Allen Frances Still Trying to Excuse Psychiatry’s (and his own) Role in the ADHD ‘Epidemic’

On November 9, 2015, Allen Frances, MD, posted an interesting article on the Huffington Post’s Blog.  The article is titled Why Are So Many College and High School Kids Abusing Adderall.

The gist of the article is that the “excessive use of ADHD medication” is a more legitimate target for a war on drugs than the ongoing war with the drug cartels.

The Huffington Post article is unusual, in that most of it is written by Gretchen LeFever Watson, PhD.  Dr. Frances wrote the introduction, ending with  “I have invited Dr Gretchen LeFever Watson, a clinical psychologist and public health researcher, to describe this growing problem.”  Dr. Watson wrote the main body of the piece; and Dr. Frances finished up with some brief concluding remarks.

Dr. Watson’s section of the post contains some very helpful information, including the fact that:

“Adderall and other stimulant medications like Concerta, Focalin, Vyvanse, and Ritalin have a high addictive potential.”

and

“Over time, use and abuse of these drugs can induce violent and aggressive behavior, anxiety and paranoia, even hallucinations and delusions. Some students experience an emotional numbing or incoherence. Withdrawal can lead to a depressed mood, fatigue, short-term memory loss, inability to concentrate, and psychomotor agitation or lethargy.”

In his parts of the post, Dr. Frances states:

“ADHD meds are the most dangerous legal drugs among young people in college and high school.”

and

“We need to stop overdiagnosing and overmedicating ‘ADHD,’ in order to reduce the massive reservoir of legally prescribed pills available for diversion to the secondary illegal market.”

and

“…we need to educate students and educators that using Adderall for recreation or performance enhancement has considerable risks and is not a normal part of life.”

and

“The epidemic of mislabeled ADHD has medicalized childhood, turning normal immaturity into a mental disorder. The excessive use of ADHD medication has been fueled by irresponsible drug company marketing; careless physician diagnosing and prescribing; worried parents; and harried teachers.”

DISCUSSION

The most notable feature of the article is the fact that Dr. Frances makes no mention of the role that psychiatry in general, and he himself in particular (as DSM-IV architect), played in the medicalizing of normal childhood immaturity.

It is an obvious fact that there occurred in DSM-IV a general liberalizing of the criteria for many of the so-called diagnoses, including ADHD.  DSM-III listed 14 criteria items for this label; DSM-IV listed 18.  One DSM-III item was dropped.  The additional five items in DSM-IV are:

“1 (a)  often fails to give close attention to details or makes careless mistakes in  schoolwork, work, or other activities.” (p 83)

Has there ever been a small child who didn’t fail to give close attention to details or didn’t make careless mistakes?  Isn’t this almost a defining feature of early childhood?

“1 (e)  often has difficulty organizing tasks and activities”

Remember, we’re talking about children below the age of seven.  Not many five/six year-olds are great organizers.

“1 (f)  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such  as schoolwork or homework)”

The word “or” is particularly important.  So if the child doesn’t like doing his/her homework, this counts as a “symptom” of ADHD!

“1 (i)  is often forgetful in daily activities” (p 84)

Again, the pathologizing of the normal.

“2 (c)  is often ‘on the go’ or often acts as if driven ‘by a motor'”

These colloquialisms are sometimes used by parents and other family members to describe young children, without any intent to pathologize. By including these phrases into the DSM’s list of symptoms, Dr. Frances and his work force have pathologized these terms, and have increased the likelihood that children who have been so described will be caught in the ADHD net. Besides, how could the terms ever be reliably defined?

In addition, the following fairly extreme item in DSM-III

“(14)  often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking” (p 53) [Emphasis added]

was liberalized in DSM-IV to the much more banal

“2 (c)  often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” (p 84)

In DSM-III, the “age of onset” had to be before the age of seven.  In DSM-IV, this criterion was relaxed to “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.” [Emphasis added] (p 84)

And, perhaps most significantly of all, DSM-IV added a “Not Otherwise Specified” category, where nothing of the sort had existed in DSM-III.

“314.9  Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified

This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.” (p 85) [Emphasis added]

In other words, a child can be assigned the pathologizing and disempowering label (ADHD, NOS) even if he/she doesn’t meet the criteria specified for ADHD.

