ADHD Isn’t What You’ve Been Told: Psychiatrist Explains

Dr. Sammy Tamini, welcome to the podcast. Thank you for coming on. We're going to be discussing topics from your new book, Searching for Normal. What I was particularly interested in this book was two issues that are really timely today, and that is ADHD and autism, sometimes called captured under the neurodivergence bucket. But everywhere I look online, it seems like these things are expanding. So, why don't we start with actually ADHD and go from there. So just to level set for the audience, what is ADHD?

Firstly, can I say thank you so much for inviting me on your show. I've known about your work as well and I'm a big admirer of what you're trying to do and what you're trying to help with both your patient group but also helping educate the public because, you know, coming back to your question about ADHD, there are so many mythologies going around about what we mean when we talk about concepts like ADHD and autism. And these mythologies have been a big reason why we've had this explosion in numbers of people who are coming forward imagining that this is a condition that they sort of have hardwired somewhere inside them and that we have the expertise and the knowledge to identify that. And that when they get a diagnosis, the person making the diagnosis has identified something characteristic and specific that's different to people who don't have this condition, which is rooted either in some sort of abnormality, so a kind of disorder in your nervous system, or some sort of essential difference that makes it harder for you with that diagnosis to get on with many day-to-day aspects of living that you imagine other people are more able to do.

And really, to kind of get under the hood, as it were, of what's happened. How did we end up in this position? I think it's important to go back and see what type of assumptions crept in along the way as these concepts developed because one of the important things to help people understand was that at no point on this journey of these concepts developing, starting out, widening, entering new populations, at no point was this following some type of scientific discovery about what is going on in people's brains or nervous system more generally.

Well, I, I mean, I think that deserves to be underlined because I think most people when they think of ADHD and the way it's discussed, you know, you know, deficit, you know, it's attention deficit hyper or hyperactivity disorder, that there is like a brain problem going on, you know, that we can scan the brains and we can find differences going on, that this isn't just normal forgetfulness. This isn't normal inattention. This is something that's categorically different, I think, in a biological way, is what most people assume. Has, has that not been the case?

You're right to say that that tends to be the assumption. So these are one of the myths around it. So it's referred to as a neurodevelopmental disorder. And as it's become more widely identified, spoken about, it has also then widened from the idea of a disorder. And then you've got the whole neurodiversity movement coming on the back of that, talking about a specific identifiable difference, an attempt to divide the population, if you like, into a group that are considered neurodivergent and a group that are considered neurotypical.

Would it help maybe to give an example with, for, I mean, I can talk through the history in a kind of nutshell of ADHD and of autism. There is some differences in their histories of how they developed, but there's also quite a lot of overlap.

Yeah, I would love that. Let, let's, let's do the nutshell version. That sounds great. Yeah, because I think that might help people understand that what is going on here is not a discovery of something that is essentially different, characteristic, that you can identify in the brains and bodies of people, but what I call a mutation of constructs. So it starts with an idea, and this idea then broadens and widens, and not in response to any new discovery about the brains and bodies of people who are being labeled with this condition, but because of a change in the way we think about it.

So if you take, for example, the history of ADHD in a nutshell. In practice, it starts out with this very rare condition referred to as hyperkinetic disorder, where the focus was on levels of activity. And in the original construction of hyperkinetic disorder, I mean, this was something that was developed as part of the practice in this country where I am, which is in the UK, but there were similar ones as well in other countries. In this construction, instruction, if you had learning difficulties, that automatically excluded you because it was assumed that if you had learning difficulties, you might have trouble settling down and focusing and so on. So the, the construct starts in that way. And when I first started as a child psychiatrist in the early to mid-1990s, I didn't meet anybody with this diagnosis. It just wasn't used.

What happens next is that the concept expands when people start saying, well, maybe it's not hyperactivity per se, but maybe this is a secondary effect from difficulty paying attention. So the whole idea of attention deficit comes into the definitions, and this allows it to expand further. The next step in the changing of the definitions was not to exclude if you have learning difficulties. From there, it then expands into the idea of attention deficit hyperactivity disorder. So it starts out as ADD, after hyperkinetic disorder, attention deficit disorder, then expands into attention deficit hyperactivity disorder. And now you're talking about a larger number of kids. Though initially, the prevalence was thought to be somewhere between 0.5 and 2%. Over time, that prevalence rate expands as the criteria are sort of loosened. So we've had different definitions coming in. And at this stage, we're still talking about something that's conceptualized as a developmental condition. By developmental condition, it is meant that it was expected that most children would grow out of it. So this was something that would present during childhood, and as the brain matures, things like hyperactivity and some of the features of difficulty paying attention and impulsivity would sort of even their way out.

But the next iteration, so in this country, we're talking about the mid to late 2000s now, the concept of adult ADHD starts coming in. So up until now, the expansion has been what you might consider horizontal. So lesser degrees of severity is coming into the definitions, which brings more children into, so the prevalence rate is increasing, or the assumed prevalence rate. But when we start the concept of adult ADHD, we're talking about a vertical expansion because now you're taking it into a new population. So in order to enter into this concept that there's something called adult ADHD and that most children don't grow out of it, the concept is now migrating into something that's considered lifelong. And that to pick it up in adults, you have to look at different criteria. So a new set of definitions comes into when you're thinking about ADHD in adults. So the screening questionnaires, if you like, for adult ADHD are different to the screening questionnaires you get for childhood ADHD because it's assumed in adulthood, it's going to present differently. So now you have an even bigger proportion of the population coming into the definition.

And the next iteration is the concept of masking comes in. Again, there's there's no evidence behind why this actually uncovers another group who have the same condition. It's simply introducing a new idea into how we define it. So the concept of masking or camouflaging is the idea that you have these behaviors, which are now constructed as symptoms because this is considered a medical condition, that you have these behaviors, you have these experiences, but people don't see them because you're really good at hiding them. But as soon as you're out of company, these other aspects of your life, you're just not able to, uh, keep them together. And the concept of masking allows ADHD to migrate from being, up until then, a condition predominantly diagnosed in males, to a condition that is now also increasingly diagnosed in females. And women for a long time have been the main psychiatric clientele, if you like. So this allows it to expand and increase in the numbers of people who imagine that they also have this condition called ADHD. So these days, the fastest group in which there is a growth of people being diagnosed with ADHD is actually adult women. So what's happened along the way is this migration, this, what I call a mutation of constructs. These are ideas being put forward. They are not, uh, evidence-based constructs. And we can see something very similar in autism.

