原標題:The Faulty Reasoning That Turned ADHD Into a Disease
來源:https://www.madinamerica.com/2023/01/faulty-reasoning-turned-adhd-disease/
https://chatgpt.com/c/66f7ea5c-4c90-800b-ae88-c9edbde2119c
Leading ADHD researchers outline four mistakes that turned ADHD from a description of behavior into a medical disease.
頂尖的多動症（ADHD）研究人員列出了四個錯誤，這些錯誤將 ADHD 從行為描述變成了一種醫學疾病。
By Peter Simons – January 10, 2023
彼得·西蒙斯 – 2023年1月10日
In a new article in Frontiers in Psychiatry, researchers explain the four strategies used to erroneously conflate the construct of “ADHD” with a medical disease.
在《精神病學前沿》的一篇新文章中，研究人員解釋了四種將“多動症”（ADHD）的構想錯誤地與醫學疾病混為一談的策略。
According to the researchers, the label of ADHD is merely a description of children’s behavior, but the way it is usually discussed “reifies” it—or assumes that description is an objective fact with explanatory power.
根據研究人員的說法，ADHD 這個標籤僅僅是對兒童行為的描述，但通常的討論方式卻將其“具體化”——或假定這種描述是一個具有解釋力的客觀事實。
“The descriptive classification Attention-Deficit/Hyperactivity Disorder (ADHD) is often mistaken for a disease entity that explains the causes of inattentive and hyperactive behaviors, rather than merely describing the existence of such behaviors,” they write.
“描述性分類注意力缺陷/多動症（ADHD）經常被誤認為是一種疾病實體，能解釋注意力不集中和多動行為的原因，而不僅僅是描述這些行為的存在，” 他們寫道。
Why is this distinction so crucial? The researchers explain:
為什麼這一區分如此重要？研究人員解釋說：
“The errors and habits of writing may be epistemologically violent by influencing how laypeople and professionals see children and ultimately how children may come to see themselves in a negative way. Beyond that, if the institutional world shaped to help children is based on misguided assumptions, it may cause them harm and help perpetuate the misguided narrative.”
「寫作中的錯誤和習慣在認識論上可能是暴力的，因為它會影響普通人和專業人士如何看待兒童，最終影響兒童如何以負面的方式看待自己。除此之外，如果為幫助兒童而建立的制度性世界是基於誤導的假設，那麼它可能會對他們造成傷害，並延續這種錯誤的敘述。」
This is even more problematic, they write, with a contested category like ADHD, which has been When the complexity of human experience is reduced to a label, other explanations and possibilities are eliminated, and potentially harmful interventions go unchallenged. This is even more problematic, they write, with a contested category like ADHD, which has been disavowed by the very people who created the construct in the first place, such as Allen Frances and Keith Conners.
當人類經驗的複雜性被簡化為一個標籤時，其他解釋和可能性就會被排除，可能有害的干預措施也無法受到質疑。他們指出，這在像 ADHD 這樣具有爭議的分類中更為嚴重，因為最初創建這一概念的人，如艾倫·弗朗西斯和基思·康納斯，已經否認了它。
Indeed, studies have repeatedly found that the diagnosis of ADHD and prescription stimulant medication are harmful rather than helpful. For instance, a recent study found that receiving the diagnosis of ADHD leads to worse quality of life and even self-harm in children: kids who received the diagnosis had worse scores on five quality of life measures, and were more than twice as likely to harm themselves, than kids who had the same level of ADHD symptoms but who did not receive the diagnosis.
事實上，研究一再發現，ADHD 的診斷和處方的興奮劑藥物對孩子不僅無益，反而有害。例如，最近的一項研究發現，接受 ADHD 診斷的孩子生活質量更差，甚至出現自我傷害：與那些有相同 ADHD 症狀但未被診斷的孩子相比，已經接受診斷的孩子在五項生活質量指標上的得分更低，且自我傷害的可能性是前者的兩倍以上。
Other research has found that:
其他研究發現：
- Stimulant drugs like Adderall and Ritalin don’t actually improve kids’ academic performance and may even increase the likelihood of kids dropping out of school;
像 Adderall 和 Ritalin 這樣的興奮劑並不能實際改善孩子的學業表現，甚至可能增加孩子輟學的可能性； - Ritalin leads to an 18-fold increase in depression, which decreases back to baseline when kids stop taking the drug;
Ritalin 會導致抑鬱症發病率增加 18 倍，而當孩子停止服用該藥物時，抑鬱症的發病率會回到基線水平； - Stimulants stunt growth and then rapidly lead to obesity; and
興奮劑會抑制生長，然後迅速導致肥胖； - Stimulants may even lead to hallucinations and other psychotic experiences in 62.5% of kids.
