficult to distinguish them from simple behavioral problems such as rejection of authority or other learning difficulties, and their various related “dys” conditions—dyslexia, dyspraxia, dysphasia, which do indeed sometimes accompany the ADHD symptoms. . . . And then it is a matter of evaluating the intensity of these symptoms, their persistence over time, and the severity of their impact on the child’s everyday life, in terms of suffering, negative impact on their capacities for learning, and repercussions on social and family life.
10 “At a secondary level this involves the child’s psychology,” says Chambry: “how he constructs his own representations of himself, how he interacts with his environment, what distresses him, how he sees himself within the story of his family.”
11 In concrete terms, the child cannot manage to pay attention, cannot concentrate on a task, all the more so if the task is a daunting one. The most minor disturbance distracts him from what he’s doing.
12 “What we see are attentional difficulties, along with agitation and impulsivity, but this is only the tip of the iceberg,” says Louis Vera, a pediatric psychiatrist specializing in attention problems and author of a comic that addresses the issue,  who has developed a treatment using Cognitive Behavioral Therapy (CBT). Below the waterline, and not so easy to spot, is a dysfunctioning of the executive functions: poor time-perception, poor emotional regulation, difficulties in initiating and maintaining a task, and an alteration of working memory; for, as he remarks, attention depends upon executive functions and working memory.
13 It is a difficult diagnosis to make. All of these children have a common symptom. But the difficulty lies in evaluating this symptom: How can we measure each child’s capacity for concentration? How do we measure mental capacity?
14 Attention deficit can be evaluated using specific tools, Jean Chambry explains. But above all, making a diagnosis calls for an in-depth clinical interview with both parents and child, conducted by a specialist pediatric psychiatrist. The indications are not the same at 6, 10, 15, or 16 years old. Some specialists also run tests, psychometric assessments, to identify other associated difficulties such as anxiety, low self-esteem, or other learning difficulties; and they provide questionnaires to be filled out by those around the child, in particular the school.
15 “For the child, we need a global approach,” confirms Louis Vera, “which can mean that a speech therapy, orthoptic, or neuropsychological assessment may be necessary. Adolescents will be more capable of describing the symptoms themselves.”
16 “All too often children are only diagnosed after a long period of trial and error,” laments Christine Gétin, president of the association HyperSupers TDAH France, the main association in France for families of hyperactive children, and which is behind the HAS recommendation. “For the last ten years in France there has been hardly any discussion of the condition. Schoolteachers don’t yet have enough training,” she continues, “they basically identify those who are the most unruly, who disturb or ignore others. If school psychologists are alerted, those children may be referred to CMPPs,  but there they will receive psychological treatments that prove insufficient and tend to cast blame on the parents, whose raising of the child is called into question.”
17 Once at junior high, it is left to parents to straighten out the situation. And only in extreme cases do they decide to seek a consultation, faced with hospital waiting times for specialists (pediatric psychiatrists) of up to ten months! They then turn to neurologists or pediatricians who make a diagnosis and immediately prescribe Ritalin without arranging any accompanying treatment.
18 Once the diagnosis has been settled upon, in the most severe cases it inevitably leads to the prescription of a drug, methylphenidate or Ritalin, an amphetamine that makes the symptoms disappear almost miraculously. The child can finally concentrate on their tasks, fidgets less, settles down, and learning becomes easier. 
“ADHD has been the object of various controversies, even if they were not so bad as those over autism,” says Jean Chambry, who led the recommendation. “So it’s a way of saying that this condition exists, of being sensitive to it, and of enabling frontline doctors, pediatricians, and student doctors to make a more informed analysis when faced with parents’ complaints and difficulties—one that does not put the problem down to a simple lack of boundaries or to learning difficulties. They will then be able to direct the parents to the most appropriate services. And above all to avoid the kind of battle that broke out over the treatment of autism—the recommendation on autism ruled out psychoanalytic treatment. We have managed to attain a broad consensus,” he adds, delightedly, “in particular on the diversity of treatments.”
Ritalin, CBT, Parental Guidance
19 It is this medical treatment—its long-term effects and fear of overprescription that has been seen in some countries, in particular the US—that provokes disagreement between specialists. At the two extremes, some believe that only a psychological approach is appropriate to care for these children, others that we need only treat the brain, since it is the brain that poses the problem and the drug corrects its dysfunction.