Let's stay, stay with ADHD for now. So if all of these, you know, horizontal and vertical expansions, the broadening of this concept, if it wasn't driven by biological discoveries in the brains, you know, that that allow us to cleanly distinguish the sick from the unsick. What has been driving this expansion? Is it as black and white as the pharmaceutical industry kind of expanding market share, or are there more forces at play that is leading people to to want to get these diagnoses and such? I'd love to to get your thoughts on on how this has happened.

Yeah, just before that, I think it is important to understand that what we're talking about here is upside-down science. So things like ADHD are facts of culture. They're not facts of nature. The, the, the way science develops is you put forward a hypothesis and you assume your hypothesis is incorrect until you can find evidence to support that hypothesis. That's the scientific method. You need something empirical, measurable. But what's happened with the concept of ADHD, the way it's expanded, concept of autism, the way it's expanded, depression, anxiety, a lot of things that come under this heading of general mental health or behavioral difference is that we've had examples of upside-down science. There is a proposal that these behaviors, for example, equate to some sort of condition that's going on in your nervous system and that's specific. And there is an acceptance of this proposal as valid before you found any empirical evidence to support this hypothesis. But worse than that, you then call on your critics to demonstrate that your hypothesis is incorrect. This is not the way science works. All the critics need to do is to demonstrate that you haven't reached the, um, basis of empirically supporting your diagnosis. So in the scientific sense, there is no such thing as ADHD because we have not yet find, you, you can't do a brain scan, you can't take a blood test, you can't see ADHD under the microscope. It's an idea. So that's an important thing to understand.

And then comes your really important question. Well, if we've got something that has very little basis in science, but it's an idea, and this idea has proved very seductive, what might be driving this? Well, we kind of see that throughout history because we are seeking meaning-making creatures. We want to make sense of what's going on in in our life. So, we've had all sorts of ways of trying to make sense of particularly when we experience distress or alienation or discomfort in our lives. We want to make sense. We want to know what might be going on. And we also want to know how, how to make a difference with that. This creates a psychological desire for some sort of idea that might provide some type of explanatory mechanism. And one of the things that has happened is because we live in a society whose cosmology, if you like, whose predominant way of trying to make sense of the world has been with this scientific approach. A lot of ideas that if you can cloak them in the language of science, if you can cloak them with an idea that they come from something scientific, prove very attractive.

And when you have something that is whose definitions are subjective, because if you look at what is considered the symptoms of ADHD, for example, I mean, calling them symptoms, you've already taken a jump in how you understand them. These things all start with words like often. So "often squirms in their seat" is a classic one for for kids in the questionnaires for kids. But what's a, a unit of squirm? You know, how long do you have to move in your seat? And how many units of squirm do you need for it to classify as often? So, you've got all of these subjective things. And the thing about when you have subjectivity masquerading as objectivity is that it can be expanded. And it's going to be expanded in times where there is a greater degree of distress, feeling you're not good enough, dissatisfaction. So they tend almost to be a barometer of what might be happening more broadly in your society, in your culture.

What's happened, I think, in, in our societies these days is we've built up a whole process which has built up something that I refer to as the mental health industrial complex. So there are these processes that can happen. The fact that you're talking about them, the fact that people are researching them, they're, uh, you know, getting on programs to talk about them, their institutes developed and research places. You, you kind of over time develop a whole ecosystem of products that are talking about this condition and talking about it and assuming, and, and who are the public to know that that's what they're hearing? They're hearing these people who call themselves scientists, who call themselves experts, talking about these conditions, talking about these behaviors as symptoms, talking about, you know, how you manage them, how you can treat them, and so on. So you build a whole machinery around.

So things like ADHD, I now think of them not as medical diagnoses, but actually as commercial brands. So around this brand has built pharmaceuticals, therapies, books, apps, educational toys, programs, research institutes, expert assessments. You know, there's a whole lot of, and, and the way I think about this is it's mostly done by people who are have the good intentions and and out there trying to help people, but it's ended up, to my mind, these are brands who are profiting from the expansion in the levels of distress and alienation that we're feeling. So in some ways, this whole mental health industrial complex, I see it as a little bit of a reflection or a barometer about how we're feeling as a society at the moment.

Is there something genuinely behind the increase in people who are struggling with attention and focus nowadays because the suffering is real. I mean, you talk, you talk to men and women as well, and they are genuinely having problems. Are things getting worse at the moment? Are we having more issues with inattention like now in 2020 than we were back in, you know, 1980? And if so, what do you think is behind more people having these types of difficulties?

It's a kind of hard one to answer that question. I know there are some researchers who feel that there is something concrete and has actually reduced our levels of attention. And they might point their finger at the things like how social media works because social media works on short attention clips and whether we're actually training people to get bored very quickly. But there's also some peculiar features. So, for example, in the diagnosis of ADHD, the way it's being conceptualized these days, if you have the ability to hyperfocus on things, you're, that's con also considered a symptom. So not being able to focus is considered a symptom, but hyperfocus is also considered a symptom. So I don't think people are losing the ability to focus. I do think we are living in a society where there is a lot of information overload. It's a very highly stimulating society. I also think we're living in a, in a very performance-driven society. So it's, it's quite easy to find yourself feeling that you're not good enough because there is an expectation that you're going to be able to demonstrate. You know, one of the ways you get social value these days is by demonstrating that you're good at something. And this is a reflection of something else which is going on within our culture, which is I think more influential per se than how we're training our young people to have these shorter attention spans with things like social media, which is that we live in a quite a hyperindividualistic culture. So the way you get value, you get value just for existing in in many cultures. I, I think I mentioned earlier on that my father is from Iraq. So I grew up until I was 14 in Iraq. It's been very interesting looking at language and what they tell you about concepts. So anthropologists have a describing different cultures. There tends to be a tendency, some cultures tend to focus more on the self as an individualistic thing. So that's very much the case in Western culture. But other cultures tend to have a more collectivist orientation. So the idea that the self cannot exist without other selves to interact with. It's a very relational, community-based, and in those cultures, the sense of value is just given. You just have a sense of value for existing. So I remember having looking into the concept of self-esteem. Self-esteem has become a very big concept. This idea that how do I feel about myself? But there isn't even a direct translation in Arabic of self-esteem. It's a very strange concept. If your concept of the self is relational, the idea of how do I feel in myself and isolated from, you know, the relationships of people around me is a very strange idea. So I think one of the things that's been happening is that we've become much more inward-looking in the way we understand our life. And we feel that sense of pressure. That sense of pressure seems to be all around us. That sense of, I'm not, I don't feel I'm good enough, and monitoring how we perform and how we do. And I think that sort of thing is affecting our levels of distress. It's, it's very hard when you're constantly trying to measure up to some abstract idea of what is good enough to psychologically feel well.