興奮劑甚至可能導致 62.5% 的孩子出現幻覺和其他精神病性體驗。
The most well-regarded and highly cited study of childhood ADHD, the NIMH’s MTA study, found that, by the six-to-eight-year follow-up, those who received medication did no better than those who did not. Moreover, none of the treatments had been successful by that follow-up: the children who received treatment still scored worse than the normative comparison group on 91% of the measures they tested.
最受推崇和引用最多的兒童 ADHD 研究——由美國國家精神衛生研究院（NIMH）進行的 MTA 研究——發現，在六到八年的追蹤調查中，接受藥物治療的孩子並未比未接受藥物治療的孩子表現更好。此外，到追蹤調查時，所有的治療都未取得成功：接受治療的孩子在所測試的 91% 指標上，仍然比標準對照組得分更低。
Four Types of Reification
四種類型的具體化
The current article was written by Sanne te Meerman and Laura Batstra at the University of Groningen in the Netherlands, as well as Justin Freedman at Rowan University in the United States.
這篇文章由荷蘭格羅寧根大學的 Sanne te Meerman 和 Laura Batstra 以及美國羅文大學的 Justin Freedman 撰寫。
They write that there are four main ways in which ADHD is reified: language choice, logical fallacies, genetic reductionism, and textual silence.
他們指出，ADHD 具體化的四種主要方式是：語言選擇、邏輯謬誤、基因還原論和文本沉默。
One example of language choice is the decision to use terminology like “symptoms” (implying the existence of a disease that is causing them) rather than something like “criteria” to describe the behaviors that comprise the ADHD diagnosis.
語言選擇的一個例子是使用「症狀」這類術語（暗示存在導致這些症狀的疾病），而不是「標準」這樣的詞來描述 ADHD 診斷所包含的行為。
For example, behaviors like a child’s difficulty sitting still for long periods or during boring lectures, or being loud when playing, are commonly referred to as “symptoms” of ADHD. However, according to the researchers, the ADHD diagnosis is a label for kids who exhibit these symptoms—not a “disease” causing them.
例如，孩子難以長時間安靜坐著，或者在無聊的課堂上坐不住，或者在玩耍時吵鬧，這些行為通常被稱為 ADHD 的「症狀」。然而，根據研究人員的說法，ADHD 診斷只是對展示這些症狀的孩子的一個標籤，而不是導致這些行為的「疾病」。
Another example is the use of violent-sounding medical metaphors designed to scare parents and kids while also reifying the idea that ADHD is a medical disorder. The researchers cite the example of an influential proponent of the ADHD diagnosis, Russell Barkely, who, in a YouTube video aimed at parents, says:
另一個例子是使用聽起來帶有暴力色彩的醫學隱喻，這些隱喻旨在嚇唬家長和孩子，同時也具體化了 ADHD 是一種醫學疾病的概念。研究人員舉了 ADHD 診斷的重要支持者之一羅素·巴克利（Russell Barkley）的例子，他在一個針對家長的 YouTube 視頻中說道：
“Now, I want you to understand something. Your brain can be split into two pieces. The back part is where you acquire knowledge. The front part is where you use it (. . .). ADHD, like a meat-cleaver, just split your brain in half.”
「現在，我想讓你了解一件事。你的大腦可以分成兩部分。後部是你獲取知識的地方，前部是你使用這些知識的地方（……）。ADHD 就像一把菜刀，把你的大腦劈成兩半。」
This is obviously untrue—the brain is not split this way, nor does ADHD sever your brain “like a meat-cleaver.” However, the researchers write that this imagery of a knife violently cutting the brain in half is frightening to parents being told that this is happening to their children—making them more likely to turn to stimulant drugs in desperation. Moreover, metaphors like these, while having no basis in fact, serve to reify the idea that ADHD is a brain disease.