It is obvious that this liberalizing of criteria has had the effect of increasing the number of people so labeled.   Dr. Frances concedes that the number of people who have been assigned the label has increased enormously, but he consistently fails to connect the dots, and to recognize that it was his own liberalizing of the criteria that was the primary cause of the expansion.  The Surgeon General’s Report of 1999 lamented the fact that “…the majority of children and adolescents who are receiving stimulants did not fully meet the criteria”, but failed to recognize that since the publication of DSM-IV in 1994, with its virtually open-ended NOS category, it was no longer necessary to “fully meet the criteria” to qualify for a diagnosis.

It also needs to be noted that there wasn’t – and never could be – any scientific justification for this expansion.  Despite psychiatrists’ repeated assertions to the contrary, ADHD is not an illness with an identifiable pathology.  Rather, it is a loose collection of vaguely defined childhood problems (and some non-problems).  There is no reality against which psychiatry’s list of symptoms can be checked.  The APA can add or delete items from their checklist at will. This is in marked contrast to real medicine, where the symptoms must conform to the objective reality of the disease in question.

If the American College of Chest Physicians, for instance, were to issue a statement that a purple rash was henceforth to be considered a symptom of pneumonia, there would be an instant outcry from rank and file pulmonologists, and from physicians generally, because a purple rash is not one of the symptoms of pneumonia.  There is a reality – namely the actual disease of pneumonia – against which assertions of this kind can be checked and refuted.

In psychiatry, except for those “mental illnesses” which are due to a general medical condition, no such realities exist.  This is the reason that the APA can add or delete criteria to their labels at will.  Over the past sixty years, they have engaged in an enormous amount of this kind of activity, the effect of which has almost always been to liberalize the thresholds, thereby increasing the prevalence.

ADHD, like all psychiatric “diagnoses” is what the APA, through successive revisions of their catalog, choose it to be.  And Allen Frances and his team of DSM-IV collaborators chose to relax the criteria for the ADHD label. By this simple expedient, they vastly increased the number of people who could be “diagnosed” with this non-illness, and, of course, proportionately increased the quantity of “medications” that were being prescribed for this non-illness.  In March 2010, Dr. Frances published an article in the LA Times:  It’s not too late to save ‘normal’ . In that paper he stated:

“Our panel tried hard to be conservative and careful but inadvertently contributed to three false ‘epidemics’ — attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many ‘patients’ who might have been far better off never entering the mental health system.”

It is frankly impossible to reconcile this assertion with the relaxing of criteria for the “ADHD diagnosis” set out above.  How can the decision to include  as a “symptom” the fact that a child doesn’t like doing his homework be considered conservative?  This “symptom” applies to virtually every child on the planet.

. . . . . . . . . . . . . . . .

But Dr. Frances seeks to deflect the blame for this “epidemic” onto: 

  1.  irresponsible drug company marketing

Certainly pharmaceutical marketing has been excessive, misleading, and at times downright fraudulent.  But there has been no shortage of psychiatric collaboration in these enterprises.  It was psychiatry that integrated pharma’s infomercials into their continuing education requirements.  It was psychiatry’s fraudulent, and often ghost-written, research that established the “efficacy” of the drugs.  And there has been no concerted attempt on the part of psychiatry to rein in the irresponsible advertizing.  In fact, for years, psychiatry ran the ads in their own journals.

  1. careless physician diagnosing and prescribing

Note the use of the word “physician” rather than “psychiatrist”.  This has become a common ploy in psychiatry’s attempts to shift blame from themselves, but it ignores the fact that GP’s couldn’t have written a single prescription for a drug to treat ADHD if psychiatry had not invented the label and relentlessly promoted it as a valid illness, caused by a chemical imbalance in the brain, and necessitating “treatment” with stimulant drugs.  And, of course, by relaxing the “diagnostic” criteria, Dr. Frances ensured that the “diagnostic” net would be widened commensurately.  His assertions in the LA Times article that this widening was inadvertent is not credible when one looks at the changes that were made.  Anybody with even the slightest familiarity with the issues could have foreseen the result.  This is particularly the case in that the drugs in question are addictive, and for that reason, if no other, were assured a strong demand.