I mean, this is so timely right now because right now, early decision for college is coming out in the US, and in our high schools, it's in many places, especially, you know, coastal cities, it's, did you get into an Ivy League school or did you get into this type of college? Many people just see that as their whole world. That that's like, am I good enough if, if I get into that school? And unfortunately, some parents see it that way as well. If my kid gets into this school, you know, I've succeeded as a parent. And so, the amount of pressure is immense. I mean, we've had rates of ADHD go up in adolescence, and recently there was a piece on this in New York magazine on on stimulants, and it was something like 17% of boys aged 14 to 17 had ADHD diagnosis. I mean, it's on face, it's absurd because, you know, that proportion of boys don't have brain disorders. And, and what we're probably seeing is kids seeking performance enhancement because they're, they're worried that they're not going to measure up. And, you know, particularly for men, I think in this, in in the United States, it's like, what job do you have? You know, where are you going to school? Like, those, those are the questions that people ask because that's how we assign value.

Yes.

And so, that's what I was saying. Yeah. That that kind of social value in an individualistic,

culture is very performance-related rather than how good you are at helping others and being support supporting your family and, you know,

correct. You know, where we're a very beauty-obsessed culture, particularly when it comes to women. And, you know, we, we often see, you know, going outside of ADHD with depression and anxiety, there's, there's a little peak in the 40s to 50s with women where they feel like, you know, they're kind of sliding out of this area where, you know, us media, all of this kind of stuff, places huge value on youthfulness and beauty. And then, you know, helping women transition out of that phase is,

grow old gracefully and just let nature take its course anymore.

Some of it's kind of crazy. Like, you know, I, I remember when I was growing up, we'd have these grandmas who would have like the short perm and they would look like grandmas. That's, that's how I would remember it. Nowadays, you see grandmas in high heels and miniskirts and they're wearing push-up bras and all of this stuff. It's just, in my generation, I've noticed this big shift from being able to simply be old to to chasing this youthful appearance to the point where it actually looks quite ridiculous.

You see, this is where we have a culture where we almost have to brand ourselves. We have to stand out as a brand. That's the kind of endpoint of this hyperindividualistic tendency that we have, where social value comes from what we do, how we appear, rather than just for being.

The other thing that that's was also coming to my mind, you know, going back to the ADHD issue is it's like incentivized to get a diagnosis now because of all of the benefits. I can't remember the exact statistics, but someone recently did a poll of people claiming like disabilities for extended test-taking time at elite universities, and it was something like 30 to 40% of of the freshmen were, you know, quote, you know, disabled, which is just ridiculous. I mean, it's a sign of people just getting these diagnoses from their doctors for more test time, better grades, and all of that. And no one being brave enough to stand up and say, "This is, this is ridiculous." You know, you know, 40% of the, you know, the freshmen at these elite universities don't have mental disabilities.

It really demonstrates how easy it is when you have such subjective criteria to stretch them in all sorts of ways. There was a study at Oxford University, or rather a report at Oxford University. It came out that when it was discovered that you could get 25% extra time in your exams if you had a diagnosis of ADHD, and they did a kind of screening program and, you know, invited students to go through the screening program, and in the screening program, they discovered that 90% of the students they screened had ADHD because people had heard that's. And it's, you're, you're not taking a blood test. You're not doing a brain scan. You're filling in a questionnaire. That's, that's what you're doing. So, of course, then if the, if you realize that there are these incentives, why wouldn't you? Because then it becomes unfair on the people who don't get the diagnosis, doesn't it? Because they have, they don't get that extra time.

Yeah. And I feel like a lot of this comes in through the the guise of compassion. It's just like, well, you know, it's the nice thing to do to give them the diagnosis. You know, that they're suffering. Let's give them something to make them not blame themselves, make them not beat up on themselves for feeling like they're having problems. You know, it's not you, it's your brain. And who am I to stand in the way of you, you know, feeling better about these struggles that you're having? And last thing I'm going to do is challenge them because gosh, if I challenge that you're not, you know, that, hey, this is just kind of normal. Some people have these difficulties, then then you look like you're insensitive and you're not taking their concerns seriously.

That's a difficult one to tread because there is a psychological function to the process. Look, I, I think it's worth identifying that people need to be heard. People need to be validated. People need to have a sense that they're being taken seriously. We kind of all need that. But we have to be careful when in our attempt to provide that psychological support for people to be listened to, we don't accidentally lead them down what I call the rabbit hole, into the Alice in Wonderland, you know, hall of mirrors where things start to stare back at you because these things are constructs, because there's, it's not identifying anything specific and concrete in your brain and body that's going on, because these act more like a commodity. It tends to have a limited shelf life. So for a lot of people, what happens is after a few months or a few years, it's not serving the same functions. They're still feeling these problems, and they start to think, well, maybe there's something more than just ADHD. And they're already some got pushed, or rather pointed down the road of thinking of their difficulties in these kind of neuroconstructivist terms. So they might now think, "Oh, I also have autism." So that's quite a common one. People who get a diagnosis of autism often then later get a diagnosis of ADHD and vice versa. That's becoming increasingly common. But I've seen this happening in young people now where I've seen, for example, a young person who came to our clinic. She was only 15 at the time. She'd already been diagnosed with autism, ADHD, PTSD, anxiety disorder, OCD, and they were now at the clinic because the young person and the mother had come to the conclusion that there's something else going on. None of these quite explain, and they've looked it up and they now think that maybe she has a bipolar disorder. So this is the sort of thing that can happen. It can lead you accidentally on a journey towards a potential lifelong relationship with a mental health system. And that can also start to include an acceptance that you need psychiatric medication. And I think, you know, all the potential harms that that might lead to, particularly for people who are actually able to function.