20 Jean Chambry thinks that these two approaches are complementary, and should not be set against each other. For him, the question, as a pediatric psychiatrist, is to know how to take advantage of the benefits afforded by the drug. “Medication in itself is not enough: both the parents and the child must be taken care of.”
21 For parents often need to be supported and offered help—especially mothers, who have too often been undermined in relation to their child. Parenting skills training programs based on CBT have proved effective, in particular those developed by Russell Barkley. Parents, who are best placed to understand their own child’s difficulties, can modify their parenting practices, share experiences, and learn to implement various strategies to control anger, for example, so as to make life easier for their child. In France, such programs have not been widely developed, are not funded, and are rarely put in place by public bodies. Similar programs exist for children, to help them to get to know themselves better, become more conscious of the way they work, better manage their emotions, and develop different learning strategies.  Jean-Philippe Lachaux, director of research at Inserm (the French National Institute of Health and Medical Research), has just launched the Atol program, which aims to develop attention workshops for all learners within the school setting, based on work in the cognitive neurosciences. The aim here is “to help schoolchildren develop a ‘sense of attentional balance’ that allows them to better manage the sources of distraction with which they are continually confronted.” Some therapists simply use drama to get their message across.
22 Individual IT-based cognitive remedial programs, aiming to take advantage of cerebral plasticity and the brain’s capability to form new neuronal connections, offer exercises to develop attention and short-term memory. One such program, neurofeedback, allows the child to follow their own brain activity, recorded in real time, as they visualize a task to be carried out.
23 “Each case, each child, each situation, is different,” states Doctor Vera, “so each one requires a specific approach. Some need individual psychological support, to regain confidence in themselves and to strengthen their self-esteem; others need the support of a speech therapist or psychomotor therapist. If the child is properly treated, then gradually he will be able to put in place strategies to get around his major difficulties, and the symptoms will reduce,” she continues.
24 While waiting for effective treatments to be developed, what were once ADHD children have now become adults. In its most serious forms, ADHD is never completely cured—one must learn to live with it, specialists say. And although some find occupations that are well suited to their liveliness and inventiveness, others find themselves in psychiatrists’ offices still in need of treatment, and above all end up succumbing to the consumption of alcohol or drugs. Hyperactivity is not a malaise of our society, and must not be taken lightly, says pediatric psychiatrist Bruno Falissard; it leads to risky behaviors and can result in premature death. This was demonstrated by a Danish study published in the Lancet in February 2015, which concludes that ADHD doubles the risk of early death in adults: accidents are the most common cause of death, and the risk is higher if a diagnosis is made late, after the age of 18, and if the ADHD is accompanied by other conditions.  This was a landmark study, showing the importance of an early diagnosis, and one which will perhaps induce the public authorities to bring France up to speed.
Ritalin: What do the Scientific Studies Say?
François Gonon is a neurobiologist and director of research at CNRS, University of Bordeaux 2. He has spent 35 years studying dopamine neurotransmission. Although he does not deny that Ritalin is effective in the treatment of ADHD, he baulks at the dogmatic insistence that it corrects a dopamine deficiency that is genetic in origin, and is the source of the condition.
Environmental Causes of ADHD. Various studies highlight the environmental causes of ADHD, mostly linked to conditions of upbringing and overuse of screens between the ages of one and three years (children are fascinated, their attention is captured in a passive manner, which prevents them from developing a capacity for active attention). But they also mention other factors. 
The Prescription of Ritalin is a Societal Choice. Ritalin was first prescribed in the US during the 1970s, and prescription grew rapidly at the beginning of the 1990s. Since 2000, it has continued to increase but at a slower rate. Depending on the state, between 5% and 12% of children between the ages of 7 and 15 take Ritalin. In France it is prescribed to less than 1% of children.  In the Italian region of Lombardy, 18 ADHD diagnosis centers have been created, with very precise and restrictive protocols; and, since 2012, the percentage of children between 7 and 15 years old diagnosed has remained stable at 0.5%. Of these, only 16% will be prescribed Ritalin. Prescription is a societal choice, and has nothing medically objective about it.
