' A NICE CASE OF ADHD'
Interview with Dr. Sami Timimi, 15.05.2007
PK Do you work with people who are referred to you because they have ADHD?
ST I work with people who are referred to me with behaviours that would be described
as ADHD, but the idea of them having ADHD would depend on how you interpret
that. From my point of view ADHD simply describes a number of behaviours. So if you
talk about people who have ADHD, for me that simply means that you’re describing people,
in my case children and young people, who present with certain types of behaviour.
And that’s all that it means. And from that point of view, I get plenty who are referred
with the sorts of behaviours that are described as ADHD. And I see plenty of people who
are referred where a parent or a teacher or a doctor are asking for us to exclude or assess
for a diagnosis of ADHD. The problem is in terms of the whole construct of ADHD; the
kind of other meanings that get woven into ADHD. ADHD has come to define not just a
description of behaviours, but also it has become a syndrome and a cause all at once, which
has kind of left it in a complete muddle. So that you have got this kind of circular situation
where we have something like a child who is presenting with something that would be described
as hyperactive and with poor concentration. And then you ask the question “well,
what is causing that?” and then somebody might answer who believes in the construct and
interprets it in a very narrow way may answer, “they have that because they have ADHD”.
So then you have to ask the question “why do they have ADHD? How do you know they
have ADHD?” That question will be answered “because they present with hyperactivity and
poor concentration”. So we have got this problem with these other meanings that get woven
into the ADHD construct. So in my own practice, I don’t go down that very narrow path.
Even though people are referred to me with these behaviours and with that question, my
assessments are not based around making a diagnosis. And my subsequent treatment is not
based around a diagnosis. So from that point of view, none of the kids I see have ADHD.
PK I have read some of your articles, in which you describe ADHD as a social construct.
Could you explain what you mean by that?
ST That’s the kind of question I could spend the next few hours on, because there
are many different aspects to that question. And there are many ways of misinterpreting
the answer. The first point to make about the idea of ADHD as a social construct is to
make sure that when talking about that I’m not saying that these types of behaviours are
not behaviours that are problematic, and their not behaviours for which we shouldn’t be
trying to provide good service and to try and help people with it. Having said that, if we
look at the history of how the whole concept of ADHD developed, what we find is that it
is not predicated on any particular discovery. There is no scientific discovery that led to the
syndrome coming into existence.
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PK Maybe it was in 1937 when Bradley first successfully used psychostimulants on
children? So that we first see the cure, and then a formulation of the problem.
ST That history is similar to the history of most psychiatric drugs. But that does not
equate with scientific evidence of an abnormality that is cured. That is sometimes referred to
as allopathic evidence: that because something changes something, you assume that therefore
an abnormality is cured. And we have many examples in medicine that that is not necessarily
the case. You don’t take aspirin because there is some identifiable biochemical abnormality
which aspirin corrects. It creates a certain type of difference in the brain, but it does not
correct an abnormal brain state. There is no such thing as an aspirin-deficiency syndrome
that is corrected by taking aspirin. In the same way, we know that it creates a different brain
state. And some people report getting social courage, for example. But that does mean that
if it cured that social problem of shyness, that alcohol is reversing some abnormal chemical
brain state. So it doesn’t quite equate with evidence with a biochemical abnormality.
And of course the kids that Bradley was using, the majority of them had been effected
by an epidemic of encephalitis a few years earlier. So they did have evidence that they had
suffered neurological insult. And that is where the kind of problem with the idea of brain
damage first came into existence. And if you look at the history of ADHD, basically it is
a mutation of constructs that has resulted in ADHD. In almost a very concrete way you
can see that the history of the definition has been socially constructed. At no point has it
been backed by any real discovery in the biological realms. Which is where the problems
start to occur for me with the whole ADHD construct, because it has come to be classified
as a neurodevelopmental disorder: a disorder of the development of the brain. And for me
this does not follow any logic or evidence. You need to demonstrate concretely that there
is some disorder of the development of the nervous system in order to class something like
that. And there is nobody who demonstrated that.
But what has happened, going back to Bradley, the idea of Minimal Brain Damage,
which is the forerunner of ADHD, gradually took hold. But it was always a small number
of children. It was a very rare disorder, and there was not much interest in it within psychiatry
or paediatrics. And the Minimal Brain Damage gradually lost interest anyway, because
nobody was coming up with any evidence of Brain Damage. And in fact children who do
have brain damage, are at risk of psychiatric disorder across the board. Not any specific
psychiatric disorder, they have a high risk of all sorts of psychiatric disorders. So there was
never any good concrete evidence that these particular behaviours were specifically linked
to brain damage. But if you look at what other gradual things that were happening, then
there is the gradual move to defining syndromes behaviourally; there is the changing in the
way that medicine was managed; there is the whole thing of the DSM changing in power
balance from psychoanalytic models in DSM I, by DSM III had gone over to the biological;
there is the whole changes in the managed healthcare in America, where having a service got
connected to having a diagnosis and the movement to treatment packages; the drug industry
came in and pumped a lot of money in it. For this is not a new drug, it has been around for
fifty-odd years. But there has been no interest in it. There is changes going on in the education
system with regard to certain disability and special needs, and how do you get access
to that, how you’re being recognised as having a ticket to various such services. There are
other wide changes taking place in the culture such that there is a gradual increase in almost
a moral panic about children’s development, and particularly about boys’ development. Remember
that this is a boy-disorder. This has to do with the behaviour of boys, as opposed
to their emotional state. It is about the behaviour of boys. And if you look at the history
of childhood, we see concern about children and their development and how we construct
them and how we conceive of them and how we go about the task of supporting them and
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parenting and so on. It seems to happen at times of greater social change, it seems to often
reflect times where the adults population are in some state of anxiety about what’s going on
in their lives. And children are often the arena where you see these things. See you this in a
small way in families, your unfulfilled wishes are often projected onto your children. . .
So there are lots of these cultural factors which are coming into play as to why,
despite so little biological evidence being around to back this idea, this becomes a problem.
There are all these aspects to talk about when we think about why this is a social construct,
and why it has become so popular, and why is it in particular countries that it has become
so popular. I’m half Iraqi, I grew in Iraq. The behaviours that are classified as ADHD at the
moment certainly from my knowledge of growing up in Iraq and from speaking to others
who come from that part of the world, that sort of behaviours are not considered the sorts
of things that, one, you would get too concerned about and, two, if you did get concerned
about them, you would not go to a doctor.
PK That’s in a lot of countries, not just culturally very different countries—also in
Spain in Italy, for example. But do you think that the management of inattentive, hyperactive
and impulsive behaviour should not belong to the medical jurisdiction at all?
ST My concern is that at the moment it belongs to paediatrics, and I do not think it
should belong to paediatrics at all. In some ways child psychiatry has been shooting itself
in the foot. Because once it began to classify these types of behaviour problems, which
has been the arena of child psychiatry for a long time, as neurodevelopmental problems,
neurodevelopmental disorders are the arena of paediatrics. What happened in the U.S. is
that paediatrics became a big growth area for diagnosing ADHD, and there is a similar
dynamics going on with Autism Spectrum Disorder, this is another boy thing. And that has
caught on in this country. So in the last five to ten years, all new ADHD clinics, or behaviour
clinics, have been run by community paediatricians. Child psychiatry, in this country and in
North America, traditionally grew out of the child guidance movement. The child guidance
movement used to have its clinics in community settings where there would be a mixture of
educational, social services and psychiatrists. So it sat in the interface, traditionally, of these
various childcare organisations, which I think is in some way quite logical. Because child
psychiatry, more then any other branch of medicine, reflects the interface between your
biology, your psychology, your social situation, because all children have to be cared for by
others, by adults around them, and have to have decisions made on their behalf. So it was
always going to be a bit different from adult psychiatry and it was always going to be a bit
different from the rest of medicine.
But what they have tried to do in child psychiatry when this biological model took
off, it has tried to become more doctory. And doing so has a say on what they [. . . ] because
now conditions like ADHD are being dealt with by paediatricians. And the problem there
is that, unlike child psychiatrists, who should better than paediatricians be able to deal with
a more broad range of perspectives, paediatricians stick to a very narrow model of ADHD.
They don’t have the training—unless individual paediatricians have decided to seek that out
themselves—in the assessment of broader factors such as school, peer relationships, trauma,
family history, family dynamics, behaviour management. . . And they don’t have the services
usually set up to offer more broad-ranged interventions. So what happens with paediatrics
quite often is that people will go and the service will be geared around making a diagnosis.
And if the diagnosis is made, putting in place a treatment plan, which often is medication
and medication only. Perhaps a bit of psycho-education about what ADHD is, that it is
caused by a problem of your brain, that you can have it for the rest of your life, that you
have to treat your son of daughter a bit differently and that you have to talk to the school
about special educational provisions to support this disability, etc. etc. And that, to me, is
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not helpful and that’s the bit that I think is wrong. I think medicine will likely always have
a role to play within people with these problems, particularly modern cultures that want
to organise their cosmology and society around rational scientific methodologies—medicine
will always have a very high status in that. So in those sorts of societies like ours we will
always have quite a high status.
But also there is a role because various physical conditions can cause behaviour problems,
and so you need to be able to recognise those. There is a lot of evidence about different
types of nutritional states, and we know that in the last twenty to thirty years the types of
food we consume have changed enormously—for the worse. And we know that quite a few
other childhood disorders—such as asthma and various kind of allergy states like hay fever,
often to do with the immune system—have also increased dramatically. So it is likely that
biology does play a role, but not in the way many people think today.
The temptation is always to try and live in a world with moral certainties, where
we can divide things quite clearly and where we can say that this is the problem, we simplify
it down, and this is our solution. And actually what I think has gone missing is an
ability to be a bit more reflective and a bit more thoughtful about the individual situation
of the particular child and their family. And I think the whole concept of ADHD has a neurodevelopmental
disorder has been particularly unhelpful, because it effectively treats huge
differences with the same [. . . ]. One child I work with might be helped with a behavioural
intervention, the next one might have educational things at school they’re not happy about,
the next one might be more nutritional type of problem, and the next by a combination of
all sorts of things, depending on what I find.
PK Do you expect that the guideline NICE is developing will alleviate the situation?
ST I was invited to speak to the Guideline Development Group [GDG], and my
concern is that whilst their intentions might be to improve the situation, the whole idea
of guidelines for ADHD is ripe with the potential to make matters even worse. If they are
properly going to grasp the nettle, then they actually need to take seriously the possibility
that a diagnosis and the culture of diagnosis is counterproductive, and actually leads you
away from understanding the particular cases or making a good stab at having different ways
of conceptualising the problem. My problem, and this is what I got from the day that I was
invited, is that they are trying to work out thresholds at which you would activate a process
to get a diagnosis. And that I think, when it comes to mental health or human subjective life
in general, is a nonsense. That is not the way you’re going to be able to develop, inmy view, a
system properly fit for the twenty-first century. Because we’re meant to be in a time in which
we’re trying to create partnerships with people, where we’re trying to understand their
narratives, etc. This is stuff that in the rest of medicine they’re taking serious now. We’ve
got narrative-based medicine, we’ve got values-based medicine, we’ve got the importance of
understanding the context of stories peoples are telling, the meanings they put on the various
things. And a sophisticated clinician should be able to work with these systems of meaning
and have big toolbox of ideas and approaches and be able to find—particularly when we’re
leaving in multi-cultural societies, where there are people who might have very different
believe-systems and different value systems about what the development or the trajectories
of children are, what their roles are in the family, what the roles of parents are, and so on—
so we need to be able to have different systems of knowledge that we can helpfully apply to
different situations. And we need to be able to use that flexibly. But this creating algorithms
by NICE is effectively pending that down. What it does what they’re trying to do is like
quality control in factories. In quality control in factories, when you’re producing washing
machines, you try to reduce human impact as much as possible by standardising processes
as much as possible. So that each washing machine is of the same standard—that’s what
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quality control is. You can’t do that when you’re dealing with mental health, with human
social relationships. Because the whole point of this type of work is that it is predicated on
relationships.
PK You said that in medicine are introducing and working with value-based medicine
and things like that, attaching value to the meaning people ascribe to their own conditions.
NICE is very proud to be working in a strictly evidence-based environment and the number
one tool of EBM is the Randomized Controlled Trial, in which all individual differences are
abstracted away from.
ST Some kinds of evidence are not appropriate for child psychiatry. That does not
mean that we should ignore the evidence base. In fact, what I’m saying is that from my
point of view entirely consistent with EBM. When EBM first came into practice, what it was
trying to do, which I fully support, was to reduce the amount of maverick interventions.
That was the whole thing, for example, about Bristol heart transplants, that were some
surgeons in Bristol who had an incredibly high death-rate. Examples like that have to do
with why the reasons why we have EBM, and the postcode-lottery. I can understand all of
that. The problem is that, just like any system you put in place, it can become a dogma.
Because this was applied by humans in various social relationships, essentially, it became the
watchword. As long as you could say that you were doing EBM you could produce a paper.
That became a kind of a dogma in itself. Which is exactly the opposite of what EBM was
meant to do. EBM was actually meant to get you to question you own assumptions. And
if you go back and look at the evidence, there is very little evidence to support the notion
that ADHD is a neurodevelopmental disorder. It is not up to me, as critics of my view come
up and say, to present the evidence on the disorder, it is up for the people who support that
idea to present the evidence, because that is the way science works.
PK These people are all on the GDG.
ST Exactly, that is the problem. They had a particular idea of what evidence is, I have
summarised the evidence, as have many people I know. One of the projects that I’m involved
in at the moment is that we’ve just completed a book which contains fifteen chapters
from various very well-know critics, it’s called Re-thinking ADHD, and it is critiques on the
construct from all different sorts of angles. From genetics, from the neuroimaging research,
from the cultural points of view, from the intervention point of view—the effects of stimulants
etc. There is a whole literature out there that points out the problem in the current
dogma about ADHD. So from a purely evidence-based perspective, the evidence about the
long-term effects about stimulants are not good. They do not produce long-lasting positive
outcomes in education, they do not produce long-lasting positive outcomes in relationships
with parents, in peer relationships, possibly in some behavioural trait. But there also appears
to be a whole set of negative things, from exposure to drugs that may have long-lasting effects
on your personality, on your cognitive functioning, on all sorts of things. On growth.
And the biggest concern at the moment is on the cardiac system, because it is a cardio-toxic
drug, and if you take it for several decades, what is the long-term impact of that? And that
is like a big experiment we’re carrying out.
PK A big experiment with a lot of people.
ST With a lot of people. So I have grave concerns about the way the evidende is
being interpreted in this group, and what their conclusions will be. Because to me, a thoroughly
evidence-based approach to the problem would have to start with what we call a
null-hypothesis.
PK It would have to start with questioning the validity of the diagnosis.
ST Yes, exactly. So I am very suspicious of the idea of an algorithm.
PK You have been to one of NICE’s meetings?
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ST Yes, I have been invited to one of the conferences of the GDG.
PK So you know the people who are on the GDG?
ST I know some of them.
PK Given that you know who they are, given that you have seen something of the
process so far, you don’t have much confidence that your view will be represented?
ST I have made it quite clear to them, for that was my concern, I was very close to
saying that I wouldn’t come along because I didn’t want to thick a box to say, yes, we’ve had
him.
PK Just as a lipservice.
ST Yes. I have nonetheless done that, and I know that another colleague of mine who
is critical has been included in the review process. It is hard to know how much influence
critical opinions will have until the guidelines come out. But my concern is that the chairperson
of the GDG is somebody who is very committed to the idea. I don’t think he is one
of the people who are slave to the drug companies, I think he is a genuine, or attempts to be,
a genuine scientist. But he has put together a life-time’s work, he has a lot of personal and
cognitive investment in this idea.
PK And professional investment as well.
ST And professional investment as well; he set up services, and he has argued for a
long time that ADHD is underdiagnosed and under-treated. And he is chairing. He cannot
be in an unbiased position, as a chair of that group. Because he has a very strong and very
public position about what ADHD is.
PK And he has had that position for about twenty years.
ST And he is not about to change his mind. Let’s put it that way. Which does make
you wonder, if the GDG—because not everybody in that group was averse to what I was
saying in my presentation—if the rest of the GDG were concluding that ADHD is overdiagnosed
and overtreated, would he feel able to leave that unchallenged? Would he be able to
agree with that, given that he has put so much energy and investment in the position that it
is underdiagnosed and undertreated. Those are my concerns.
PK To come back to something you said earlier about the development of the concept
of ADHD, you mentioned that in the change from DSM-I or DSM-IV, psychiatric
classification became, in a sense, more biologically prone, but diagnoses also became more
on behavioural symptoms. There is a bit of a tension there, as I see it. Can you say something
about that?
ST When DSM was originally conceive, and particularly when DSM-III was conceived—
which was the one that marked the shift towards “operationally defined”, which is a thicklist
of symptoms, which is a peculiar way to think about it. In the rest of medicine, we
have symptoms and signs. Signs is your physical signs, and that’s all they are. So you try put
together all your symptoms and signs, and then based on that you do whatever investigations
you think is needed to throw up your differential diagnosis and you come up with a possible
diagnosis that would fit these particular symptoms and signs. But you’re eventually trying
to decipher an underlying pathological process.
PK Aetiology.
ST Yes, that what it is based on, it is an aetiological based system. This is a rather
peculiar way of trying to deal with the shortcomings of not being able to do something like
that in mental health. And whilst the DSM [III] originally set out that it was going to be
an a-theoretical manual, it was going to divide phenomena according to operational criteria,
which was a thick-list of symptoms, and these were effectively done [. . . ]. It went out to
consultation psychiatrists across America, and various groups met in committees, and then
you submitted your data to the committees, and then eventually these committees voted.
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And what happened over the years is that the number of diagnoses in each manual started
increasing. That a whole other system came built around them, so that they become more
than just diagnostic categories. One of the big things about DSM-III is that it was the kind
of killer-challenge to psychoanalysis in American psychiatry. So it was kind of a victory for
the biological ones. And it pretty quickly got tied into the pharmaceutical industry, because
now pharmaceutical industry got into selling diseases. Because that is how they actually sell
drugs; if they sell the concept of depression, and if they popularise the concept of depression
among doctors and among the public, then people who are unhappy come more and more
to think that they need help.
PK How is that in the UK, are pharmaceutical companies allowed to act directly on
consumers?
ST In America they are allowed to act directly on consumers. In the UK they’re not.
But of course they do all the time, because we have got the internet. And companies set
up lots of internet sites. And they’re internet sites which have to do with diseases rather
than drugs. And they also support various pressure groups, consumer groups, and so on.
So that’s the way they’re acting directly on consumers. And of course they’re constantly
lobbying doctors. So there is that factor in there.
The shift to using operational criteria cleared the path for biological psychiatry to
take the upper hand. And it is not because of any new evidence. We have had the decade of
the brain, in which psychiatrists had all sorts of new tools to play with. And the promise of
the finding of the pathology was always just around the corner. Now we’ve got MRI, we’ve
got CAT-scans, we’ve got molecular genetics—the will o’ the wisp: you often think you
see something, but every time you approach it suddenly disappears. And there is actually
nothing there. Every time they look, they can’t find it.
PK Genetics is the contemporary example I guess, but many people are already realising
that there is nothing there, or at least not enough.
ST That it is more complicated than that it can be reduced to it, as you can have an
idea with other medical genetics. Something we clearly know is due to a pathological process
such as diabetes mellitus type 1. We know that is kind of genetic, and yet we know there is
huge environmental thing going on there which we don’t yet understand. Because rates of
insulin-dependent diabetes type 1 have increased and they seem to be presenting at younger
ages. And it is quite hard to know what combination of things is causing it. And the genetics
of that is quite complicated, it is not just one gene, but we know what protein is at issue.We
know that we need to look at the proteins that code for insulin, for that is the protein that
malfunctions. Or the proteins that code for the islands in the pancreas that make. . . and so
on. So we kind of know where we’re looking. It’s a huge step to go from vague behaviours
to genes. It’s an impossible leap.
PK Still, there is a molecular geneticist on the GDG for ADHD.
ST Is that Chris Hollis.
PK Yes, it is.
ST He is at Nottingham University, and he does a lot of research on genetics and so
on, and again, he is a hard-line ADHD supporter, and he does get drug-company money.
And the evidence on the genetics has been summarised by several people, probably the best
one is J. Joseph, he has written several articles and a couple of books. And basically, the
evidence is not there.
PK Except for twin-studies?
ST The twin-studies are an interesting case in point, because they actually provide no
more support for the genetic hypothesis than family-studies. Because so many psychological
studies have shown that identical twins are psychologically very different, because they’re
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very often reared as a unit, they often report identity confusion, they often swap roles, they
have an intense relationship. There is lots of studies out there that say you can’t differentiate
the psychological from the biological. So the twin-studies provide no more support than the
family-studies. Just because things run in families doesn’t mean that they’re genetic. It might
be genetic, but it could be entirely psychological. Simply that technique will not be able to
differentiate.
PK The eventual goal of any guideline is to make clinical practice more equal. What
are your expectations on that if that happens with the guideline on ADHD that is being
produced right now?
ST Depending on what the guideline produces, I think it has the potential to cause
more problems. It could also become a cause for the good. [. . . ]
It could actually become a warning about the early use of diagnosis and the ease
with which diagnosis can be a dumping ground for a whole manifold of problems. And if
it became something that actually encouraged clinicians to look more widely. And if it did
that, it would essentially be shooting down the concept of ADHD. That’s probably what I
would expect it to do, because eventually somewhere along the line a guideline will have to
address the question of the validity of the diagnosis.
PK Do you think this guideline will do that?
ST No, I don’t think so. It might still be a cause for good if it produces a guideline
that is quite strict about the overdiagnosis. Because in some ways I had a big problem with
the guideline on childhood depression, because it never questioned the concept. However,
there were some positive thing about it, which was that it did evaluate the evidence about
anti-depressants and it went further than I thought it would in terms of not recommending
it as a first-line treatment. Nevertheless I think it doesn’t go far enough, because actually
the evidence on anti-depressants for children says that non of them are particularly effective,
and they all have a potential, a small rate, but a potential of quite serious danger of inducing
suicidal thought. But it went a lot further than I thought.
PK It is very careful with respect to mild depression, for example. Do you think that
this might happen with the ADHD guideline as well?
ST The problem is, again, the devil is in the detail. Because different clinicians have
very different ideas on what is mild depression, what is medium depression, what severe
depression? Or what does depression mean? How do you differentiate it from unhappiness?
These kind of more conceptual problems. But nonetheless, it set a scenario that said that
we were using too much anti-depressants in children and that we have to stop using them
all the time. And that was helpful. It didn’t go far enough, but it was a step in the right
direction. These guidelines on ADHD could do the same. It might not be enough, in terms
of the proper critique of it. For in a way what the childhood depression was virtually saying
was that childhood depression was not that useful as a concept, in a roundabout way. It
couldn’t quite say that, but it was virtually saying that. And if the ADHD guideline moves
in a direction saying that we need to be much more cautious than we are being, then that
could be helpful. And that would be the most I could hope. But we need to wait and see.
If the algorithm is treated to concretely and if it remains in the arena of paediatricians
to treat it, because that is the other helpful thing this guideline could do: it could take it away
from paediatricians.
PK And move it to psychiatry entirely?
ST Exactly.
PK Actually I think you sound quite hopeful. I maybe expected that you’d be less
optimistic about this guideline, for example because of the people who are on the GDG.
ST I am concerned about what will come out. However, I do think the tide has been
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turning slowly. And a lot of it has been after the negative publicity about anti-depressants
in children. The climate is sceptical again. For a while biological models and the use of
medications were just going full speed ahead. But there is a sceptical attitude again, the press
is sceptical, a lot of the public is sceptical, in my interaction with them. And there are certain
elements within the profession that are sceptical. One thing that is of interest to me is that I
have had a number of times where I’ve had debates where there were no child psychiatrists
or paediatricians—I know lots of child psychiatrists and paediatricians who are actually very
much in agreement with the thoughts that I expressed—but I’ve had some debates with
hospital doctors in general, who are not part of the [ADHD community]. And when we
have a show of hands at these debates, the majority of doctors are actually in agreement
with ADHD being a social question and not a biological one. So I think there is actually a
silent majority even within medicine.
PK But the rise of ADHD diagnoses doesn’t really support your point.
ST I can only comment on the doctors I have had contact with in this country.
PK I’m talking about the UK. The prescription rates for methylphenidate are still
rising.
ST Yes, but you have to understand that a certain dynamics is happening, and that
there are certain interested parties. For example, community paediatrics is an interested
party that has expanded its role hugely. And all it takes, for example, in Lincolnshire we have
quite high rates in certain parts of the county and it is accounted for, more or less, by two
doctors who have clinics that are almost pumping children out. I don’t know how much,
but I would estimate hundreds of children are going through these two particular clinics,
having short appointments, being diagnosed, being put on medication, review every six
months, medication repeated. I know another paediatrician, in another part of the county
who works very differently. This paediatrician diagnoses much more rarely, she still uses
medication. Even within a small area like that, you might find that a county with a high
amount of prescribing, and it is accounted for by three or four doctors. I was working for
a while in North-East Lincolnshire and they had the same problem there. They had one
doctor there with a case-load of over seven hundred children on psychostimulants. And
you’ve got the drug companies in there, you’ve got certain parent support groups, but my
experience is actually that if you took doctors as whole in this country and I wouldn’t be
surprised, although I don’t know for sure, my straw pole as it were for times that I have
done debates with people is that in terms of doctors in general are sceptical. Certainly other
professions in mental health, like psychologists, social workers, nurses, psychoterapists.
PK It’s all a bit of guesswork, but you don’t think there is a chance that the GDG
might say that ADHD needs to be moved to primary care.
ST My god, I hope not. Have you picked up that there might be a chance that they’d
do that? I know that it happens in America.
PK It happens in America, that is one reason, another is that atomoxetine is being
prescribed by GPs, so it might be that also methylphenidate moves to their range.
ST Up until now the guidelines that have been produced have been saying thatADHD
has to be seen by a specialist. But I would hope that at least that would not happen.
PK Because you think there might even be more restriction when it comes to who is
in charge of ADHD?
ST There might be; I don’t know. And certainly I have the feeling that some members
on the panel are sensitive to that. I did hear this. They produced a draft after that day that
I have been there, and it went through nine revisions, because the members of the panel
couldn’t agree. So it sounds like there is some interesting internal politics going on. Maybe
they regretted having invited me afterwards. It might have stirred the pot a bit.
76 E j Interview with Dr. Sami Timimi
PK With respect to the internal politics, I find it very interesting that there is a group
of five people within the GDG—which in total doesn’t consist of much over twenty people—
who all published together.
ST That has been mine concern about the group from the start, when I was first
invited and I knew who was on the group. The chair-person is responsible for deciding who
is on the group. And, without being argument, why wasn’t I invited? I published widely,
I’ve written several books, I present at conferences regularly and internationally, I do regular
clinical practice, I’ve actually run an ADHD clinic before.
I was invited for a one-day thing.
PK And it is not just that you are not on the GDG, but no one like you is on the
GDG.
ST Exactly. Why did they not have a critic on that GDG? Depending on what they
produce—because I also have contacts in the press—I will certainly be contacting my contacts
in the press to make that very point about the membership of the GDG which is
fundamentally flawed.
PK Is that something you think, that it is fundamentally flawed?
ST Absolutely. They can’t magic away the fact that this is a controversial realm. That
it is controversial. There is a very large critical literature, and it needs to be fully incorporated
into their thinking, if they are to produce an evidence-based guideline.
PK So for you that would mean not just reading all the critical literature, but actually
importing the critical people into the GDG. And even though not all the people on
the GDG have been former students of Professor Taylor, no one on the panel has written
anything critically about ADHD.
ST Absolutely. And that is the fundamental failure, which was evident from the start.
There might actually be some people on the panel who are actually trying to take seriously
the critical literature, because I also submitted a series of articles and various things that I
wanted them to read. But that is not good enough in my opinion. It will be interesting to
see how much of that criticism actually gets taken on board
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