This is a very welcome book that deserves a central place in the unfolding debate (or is it ‘paradigm war’? – see the above epigraphs) about children’s well-being and suffering in modern Western culture, and which has been gaining increasing policy-making and media prominence since the dawn of the new millennium; or as the editors write (p. 9), it constitutes ‘an attempt at providing an antidote to the one-sided mainstream literature’ . What is at stake in this debate is the foundational worldview from which we understand and respond to children’s challenging behaviour in general, through the lens of so-called ‘Attention Deficit Hyperactivity Disorder’ (or ‘ADHD’). The culturally hegemonic worldview that has come to dominate the scene, and which this book is fundamentally challenging, is one very much ruled by a materialistic, medical-model perspective on children’s suffering, whereby children’s behaviour deemed to fall outside of some putative societal ‘norm’ is judged to be ‘(psycho)pathological’ and therefore in need of medical ‘treatment’, typically of the psycho-pharmaceutical kind. It was French philosopher Louis Althusser who convincingly showed how any given social formation will tend to generate a state apparatus that actively reproduces the prevailing status quo; and in a similar way, we can argue that the materialistic Zeitgeist simply daren’t even begin to admit to the possibility that ‘ADHD’ may not be a medical diagnostic category at all, for to do so would mean that ‘the system’ would need openly to look at those aspects of materialism and technocratic modernity that are responsible for generating such angst and anomie; and of course, and understandably, there exists enormous individual and cultural resistance to doing so.

What this book does so effectively is, first, to show how such the conventional medical-psychiatric view is so often ideological, culturally constructed and vested-interest driven, rather than scientific and objective; and second, to give us strong indications of what an alternative, far more humane and informed response to these grave concerns might look like. To give just one of many extraordinary statistics as a contextualizing backdrop, Craig Newnes tells us that around 1990, there were just 5,000 children diagnosed with ‘ADHD’, yet by 2003, there were over 200,000 (p. 161). As we will see, this book goes a very long way to teasing out just how this scarcely believable state of affairs has come about in modern Western culture.

Before discussing the book itself, some preliminary contextualizing comments are in order. As critical psychologists Ian Parker, Mary Boyle and others have argued, the medical-model practice of diagnosis is simply not appropriate to the human difficulties of living – and such a diagnostic mentality does, of course, inform and underpin the massive industry that has grown up around the ‘ADHD’ diagnostic category. The kind of arguments developed in this book are closely coincident with the arguments of Peter and Ginger Ross Breggin, who have pointed out that, ‘When psychiatrists do find physical impairments in the brains of mental patients, they are almost invariably the result of treatment with drugs and electroshock. It is shameful that treatment-induced brain disorders are blamed on the patient’s so-called mental illness.’ More on this in relation to ‘ADHD’ later.

Thus, far from their being ‘objective’ and scientific in nature, conventional psychiatric systems of diagnosis and classification are necessarily underpinned by an implicit normative metaphysical foundation (typically founded in a materialistic, reductionist and deterministic paradigm) that is rarely if ever examined, and which, crucially, and contrary to its own ideological propaganda, is no more or less metaphysical than are many other worldviews we might consider. Moreover, as Parker and his colleagues have argued, professional discourses ‘always entail relations of power’, with language both organizing reason and also structuring what we imagine to lie outside reason (Deconstructing Psychopathology, Sage, 1995, p. 14). On this kind of ‘deconstructionist’ view, then, the very identities of ‘patients’ are seen to be actively constituted in and by professional discourses.

It is essential to realise, then, that allegedly ‘scientific’ psychiatric knowledge gains its privileged cultural status through what is a fundamentally ideological, socially constructed process, which is in turn indissolubly intertwined with issues of power. Thus, the official psychiatric diagnostic systems of DSM and ICD are routinely used to categorize individuals as ‘abnormal’; yet if the conventional oppositions between so-called ‘normality’ and ‘abnormality’, and health and illness, are to a major extent socially and culturally constructed and contingent, rather than being the ‘objective’ scientific categories that traditional psychiatry claims them to be, then any scientific-medical pretensions to pronounce upon the nature and aetiology of children’s difficulties of living and challenging behaviour need to be treated with, at the very least, extreme caution. These arguments will be fleshed out in the later discussion of the book under review. Certainly, on page 147 we read that ‘Managed health care has meant that an economic system has come to be built around DSM-IV diagnoses... DSM-IV... is a legal, financial and ideological document, driving thinking about all sorts of emotions and behaviours, including those of our children, towards ever more medicalized notions.’