這顯然是不真實的——大腦並不是這樣分開的，ADHD 也不會像菜刀一樣把你的大腦「劈成兩半」。然而，研究人員指出，這種用刀暴力劈開大腦的比喻會讓家長感到恐懼，因為他們被告知這正發生在他們的孩子身上——因此更可能絕望地轉向使用興奮劑藥物。此外，這些隱喻雖然沒有任何事實依據，但卻強化了 ADHD 是一種腦部疾病的觀念。
te Meerman, Batstra, and Freedman write:
te Meerman、Batstra 和 Freedman 寫道：
“The meat-cleaver metaphor, in particular, is a ‘deceptive metaphor’ in that empirical evidence does not support this comparison with ADHD; empirical findings indicate versatile, interacting causes and motives for such behaviors while the molecular-genetic and neuro-anatomical correlations are weak and causality is far from clear.”
「特別是菜刀的比喻是一種‘誤導性的隱喻’，因為經驗證據並不支持這種與 ADHD 的比較；經驗研究表明，這類行為的成因和動機是多樣且相互作用的，而分子遺傳和神經解剖學的相關性微弱，因果關係遠不明確。」
Logical fallacies include the ecological fallacy, circular arguments, and mistaking correlation for cause. In the ecological fallacy, slight average differences between populations are treated as if they mean something to individuals. For ADHD, this often comes in the form of brain size differences. While these studies have numerous methodological problems—such as false positives due to multiple testing and failure to replicate—they also exhibit the ecological fallacy.
邏輯謬誤包括生態謬誤、循環論證以及將相關性誤認為因果關係。生態謬誤是指將群體之間微小的平均差異當作對個體具有意義。對於 ADHD，這通常表現為大腦大小的差異。儘管這些研究存在許多方法學問題——例如多重測試導致的假陽性和無法重複驗證——它們同樣展示了生態謬誤。
In the quintessential example, a 2017 study in The Lancet claimed to find that kids with ADHD had smaller brains than kids without the diagnosis. However, an entire issue of The Lancet was devoted to researchers criticizing this conclusion. The data showed that 95% of the participants had overlapping brain sizes: almost every participant in the ADHD group had a similar brain size to a participant in the non-ADHD group. Once researchers accounted for IQ among the participants, even that tiny difference between the ADHD and non-ADHD groups vanished.
一個典型的例子是，2017 年發表在《柳葉刀》上的一項研究聲稱發現，患有 ADHD 的孩子的大腦比沒有被診斷的孩子大腦小。然而，《柳葉刀》專門發行了一期來討論研究人員對這一結論的批評。數據顯示，95% 的參與者大腦大小是重疊的：幾乎每一個 ADHD 組的參與者的大腦大小都與非 ADHD 組的參與者相似。當研究人員將 IQ 考慮在內後，ADHD 組和非 ADHD 組之間那一點微小的差異也消失了。
This slight average difference—found only in extreme outliers—certainly doesn’t provide any data about the usual child with an ADHD diagnosis. Instead, the researchers could have reached the conclusion that there is no brain size difference between kids with ADHD and kids without the diagnosis.
這種微小的平均差異——只在極端異常值中發現——當然無法提供任何關於 ADHD 診斷兒童的普遍數據。相反，研究人員本可以得出結論，ADHD 兒童和未被診斷的兒童之間的大腦大小沒有差異。
Allen Frances and others make that point in one article in that issue:
艾倫·弗朗西斯（Allen Frances）和其他人在該期刊的一篇文章中指出了這一點：
“The most important argument against the authors’ conclusion that ‘patients with ADHD have altered brains’ is that it is not supported by their own findings.”
「反對作者得出‘ADHD 患者的大腦有改變’這一結論的最重要論點是，他們的發現並不支持這一結論。」
They add that the conclusion “is wildly speculative and dangerously misleading.”
他們補充說，這一結論「極具猜測性且具有危險的誤導性。」
However, findings like this are reported in the popular media, while the retractions and critiques that follow are rarely mentioned to the layperson.
然而，這類發現經常出現在大眾媒體中，而隨後的撤回和批評卻很少被公眾提及。
In genetic reductionism, tiny genetic correlations are discussed as if they explain the cause of ADHD, even though no genetic test can be found, and genetic studies fail to explain whether a person will receive the diagnosis or not.