  1. worried parents

When I was a child, back in the 50’s, ADHD didn’t exist.  Inattention, hyperactivity, and impulsivity were considered normal traits of early childhood, and were remediated through the time-honored methods of training, encouragement, discipline, etc…  This system worked remarkably well.  Despite larger class sizes, there was no running around or unpermitted leaving of seats in the classrooms, and children whose attention drifted were routinely brought back to task with the oft-heard phrase “pay attention!”

Then along came psychiatry, with the great “insight” that inattention, impulsivity, and hyperactivity were symptoms, of a brain illness!  And not surprisingly, a great many parents, unfamiliar with the fact that psychiatry is founded on a tissue of falsehoods, took this inanity seriously and – guess what? – became worried!  And why wouldn’t they be worried at the prospect of their children being afflicted with brain diseases?  And now Dr. Frances, who single-handedly did more to expand the ADHD net than any other person, is blaming this expansion, and the phenomenal level of entailed drugging, on worried parents!

  1. harried teachers

As I mentioned above, teachers in previous generations accepted, as an intrinsic part of their job, training children to pay attention and to master their impulsive and disruptive tendencies.  Many today would argue that they were overly zealous in this regard, but that’s a separate issue.  The point is that they accepted the job, and they were almost always successful.

But this former culture of successful training and discipline was torpedoed by psychiatry’s blatant, self-serving lie, that overly active, inattentive children had a brain illness that essentially precluded the possibility of successful training.  This false message was developed by psychiatry, and was fully integrated into teacher training curricula.  Today a teacher who doesn’t buy into the ADHD hoax, and who doesn’t make “medication referrals” for these undisciplined and disruptive children, would be at risk of losing his/her job.

Teachers of the world have been deceived and betrayed by psychiatry, and now Dr. Frances has the unabashed gall to blame them for the present state of affairs.  And note the adjective “harried”, with its subtle connotations of disorganization and ineffectiveness.  I couldn’t begin to estimate the number of perplexed teachers that I worked with during my career who struggled endlessly in their attempts to reconcile the obvious reality that the children concerned were essentially undisciplined with the inane psychiatric “orthodoxy” that they were sick.

CONCLUSION

Dr. Frances is correct in saying there is too much diagnosing of ADHD and too much use of stimulant drugs to “treat” this problem. Though he is incorrect in the unstated implication that there is a correct amount of both, which he, and psychiatry generally, have valiantly sought to establish and maintain.

Psychiatry’s obvious agenda in every revision of the DSM, and particularly DSM-IV, has been expansion of their “diagnostic” net.  In this task, they have been ably assisted by pharma, but without psychiatry, pharma could never have gotten even one of their psychotropic drugs to market.

Attempts by Dr. Frances to expose the destructive and disempowering increase in the use of these products, and to put himself on the right side of history, would be more convincing if he would point the finger of blame towards psychiatry, and, in particular, towards himself.

. . . . . . . . . . . . . . . .

ADHD is not something that a child has; rather it is something that a child does.

  • S Randolph Kretchmar

    Several years ago I pointed out what I still think is a fascinating historical comparison, between Allen Frances and Samuel Sewell, the judge at the Salem witch trials who later publicly apologized for his role in that travesty…

    http://refusingpsychiatry.blogspot.com/2010/03/alan-frances-and-samuel-sewell.html

    Unfortunately, Dr. Frances’ personal moral failure has caused far more harm than Sewell’s ever did. That may be why Frances has been incapable, so far, of any honest apology.

  • Mark Eccles

    Great article Dr. Hickey. Parents fear for the health of their child and for a licensed doctor to support unwarranted fear, and prescribe drugs to change normal childhood behaviour is criminal.

  • Phil_Hickey

    Randolph,

    Yes. He’ll offer all possible expressions of regret short of an actual apology.

  • Phil_Hickey

    Mark,

    Thanks. It ought to be criminal, but tragically is legal, and even passes for medical treatment!

  • Nick Stuart

    Phil.Excellent piece as usual. I realised the type of person Allen Frances is when he tried to undermine Thomas Szasz after Szasz’s suicide. Despicable behaviour that should have its own category in the DSM 6.

