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and, via ‘green urbanism’, reconnecting with nature. In contrast to
the hard-nosed social psychiatric research that forms its bulk, the
final words of this slim, eloquent and indispensable volume are
‘plum blossom in spring’. Make that into your next app, Bill.
Jeremy Holmes, School of Psychology, University of Exeter, Exeter EX4 4QG, UK.
Email: j.a.holmes@btinternet.com
doi:10.1192/bjp.2018.51
Global Perspectives on
ADHD: Social Dimensions
of Diagnosis and
Treatment in Sixteen
Countries
Edited by Meredith R. Bergey,
Angela M. Filipe, Peter Conrad and
Ilina Singh.
Johns Hopkins University Press.
2017.
£48.00 (pb). 416 pp.
ISBN 9781421423791
My child psychiatry training from the early to mid-1990s was largely
systemically orientated. During my training years, I came across occa-
sional diagnoses of hyperkinetic disorder and even less occasional
prescription of stimulant medication. Sadly, some systemic and psy-
chotherapeutic practice in those days was caught up, whether inten-
tionally or not, in parent-blaming (particularly mother-blaming)
narratives. In the mid-1990s a mixture of factors contributed to the
rise of the ‘it is in the child’s genes/biology’paradigm as opposed to
the ‘parents –they f**k you up’story. Understandably, this felt like
a positive change for many parents. Pharmaceutical marketing, neo-
liberal commodification, performance-obsessed institutions (schools,
clinics) and therefore performance-anxious parents and/or children,
shifting cultural spaces for young people (e.g. the move online), guild
anxieties (doctors who do not feel they can be doctors if they are not
prescribing), pharmaceutical-supported parent advocacy, media
campaigns and so on all played their part in expanding the diagnosis
from the narrow, rare diagnosis of hyperkinetic disorder to the now-
ubiquitous diagnosis of attention-deficit hyperactivity disorder
(ADHD). None of the reasons behind this growth related to
science because (despite decades of research) no replicable evidence
exists to support the idea that ADHD can be viewed as a known/
knowable ‘natural category’with unique characteristics that enable
it to be differentiated from other natural categories. It is therefore
an excellent example of a ‘cultural construct’.
Therefore, as you can imagine, I was pleased to be asked to
review this book. Written largely by sociologists, I thought this
would be an ideal opportunity to scratch below the surface and
examine how the concept of ADHD intersects with a variety of
local dynamics around childhood, consumerism, globalisation,
family and education (to name but a few). The book has chapters
relating to practice around ADHD in sixteen countries: USA,
Canada, Australia, Germany, UK, Portugal, Ireland, Argentina,
Brazil, Italy, France, Japan, New Zealand, Chile, Taiwan and
Ghana. Unfortunately, the book largely fails to deliver. Each
chapter is mostly a rehash of previous chapters, illustrating the
depressing expansion of the concept of ADHD with little attempt
to situate this in the broader context of discourses about childhood,
child rearing and economy (for instance). Most chapters have a pre-
dictable format and include facts and figures around epidemiology,
rates of diagnosis and use of medication or therapy. They look at the
role of advocacy groups, the impact this has had on aspects such as
educational or social policy, and skim over the contribution of the
pharmaceutical industry. Most chapters approach ADHD as a
static ‘thing’that is being more ‘recognised’. Few approach
ADHD as a dynamic cultural construct to start with, which would
have led authors to be more open to examining social/cultural
and political dimensions of how such a category emerges in relation
to existing discourses about childhood, parenting and child
development.
Some of the more interesting exceptions included the chapter on
Chile, which discusses how the neoliberal economic reforms (Chile
was one of the first countries in the world to implement such
reforms) led to ‘constant and sharp surveillance of children’s
actions and behaviours’, which in turn spurred on the extensive
use of methylphenidate in young people. The chapters on Japan
and Ghana were also interesting as they revealed how some coun-
tries were not caught up in the globalisation of the ADHD epidemic,
mainly due to more robustly held cultural attitudes towards parent-
ing and children’s development. In Japan this was reflected in the
‘official’guidelines for treatment of ADHD, which emphasises psy-
chosocial approaches and has strict criteria around the prescription
of pharmaceuticals, including advice about dosing, duration, mon-
itoring, treatment goals, and warnings about addiction and abuse
potential. These guidelines are much better in terms of both evi-
dence base and clinical relevance than the current National
Institute for Health and Care Excellence guidelines.
Overall, there were a few bright spots in an otherwise disap-
pointing book.
Sami Timimi, Consultant Child and Adolescent Psychiatrist, Lincolnshire Partnership
National Health Service Foundation Trust, UK. Email: stimimi@talk21.com
doi:10.1192/bjp.2018.108
Thinking Fast and Slow
By Daniel Kahneman.
Penguin. 2012. £10.99 (pb). 512 pp.
ISBN 9780141033570.
In his book Thinking Fast and Slow, Daniel Kahneman puts the cat
among the pigeons as regards human rationality. He purports to
Book Reviews
563
demonstrate that we are seriously irrational in some areas of our
lives. It is like asking ‘is the Queen English?’and finding out she
isn’t! We always thought we were rational but it seems we aren’t,
at least according to Kahneman who got a Nobel prize in economics
(not medicine) for his trouble. But didn’t we build up the worlds of
science, engineering, agriculture, etc. based on logical thinking and
reasoning? Reason has served us very well so far, has a track record
and has stood the test of time.
