In the United States, approximately 5 percent of school-aged children have been diagnosed with ADHD and are taking pharmaceutical medications. In France the percentage is a mere 0.05 percent. How come the epidemic of ADHD -- which has established itself firmly in the United States -- has almost completely passed over children in France?
First, is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the United States. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological -- psycho stimulant medications such as Ritalin and Adderall.
French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress -- not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child's brain.
French child psychiatrists don't use the same system of classification of childhood emotional problems as American psychiatrists: The Diagnostic and Statistical Manual of Mental Disorders. In 1983, in part as a resistance to the influence of the DSM-III, the French Federation of Psychiatry developed an alternative classification system. This was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983 and updated in 1988 and 2000. The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding symptoms that will qualify for the best pharmacological bandaids to mask them.
To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis.[1] Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior. The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.
Sociology professor Manuel Vallée points out another important but often-overlooked advantage of the French approach, which is more holistic and psycho-social. The French point of view allows for considering nutritional causes for ADHD-type symptoms -- specifically the fact that the behavior of some children may be worsened after eating foods with artificial colors, certain preservatives and/or allergens.[2] Clinicians who work with troubled children in this country -- not to mention the parents of many ADHD kids -- are well aware that dietary interventions could potentially help the child's problem. In the United States, the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.
And then, of course, there are the vastly different philosophies of child-rearing in the United States and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her book, Bringing up Bébé. I believe Druckerman's insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the United States.
From the time their children are born, French parents provide them with a firm cadre -- the word means "frame" or "structure." Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it. French babies, too, are expected to conform to limits set by parents and not by their crying selves. French parents let their babies cry it out if they are not sleeping through the night at the age of four months.
Consistently enforced limits, in the French view, make children feel safe and secure. Clear limits, they believe, actually make a child feel happier -- something that is congruent with my own experience as both a therapist and a parent. Finally, French parents believe that hearing the word "no" rescues children from the "tyranny of their own desires." And spanking, when used judiciously, is not considered child abuse in France.
As a therapist who has worked with children for more than twenty years, it makes perfect sense to me that French children don't need medications to control their behavior because they learn self-control early in their lives. The children have grown up in families in which the rules are well-understood and a clear hierarchy is firmly in place. "C'est moi qui décide" ("It's I who decide"), asserts the French parent. In French families, as Druckerman describes them, parents are firmly in charge of their kids -- instead of the American family style, in which the situation is all too often vice versa.
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References:
[1] Vallee, Manuel. (2011) "Resisting American Psychiatry: French Opposition to DSM-III, Biological Reductionism, and the Pharmaceutical Ethos" in Advances in Medical Sociology, Volume 12, p. 97.
[2] Valle, Manuel. (2010) "Biomedicalizing Mental Illness," Understanding Emerging Epidemics: Social and Political Approaches Advances in Medical Sociology, Volume 11, pp..290-291