Saturday, December 31, 2005

Psychotropes and social institutions: Ritalin in France from 1995 to 2005.
On July 31st 1995, the drug Ritalin is approved in France for Children with Attention Deficit Hyperactivity Disorder (ADHD) under the following conditions:

It might be prescribed after clinical and neuropsychological exams diagnosing ADHD.
The diagnosis itself should not be definitive if the symptoms are recent.
Ritalin can be prescribed only to children older than 6 years, it is not suitable to all subjects diagnosed with ADHD, it should be part of a larger treatment strategy including psychotherapy, special education and counseling, it can be obtained only via prescription from a specialist in the first place working in a university hospital (Pediatrician, Psychiatrist, Neurologist) and renewed only for one year by a private practice doctor. (Réservé aux enfants de plus de six ans, Le Monde, 15.09.95).

Before 1995, French parents with ADHD children had to rely on a complex procedure in which the medication was bought from countries outside France under a special request.
In 1995, Ritalin is overprescribed in North America (United States and Canada). It is even sometimes recommended by teachers to parents and pupils in the States and publicized on TV to the extent that some states voted to prohibit non medical personnel recommending Ritalin.

When the authorization for Ritalin is given in
France, it is immediately perceived as an importation of the American way of life, mercantile above all other considerations. France is and still a country where Psychiatry is practiced mainly on the basis of individual psychotherapies and psychoanalysis*, where Psychiatrists are reluctant to medicalize psychological problems and doubt biological psychiatry in general and where Freud and Lacan are revered as if they were Rock Stars. This context for Psychiatry is within the cultural context of the French society, a more general one in which the social contract, when compared to north America, is well and alive, and in which the Mental is seen as the product of the society and its institutions, specially when it comes to the mental well being of children.

The first reactions to the introduction of Ritalin in 1995 are suscpicious
The pharmaceutical indutstry is accused of trying to heap up its profits on a product prescribed only for few conditions (Bernard Chalchat, président des laboratoires Ciba-Geigy « Nous n'envisageons nullement un accroissement massif des ventes », Le Monde, 15.09.95).

The diagnosis for ADHD is seen as socially biased in the sense that this trouble does not exist in itself but is correlated with changes related to the school and to the society.

For critics of Ritalin, the use of the medication is believed to hasten the Americanization of French society, a process which is seen as a prelude to the decrease in institutional commitment in lending help to the children and their families.

''Many psychiatrists fear that the authorization given to Ritalin in the treatment of ADHD is the symptom of the collective regression of French society in its ability to help children, who certainly manifest difficult behavioural problems but for whom the attentive availability of educators can replace the drug treatment.'' (Jean-Yves Nau, Un médicament pour enfants « hyperactifs » suscite une controverse, Le Monde, 15.09.95, my translation)

    In 2000, the pharmacological ADHD treatment is still seen as radical in France and the WHO classification of ADHD still disputed.

    The success of Ritalin is explained by pressures exerted on medical specialists coming from:

    The parents and the school who want the child to conform to the school system,

    The increasing influence of medical personnel inside the school system,

    The profit orientation of social insurance compagnies who find the treatment less expansive than psychotherapies. (Les tout petits enfants américains se soignent aux psychotropes, Le Monde, 29.02.00)

    Child psychiatrists send a Cri d'Alarme in the pages of the first national newspaper, le Monde (Ne bourrez pas les enfants de psychotropes !, Le Monde, 27.05.00 ). Contrary to what the title suggests (don't stuff children with psychotropes), the psychiatrists who signed the article use the case of Ritalin in ADHD children to highlight the dangers of a wider trend in French Psychiatry, ''the univocal medicalization of mental troubles deprives the patient from the ability, given to him by Psychotherapy, to reflect on the profound sense of his mental uneasiness, discomfort and ill-being.'' (My translation). Also, contrary to what the title suggests, the signers express their concern not only for the use of psychotropes in children but for its use in Psychiatry in general and the impact this use has on the classification of mental illnesses. They affirm that the use of psychotropes reduces the mental illness to the neuronal and chemical elements and their perturbations. This is correct as long as Psychiatrists continue to ignore Integrative Neuroscience where concepts of relations and maternal care are being investigated as neurobiological concepts integrating social aspects to the biological view of the mind. And they conclude erroneously that this reduction is made accordingly to the reductive DSM (Diagnostic and Statistical Manual for Mental Disorders) and WHO (World Health Organization) classifications. DSM classification takes actually into account not only the biological aspects of the disorder but also the emotional, family and social aspects.