But not so fast! It seems we are prone to no end of hidden biases
in our intuitive thinking and, even worse, we don’t change when our
errors are pointed out. We think fast with what Kahneman calls
System 1, which is another name for our spontaneous automatic
thought processes, and slow with System 2, the workhorse of
rolling up your sleeves and getting stuck into a problem and fully
engaging the brain. Everyone agrees that we do have these discrete
yet complementary mental capacities; he is not claiming to have dis-
covered them. What he does lay claim to is showing how they can
both make basic logical mistakes –especially System 1, mainly
because it is lazy. No heresies yet.
The bulk of his work involved the study of decision-making
under risk, calculating logical probabilities and showing how we
make basic intuitive calculating errors. A lot of what he says
could be put down to common sense, or the lack of it, and the
absence of experience based on a predictable environment with
repetitive rapid feedback. The 10 000 h rule, or spending sufficient
time and effort to master something with proper guidance, cuts
out much intuitive error. Establishing baselines and reference
points, being aware of common pitfalls and having error-detecting
systems in place are all common practice for any self-respecting
enterprise. So this is not new knowledge. Individual appraisal
with inbuilt system error detection alleviates most errors ‘in
reasoning’.
The book uses heuristics to explain some of our common, error-
prone tendencies:
(a) Risk aversion: We just don’t want to gamble if we might lose
our status quo.
(b) The peak-end effect: We give more importance to impressions
of severe pain or joy and how things finish, rather than to the
assessment of the grand total of pain or joy over time. We
ignore duration of experience in favour of quality (good or
bad).
(c) Regression toward the mean: This is an established statistical
observation that things in life tend toward the average of
what is measured. This is an observation but not a causality,
and you could say that’s the way life is and everyone knows that.
(d) We are built to believe and we have to try to unbelieve: This is a
very interesting observation but no explanation as to why this is
the case is given.
(e) Framing: If something is put another way, we will give a differ-
ent answer to the same problem. Unless you have done your
homework beforehand and are immovable, it will be difficult
to avoid giving in a little.
(f) Anchoring: We are influenced by flimsy hooks or numbers that
somehow register with us as a bargaining position in the back of
our minds. All things being equal, if you haven’t made up your
mind firmly about a topic, this will sway you.
(g) Two selves: We have the remembering self, which is seemingly
most well-known to us and which makes our decisions, and we
have the here-and-now self, which we cannot grasp and is more
elusive. This is Kahneman’s idea. What about the future self?
(h) Priority of what we already possess: What counts for us is what
value things have for us here and now, which Kahneman calls
their utility. This means whether we are going to gain or lose or
go up or down in our position of finance, prestige, worth etc.
This tallies with the concept of possession being nine-tenths
of the law.
These are very revealing if not disturbing exposures of our dearest
organ –the brain. We are absolutely in the disability category
when it comes to thinking straight, according to this book. We
are put off by extraneous noises, superficial comments at the
wrong time and good-looking people. The latter is called the ‘halo
effect’. Something you find attractive expands to encompass every-
thing about the person or thing, even though you haven’t any proof
of its entire wholesomeness. However, many of Kahneman’s experi-
ments were done in classroom situations or Gallup-poll scenarios
which are not real life. It seems unbelievable that a judge’s senten-
cing pattern could be changed by suggesting an extraneous
number before deciding on a case. In the book, a lady (Linda) is
described as an active feminist with librarian skills and you are
then asked do you think (a) she is likely to be librarian, or (b) she
is likely to be an activist and a librarian? The correct answer is
given as (a), which is to send the herd the wrong way and then
tell them they are all wrong! A similar scenario applies to Tom
the librarian; they are trick questions. Another straw man is his
assessment of recruiters for the Israeli Army, which is a bit unfair
to the status quo and probably wrong. The recruiters had experience
along with the 10 000 h and feedback, and Kahneman acknowledges
it is a somewhat impossible task to predict who will be a leader or
not based on performance climbing a wall. He ends by suggesting
a rating scale for attributes for leadership, which is a great sugges-
tion (and one much used in hiring people).
The Prospect Theory is Kahneman’s calling card and the
associated infographic is an S-shaped curve which was embel-
lished to be his Nobel crest. It designates an economic pattern
of behaviour when dealing with gain and loss. As such, the econ-
omists give it praise. However, when it comes to the human mind
and how it works, and extrapolating outside the box of what he
has demonstrated in one more acceptable way or another, he is
not correct. He talks about happiness, the good life, luck,
chance and statistics. Coming from a background of numbers
and biases, it is improbable that he could be an expert on affective
life, causality (if you deify luck and trends and don’texplainwhat
causes them), fulfilment in life andtheextraordinaryworldof
love, emotion, desire, lust and belief to mention a few of the head-
line items in any human mind. These are serious biases for any
cognition and are the major players in our thought and affective
lives.
Kahneman has very interesting insights into heuristic biases and
very intelligent and practical advice about not making basic errors in
logic. To suggest that we are less than rational and should doubt our
reason is not seriously challenged by his work. He mainly worked
with hypothetical scenarios, whereas the last 15 millennia of
human development has proven beyond doubt that man is truly
rational and his use of cause and effect should be trusted.
Kahneman should stand back and allow those who want to ask
the ‘why’questions, about how and why the human mind works
the way it does, get on with discussing the broader understanding
of what it means to be human.
Eugene G. Breen, Consultant Psychiatrist, Psychiatry Sector, Mater University Hospital,
Ireland and Associate Clinical Professor, School of Medicine, University College Dublin,
Ireland.
Correspondence: Eugene G. Breen, Psychiatry Sector, Mater University Hospital, 62/63
Eccles Street, Dublin 7 DO7 YH5R, Ireland.
Email: ebreen@mater.ie
doi:10.1192/bjp.2018.109
Book Reviews
564