Yeah. I want to flesh that out a little bit and see what you think about this because, you know, okay, say you have an ADHD diagnosis. I mean, we talked about many of the reasons why someone could be suffering, but there's a few more in there. I mean, they could be having, there could be some traumatic things happening in the home. You're very distracted. I, for one, actually actually believe that food is a problem with a, you know, depression, anxiety, even ADHD. I think, you know, we're getting 60% of our calories in children in the US from ultra-processed foods, which are nutrient-poor and high in sugar. And that, you know, not only is it driving insulin resistance at rates that are insane, it, it's also highly correlated with all kinds of mental health problems. And so, you know, we've got trauma, we've got food issues, we've got people smoking cannabis.

We have like identity issues where my whole identity is how well I do on this test, even though maybe I actually don't really even care about the subject in the school and I'm just getting pushed. And so there's, there's a million different ways you could end up struggling. But if you go and see the doctor and they say, "Hey, you have ADHD." And the language that they use infers that you have a mental disorder. You don't actually look at all of those other reasons where you could, hey, maybe I'm work on my sleep, exercise a little bit more, kind of have a closer look at what I'm eating, do some soul-searching, find out what subjects I'm really interested in, you know, do some therapy with mom and dad, kind of work on these, you know, a more root cause holistic approach. Instead of doing that, it's like, oh, well, you know, it's a dopamine deficiency and I need, I need my Adderall. You get on the Adderall, all of a sudden you're feeling a little bit jittery, and the doctor says, well, maybe you have an anxiety disorder. Next thing you know, you end up on some Lexapro, and you have an episode of impulsivity or even irritability or sometimes even aggression.

Oh, this is pediatric bipolar disorder. And before long, this thing, you know, you've morphed into a mental patient.

Yes. And, and the system has created that mental. You, you make an extremely important point around causation because the way we think about diagnosis is, I mean, in medicine, diagnosis is a system of classification based on an understanding of a proximal cause. But in most of the psychiatric presentations, we have a system of classification which is descriptive. It is not based on an understanding of proximal cause, but we treat it as if it does. You know, when, when you have a condition like diabetes, you have something external to your subjectivity that you can measure as to whether the treatment is making a difference because you can measure the blood sugar. There's different ways you can measure in the short term and the long term to see if the treatments is making a difference. So it makes sense to talk about it as a diagnosis because that diagnosis will help you with devising a treatment, and you then have mechanisms. And so in many other branches of medicine, because we can build technical knowledge around that, we've seen a lot of progress in outcomes. But in presentations like what we're calling ADHD, we're making a basic philosophical error. If you say the reason that I'm impulsive and can't settle and finding it difficult to concentrate is because I have ADHD, you have to ask, well, how do you know it's because you have ADHD? And this is, by the way, the way we use ADHD. We say it's causing us to feel like that. But if you ask the question, how do you know it's ADHD? You can only answer it with this circular answer by saying, "I know it's ADHD because you're having trouble settling down and because you're experiencing impulsivity." So, a definition that's descriptive. It's like a description cannot cause itself. And the problem with that is it's the opposite of holistic. What you're doing is you're taking all the things that could be happening in that person's life and taking them out of the picture and putting you down a very narrow pathway. So all the things that you're talking about, because sometimes these behaviors could be symptoms. So I've come across children who've had a malabsorption syndrome. You know, I picked it up by just doing some basic medical questions, talking about asking about symptoms, asking about, you know, I've come across young people who've had a poorly controlled asthma. It causes irritation in the body. Of course, they're, they're kind of jumpy and they can't settle. You know, anybody who's got anything going on like that will find it hard to settle. But I've also come across kids where the parents just were lacking confidence and were hoping that a professional would tell them. And so there was this kind of power imbalance in the family. And sometimes they've been already been to see someone who's given them a diagnosis, and now they assume there's something special that they have to do with their child, and that they need an expert to talk to them, and they shouldn't intervene or guide them because they don't know how to because they're not a professional. So it could cause all sorts of implications for family dynamics. Yet again, I've come across other people where there is a father who's who's lost contact, and the child doesn't understand why and what happened. Uh, and I've come across other children who've been exposed to horrendous domestic violence. And the one of the ones that kind of particularly troubles me is the number of children in care who are now getting these diagnoses.

Is that foster care? Foster care or children's homes. Yeah. Yeah. Because by definition, the adults in their life have let them down. They are dealing with a lack of trust that their living situation is going to be stable, predictable, and a lack of trust that they can attach to anybody because their experiences. You can't trust people who will stick around, will treat you well, will look after you. And these people are getting diagnoses of autism and ADHD by the bucketload. And, and that seems to be, you know, an abrogation of a holistic approach. So you're absolutely right. The problem is if we assume that these labels that we're giving are diagnostic, in other words, telling us anything about cause, we're making a potentially harmful assumption that makes it harder for us to look at things that might be going on that might have more explanatory value and might help us devise interventions or at least ways of thinking about and understanding what's going on in that person's life that might make a more lasting difference.

So that, I mean, that makes a lot of sense to me. But I imagine some people may listen and just say, "Yeah, I get what you're saying, but listen, when I take Adderall, or when I give my kid Adderall, you know, they're doing better now and they've been doing better on this for, you know, you know, last couple of years. What's the big deal?" Certainly looks like a dopamine deficiency to me because I put, you know, I put Johnny on the on the medication and grades are going up and the teachers say he's doing better. Tell me a little bit about stimulant medication, like how effective is it? You know, what are the risks of just defaulting to that? Yeah, tell me about that.