在基因還原論中，微小的基因相關性被討論得好像它們能解釋 ADHD 的成因，儘管沒有基因測試能夠證實這一點，且基因研究無法解釋一個人是否會被診斷為 ADHD。
Moreover, heritability estimates—which include the family environment as well as genetics (nurture as well as nature) are discussed as if the genetic part is the only influence.
此外，遺傳力估計包括了家庭環境和基因（後天養育和先天遺傳），但這些估計被討論時，卻常常暗示只有基因才是唯一的影響因素。
Powerful environmental factors are consistently found to make kids much more likely to get a diagnosis of ADHD.
強大的環境因素一直被發現會使孩子更有可能被診斷為 ADHD。
The fact that these are not discussed, while tiny, irrelevant genetic correlations become the focus of conversation, is an example of textual silence.
這些環境因素沒有被討論，而微小且無關緊要的基因相關性卻成為對話的焦點，這就是文本沉默的一個例子。
Textual silence refers to the omissions made when discussing ADHD. For instance, articles rarely mention that one of the top predictors of whether a child will receive an ADHD diagnosis is relative age—although this is one of the most consistent findings in all ADHD research.
文本沉默是指在討論 ADHD 時所做的省略。例如，文章很少提及影響孩子是否會被診斷為 ADHD 的最重要預測因素之一是相對年齡——儘管這是所有 ADHD 研究中最一致的發現之一。
Over and over, researchers have found that the youngest children in a classroom are far more likely to be diagnosed with ADHD and prescribed stimulant drugs, indicating that it is relative age—the relative immaturity of a 5-year-old compared to the 6-year-old right beside him—that accounts for supposed “ADHD symptoms.”
研究人員一再發現，班級中年齡最小的孩子更有可能被診斷為 ADHD 並被開具興奮劑藥物處方，這表明所謂的 “ADHD 症狀” 實際上是由相對年齡引起的——也就是說，5 歲的孩子與身邊 6 歲孩子相比的相對不成熟。
Other findings that make kids much more likely to receive the diagnosis are poverty and overcrowded classrooms, according to te Meerman, Batstra, and Freedman. Again, these are consistent findings across the literature but rarely mentioned in discussions of ADHD.
根據 te Meerman、Batstra 和 Freedman 的研究，貧困和過度擁擠的教室是使孩子更可能被診斷為 ADHD 的其他因素。同樣，這些都是在文獻中一致發現的結果，但在 ADHD 的討論中很少被提及。
When facts like these are not included, the public gets a skewed picture.
當這些事實未被包括在內時，公眾就會得到一個偏頗的認識。
Conclusion
結論
Articles, textbooks, and expert interviewers repeat genetic and neurobiological claims even though they fail to replicate, use medical language and frightening metaphors to describe ADHD, commit the ecological fallacy, and fail to mention the strongly supported environmental and social components to behavior, even though these have been found to play a role in study after study.
文章、教科書和專家訪談經常重複基因和神經生物學的說法，儘管這些說法無法得到重複驗證，且使用醫學語言和恐嚇性的隱喻來描述 ADHD，犯下了生態謬誤，並忽視了那些已經在研究中被反覆證實的環境和社會因素在行為中的作用。
It’s no wonder the public believes that ADHD is a medical disease that causes behavior rather than just a descriptive label for that behavior. And it’s no wonder the public doesn’t think anything can be done except prescribe medication.
難怪公眾會認為 ADHD 是導致行為的醫學疾病，而不是對這種行為的描述性標籤。同樣也難怪公眾認為除了開藥以外，別無他法。
“How social institutions, such as schools, understand and respond to children rests upon ADHD being constructed, or reified in discourse, as a disorder that some children have and others do not,” the researchers write.
研究人員寫道：「社會機構，例如學校，如何理解和應對孩子，取決於 ADHD 在話語中被構建或具體化為一種只有部分孩子患有的疾病。」
Do we work to improve conditions in schools, decrease poverty, and allow younger kids in the classroom to be a little more restless than their older peers—perhaps even letting them take breaks to play? Or do we see those kids as medical cases to be drugged?