The results of studies on the risk of substance addiction do not agree and are not reported in the same way. Large American cohorts show that, statistically, as adolescents ADHD children display more substance addiction behaviors than others: they smoke their first cigarette earlier, drink more, and quicker. . . . As to whether Ritalin protects against or aggravates this risk of substance addiction, a first 1998 study concluded that it made it worse. The following year, Joseph Biederman, a researcher at Harvard University and a great promoter of the prescription of Ritalin, asserted on the contrary that it played a protective role against substance addiction. This research was widely reported. 
Barely ten years later, in 2007, this same researcher, with the same team, carried out new research on a far larger population, and this time concluded that Ritalin does not offer protection from the risk of substance addiction. These results were not reported in the media. In 2013, a meta-analysis bringing together all of the data concluded that taking Ritalin has no effect on the risk of substance addiction.
More than Ritalin, it is parental support that makes a difference to educational success. It has been demonstrated and verified that hyperactive children who have difficulties in school are around 15% more productive when taking Ritalin, and are better at completing their duties; although if the treatment increases the quantity of production, that does not necessarily mean that it increases its quality. But these are essentially short-term studies of two or three months. There are good biological reasons to assume that Ritalin treatment will become gradually less effective over time—something that is true for all treatments.
An American study has shown that, over the long term, school success does not depend on Ritalin, but on good support from the parents.
In Canada, a full-scale experiment compared two cohorts of hyperactive children treated more or less mainly with Ritalin.  It seems that the Québecois ADHD children obtained worse school results than the rest of Canada, particularly in math. Their repetition rate was also greater. Another worrying point is that more cases of depression were observed among girls. 
Ritalin is not especially dangerous, and its side effects are limited. But what is most worrying is that, in the US, following the wave of prescription of psychostimulants, today there is a new wave of antipsychotics—which certainly calm children down, but present metabolic risks such as diabetes and weight gain. And, of course, it is more difficult to do your homework while being force-fed neuroleptics. . .
Today there is considerable pressure for educational success, and we expect the school to make everyone succeed. But what is to be done for those 15% to 20% of children who finish elementary school without being able to read well enough to keep up at junior high? The temptation is for school, and society, to turn to medicine to resolve what are principally social problems.
Interviewed by Peggy Pircher
Diagnostic and Statistical Manual of Mental Disorders, the American classification system.
Théo et le TDAH, ill. X. Husson (AB Studio).
Centres médico-psycho-pédagogiques, Centers for Medical, Psychological and Educational Assistance.
Ritalin artificially activates the immature part of the brain. It is only prescribed for children over 6 years old, and can only be prescribed by a medical specialist in pediatrics, neuropediatrics, or a pediatric psychiatrist. Family doctors can renew the prescription for up to a year. Although some find it genuinely helps, it often brings about a mental rigidity that can be very difficult for others to deal with.
Starting out from the child’s strengths, these workshops aim to establish new routines and ways of doing things, so as to help them overcome their difficulties in carrying out tasks (dispersion, disorganization).
The researchers followed children, adolescents, and adults born between 1981 and 2011 over a thirty-year period. Of these, 32061 were diagnosed ADHD, 117 of whom died before reaching the age of 32.
The main environmental risk factors for the occurrence of ADHD mentioned in the studies are: poor economic status of the parents, premature birth, consumption of alcohol and tobacco during pregnancy, young mothers, mothers bringing up boys on their own, parents with mental health problems, mistreatment, and excessive consumption of television between 1 and 3 years old.
This is estimated on the basis of the number of bottles of Ritalin reimbursed for by Social Security. However, we do not know the percentage of children diagnosed with ADHD who take Ritalin.
The 1998 study was reported in three press articles, Joseph Biederman’s in eighteen.
In 1997, Ritalin prescription and reimbursement were made more available in the Province of Quebec. The rate of Quebecois children treated went from 2% in 1994 (the same rate as in the rest of the country) to 9% in 2006/2008 (the rate was variable depending on sex: in 2006/2008, more than 12% of Quebecois boys were on Ritalin, less than 4% of girls). The prescription rate for the rest of the country was 4%.
See Janet Currie, Mark Stabile, and Lauren E. Jones, “Do Stimulant Medications Improve Educational and Behavioral Outcomes for Children with ADHD?” Journal of Health Economics 37 (2014).