The evidence on stimulants, and it's really important we know what we're talking about. We're talking about, I mean, for example, Adderall is an amphetamine-based substance. We're talking about the same sort of substances. These are controlled drugs. They work in a similar way to, you know, as a street drug, we'd call it speed or cocaine. That's, they work in similar ways to that. So, we're not talking about substances that are fairly lenient in terms of their effects on your body. We're talking about substances that we warn people of the dangers physically and mentally of taking them. So, first of all, we need to make sure we understand what we're dealing with here. And so what you need in the evidence base if you're going to give particularly children, but anybody, these substances, and we're not talking about regimes that talk about, you know, give it for a year and then wean them off, you know, use it as a window of opportunity, for example, if they're feeling a bit better, doing a bit better, use that as a window of opportunity to build other things in. We're talking about things that are conceptualized as something that you would have to take for years, possibly the rest of your life. So, we need to have clear blue water in the evidence base that taking it long-term leads to significantly better outcomes for the people who take it compared to people who don't who have similar levels of behavioral problems. Now, there's a whole heap of evidence that tells us the picture is, if anything, the opposite of that. Long-term outcomes are, if anything, worse in a number of ways in terms of people who do take these medications long-term compared to those who have similar behavioral problems according to rating questionnaires of a similar severity, but who don't take that.

There is a Norwegian professor who I've recently got to know called Professor Mikkelton, who's been doing a number of research projects looking at various aspects of both the effect of a diagnosis of ADHD and also the effect of medication because they have very large health data registers in Norway. So they can follow people up for many years. And one thing that there's been this idea that stimulant medication leads to better academic outcomes. Not true. No difference. Compared people who take medication with an ADHD diagnosis and have similar presentations compared to people who don't or who have never taken it. It's not true that it leads to lesser likelihood of injuries or going to prison or so across a lot of indications, there's no evidence that in the long term it leads to better life outcomes.

But his most recent study that he is now been speaking at international conferences. So this has not yet been published, but it has been on the conference presentations because it's completed. What they have in Norway is they have 23 regions where they have child and adolescent mental health services, and there's a 10-fold variation in the rates of diagnosing children with ADHD. So using economic models of research, this is what's known as a natural experiment. You can look at the outcomes from the different regions and follow up the individual patients and make a comparison in following up the patients who had similar behavioral presentations in the regions where they got high levels of diagnosis compared to the regions where they got low level diagnosis and control for other factors like socioeconomic status, etc. And if you get a diagnosis of ADHD during childhood, you had a higher risk of dropping out of school and a higher risk of ending up unemployed and drawing disability benefits. Now, he says this is the economic model system suggests this is causative. In other words, getting a diagnosis of ADHD actually causes worse outcomes.

This actually accords very well with two other studies. One was done in Ireland and one was done in Australia. And there's a group of studies around at the moment where they take a cross-section of children and they follow them up and they do a battery of tests every two to three years and they follow them up into adulthood doing a number of health screenings. And because there are more children who are diagnosed with ADHD and they do a lot of these screenings, including behavioral questionnaires, they have a group of children who get a diagnosis of ADHD and they can compare with a group of children who don't get a diagnosis of ADHD, but had similar levels of ratings on these behavioral questionnaires. So in the Ireland study, they had about 127 children with the diagnosis of ADHD. In the Australian one, they had about 400 children. So, you know, reasonable numbers, and they were comparing with a similar group who didn't get the diagnosis. And in both the Irish study and the Australian study, the Irish study had followed them up for, I think, an average of nine years, so into late teens, and the Australian study, I think, was into the early 20s. They had a slightly longer, I think it was 14 years average. And they found that on a number of measures, including self-esteem, likelihood of mood problems, a sense of self-efficacy, uh, on a number of these measures, the children who got a diagnosis of ADHD were actually doing worse.

And a lot of the, the sense that the stimulants are useful for you comes from their short-term effects because in the short term, you can see quite dramatic effects, and it's very seductive when you see a child who seems to have been bit all over the place, not sitting down and concentrating, who appears to have started, uh, doing that. But that's a generic effect. What they do pharmacologically is they give you a kind of tunnel vision. So things that you, you found boring before, you, you're more likely to get into them. It's the same reason why people take speed if they go to a rave because you'd get right into the music. You just gives you that tunnel vision. So it's a, it's a generic effect. It's not a lack of dopamine effect. People have looked for dopamine deficiency. They haven't found it. But the problem is once you've got caught into that way of thinking about it, the brain, as you know, has homeostatic mechanisms, like the body has all sorts of homeostatic mechanisms. So if more dopamine than usual is being released, it starts to turn off receptors. And this is why you often see people having the dose go up. It also has lots of interferences. You've probably come across the famous MTA study. This was the multimodal treatment of ADHD, where they compared behavior and medication and a community sample. Well, they followed them up for three years, and even though after 14 months, they assumed that the medication was having benefits over and above behavioral approaches by themselves, by three years, those differences had disappeared. But the people who'd been taking medication continuously were now shorter and lighter, were having trouble with sleeping. So, it's quite common that people who take stimulants also get prescribed some sort of sleeping aid. And you've just given a very vivid description of once you go down that pathway, you'll start being more accepting of other diagnoses and other medications. And this is how you can accidentally create this potential long-term patient, which never needed to have been the case.

That is terrifying because right now in the United States, 5% of our children are taking ADHD medication, and it does sound like, you know, the long-term effects are poor, and there's sleep issues, and there's height and weight issues. That's been greatly hidden from people. I think that's something that no one really talks about.

Yeah, I think people are not really exposed to what this potential long-term out, even if the effect is exaggerated, or even if there was no effect. There has to be clear blue water in the long-term evidence. If you're going to give something long-term, you have to really have a pretty solid grounding that this will, you know, you're exposing your body to things that increase your metabolic rate in all sorts of ways. So, if you're going to do that, you have to have clear evidence that this is going to lead to a lasting beneficial change. And we don't have that.

Now, this is a bit of a technical question, but I'm, I'm very familiar with the SSRI medications, and we've done two very, well, I mean, they're large for primate studies, you know, they're about 30 rhesus monkeys in each cohort, one in Maryland, one at UC Davis in California, where they put the young monkeys at one year of age on fluoxetine, and then they measure a whole bunch of, you know, behavioral changes, neurological changes over time. And, and I think they, the monkeys take them for two years, and then they come off the medications, and then they follow them for 18 months, which is essentially in monkey years, it's, it's like being on it for your whole childhood until adolescence, and then taking a break, and then doing the measures in monkey, you know, young adulthood. And they find neurological changes in the brain that that do not reverse after they come off the medications. They find changes in serotonin receptors. Now, these are smaller studies, but they do find trends in, there's a decrease in dominance type behaviors. The monkeys tend to be slightly more submissive afterwards. Again, these are trends, but it does suggest that at least exposure during that critical period of brain development, it does change the trajectory of brain maturation, and it does result in some behavioral differences. And so with with ADHD, to your knowledge, like when, when you think about, I think it was Mickelton was looking at, like, do we think the risks are coming because people identify with the illness and then the behavior that follows from that identification leads them to becoming more likely to be unemployed later on? Or is there any evidence that just being on the medication long term, like with the monkeys on the SSRI, could actually also be harmful? ful in a way, just purely the the medication effect over time.