In subjecting the notion of so-called ‘psychopathology’ to searching deconstructive analysis, then, it seems to make more sense to see ‘abnormality’ not as some objective statistical generalisation falling outside of a ‘normal’ distribution curve, but rather as a fear-induced, socially constructed category, one of whose key unacknowledged functions is to reduce anxiety in the face of others’ (often radical) difference. Thus, notions of the normal and the pathological, far from being scientifically or statistically determined, are value-laden concepts deeply embedded within economic, technological and even political imperatives (Brian Kean, for example, shows in Chapter 6 how the Australian government has connived with the promulgation of ‘ADHD’ as a psychiatric ‘disorder’ requiring stimulant medication – pp. 183–5). We can also point to the tautological circularity of traditional psychiatry’s approach to labelling and diagnosis – an argument that is highly relevant to the ‘ADHD’ question (again, referred to later). Thus, at the outset a ‘disorder’ is assumed to exist (e.g. ‘abnormal’, ‘hyperactive’ behaviour), and research then actively constructs a version of normal and abnormal behaviour, which is subsequently applied to individuals who are classified as ‘normal’ or ‘abnormal’. Existing clinical categories are then drawn upon, and research results are fed back into the diagnostic systems. In this way, psychiatric language, embedded as it is in research and clinical practices, constitutes the very ‘pathological phenomena’ it claims to explain, and which it has from the outset assumed to exist. So as Parker et al. point out, ‘a vicious circle is created where diagnosis and research encourage one another leaving their assumptions unquestioned, while maintaining the same practices’ (op. cit., p. 97).

We can see this as a perverse kind of alchemy whereby the ordinary (albeit often distressing) everyday difficulties of living and existence are surreptitiously transformed into a mechanistic professionalized lexicon of medical terminology that legitimizes a professional ideology that, in turn, self-fulfillingly becomes the guarantee of its own existence. A further tragic consequence of this state of affairs is that ‘psychiatric patients, through the course of repeated assessments, come increasingly to define their experiences in accordance with a professional definition of psychiatric illness... – thereby influencing both the types of subjectivity and identity that are brought into being, ... and [making] it impossible for [them] to "think" or even imagine an "elsewhere"’, outside of the professional hegemonic discourse (ibid., pp. 89, 73, 75).

If Parker and others’ analysis is anything like right, then a wholesale paradigm shift in the theory and practices of ‘mental health treatment’ is surely indicated – and, some would say, long overdue; and as I will now show, the book under review can make a major contribution to this urgently needed paradigm shift.

The book comes in four parts. Part I consists of three chapters focusing on the role of medical-model thinking in the ‘ADHD’ phenomenon. (Please note that throughout this review, my quotation marks around the term ‘ADHD’ denote, first, that I do not recognize it as a legitimate medical syndrome, diagnosis or illness (see below), and second, that it is far better conceived of as a culturally, ideologically and economically generated category than as a ‘scientific’ one.) Lydia Furman starts the book off with a comprehensive review of our current state of knowledge with regard to what is termed ‘ADHD’ (with a very extensive and useful list of references taking up some 13 pages). Part I includes a discussion by Jay Joseph of the genetics question (no gene for ‘ADHD’ has been discovered, of course), and an extensive critical review of the kind of neuro-imaging research which has played such a key role in the sanctioning of ‘ADHD’ as a valid diagnostic category (Jonathan Leo and David Cohen; more on this later).