我們是否應該努力改善學校條件，減少貧困，並允許班級中的年幼孩子比年長的同學稍微多一些好動——或許還可以讓他們休息片刻去玩耍？還是我們把這些孩子視為需要用藥物治療的醫療案例？
te Meerman, S., Freedman, J. E., & Batstra, L. (2022). ADHD and reification: Four ways a psychiatric construct is portrayed as a disease. Frontiers in Psychiatry, 13(1055328). https://doi.org/10.3389/fpsyt.2022.1055328 (Link)
te Meerman, S., Freedman, J. E., & Batstra, L. (2022)。ADHD 與具體化：精神病學構建被描述為疾病的四種方式。《精神病學前沿》，13(1055328)。https://doi.org/10.3389/fpsyt.2022.1055328（鏈接）
Peter Simons
彼得·西蒙斯
Peter Simons was an academic researcher in psychology. Now, as a science writer, he tries to provide the layperson with a view into the sometimes inscrutable world of psychiatric research. As an editor for blogs and personal stories at Mad in America, he prizes the accounts of those with lived experience of the psychiatric system and shares alternatives to the biomedical model.
彼得·西蒙斯曾是一名心理學學術研究員。現在，作為一名科學作家，他試圖為普通人揭示有時難以理解的精神病學研究世界。作為《Mad in America》的博客和個人故事的編輯，他重視那些有過精神病系統親身經歷者的敘述，並分享對生物醫學模式的替代方案。
/*小編備註:
“文本沉默 (Textual Silence)” 指的是在討論某個主題時，有意或無意地忽略或省略了關鍵的信息或觀點。在 ADHD 的討論中，這種文本沉默常常體現在一些重要的事實或研究結果被忽略，而某些片面的、具有爭議性的觀點卻得到更多關注。
在 ADHD 討論中的具體例子
1.環境因素的忽略
許多 ADHD 的討論集中於基因和神經科學的研究，但經常忽略強大的環境因素，例如家庭環境、學校體系、社會壓力等，這些都被發現會顯著影響孩子被診斷為 ADHD 的可能性。例如，有研究顯示，社會經濟地位較低的家庭，其子女被診斷 ADHD 的比率較高，這可能與壓力、教育資源缺乏等環境因素有關。然而，這些研究在大眾媒體或醫學討論中往往被忽略。
2.相對年齡效應
研究一致表明，相對年齡是決定孩子是否被診斷為 ADHD 的一個關鍵因素。相對年齡效應指的是，年齡相對較小的孩子（例如班上最年輕的孩子）更有可能因行為不成熟而被診斷為 ADHD。然而，這樣的發現卻很少被提及。換句話說，僅僅因為孩子在同齡人中相對年幼，他們的行為可能更具活力或難以集中注意力，但這並不意味著他們真的患有 ADHD。
3.治療失敗的報導缺失
很多關於 ADHD 的報導聚焦於藥物治療的成功案例，但很少提及藥物治療失敗或帶來的副作用。例如，興奮劑藥物（如 Adderall 和 Ritalin）的潛在副作用，包括抑鬱、焦慮、食慾不振、睡眠問題等，往往在主流討論中被淡化或忽略。這些副作用對兒童的長期影響可能很嚴重，但大眾媒體通常不太報導。
4.文化差異的忽略
在不同文化背景中，對 ADHD 的理解和診斷標準也有所不同。例如，在某些文化中，活躍的孩子被認為是健康的，而在另一些文化中則可能被視為行為問題。這種文化差異在診斷過程中影響甚大，但這方面的討論往往被忽略，導致 ADHD 的全球化定義過於單一和狹隘。
文本沉默的影響
1.對診斷的過度依賴
由於文本沉默的存在，醫學和大眾輿論過度依賴基因和神經科學的解釋，忽視了其他可能的影響因素，如心理社會壓力、教育環境、家長教養方式等，這可能導致誤診或過度診斷。
2.增加家長和患者的焦慮
當關於 ADHD 的某些信息被放大，尤其是像“ADHD 是大腦疾病”這樣的簡單化結論時，家長和患者可能會感到更大的焦慮和無助，從而更傾向於依賴藥物治療，而忽略了非藥物的干預手段，如行為治療或家庭支持。
文本沉默的克服方式
為了克服 ADHD 討論中的文本沉默，研究人員和媒體應該更加全面地報導 ADHD，包括環境因素、相對年齡效應、治療副作用等，並避免將 ADHD 的成因過度簡化為單一的基因或神經因素。同時，應該更廣泛地討論文化差異和多樣化的治療方法，讓家長和專業人士能夠做出更加知情的決策。
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