I think it's likely to be a mixture of both. I mean, your, your brain is still maturing, and you're messing with the homeostatic balance of your neurotransmitter system, uh, in your brain. So, I'm trying to recall. I, I remember many years ago, I looked at some of the animal studies, and I remember there were a number of studies with stimulants involving rats, and I might be wrong about this, but I do remember it had an effect. I think the effect was that when they became adult rats, their level of curiosity and their sense of giving up on something was a lot more than those who didn't. Is, is kind of the, you know, the, the normal, you know, seeking and discovering, uh, activities that, uh, rats would undertake, you know, to find food, mates, whatever. It appeared to be interfered with. I might have misquoted that, but I do remember there were some, uh, behavioral effects, and it would be surprising if you've been exposed to medication all this time that it didn't have behavioral effects.

But I've seen another effect, which I think this might be a chemical effect, but I've got a feeling it's, it's a different type of effect. So I've been involved with weaning young people off, uh, stimulants, and one of the things that happens is that they do start becoming more agitated, more difficult, more argumentative, and, you know, parents can find that quite difficult. So, I've learned to actually warn people that that's likely to happen. And I've began to wonder, and so this is one of my interpretations of what might be going on. I began to wonder when you're on a stimulant, you've got this kind of focus, your ability to cope with multiple inputs. So one of the side effects of stimulants is, of course, is something we call perseveration. Getting stuck, you know, like this, the old-fashioned vinyl stuck records, stuck doing the same thing. This is a, this is a side effect. Now, that might be quite good when you're younger, but when you're older and going through a phase of learning, does it interfere with your capacity to keep lots of lot more complicated ideas, keep more than one idea going? And does it also interfere with your capacity in the changes that happen in how you feel things? So, one of the things I started to wonder is as you come off stimulants, are you actually starting to experience the full force of what it's like to grow up and feel things and be angry and get love and all of these more intense emotions? Is it a bit like you're suddenly experiencing emotions in their

more fuller form? You you've missed out on all of that for many years, and families can find that hard to deal with. But actually, with a bit of patience, if you talk to them that this might be going on, actually people find a way through because then they've been given a model, a way of understanding what might be happening.

>> That wouldn't surprise me at all. I mean, I wean quite a few people off antidepressants and antipsychotic medications sometimes who have been put on them in their teenage years and they're coming off in their late 30s, early 40s, and in some ways, they're emotionally stunted.

>> And not medication. Yeah. We've we've robbed them of the opportunity of weathering emotional problems, disagreements, and and finding the skills and the tools to to manage their emotional states and and work through things. And so all of a sudden, they're hit with all of that at age 40, you know, and it's happening 20 years later than than it normally would. And they get through it, you know, but it takes time. And it's quite terrifying for them to have to feel all of those things at full intensity.

>> Yes. And it can be dangerous. You know, people who've not used to emotional intensity may come to the conclusion that, oh my god, I can't manage. So, you do have to help them and prepare them for that. But people do get through it. I I've been so impressed by the capacity that humans have to find a way through even the most difficult situations. You know, I've over my three decades plus of of practice, I've seen people who've been incredibly disabled by the nature of the distress that they're experiencing. And I've seen people after many years of going in and out of inpatient units, tried on this treatment, that treatment, just finding a way through. We undermine our natural capacity. So I'm one of these people who don't believe you can teach resilience. Resilience is something you have to discover. You can only discover what you're able to withstand by having to go through it. There's no shortcut to that. But when we try and sedate people or calm people down or use various pharmaceuticals to short-circuit that process, you're actually robbing people of the chance to develop that natural resilience. You're disempowering them from being able to discover, you know, that depth in the human condition, the sort of thing that leads to psychological development.

Let's change gears now because I want to ask you about autism and what's going on there. Could you do the same thing that you did with ADHD where you sort of just walk through the evolution of the condition? Because I think that was a really nice way to start. It's a similar story but with some important differences. So autism is originally used, and I think that's the last time it was used correctly in my opinion. It was used as a descriptive term. So it was talked about an autistic state of mind, and and actually, it was used, uh, you know, back over a hundred years ago to describe people in a psychotic state of mind. So autism refers to aloneness. So it was the idea that you're in a state of mind where you've withdrawn from contact with reality. You're in your own little bubble. But the first time it's used as a diagnostic term is in 1943 by the psychiatrist, uh, Leo Kanner, and he wrote a paper in which he described 11 children with what he now termed a autistic psychopathology. That's what he termed it. That was the first time it was used as a diagnosis. And those 11 children had moderate to severe learning difficulties. And then the early studies using that definition found a prevalence rate of around 0.01 to 0.04%. So these were the studies that took place in the 1960s. And this is when we refer to classical autism. That's often what we're referring to. Children who had visible, likely some sort of neurological compromise. People who often didn't develop language, or if they developed language, it would be rather stunted with all sorts of unusual features, and they tended to be people who had significant learning difficulties and required a lot of educational, social, and clinical care. They often had other conditions like epilepsy or genetic conditions. So we were originally talking about a group of children where there was a lot of evidence that there was some sort of neurological compromise going on.