Part II looks at ‘ADHD’ and culture, including a focus on cultural aspects of the burgeoning diagnosis of ‘ADHD’ and on the context of globalization (Timimi himself and Begum Maitra), Clinical Psychology’s relationship with ‘ADHD’ (Craig Newnes), and the data and discourse of ‘ADHD’ in Britain and North America (Nicky Hart and Louba Benassaya). Then in Part III the book turns to the drug therapies, with compellingly strong arguments marshalled against the use of medication in ‘treating’ ‘ADHD’ (Grace Jackson), and systematic and devastating critiques of data manipulation (Jonathan Leo and Jeffrey Lacasse) and of research deficiencies (David Cohen et al.). There is also a chapter looking at the role of diet and nutrition in relation to the symptoms labelled as ‘ADHD’ (Basant Puri), which concludes that ‘there appears to be good evidence in support of the alternative use of fatty acids and of removing artificial colourings from the diet’ in the treatment of ‘ADHD’ symptoms (p. 345; no profits for the pharmaceutical companies there, then). Finally in Part IV, we are introduced to ‘alternative paradigms’, with four chapters offering diverse approaches to understanding and responding to children’s challenging or disturbed behaviour.

It is very difficult to know quite where to start in reviewing this book, as at well over 400 pages it is overflowing with relevant arguments and information (and in passing, it is also exceptionally good value for money!). Before giving appropriately close attention to the key issue of research, several of the more notable highlights of the book for me were that ‘It is difficult to identify a review article about ADHD whose authors do not receive funding from a pharmaceutical company that manufactures ADHD medications’ (p. 43); that ‘It was recently reported that 13 of 21 individuals who set criteria for the DSM-IV diagnosis of ADHD have financial ties to pharmaceutical manufacturers of ADHD medications’ (p. 43); that ‘A convergence of societal and financial pressures has created an ADHD industry which does not serve the interests of the individual child’ (p. 44); and that ‘ADHD is simply a grouping of socially disapproved behaviours falsely passed off as a disease’ (p. 75).

There is also the issue that Ritalin is essentially cocaine, and that ‘psycho-stimulant medicine acts directly on the circulatory system, raising blood pressure and heart rate in ways that could have long-term deleterious effects’ (p. 225). According to Grace Jackson, ‘For more than 40 years, research... has demonstrated the disruptive effects of stimulants upon development and growth. Tragically, the reality and implications of this toxicity have been ignored’ (p. 256, original emphases). Nor is there any significant concern shown in the professional or research literature that challenges the ethics of prescribing psychoactive medication to compensate for problems originating in the social environment (p. 227).

Moreover, at a time when new research is emphasizing the crucial developmental importance of sleep for children, it is also noteworthy that sleep disruption is acknowledged to be a major side-effect of stimulant medication, with ‘sleep disturbance being a significant problem for 30–50 per cent of patients during drug initiation’ (p. 274). Jackson also reports that there have been found to be statistically significant relationships between early exposure to stimulant medication and future dependency on nicotene and/or cocaine, and also an association between duration of childhood stimulant medication and future addiction (p. 276); that early exposure has been shown to lead to a decreased capacity for neuronal plasticity in a brain region that is critical for memory and learning (p. 278); and that there is a reduced capacity for learning following stimulant medication due to ‘reducing the experience-dependent growth of neuronal dendrites’ (p. 277). Jackson dramatically concludes that ‘Forty years of evidence have shown that stimulants are a prevalent source of developmental toxicity’, and that ‘It is time for the medical profession to repair this tragic and overly long chapter in its history’ (p. 278).

The machinations of the consumer advertising of ‘ADHD’ as a medical condition requiring medication is also systematically deconstructed in Chapter 10 by Jonathan Leo and Jeffrey Lacosse. They show how advertising claims are often highly questionable from a scientific standpoint, with ‘tentative hypotheses’ routinely being presented as ‘well-established facts’ (p. 13), and with such advertising very likely shaping public perception. The extraordinary story of Pediatrics journal’s 1999 commissioning of ‘expert’ commentaries on the case of a teenage boy who had been taking Ritalin for several years really does repay close attention, as it is perhaps emblematic at the way in which data manipulation and what are ideological positions can misleadingly masquerade under the apparently respectable label of ‘science’.