  • Phil, Why is this article not on Mad In America? Too controversial for them?
    I agree with this article’s points. Allen Frances was fine with what psychiatry was doing while he was taking hundreds of thousands of dollars for being the architect of DSM IV, and working with drug companies creating guidelines to expand their product reach. Then once he had enough money, he cut himself loose and pretended to be a good guy criticizing his old profession. But it’s not hard to see that even now he can’t be honest about his own role and other psychiatrists’ role in creating this epidemic. That’s why I call him “Janus” (after the two faced Roman God). He adopts whatever position is most advantageous and profitable to him without regard for honestly or how it affects others (isn’t that a characteristic of sociopaths, by the way?).

  • Phil_Hickey

    Nick,

    Yes, that was a low point in this “illustrious” career.

    His present attempts to portray himself as the person who had always advocated moderation are just not convincing. He would be better to just slip into retirement

  • Phil_Hickey

    Edward,

    I don’t think it’s too controversial for them. I think they just prefer to
    focus on issues rather than individuals. I agree with this in general, but sometimes the two are inextricable. And when Dr. Frances blames parents and teachers for the ADHD “epidemic”, I feel I have to call him on this.

    Best wishes.

  • Paula J. Caplan

    Another brilliant, scrupulously researched and argued essay from Dr. Hickey! I wish you had written this in time for me to quote from it extensively in http://www.madinamerica.com/2015/10/diagnosisgate-a-major-media-blackout-mystery/ and/or in http://www.oa.uottawa.ca/journals/aporia/articles/2015_01/commentary.pdf — which might be of interest to your readers.

  • Hankie

    When he had enough money! Another comment with great genius at its core. Golly, how much is enough?

  • Cledwyn’s Pus Poetry

    Most people who write about psychiatry are just prostitutes, tailoring themselves to the demands of their market, potential or otherwise, lest they alienate them; winking seductively and giggling coquettishly at their customers; arousing them with their heads looking back over their shoulders at them, whilst slapping their bottoms and lavishing sighs of simulated sexual delight.

    Frances seems to think there is something radical about his critique of psychiatry’s “war on normal”, or whatever people are calling it, but he’s just fellating the mass phallus, faithfully preserving a heritage of populist prostitution whereof most men who put pen to paper partake, usually with an eye towards furthering a career, or to inveigling themselves into the hearts and minds of others and establishing thereover their own empire or that of their group, all done, of course, on some sanctimonious pretext.

    What a lot of whores there are in this glorified brothel we call the world!

    He seems quite desperate to save the “normal” from becoming entangled in modern psychiatry’s diagnostic web, though I would suggest closer scrutiny shows that the encroachment of the organized madness that is psychiatry – which like just about all faiths is the plague to which it proffers a solution – upon the scared territory of the “normal” greatly antedates modern psychiatry, its roots extending much further back and all the way to the founding of the profession itself, for what could be more normal than madness – the study and “treatment” whereof being the profession’s raison d’etre, amongst other things – and more utterly heteroclite than reason?

    The madness psychiatry attacks is just about always normal inwardly, though admittedly it does often outwardly deviate in the matter of certain particulars, allowing the illusion that there is something inherently alien about it. Yet an illusion it is, and the man who believes that there is a line running through human societies along which people can be divided into the categories of the sane and the insane is merely a slave to appearances.

  • all too easy

    Once again, Phil ignores the loss and deprivation experienced by those cursed with this disorder and the profound benefits medication makes in their lives.

  • all too easy

    how much suffering, real, prolonged, crushing and desperate agony can one child endure?

    you add to it

  • all too easy

    Let’s see proof that in time these drugs cause aggression. Exactly what do they do within the brain that forces someone to become violent? Where are the objective, scientific tests you refer to when making such a frivolous, outrageous, unsupported, preposterous accusation? GOT NUTHIN!

  • all too easy

    Tis indeed an epidemic when you are the only one who has it. It makes no difference what others may believe it to be. Their swords will pierce their own necks. It does matter in the life of a child, though. A defenseless, sweet sweet little boy who never would have harmed anyone. You see, Phil knows my type. Phil joins the chorus, singing with glee and self-righteous pride, that I choose to screw up and always have. He knows. See, Phil must be convinced that what he reckons are clear physical imperfections will be manifest on a scientific and objective testing format before he will concede a problem of a bio-chemical/electrical weakness exists. Not until then will he stop condemning me, and ridiculing me for all the time I wasted as a child. He would have been laughing, too. It is, after all, a simple issue of willpower. He knows this to be true because having never had the sweet pleasure of meeting me, he knows how lousy I have been since third grade when I yearned to learn French and math and spelling, and I couldn’t. Phil was right there, by my side, as others called me stupid and dumbo and laughed at me to my face cause I could not pay attention. He was there when I was repeatedly sent to another class where they even set up a table just for me; where I bowed my head in shame, beet red, unable to identify what I had done wrong and feeling overwhelmed.

