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.”
“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.”
“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.”
“…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.”
“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.”
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:
- 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.
- 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.
- 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!
- 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.
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.