    I believe that the fierce opposition of some French psychiatrists to the DSM is actually hampering their understanding of this diagnostic tool, because clearly DSM classification offers a window for a variety of treatments, sometimes multimodal where actually Psychoanalytic classification does offer only one alternative for treatment. The signers accuse the media of broadcasting and reverberating the 'triumphalism' of American Neurobiological theories of Mental illnesses. Within this general context, they see the use of psychotropes to treat children as a risk for an increase in the intake of illicit substances when these children will reach maturity. They surprisingly conclude by advocating multidisciplinary approaches for the treatment based not only on psychotropes but also on Phenomenology, Psychoanalysis, Sociology and transcultural studies...The closing lines of their discourse highlight the dangers of a univocal medical approach on both the future of child psychiatry and the future of mental development in children. However I believe these alternative treaments, while highly recommandable, are not embedded in a standardized, systematic and evaluation prone approach which can offer a rapid answer to a wide and urgent public health problem concerning children and families living very difficult situations which require prompt interventions. When health problems of that scale exist and concern the well being of a large part of the population, specially when it comes to children who are tomorrow's adults, the solutions designed must conform with the most basic criteria for public health interventions, standardization, evaluation and cost effectiveness. This is not to say that treating mental health problems is like treating any other physiological problem, the former require that social , psychological and emotional dimensions should be adressed, however effective Psychoanalysis can be, it does not answer one of these basic criteria and it even refuses to adress them.

    The first question arising from this attitude is that why French child psychiatrists oppose Ritalin when they advocate a multimodal approach to the care of ADHD children in which Ritalin could be a component ? It is because they know very well that at the time we are discussing these matters, the other components are not able or does not have the correct structure to adress a problem that has an impressive epidemic and an urgent call for effective solutions. They know that in the short and middle terms, Ritalin will be adopted by parents and educators and public health officilas looking for these rapid and effective solutions.

    2005: the emergence of official and public reports on the treatment of ADHD children with Ritalin in France.

    In ''Dépister et traiter l'hyperactivité'' (Le Monde, 08.11.05), ADHD is not seen anymore as an 'American invention'. The article insists that ADHD is not a trouble, neither the extreme of some normal behavior. It is a constitutive illness with tremendous negative implications on the child, its learning capacity, its well being and its later social integration. For the first time, psychiatrists recognize that the manifestations of ADHD are not under anybody's control, children and parents included. This goes along the recognition of biological factors predisposing for ADHD, contrary to the notion that society and its institutions are the sole repsonsible for the mental well being of individuals. Coming from where they started when the medication was introduced in France this can be seen as a swing to the other extreme. For the first time, DSM and the related WHO classifications of the ADHD are mentioned as acceptable references (in the press). For the first time, the combination of Psychotherapy and Ritalin is mentioned as the best treatment. For the first time, child psychiatrists start to recognize that treatment with Ritalin is necessary to put the child on a positive path which will be successful in a ratio of two children over three. However some insist that Ritalin intake must be accompanied by psychotherapeutic treatment because they believe that family and social contexts have a great impact on the condition. A psychiatrist mentions for example that 80 % of children who were abused or come from negligeant parents, and children who had postnatal treatment which kept them at the hospital, develop the symptoms for ADHD.