    Cancer didn’t exist, before it could be isolated and studied. No one ever had a heart attack until someone figured out that blockage develops in arteries.

    That other know-it-all Boob, Robbie, the humongous, irritating creepy weirdo, with every answer for no one’s questions, spews endless rubbish convinced he has something for everyone even though no one is listening.

  • doppelganger

    Liar.

  • all too easy

    I know a liar when I see one. Your problem is that you can’t. Don’t try to be like me. Be you. I sense things immediately and see through others with uncanny and astonishing accuracy. It is a gift. I cannot take credit for it. People with ADHD often are blessed with intuitive perception that is truly remarkable. You don’t have it. Few do.

    You, my dear phony, are a LIAR and you know I am telling the truth, don’t you? Be honest

  • doppelganger

    I can spot a liar faster than you can. Liar.

  • all too easy

    that’s what i said. now, run along and continue proclaiming you know everything. boring.

    raise them thar non-ADHD boys, will ya? and go to mommy for some hot chocolate

  • doppelganger

    I know everything. I am a genius of extraordinary abilities, even for a true genius.

  • all too easy

    Normal childhood behavior does not render a child unable to focus her attention when it is necessary for her to do so. The deceitful characterization of ADHD by this band of boobs generally represents the reasons no one is listening to them.

  • all too easy

    I am. I know. Remarkable. I am deeply grateful for with my vastly superior gifts, the proper ADHD diagnosis and treatment, and the certainty of the righteousness of this cause, little children and teens and adults will be free of the poison you have spread about them. We shall defeat you ultimately in our courts as we have in the realm of public opinion. You shall pay a terrible price for defaming and engaging in hate speech directed at an entire group of disabled Americans.

  • doppelganger

    Prove it.

  • doppelganger

    Broken record. Take some more acid.

  • all too easy

    “Most people who write about psychiatry are prostitutes…”

    Like Paladapus. No one writes more about it than she does! Always knew she was in on the money making schemes of big pharma! I miss her. She doesn’t post much anymore, ever since she hit her stride as a stand-up comedian. Whilst those required optimists go on their merry way. Oh, the inhumanity, Paladapus!

  • doppelganger

    TWEAKER. Most meth heads are prostitutes too. You’re smarter than that, though, aren’t you? You get your health insurance or your mommy to pay for your amphetamines. What a neat trick.

  • all too easy

    Phil, my dear confused friend, you accuse parents and teachers!

  • doppelganger

    Liar. Dr. Hickey is not confused. He is hardly your dear friend either.

  • johnnybe

    little children and teens and adults will be free of “the poison you have spread about them”. tell ya what though- that would be a lot better than “the poison you force down their throats” .

  • all too easy

    They prescribe drugs to change normal behavior? Is that right? Who does this? Name names. Come on! They should be arrested and charged with felonies, right now. Don’t you think? The cops will arrest them, if you report them. It is against the law to prescribe Schedule II drugs to children if they don’t have any need, if they’re just fine. Report them or share their names publicly. Come on doc.

  • all too easy

    “There are no medical tests…” What is a medical test? You don’t claim there are no tests, just no medical tests. So, define medical test.
    This ought to be entertaining.

  • all too easy

    Tis time to hear from Lil Stevie No Wonder, the boob who can’t refrain from making vast generalizations that are grossly inaccurate, dumb, irrelevant, but which allow him, to ease his ceaseless efforts to become perceived as a person with half a brain, to be convinced he actually knows a thing or three when, in reality, he has no clue.
    “We all hate others…” We all believe…” We are convinced that…” “All people are certain…” “Everyone is tempted to believe he is special…” He is inspiring, to say the least. Those two boys of his are just crazy about him. Such charisma!