Then in the late 1970s, early 1980s, a a paper written by the Austrian child psychiatrist Hans Asperger was translated from German into English. And Asperger had described four children who were actually didn't have any learning difficulties, but were considered to be antisocial in some sort of way. Now, Asperger, people who've looked into Asperger's history, it turns out he was a Nazi apologist. He was involved in referring children to a well-known hospital in Vienna where children were were euthanized. There was that concept of a life not worth living, and that it was a medically kind thing to do to put them out of their misery. Asperger was involved in all of that. But he identified a group of children who he thought were potentially educable, because that was one of the things. So he is coming up with this idea, and he uses the word autism as well in his paper. But you have to remember he's writing in a society that is very preoccupied with classifying human beings and classifying human beings hierarchically. So this introduces the idea of a spectrum, and from there, that concept of autism as existing on a spectrum was further supported by two people: psychiatrist Lorna Wing, who started talking about autism as a set of traits, and she brings in the now familiar triad that it was social communication, language, and repetitive behavior. So a lack of imagination. At that point, we were still talking about having a large number of children who also had significant learning difficulties, but the idea was being set into motion that even children who don't have learning difficulties had these sorts of traits. And the other one was Michael Rutter, who proposed that it's likely that these are inherited genetically. So as the concept of autism expands, it lags a little bit behind ADHD. But in in the years following the expansion of ADHD, something very similar starts to happen to the concept of autism. Firstly, it expands horizontally. So lesser extremes of these behavioral presentations, this triad, repetitive behaviors, social communication difficulties, and the language difficulty or the lang unusual language starts to drop off, and it becomes much more about being, if you like, getting very obsessed with particular topics. So this was thought to be the trait of, you know, repetitive behaviors, getting very absorbed in a particular topic, and being awkward socially. These become the kind of the way it it expands. So now it starts to take in an idea that this is something lifelong. And again, at that point, we're still talking about something predominantly male. But as it takes on this more diffuse concept, people start looking back at famous historical figures and saying, people like Einstein. Well, he was really, you know, he was very focused on what he was doing. He was famously socially awkward. Didn't like small talk. And then you start finding more and more people who are getting this label, "Oh, maybe they had these autism traits." And then the concept of masking came in. So just like ADHD, when masking comes in, the idea is you have these traits, but you're very good at hiding them. I find the masking concept very strange because I think it's something that we ought to teach our children. In fact, we do teach our children to behave in certain ways. We don't expect them to behave the same way that they behave at home than when they behave in in company or at school, or, you know, we're not going to behave in the same way when we're seeing a patient to the same way when we're interacting with our children or whatever, you know. So, if you like, social an understanding of social rules seems to be like an accomplishment, not a problem, anyway. But the concept of masking allows it to migrate into women. And again, like ADHD, the population in which the most growth of diagnosis is currently taking place is adult women. That's where the concept is is really taking off. But what we've ended up with in autism is a construct that goes from people, some of whom will require 24-hour care, who've got a lot of clinical, educational, and social needs at one end of the spectrum, right up to Elon Musk, who is meant to have an autistic presentation. So, the richest man in the world, I mean, that's the entire spectrum of human functioning. And when you've got an entire spectrum of human functioning from a clinical point of view, from an educational point of view, it seems that there is no longer any utility in the construct. It's not going to tell you anything specific about what the needs of this particular person at this particular moment in time. Just because they have a label of autism, it's going to tell you very little about their needs. So if it has no clinical utility, why does it seem like so many people are clamoring for a diagnosis now, sharing it widely online, on social media? What is like the hidden utility of it? Because clearly there's something there.

>> Yeah, it's like you say, it's it's not a utility in terms of helping us with understanding what the clinical or educational social needs might be. And we have an increasing number of people who are very successful, who have done well in their life, who are now identifying as potentially having this condition and wanting to talk about it. So this is a situation where I feel this mental health industrial complex that I mentioned earlier has merged into the whole identity politics movement. And I think this is this is a product of that hyper-individualism where we're kind of feeling that we have to brand ourselves. And it's coming into play in a society where what we were talking about earlier about how you get a sense of social value. So a lot of people feel that they're not good enough. There's a lot of people who feel ashamed, who feel they're being judged. And if you're in the public eye as well, some of these feelings might be harder to deal with. So I think that's the attraction is it appears as if it provides an explanation for why you might feel like that. Whereas from my point of view, this is the product of the types of psychological values and psychological functioning that has spread because of the nature of our economic and political and social system, because of this kind of performance demands that we have in order to feel a sense of value. So it's become an identity that people wear. Like I was saying, it's the same dangers when you imagine that this provides an explanation, but a description can't provide an explanation. There is always a danger that at some point you will feel there's something more. There's something else. But you've already your concept has turned inwards rather than looking more holistically.

>> To contrast it against, so ADHD. You know, a moment ago, we were talking about how when you feel inadequate because of maybe your academic or career performance, that could be a a soothing diagnosis to have. With, you know, with autism, are you saying that, you know, we put this value on being able to be socially comfortable, you know, wanting to interact, you know, be able to, you know, maybe converse about, you know, current events and topics and just have this ease about you. And if you're someone who doesn't necessarily like that and you're someone who is kind of ultra-focused on one niche or topic, that you're going to feel not good enough or you're going to feel like you don't really fit in, and then you can take on that diagnosis as a way of saying, you know, it's, you know, it's not me, it's my brain, which is a strange saying, isn't it? Because it's like, it's me and not me all at once, you know, it's my identity, but it's also something that makes me do this. So, it's it's it can function as a me and not me at the same time. So, there's all all of these contradictions. But what you're talking about is something that I've wondered about with other people. I wrote a book many years ago with a couple of adults who'd contacted me separately. The book was called The Myth of Autism: Medicalizing Men and Boys' Social and Emotional Competence. And that was at the time when it was still the predominantly male diagnosis. They'd both been diagnosed and initially felt, "Oh, this explains a lot." But because they were both curious to look at the research, they'd started to question, "Actually, this hasn't explained anything." Anyway, we wrote this book together. And one of the things we wondered about was what impact does moving from a predominantly industrial factory-based economy where you don't have to interact with members of the public, where the tradition was, you know, at the end of the working day, you might go to the pub with your mates and play some darts and have a couple of drinks of beer. What difference is it when the workplace demand is now a lot more service-based, a lot more customer-facing? Uh, so a lot of, you know, the whole being a salesman, advertising, having to sell yourself. So we have this kind of language about emotional intelligence, which is a a weird idea, mixing that that there's such a thing as emotions that can be intelligent. I mean, intelligence is a cognitive thing. Emotions are emotions, you know, but all of these ideas that have come in, and and we often use this idea of emotional intelligence in a lot of workplaces and in a lot of advertising and promotion and sales in order to try and manipulate people. So we have a culture which is promoting certain ways of selling ourselves in order to be with people that doesn't feel genuine either. So it's not surprising that a lot of people feel, you know, how do I come across? Am I coming across in a genuine way? So we did wonder how much it might also reflect a kind of economic shift in the types of demands that are being made on us.