Finally, with regard to alternative paradigms, Jon Jureidini’s discussion in Chapter 13 reminded me of the work of key child authorities like Susan Isaacs, Rudolf Steiner and Donald Winnicott, all of whom place the child’s capacity for imaginative elaboration at the centre of healthy child development (e.g. see p. 354). I agree wholeheartedly with Jureidini that ‘Because behavioural symptoms... can be active attempts to achieve regulation in the face of unmanageable arousal, we might question the common clinical response of trying to eliminate "bad" behaviour, either with medication or behavior modification’ (pp. 355–6). For him, what is required are ‘thoughtful strategies’ (p. 357) – for ‘the first question should not be "Does this child have ADHD?". Rather it should be "What is this child’s predicament?" The task is to listen rather than list, to trawl the history for clues rather than symptoms’ ( ibid., original emphases). I also strongly agree with Chris Mercogliano (Chapter 15) that ‘childhood itself is in trouble’ (p. 382), with children’s lives being routinely over-controlled by anxious adults (p. 385), and that ‘the ADHD question’ is an issue about childhood in general and its various ‘toxicities’, and the quality of life that we create for our our children in late-modern technological society. Thus, we need to start seeing so-called symptoms as distress signals, not as some kind of ‘neurological pathology’ (ibid.); and for Mercogliano, ‘The relentless forces of modernity are... squeezing out the novelty, the independence, the adventure, the wonder, the innocence, the physicality, the solitude... from the lives of all of today’s children’ (ibid.). Recent mounting concerns with the over-commercialization and ‘commodification’ of childhood suggest that the quarries that Mercogliano targets – a brutalizing schooling system, the electronic and televisual media, and advertising and the media more generally, with the associated ‘arrested adulthood’ phenomenon (pp. 392–4) – are what we should really be addressing in the paradigmatic debate about children’s challenging behaviour. Have we even begun to contemplate the depths of the impact of a comparatively recent seismic cultural shift in which, for example, ‘the average American child spends over four-and-a-half hours a day sitting in front of some kind of screen’, and in which ‘the average child is exposed to nearly eight hours of media daily’ (p. 388)? Tragically, I think not. And on this view, stimulant medication for challenging behaviour is merely a noxious modernist distraction from the real cultural issues that require our urgent addressing.

But I want to give particular attention in this review to the issue of research, as the ‘ADHD industry’ eagerly elects to claim the scientific high ground in this field; yet when that ‘high ground’ is closely and relentlessly examined (as it is in this book), it turns out that the ‘ADHD’ edifice is built upon a flimsy foundation of sand. The outrageous way in which research has been manipulated and biased in this particular field is just one salutory example of the way in which research in general, whatever the field of study, is routinely politicized and biased, and blows apart the modernist myth of a value-free, so-called ‘objective’ science (and not least, how positivistic ‘research’ routinely self-fulfillingly ‘proves’ precisely what it has tacitly assumed to exist from the outset). I will therefore spend some time looking at the issue of research as addressed in the book.

We see close deconstructions of the research in this field in Chapters 3 and 11. In Chapter 3, Leo and Cohen show how, in the neuro-imaging studies that are used to support the view that cerebral pathology causes ‘ADHD’, researchers commonly ignore, or severely downplay, the role of prior psychotropic drug use and its impact on research findings. We also read of a scarcely believable tale of ill-matched control groups, and decisive and entirely feasible further analyses of their data that researchers simply refuse to conduct (e.g. see pp. 114–15, 123–4). Moreover, quoting Bremmer (2005), Leo and Cohen also write that ‘we are not at a point where brain imaging can be used routinely for the diagnosis of psychiatric conditions... We still do not understand the patho-physiology or mechanisms of response to treatment for most of these disorders’ (p. 94). And in any case, as Newnes points out, ‘we have no idea how any given individual is meant to develop neurologically, nor can we know that a person is neurologically disordered from behavioural observation. Yet ADHD is solely diagnosed through such observatons’ (p. 161; see also p. 170).