    Another article, Les tribulations de la famille d'un hyperactif (Le Monde, 08.11.05) exposes, for the first time and at length, the suffering and the wandering from one doctor to another of a family with an ADHD child in France. The child experienced problems at his first year at school when he was 4 years old, however the parents started to consult only two years later when the problems reached a peak. Early consultations did not yield any clear diagnosis and treatment. It is only when the parents went to a child psychiatry service where biological concepts in Psychiatry were accepted and operationnalized that they heard for the first time of the ADHD diagnosis. Even then, they refused to accept the diagnosis because they heard from the media that ADHD is an American 'invention' and that it does not exist in France. They even refused to treat their child with Ritalin fearing negative consequences like addiction to Amphetamines because they heard that Ritalin is an Amphetamine molecule, even though there is not one study ascertaining Ritalin treatment as a cause for later addictive behaviour. But with the situation worsening years later and the child having great difficulties keeping up with the pace of normal schooling and social integration, the parents finally accepted to treat the child with Ritalin. They did it with the help and the support of a national association of parents of children with ADHD. This made it possible for the child to stay in the normal school system. The article informs the reader that Ritalin is in fact like a pair of eyeglasses, its effect being displayed only upon intake and lasting only 8 hours a day.

    The story of this family takes place between 1995 and 2005 and summarizes the changes and the struggles in social and medical perceptions toward ADHD and its treatment in France. During this time, public perceptions about ADHD and its treatment started to change under the pressure of public health personnel and parents. A public report on mental disorders in children including ADHD was made public in September 2004 by the government sponsored clinical research insitute, Institut National de la Santé Et de la Recherche Médicale (INSERM). The report adopts the international classification for ADHD for purpose of identification and diagnosis and recommends a systematic and early diagnosis in children as part of a national effort to prevent the early negative impact of ADHD in school age children. There were instant negative reactions to the recommendations made in the report. Specialists of children's mental health, mostly France's community of child psychiatrists wrote their disagreement with the report in the national press. Even a year after its release, the report is still disputed.

    Pierre Delion, chief of Psychiatry at the university hospital in Lille told Le Monde (23.09.05) that ADHD is a disputed classification because it refers to external social norms like behavioural disorders while he prefers to use the concept of 'psychological suffering' to characterize the condition of the children showing this trouble. He points to the risk of teachers using this external classification in order to recommend a medication for the child. He accuses the pharmaceutical business of advancing the concept of ADHD and pushing Ritalin in the market in order to boost the profits. He refutes epidemiological results showing a high incidence of the disorder among children as mere statistics that do tell a lot about the way society view and treats the children but that do not tell anything about the child's psyche or the way we should face the child as carers who must feel responsible for the child's condition.

    What a debate like this do tell us about the relations between Scientific applications in Mental Health and Society ?

    It must be noted that, despite nationwide negative reactions to the introduction of Ritalin in France for the treatment of ADHD, there was a rapid and positive evolution for the acceptance of the medication, made possible, on the parent's side, by the need for an effective and a rapid care for these children to facilitate their integration in school. For the health authorities, the problem was to find a cost effective approach to an ever growing concern for children's mental health and to a public health problem.

    However, the resistance to this evolution in the French society and among french Psychiatrists shows that the resistance to the pharmacological approach to mental health problems in children in particular and to an external classification or characterisation of the problem created a vacuum which rendered a constructive and critical approach to the medicalization of ADHD impossible. This resistance derives from two major social conceptions of the child and the mental. The French society inherited a conception of the child which dates back to Les Lumières, a century which is not only characterized by the triumph of reason but also by the concern the adults had for the intellectual well being of children and for knowledge transmission. Most importantly, what the conception of the child in Les Lumières shows is that an adult could not consider the child as his equal, because the child requires his care and his instructions. Hence the feeling that children's attention and learning disorders must be resolved within a social setting providing what is necessary for these children to perform in school, hence the resistance to the classification of ADHD as a biological problem, hence the resistance to the idea that drugs can resolve what is considered as a learning and a social problem, hence the appeal to social institutions to provide the adapted educational framework for these children. But this conception of the child, which is still rooted in the French educational system, does not explain, on its own, the many problems encountered by the introduction of Ritalin in France and the reactions and regulations that accompanied this introduction.