>> Yeah, I hadn't thought about it that way, but you've given me a lot to think about because I know following the Second World War, you know, the especially in the US, I mean, we have the rise of the corporation, the mega corporation. You know, all of a sudden, people, they're they're not working close to their local towns. You know, commercial flying really takes off. The interstate highway develops, and you have all of these people converge on New York and LA and these big hubs. You know, they're working in organizations with thousands of people, and and the demands to interact in a politically savvy way with people from huge hugely different walks of life, you know, people you would never have been around before. And it's a lot, you know, it's a lot more demanding. And so you see that happening. But also nowadays, I mean, with a new sort of feather in your hat or or status symbol for a young person, you know, it's not how beautiful you are or how much money you make. Now, it's kind of like how many followers do you have online?

>> And so there's also this like performative part where you you need to be online and charming and funny and

>> Branding yourself.

>> Yeah.

>> You have to brand yourself in some way. So if you're if you don't feel that you're good at branding yourself, you might imagine other people are good at it, and you you're seeing because of course on social media, you don't see what is going on in people's minds. All these people who are branding themselves and appear to have these amazing lives, they're often feeling really inside. Excuse my language. So you imagine everybody else is able to get on with things that you're not able to get on with because it's all surface space.

>> Yeah. And you get like shamed. You I know the last 10 years have has been like this. If you have a faux pas or you misstep or you, you know, say something wrong,

>> That doesn't happen privately anymore. You know that that you know that that gets put online as well. And so it's almost like the stakes are even higher to say the right things and look the right way and and and all of that.

>> Exactly.

>> So what are the risks with this autism diagnosis? They they seem a little bit different from the ADHD ones. I mean, ADHD to me, it's like a fast track onto medications for most people. You know, we talked about the risks of the medications. Autism, yes, severe autism, you know, with a lot of behavioral problems. You know, they end up on antipsychotics, antidepressants, mood stabilizers. But, you know, the the faster growing area, which is just these people who maybe less social, maybe less, you know, have these sort of fixed interests. Is it really that harmful to to get one of these diagnoses and look at yourself in that way? Talk talk me through what you you think of as the the risks of self-identifying in that way.

>> I think if you self-identify and it helps you in some way, you're one of these people who doesn't want to take medication. I don't see anything wrong with that. You're not hurting anybody else. You're not, you know, that if that's something that that you feel has has helped you and you go down that route, great. But I think there is this silent danger, which is once you've started to focus on an idea that there's something in you that makes it difficult for you compared to most of the rest of the population to function within the society as it is constructed at the moment, you have the potential. I mean, you know, sociologists have known about the power of labeling for a long time. You may start impeding yourself by accident. You may start coming to the conclusion that there are certain things that you can't do, and so you won't attempt them. And it would make it can make the experience of failure and dealing with failure and trying again much more difficult. One of the podcasts I did a little while back is with somebody who did get a diagnosis of autism when they were growing up, and they went to university, and they were told at university that before they went that, uh, to be careful, manage your time, you won't be able to do this, and all sorts of things about, you know, warnings about. And at some point, he decided decided, "I'm going to do this. I'm going to go out there. I'm going to try. I'm going to meet people. I'm going to go to my classes. I'm going to." And anyway, he managed to get through. And eventually, now he looks back and he wonders how much was what he was being told. He wasn't on any medication or anything. How much of what he was being told had actually hampered him in being able to try things and and do things? So, so there is that danger that you might accidentally disempower yourself and unnecessarily hinder your functioning. But the other danger is of course that people, once they've thought of this and conceptualized it in terms of something to do with their mental functioning, there can be a tendency to deal with distress using pharmaceuticals. So what I've seen is there's a whole discussion amongst groups about how certain SSRIs work really well with anxiety as a result of autism, which but they don't work that well in people who don't have autism. So sertraline, for some reason, seems to be one that seems to be popular with people, you know. So this is something that's going on, and antipsychotics are often used. So there was a uh editorial a good few years back, and I remember challenging it, which was saying that you should consider using antipsychotics for irritability in autism. So the idea was that children and young people who have autism uh get irritable because they're sensory overloaded, and that antipsychotic medication helps. In this editorial, which was in the British Medical Journal, they quoted two studies. In both studies, the people put on a lot of weight, which is what you do with antipsychotics. And the one study followed the children for over six months. And after six, by six months, the differences in the behavioral outcomes had disappeared. The ones that were evident in the first few months were beginning to disappear because of this thing of tolerance and the homeostatic mechanism. So, and I still see examples of that, people believing that with autism, you should in situations where you're struggling with your child, you should prescribe antipsychotics. So it can also lead to, because it's being conceptualized as something in the person's brain, it can also be that opening towards this patient status.

>> Well said. So Dr. Sammy, we we have covered a lot today. Is there anything that we haven't discussed which you think would be important to share with the audience before we bring the interview to a close?

>> Well, there is so much. I mean, you you can only cover so much, and I think we we have covered. I I just hope that there was a way to help people understand that the narratives that we're being sold about mental health, about neurodiversity, about the treatments that we have on offer are really problematic. They don't really reflect uh the evidence base. They don't reflect our scientific understanding, but they also are leading us because I I I think, for example, we've never had a generation of young people as pathologized as the current generation. And I just worry what that means when we have a whole generation of people growing up with so many of them believing that there's something broken or dysfunctional or dysregulated in their brain. I just worry about where that might lead. I just want people to understand that I I often say to adolescents that I see and parents of adolescents, look, I wish that reincarnation isn't true because I don't want to go through my adolescence again. You know, growing up is tough, and we experience intense emotions. This is part of being alive. It's part of being human. Don't join in this war against emotions. Struggle. You know, stories of suffering are also stories of survival. This is how we develop depth. We develop an a capacity to deal with all sorts of adversity. Please don't take that away from the next generation.

>> Well, thank you so much for coming on and speaking with my audience. Where can people find your book?

>> All the usual channels, all the usual booksellers. I mean, I do have a website which is sammyimi.co.uk. There are links on there, but you know, wherever your favorite bookseller is.

>> All right. Thank you so much.

>> Okay. Well, thank you so much for inviting me.