Moreover, rather than even beginning to consider the possibility that there simply exist no biological markers in the brain for ‘ADHD’, what tends to happen is that the neuro-imaging research gets more and more sophisticated (and expensive) in its wild-goose chase of seeking a biological marker, on the assumption that ‘if we’ve not found it yet, it must be because our technology isn’t yet sufficiently sophisticated’. Such a view also ignores the even more fundamental point that even if some reliable and valid neurological ‘correlate’ were to be found for ‘ADHD’ symptomatology, whether the biological marker could be assumed to be the cause or the effect of ‘ADHD’ would be an open question. Timimi and Maitra, for example, show how in Egyptian psychiatry, presenting problems tend to be viewed as residing in fragmented interpersonal relationships and the social structure, rather than intrapsychically ‘within’ the person displaying the symptoms (pp. 205–6); and they bemoan the tokenistic lip-service that is currently paid to the cultural dimension in training and research in child and adolescent psychiatry (pp. 208–9). And according to Hart and Benassaya, ‘the available evidence continues to suggest that the symptoms of ADHD... are the product of health inequality arising from social disadvantage in early life’ (p. 246).

Timimi and Maitra go on to expose the scandalous cultural imperialism exhibited by Western bio-medical psychiatry in highlighting the extraordinary phenomenon of the so-called ‘Global consensus on ADHD/HKD’ (p. 209), which left this reader quite speechless. This consensus statement, published in 2004, stated ADHD to be ‘a valid neuro-developmental disorder that is found in all cultures..., stating ADHD to be a genetic condition, with core... pathophysiological features, whish is thus amenable to developing a uniform treatment (mainly medication) that can be applied across the world’ (ibid.). Yet according to Timimi and Maitra, it is nothing short of ‘institutional racism’ (not to mention about as appalling a case of Eurocentric cultural imperialism as one could imagine) that one flawed study that took place in a Western country and that went unchallenged in a peer-reviewed international journal should be used to claim that ‘ADHD’ is ‘under-diagnosed and under-treated across the world’ (p. 210). Better news for pharmaceutical profits there, then.

Continuing the research theme, it comes as no surprise when we read that ‘ADHD research has largely ignored emotional, developmental, and personality factors’ (p. 31); that ‘the idea that ADHD is a medical disease shapes how the research is then conducted’ (p. 142); and most telling of all, that ‘long-term studies into the safety and efficacy of [stimulant medication] treatment have not been established’ (p. 179). Then in Chapter 11, Cohen et al. look at the case of Strattera^TM (i.e. atomoxetine), finding major discrepancies between published and non-published versions of the clinical trial data. Jay Joseph writes that ‘future research should be directed towards environmental factors’ (p. 79) – but surprise surprise, such research has been largely ignored in this medically dominated field. As a strong anti-vivisectionist, I was also personally outraged with the fact that countless animals’ lives have been sacrificed in appalling circumstances on the altar of this entirely bogus science – and if we’re talking of ‘symptoms’, then this is surely symptomatic of the ethically bankrupt nature of ‘late modernity’ in all its manifold machinations.

Finally with regard to research, there are close and devastating analyses of the Castellanos study (2002), described by Grace Jackson as ‘the linch-pin of the American "ADHD industry"’, which concluded that ‘the brains of children with ADHD were three percent smaller than control brains’ (p. 290), that the medications were not responsible for brain volume reductions, and therefore that ‘There is no evidence that stimulants cause abnormal brain development’ (p. 264; see also pp. 111–13, 118, and 289–90). It was in this study that the control group was around one year older than the ‘ADHD’ subgroup as a whole, and older by around three years than the 49 patients who had never received stimulant drug treatment (p. 265); and Leo and Lacasse are mystified as to why, ‘once a group of non-medicated ADHD children was identified, it suddenly became difficult to find age-appropriate controls’ (p. 290). As a final sobering salvo, in Chapter 11 Cohen et al. go as far as arguing that ‘the entire clinical trial enterprise might be characterized by deception and manipulation, such that the boundary between marketing and scientific activities had been virtually eliminated’ (p. 313) – with the rest of their chapter detailing just how this was the case with the drug Strattera^TM. What is especially useful is their analysis of the literature arguing that clinical trials are quite unable to provide an accurate picture of a drug’s adverse effects (p. 324).

