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Diagnosing ADHD: Different Countries, Different Approaches

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT
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ADHD Controversy

Over the past decade, there’s been widespread public debate about the increase in reported rates of ADHD diagnosis in the USA and how they compare to those in the rest of the world, particularly countries in Western Europe such as France. Though it’s possible to trace this discussion back as far as the early 2000s, beginning with articles like The Worldwide Prevalence of ADHD: Is it an American Condition?, the debate was resurrected by Marilyn Wedge’s article “Why French Kids Don’t Have ADHD” published in March 2012 in the magazine Psychology Today.

Wedge’s article circulated broadly through various social media sites. Both parents and child professionals alike were up in arms about claims that ADHD rates in American children were at least 20 times higher than those in French children. The prevailing notion was that the ADHD epidemic among American children was really nothing of the sort. It was simply a matter of over-diagnosis. American doctors were accused of using criteria that were far too broad in diagnosing ADHD. American parents were accused of being too quick to jump on the ADHD bandwagon.

Critics painted the approach to ADHD in the USA with a largely negative brush. Compared to France, it appeared most American doctors and parents preferred the quick and easy route. Meaning they appeared happy to label a child with a pathology, prescribe medication, and be done with it.

The Plot Thickens

Before long, however, articles began to appear that brought balance to the debate. Within a week of the appearance of Wedge’s piece in Psychology Today, Dr. Vincent Iannelli wrote an article called “Why French Kids Don’t Have ADHD? Actually, They Do”  in which he cited several studies that directly contradicted Wedge’s claims. Psychology Today also published a response to Wedge’s article in September 2012 called “French Kids do Have ADHD: An Interview”. In addition, concerned parents from across the world began publishing blog posts that questioned the notion that kids in France don’t get ADHD. They had titles like “Oui, Oui, French Kids Have ADHD” and “French Kids Don’t Have ADHD? Well, Mine Does.”

So, what exactly is the truth about the differences in ADHD diagnosis between the USA and France?

Diagnosing ADHD: Two Approaches

All available evidence indicates that there are two completely distinct approaches to diagnosing ADHD in the United States and France. These differences exist for a wide variety of reasons, summarized by placing them in two categories: Scientific and Cultural.

Scientific Differences in ADHD Diagnosis

The guidelines for diagnosing ADHD in the United States are not the same as the guidelines used in France. In the United States, they come from The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM V). In France, they come from the Classification Française des Troubles Mentaux de L’Enfant et de L’Adolescent (CFTMEA).

The main difference between the two sets of guidelines is that under the DSM-V, one expert observer – usually a child psychiatrist or psychologist – can make a diagnosis over a relatively short period of time. Parents fill out questionnaires to confirm the presence of ADHD characteristics in their child over a period of six months or more. Observers generally ask for the input of teachers and/or school officials. However, in the U.S., a family can see a child psychiatrist one day and receive a diagnosis for ADHD the next.

In contrast, the CFTMEA protocol used in France takes a great deal longer and involves the input of more people. Rather than solely observing and asking questions about a child’s behavior, therapists in France take a broader perspective. They consider the familial and social circumstances at play in the life of the child. They interview teachers and school officials over a period of six months to a year. A positive ADHD diagnosis in France usually takes close to two years to receive, and sometimes even longer.

Cultural Differences in ADHD Diagnosis

In the USA, the culture surrounding the practice of medicine can be characterized as prescriptive. Scientific data drives diagnosis. American patients and doctors tend to handle emotional or behavioral issues in the same way that they handle physical issues. When Americans get sick, the process is usually fairly straightforward. Go to the doctor, perhaps have some tests done, get a prescription, go to the pharmacy, get medication, get well. Americans view ADHD in a similar way. Parents who suspect their child might have ADHD go to a professional, have them screened, and then decide whether or not to put them on medication. With regard to ADHD medication, parents will often hear their doctor say something like “if your child was diabetic, you wouldn’t hesitate to administer insulin.”

In the USA, medicating children for ADHD is the cultural norm.

In France, medicine is slightly different. French patients and doctors tend to have a more holistic approach to diagnosis. Scientific data plays a large part in the process, but doctors take other factors into consideration, as well.  For both physical and emotional issues, external influences such as lifestyle, diet, and environment are always part of the diagnostic conversation. They also consider internal emotional influences such as stress, anxiety, and history of trauma. The process is the same for the diagnosis of ADHD in children. French doctors take a holistic approach, and don’t just look at a behavioral checklist in order to determine whether or not a child has ADHD. Also, in France it is illegal to prescribe stimulants—the prescription of choice for ADHD in the USA—to children under the age of six. Therefore, medicating children for ADHD is not the cultural norm.

The American Approach or the French Approach: Which is Better?

According to the CDC, roughly 9.5% of children in the USA have been diagnosed with ADHD, whereas research based in Europe shows that between 3.5% and 5.6% of children in France have been diagnosed with ADHD. Differing diagnostic criteria explain these differences, which, in turn, are explained by the differences in the prevailing scientific and cultural norms that dominate the practice of medicine in the USA and France.

Experts now recognize that ADHD is just as common in the rest of the world as it is in the USA. The most important issue left to address is that of treatment. Is the medication-based American way better? Or is the holistic French way better?

Children’s health professionals across the world are working diligently to answer these questions every day. When the data are in, it’s most likely that the practical wisdom in the old French saying will be confirmed:

“La verite est entre les deux The truth lies between the two.”

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