    Another framework is the psychoanalytic tradition in French psychiatry. Psychoanalytic approach opposes the exclusive use of drugs for therapy and considers the drugs as primers for facilitating the therapy. However, I think that while opposing Ritalin, Psychoanalytic conception of mental illness have actually facilitated the acceptance of Ritalin by parents for the following reasons: 1) Psychoanalysis tells us that everthing that goes wrong with our mental life has roots deep inside in our subconscious and in the way this subconscious is affected by our relationships with others. French psychiatrists still call the object of Psychiatry as being 'La Pathologie du Lien', 'The Pathology of the Relation' but the target of Psychoanalysis is not the relation, it is the inner self. From a behavioural problem, ADHD becomes, within the psychoanalytical framework, internalized as a mal d'être, a psychological suffering, at the image of the psychological suffering of adults. This is not to say that a behavioural approach does not recognize the psychological suffering of children but the psychoanalytic approach constrains the symptoms to the inner part of the child-individual and therefore, constrains the treatment to what is going on in the inside focusing, like the pharmacological approach, on the inside. However, things can be seen the other way, even with a psychoanalytical approach. For example, Alain Ehrenberg, a French sociologist in his book, 'La fatigue d'être Soi', explains the phenomenon of the excessive use of psychotropes in France by the demise of the state and of political and social institutions, in other words, the relation between the individual and failing social institutions is bringing mental suffering and misery upon individuals. This is a psychoanalytical explanation. But the remedy, suggests Ehrenberg, is in institutional change, not only with Psychotherapy. 2) In France, as in developped countries, the economic crisis that brought unhappiness and the political changes that accompanied this economic transformation made room for a change in the conception of the child. This change led to the declaration of children's rights, at the image of human individual rights, a good and a great move, but at the same time a move by which the child acquires the status of the adult vis-à-vis the political, legal and economic spheres (see Alain Renault and Sylvie Mesure in Alter Ego, les paradoxes de l'identité démocratique). The child, as an individual, is more and more seen as an equal to the adult. This goes along an internal Psychoanalytical conception and classification of mental problems in children and against Les Lumières where children were seen as requiring adults care in order to achieve maturity but most importantly this leads to our recognition of the existence of an internal psychological suffering, at the image of ours, in the child. So here the Psychoanalytic conception of the mental in children is in contradiction with the conception of Les Lumières.

    So here we have two competing conceptions of the child, one inherited from Les Lumières , may lead to an anti-psychotropes attitude stemming from external considerations related to the responsibility of adults and institutions for the mental and intellectual well being of children. Another conception, inherited from Psychoanalysis, is against psychotropes consumption because it is against an external classification of mental problems, a classification that does not explicitly aknowledge the internal mental suffering of the child both as the source of the problem and the target of the treatment.

    Psychoanalysis does not offer an alternative and reliable classification of ADHD which can be operationalized and tested in the context of a pulic health approach, neither a reliable testable therapy and most importantly, it does not offer social institutions, concerned by the well being of the child, a plan of action at the national level and a cost effective strategy for a public health problem.

    And as Integrative Neuroscience aknowledge the influence of social and emotional factors on the brain and the mental well being, we know that we may not fully control the causes of ADHD, specially when they are related to developmental processes where they can participate in the structuring of children's brains and minds and cause them trouble at school. However, we might be able to help our children achieve a healthy and successful life by being open to new knowledge on the brain and the mind including how biology is shaped by society and culture and prevent some hypothetic dramatic shifts which derive from this at the social level**. Understanding this new reality by accepting an open and a honest debate and adapting accordingly from all parts of society to make sure that ADHD children have a good chance for the future, is a priority if we want to keep our educational goals and our responsibilities toward children.

    I am quite sure that the real debate on the medicalization of children's problems is about to start now...

    * French adults are known to be heavy on light psychotropes consumption, antidepressants and anti-anxiety drugs, prescribed mainly by General Practitioners.

    ** The poor performance of boys in the school system is one of the biggest challenges in Education today. It is also well known that ADHD affects more boys than girls and could be linked to their overall academic performance.

    No comments: