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French children do get ADHD: calling nonsense on stern parenting

There’s an article from Psychology Today from 2012 going around my facebook newsfeed today, entitled “Why French kids don’t have ADHD.” Every post is followed by comments from people in their 20s and 30s who seem to yearn for “good old days” of stern Victorian parenting that they don’t actually remember, days when kids obeyed silently, parents ruled and didn’t need an iron fist because the kids stayed in line, and days when people just loved discipline. According to the article, that sort of approach would help reduce the number of children who are medicated for ADHD, because what kids really need is structure. It’s a bit late now, but I would like to call nonsense on at least some of that.

First of all, over-diagnosis is not proven by under-diagnosis. We know that kids in the US and other (usually anglo) countries are prescribed medications like Ritalin at incredible rates, and that there is probably something seriously wrong with that, and yet to say that this is just not a problem in France is deceptive. Kids in France are indeed diagnosed with ADHD. Maybe some are missed. Maybe there are other ways of treating it. But it exists in spite of the click bait title.

The author also discusses therapy and how that is used as a treatment before drugs in France. That’s valid – behavioural support and understanding development are extremely important, and we know that many mental health and development issues are totally culturally relative and there are some fascinating examples out there of differential diagnoses or even the total absence of diagnoses in some cultures versus others – this is the best article I’ve seen on that topic. Basically, after decades of research into mental health and behaviour we now know a lot about white middle class American college students and the kids they go on to have, and it’s short-sighted to take that as general gospel.

So, sure, let’s look at social ways to treat ADHD and other conditions and learn how to manage their symptoms. But why does it always seem that the answer turns to stern authoritarianism that anglo (usually American) authors seem to really admire? This author specifically mentions:

  • Cry it out sleep training so babies sleep through the night starting at four months
  • Restrictions on when to eat
  • Spanking
  • General discipline & expectation of conforming to strict limits

For the first three, why is this something to aspire to? Why does these general parenting philosophies have anything to do with ADHD?

The efficacy of CIO sleep training seems to be established by research but the emotional benefits and risks are less clear. If anything, there is a fair amount of research to show that babies benefit from attachment to primary carers right from the start and that leaving them scared and alone is detrimental. The moral side of it is that many people actually want their babies to know that someone is coming for them when they cry, so training them otherwise is not in fact desirable. Then there’s the angle that a 4 month old starting to sleep through the night is going to have a major effect on breastfeeding. If the baby wants to sleep, fine, but to train the baby toward that is detrimental to a breastfeeding relationship, and since the benefits of breastfeeding to both mother and child are backed up by near-endless evidence it’s hard to support anything that would disrupt that where it exists. I don’t think it’s a huge coincidence that France has extremely low rates of breastfeeding compared to other similar countries.

The author also makes the point that food can affect ADHD behaviours, but she makes a huge leap. Food can certainly affect ADHD behaviours but it’s not causing them. Controlling dietary factors is important, and many parents of children with ADHD know this well, but that is not what is separating American children from French children in the diagnosis. She also says:

Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it.

Well, actually, research is increasingly supporting the notion that when babies and children are given control over their food intake that they are at lower risk of obesity and type II diabetes: they learn when they’re full, what they want to eat, they eat because they want to not because they have to, and overall can develop healthier habits. If anything, even if what she says was true, the appalling state of socioeconomic inequality in the US, the existence of massive food deserts, and industrialisation of the food supply are the problem. Just telling parents to feed their kids better food won’t address that.

I’m not even going to go into the spanking topic because mountains have been written about how violence is no way to teach children and the author herself says that she doesn’t personally support it.

But she also says:

French babies, too, are expected to conform to limits set by parents and not by their crying selves.

I’m getting really sick of this fetish for silent French babies. Book after book after book has been published, adoring the (stereotypical) French way, which to be clear is a reflection of the people who worship it regardless of the reality. And yet in many other cultures, where babies don’t scream and cry all the time, they are attached to the parent, nursed on demand round the clock, and carried everywhere. How about instead of extremes – either expecting children to be silent backseat ornaments in our lives, or indulging in every passing whim, we find some balance? Including children in our lives and letting them learn by example surely is a better way to go. I don’t really want my child to obey because I told them to. I want them to develop the judgement to do the right thing, without it being about compliance and conformity.

None of this, however, has anything to do with over-medication of ADHD. Absolutely nothing, and as a scientist the author should know that. She says:

To the extent that French clinicians are successful at finding and repairing what has gone awry in the child’s social context, fewer children qualify for the ADHD diagnosis. Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to “pathologize” much of what is normal childhood behavior.

The French diagnosis is narrower and consequently fewer French children fit within the diagnosis. This is painfully obvious. If the American definition were applied to France would the same number of kids fit? I think that’s pretty possible. That means this has nothing to do with discipline or rules or structure, just different criteria.

I definitely agree that we pathologise normal child behaviour, but the key here is normal. That doesn’t mean that it needs harsh restrictions to manage it or contain it. It means that we have to find ways to work with it and fit it to our society, without creating spoiled monsters who lack boundaries. Like anything in life, balance is ultimately the key, and acknowledging a genuine condition that sometimes needs medication and always needs understanding and support is important. All the strict rules in the world won’t change that.

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