Marino Pérez Álvarez is a clinical psychologist and professor of Psychopathology at the University of Oviedo. I asked for an interview after knowing a book of which he is co-author called "Returning to normal: the invention of ADHD and bipolar disorder”(Published this year in Editorial Alliance).
He is also the author of numerous articles in specialized journals, and other books such as "The myth of the creative brain" and "The roots of modern psychopathology."
In "Returning to normal ..." warns about the capitalization by the pharmaceutical industry of some problems that adults have with the attention, activity and humor of children. As noted at some point during the interview, it is a controversial issue and for many delicate, but I think it is important that we reflect on it
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The label is unfortunate because it qualifies and stigmatizes the child, without serving to explain anything
Peques y Más.- I confess that your statements surprise me, and at the same time it gives me some relief to hear someone who bets on "returning to normalcy" and paying attention to children, instead of attributing various disorders to them.
Until now I had heard about overdiagnosis by ADHD, and we all know that Leon Eisenberg confessed before he died that it was an invented disease ... You subscribe to the words of the inventor of the disorder, do you mean there is no way to diagnose it as a disease?
Marino Pérez.- ADHD cannot be diagnosed more than by the behaviors of inattention, hyperactivity or impulsiveness of children and that parents and teachers often refer to. There are no clinical tests, neither genetic nor electroencephalogram, nor reuroimaging that serve to specifically differentiate children from those who are said to have ADHD. So there is no basis to argue that it is a neuroevolutive disorder of genetic origin, as implied.
In my opinion, ADHD is nothing more than an unfortunate label to describe some behaviors of children that pose a problem for adults. But not because certain behaviors pose a problem, are therefore a disease or constitute a clinical diagnosis. The label is unfortunate because it qualifies and stigmatizes the child, without serving to explain anything.
PyM.- However, lately I have read that there are neuroimaging tests that are capable of detecting abnormalities in the brain of those affected, what can you tell us about it? Not counting that there are also behavioral indicators, or do they not serve for diagnosis?
M.P.- Yes, indeed, there is sometimes talk of neuroimaging studies that show abnormalities in the brain in ADHD children. Regarding this, I would say two things.
The first is that the studies are not consistent: for one who shows them there are many more that find nothing significant. However, the "positives" are displayed. It seems that there is a morbid eagerness and interested in finding something anomalous in children's brains, as if that were better.
The second thing is that even though there are "abnormalities" in the brain associated with people's activities, that is why they are not their cause, nor do they define a disease. Thus, for example, the brains of musicians are relatively different from the brains of non-musicians and even that of pianists is different from that of violinists. But that "anomaly", which is no anomaly but the adaptation of the brain itself to the activities of individuals, is not the cause of playing musical instruments or being a musician - as far as it is known - is no disease. In fact, neuroimaging does not serve to establish or confirm any diagnosis.
The so-called behavioral "indicators" are the problem itself; They are not indicators of any internal abnormality, such as fever and cough are symptoms of a flu infection.
PyM.- If there is no such disorder, what factors come together so that we can label children who are supposedly suffering from it? (or what is the same what reasons we have to need those diagnoses)
M.P.- Naming behaviors that are striking or problematic is normal. It has always been done and so these children were called "restless", "no stop", etc. The point is that The ADHD label is used as a diagnosis of an alleged mental disorder or illness. One of the biggest reasons is that it has served laboratories to market medicines. It has also served to "reassure" parents overwhelmed by the inattention and overactivity of children, seeing that this problem had a name.
The fact is that the laboratories have used the parents to justify the diagnosis and for their part the parents have felt supported by the laboratories
It is no coincidence that the first association of parents concerned with ADHD, the powerful CHADD (Children and Adults with Attention-Deficit / Hyperactivity Disorder), was sponsored in 1987 by the Ciba-Geigy laboratory, manufacturer of Ritalin, the most used medication in times for ADHD. Today, most ADHD associations receive support from shift laboratories and refer to them to explain what it is, how it is diagnosed and how it is treated. It is as if sheep safety is in charge of wolves. Laboratories are lobbies or lobbyists capable of influencing political decisions, as happened in Spain, where they got the ADHD to appear in the LOMCE.
PyM.- Is the diagnosis by ADHD in our country far from the figures in the United States? Even so, there is much talk in health and educational settings, does this respond to the search for solutions or to certain interests?
M.P.- Spain is approaching the US in the figures of diagnoses and consumption of drugs for ADHD, thanks to the awareness campaigns carried out, with the "complicity" of politicians. I don't want to say that they have done it consciously, but politicians have contributed decisively to putting Spain at the head of Europe in ADHD, and this in my opinion is not to thank it but to regret and denounce it.
PyM.- I don't know what reactions your statements provoke, there will be even those who get irritated or not? The fact is that I read you saying that Childhood Bipolar Disorder must also be demystified.
M.P.- The issue is controversial and divides clinicians, teachers and parents. Thus, my statements congratulate and reaffirm some, who say that "it was time" to raise this. But they may also irritate others, who sometimes react impulsively without noticing that my statements, far from being free, derive from a whole book of more than 300 pages written with experts on the subject over 4 years.
Childhood bipolar disorder is another example of re-qualification of normal problems, in this case "tantrums" and mood swings, as diagnoses to medicate. Now that the specialty of child psychiatry has been established, there is more "danger" that problems of childhood and adolescence will become psychiatric disorders. Some specialties need more from customers than their customers.
The apparent improvement of the attention under medication, it may be more than anything loss of interest and curiosity of the child for everything, instead of concentrating on the task that matters
PyM.- If the "diagnoses" of ADHD and Bipolar Disorder generate so much controversy as to divide the scientific community; Your book "Returning to normal" I imagine that it will also be seen as controversial. But it can also help us to reflect on the continued administration of drugs to children. What is known about the long-term effects of these medications?
M.P.- Indeed, a controversial book, but reasoned and documented as I think is ours, can serve to the reflection in a so delicate subject like the pathologization of the childhood.
Regarding the long-term effects, it is known from studies of 6, 14 and up to 17 years of follow-up that the medication is associated with worse school performance (not better), which is not surprising, because the medication does not teach the appropriate behaviors, limiting itself to reducing some inadequate Like overactivity. The apparent improvement of the attention under medication, it may be more than anything loss of interest and curiosity of the child for everything, instead of concentrating on the task that matters. Long-term medication is also associated with emotional and behavioral problems, as well as medical problems, which is also not surprising, because the medication is not harmless.
PyM.- Before the summer we listened as Primary Care pediatricians pointed to a worrying increase in cases of behavioral, emotional and psychiatric disorders in children and young people. When I read this I thought, would such disorders exist without the factors that favor them? Even if you don't want to call them "diseases", do you think that certain behaviors in children may be due to causes such as toxic load, or sedentary lifestyle and lack of contact with Nature, as I have sometimes read?
M.P.- In general, the unfortunate label of ADHD refers only to the behaviors of children who, however, pose problems for adults, when you would expect them to be more attentive and focused on the tasks we propose. What happens is that some children may not have learned the controlled behavior that is required, such as caring, waiting, following rules and striving. Or, in other words, what they have learned is to attend to what they like best, to want everything immediately, to get away with it and to do the easiest. The key is to learn and teach.
But for whatever reason some children have not developed adequate self-control: because we have less time to be with them quietly, we mistakenly believe that setting rules frustrates them, we naively assume that everything is learned in their own time by spontaneity; because the children themselves are accustomed to everything revolving around them ("little tyrants"), nothing is missing, nor do they have to wait or strain. It may also be that some children have a more “reactive” or “impulsive” temperament, but nothing changes, more than in this case more training is needed.
Another thing is that attention, hyperactivity or impulsivity problems are due to medical problems as, for example, thyroid dysfunction, sleep disorders, sensory problems, so we would not even talk about ADHD. As regards the toxic load, sedentary lifestyle and lack of contact with nature, they are "folkloric" causes, without much meaning.
Although today's parents have more “information” of everything, on the contrary they have less common sense, like the one the previous generations had
PyM.- I am convinced that your words will sound like a balm for some families that are in a kind of dead end; The problem in these cases may be the solution of those problems.Certain behaviors in children are a challenge, so far agree; but you will agree with me on the difficulties to educate in today's society ...
M.P The education of children is a challenge and much greater in today's society, where parents have less time and often end up taking out what they need to be quietly with children. On the other hand, although today's parents have more “information” of everything (where information is not the same as knowing more), they have less common sense on the contrary, like the one the previous generations had; So, for example, there you have a father or mother 30-40 years old who does not know what to do with your 3 or 4 year old son, behind him or her with a spoon throughout the house or throughout the park and Things like that.
And if that was not enough, our society encourages changing attention, hyperactivity and impulsivity, starting with adults, from whom children learn. The striking thing is that all children are not ADHD, as the pharmaceutical industry would like. That is why the next fashion is adult ADHD, which few will get rid of, as we do not put common sense.
Professionals can help parents in how to do better what they do, without needing to diagnose the child
PyM.- Finally, and returning to the book: do you say that parents with training in behavioral patterns can cause greater changes than medication? Do you realize the implications that this has in our model of life with parents who barely have time for anything? That training should be received from health and psychology professionals, I imagine, would it imply a change in the care model or is it a service already offered?
M.P.- Children aged 4-5 who are destined to receive the diagnosis of ADHD and medication to use learned self-controlled behaviors, similar to those of children who are not candidates for diagnosis, through games with their parents.
In one study, psychologists taught parents in several sessions to use common games that contain activities that require attention, follow instructions, memory, know how to wait and impulse control. It refers to games of the type "Simon says" where the key is to attend to how Simon says what to do: if the phrase is "Simon says jump", you have to jump, but if you say only "jump" you don't have to skip. Another game is the Frozen Dance (Freeze dance) where at some point the dance stops and “freezes” the movement to resume it shortly. Any game or activity that involves following rules, remembering something, waiting for a turn or planning a task would be good.
The issue is not merely that parents play and spend time with children. The important thing is that the game or activity contribute to learn behaviors relevant to the child's development, in this case, tending towards self-control. If the parents are themselves hyperactive and impulsive, attending to several things at once and simply distracting them, that is what the children learn, instead of the self-regulation that they are expected to have. Professionals can help parents in how to do better what they do, no need to diagnose the child. It is not that it is easy in relation to a child already "trained" and "accustomed," but an ADHD child has nothing wrong with the brain or the mind.
Finally, I thank Mariano for his selfless collaboration, I think that it is important to spread the pathology of various childhood problems that seems to be occurring, as a starting point for their solution.
As with Mariano Pérez's statements in other contexts, or with his book, this interview may be controversial. But in any case it is about accepting or not that the number of children with different disorders grows, also increasing the number of them to whom medication is prescribed. It is what is really striking to me.