In the book we also find a number of examples of the tell-tale circularity that often recurs in this field (already referred to above in my discussion of the vicious circularity of psychiatric diagnosis). Thus, for example, on page 72 we read that ‘Psychiatric conditions such as ADHD remain "complex disorders" even after initial gene-finding efforts come up empty, while subsequent gene-finding failures are explained on the basis of the "complex" nature of the "disorder"’. Then on page 143 we read of another circular argument often encountered: ‘this child is presenting with poor concentration, impulsivity, and hyperactivity. What is causing this? Answer: it is caused by ADHD. Question: how do you know it is ADHD? Answer: because he or she presents with poor concentration, impulsivity, and hyperactivity.’! And on page 161 yet another example: ‘we diagnose ADHD by observing behaviour and then claim that behaviour is caused by ADHD’ (original emphasis). What is really interesting here is that when a field like this is based on fatally flawed foundations, it is pretty much inevitable that it will have to resort to tautological circularites of argument in attempting to justify its existence; and the teasing out of these often subtle circularities is surely a key task for anyone involved in critiquing the field.

Finally, some minor suggestions as to how this splendid book might have been improved. There might have been some more concerted discussion of the core philosophical problem of reducing human behaviour and experience to neurological processes in the brain (the paper by Thomas Nagal, ‘What is it like to be a bat?’ is still seminal and compulsory reading in this regard). While some attention is given to the issue of television and screen culture (e.g. pp. 138–9, 388–92), my strong sense is that this is one of the most underrated factors in children’s disturbed behaviour in modern technological culture (see, for example, Sue Palmer’s work on ‘toxic childhood’, and Aric Sigman’s work on the mal-effects of televisual culture). As I have written elsewhere, ‘[I agree that] children should ideally not start watching television, or begin using computers, until at least the age of 7. My own hunch is that if this advice were followed faithfully by today’s families, not only would conditions like "ADHD" virtually disappear overnight, but the overall quality of family life would improve immeasurably.’

There is also less attention given to the impact of the educational system than I would have liked (it is considered briefly, however, on pp. 139, 142, 149–50 and 400). Children spend a considerable proportion of their waking lives in the schooling system (often surviving far more than thriving, and often beginning quasi-formal, overly cognitive learning at far earlier an age than many of us believe to be developmentally appropriate). As Robert Sardello has evocatively written, ‘Materialistic learning – education, as we know it – from pre-school through graduate school, damages the soul’. I agree wholeheartedly with Sardello’s assessment, and again, if this view is anything like right, then it would be extraordinary if the nature of the schooling system were not playing a major role in children’s challenging behaviour.

There are also times when the language and way of speaking about ‘ADHD’ that are used in the book sound like the very medical-model cosmology that is rightly being challenged throughout. For me, this emphasizes just how easy it is for all of us to slip back into thinking about children’s challenging behaviour in a ‘modernist’, medical-model way, often without even realizing we are doing it. Thus, on page 212 we read that ‘it charges those who fail to diagnose and treat it [ADHD]’…; on page 218 we read of ‘the true incidence of ADHD in the US’; and on page 245, ‘the incidence of the disorder in the UK did not change…’. This is by no means mere nit-picking; rather, it is to make the point that the prevailing Zeitgeist and accompanying modernist paradigm are very powerful, and we must be eternally vigilant about their insidious effects, and the ways in which a way of thinking can penetrate our consciousness without our even being aware of it.

What I am left with after reading this counter-cultural book is that in any reasonably rational world, a book like this would most certainly herald the death-knell of the medical-model, psychiatric diagnostic category known as ‘ADHD’. And that this will not happen – at least not yet – shows that we live in a far from rational world, in which ideology, and material and professional vested interests, commonly far outweigh the power of rational argument. Faced with this reality of a paradigmatic worldview that will fiercely defend its illegitimate hegemony at virtually any cost, then we are left with the task of relentlessly challenging the Kuhnian ‘normal science’ of the status quo until such time as the existing paradigm is no longer sustainable, and a Habermasian ‘Legitimation Crisis’ of such proportions is precipitated such that a new worldview can prevail. This excellent book will undoubtedly play a key role in that process, and for that reason alone it deserves as wide a circulation and exposure as possible – and not least within the world of psychiatry and medicine.