Tag Archives: ADHD

Allen Frances and the “Overdiagnosing” of Children

On October 31, 2016, the very eminent psychiatrist Allen Frances, MD, architect of DSM-IV, published an article on his Psychology Today blog, Saving Normal.  The article is titled DSM-5 Diagnoses In Kids Should Always Be Written In Pencil.  (The piece also appeared on the Huffington Post Blog on the same date.)  The subheading is “Mislabelling children and adolescents is frequent and can haunt them for life”

As in many of Dr. Frances’s recent articles, the bulk of the text is written by someone else, and Dr. Frances provides an introduction and a summary/conclusion.  In this case, the core of the article is written. by Juan Vasen and Gisela Untoiglich of Forum Infancias, an Argentine organization of mental health workers dedicated to the “proper diagnosis and treatment of children and adolescents”.

The material written by Drs. Vasen and Untoiglich is basically sound, e.g. “Children and adolescents vary dramatically in the way they develop and in the chronology of their developmental milestones. Individuality and immaturity should not be confused with disease”, but there is also the implication that ADHD is a real disease entity which can be identified with careful and painstaking assessment.

“Accurate diagnosis in children and adolescents takes a great deal of time in each session and often many sessions over a number of months.”

Dr. Frances opens the article by lamenting what he describes as the “three most harmful fads in psychiatric diagnosis, during the past 20 years,”  These are:

“Rates of Attention Deficit Disorder have tripled and rates of Autism and childhood Bipolar Disorder have multiplied an incredible 40 times.”

Dr. Frances goes on to write that “Powerful external factors have contributed greatly to this massive mislabelling of kids.”  From the general context it is clear that what Dr. Frances calls “massive mislabeling” is not the assignment of psychiatry’s spurious labels as such, but rather what he calls the overuse of these labels.

He then takes his usual shot at pharma:

“For ADHD and kiddie Bipolar, drug companies misleadingly and aggressively sold the ill to peddle their expensive and profitable pills. Their marketing strategy was based on the cynical assumption that starting a kid early on pills might make him a customer for life.”

Dr. Frances frequently blames pharma, while ignoring the role that psychiatry, and he himself personally, played in the proliferation of psychiatry’s so-called diagnoses and the progressive relaxation of the criteria for these diagnoses.  I have spelled out in an earlier post how the criteria for ADHD were markedly relaxed in Dr. Frances’s own DSM-IV.

The widespread application of the “bipolar diagnosis” to children was the brainchild of the Harvard psychiatrist Joseph Biederman, MD, but some of the groundwork for this had been laid in DSM-IV.

The earlier edition of the manual (DSM-III-R) had stated that the age of onset of manic episodes

“…is in the early 20s.  However, some studies indicate that a sizable number of new cases appear after age 50.” (p 216)

The corresponding statement in DSM-IV reads:

“The mean age at onset for a first manic episode is the early 20s, but some cases start in adolescence and others start after 50 years.” (p 331) [Emphasis added]

So it was Dr. Frances’s own DSM-IV that first legitimized the notion that this so-called diagnosis could be applied to children.

Certainly, pharma played its part, but psychiatry was hand-in-glove with its generous benefactor, as it has been since the 60’s-70’s.

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

The explosion of Autism resulted from the combination of two things: the DSM-IV introduction of a much milder form (Asperger’s) and the far too close linkage of the diagnosis to eligibility for enhanced school services. DSM diagnoses developed for clinical purposes are inappropriate gatekeepers for allocating educational resources. Educational decisions should be based on the child’s educational need, as assessed by educators, using educational tools.”

The reference to Asperger’s disorder is probably accurate, and represents an honest admission on the part of Dr. Frances, but the statement:

“DSM diagnoses developed for clinical purposes are inappropriate gatekeepers for allocating educational resources. Educational decisions should be based on the child’s educational need, as assessed by educators, using educational tools.”

is extremely misleading.

The issue here is that, in general, public schools are required by federal law to make accommodation for children with disabilities.  It is also required that these children be taught, not in special education settings, but rather in regular classrooms, whenever possible.

Disability is obviously a complex, and difficult-to-define concept.  But for practical purposes, the Social Security Administration (SSA) has two broad criteria.  Firstly, the child must have a confirmed illness; and secondly, he must have confirmed illness-related functional limitations.  Both autistic disorder and attention deficit hyperactivity disorder have been accepted by the SSA as covered illnesses.  Evidence of functional limitations is usually gathered from the child’s treatment providers, supplemented as needed by reports from outside consultants.

So – and this is the critical point – “DSM diagnoses” are not being used as gatekeepers for allocating educational resources.  Rather, they are being used as the first stage in disability determination (i.e., the presence of illness).  And it is the disability determination that in turn drives the educational decisions, and, in some cases, channels additional funding to the school.

So Dr. Frances is, in effect, lamenting the use of “DSM diagnoses” to determine the presence of psychiatric “illness”, which seems a major about-face for someone who routinely asserts the validity and usefulness of these “diagnoses” for precisely these purposes.  The point is this:  Once the APA invented the ADHD illness, the door was opened for this illness to become disability-eligible.

And, incidentally, the plot thickens.  In 1985 the SSA contracted with the APA to conduct a major study of the standards and guidelines for the assessment of mental impairment.  The study lasted two years.  The APA made some minor recommendations, but “All recommendations were made on the premise that the basic construct of the SSA’s medical standards and guidelines for the evaluation of claims based on mental impairment should be retained.” [Italic emphasis in original]   So whatever criticism Dr. Frances has of the present system, he needs, I suggest, to acknowledge the part his own profession played in the creation of this state of affairs.

But the plot thickens even more.  Most of the details involved in the education of disabled children are set out in the Individuals with Disabilities Education Act (IDEA), 1990.  When this bill was being drafted, there was considerable controversy over whether ADHD should be included as a covered “illness”.  Opposition came from teacher organizations and the NAACP.  The original act (1990) did not include ADHD.  However, in 1991 the Department of Education issued a clarificatory memo stating that “ADHD” is a covered disability under IDEA.  This amendment was the result of intensive lobbying by CHADD and others.  And organized psychiatry has been a long-time supporter of CHADD. At the present time there is a downloadable document titled ADHD: Parents Medication Guide on the APA website.  CHADD is mentioned five times and is recommended as a source of information.  The document was prepared by the American Academy of Child and Adolescent Psychiatry and the APA.

“OVER-DIAGNOSIS”

Dr. Frances continues:

“It is long past time to tame the wild DSM over-diagnosis of kids.”

Then, after the material written by Drs. Vasen and Untoiglich:

“Thanks so much, Juan and Giselle, for poetically cautioning clinicians to be conservative, never careless or creative, in diagnosing kids. Mislabelling has serious and often longstanding consequences on how the child sees himself, how the family sees the child, and on the misuse of medication. Diagnosis should never be taken lightly.”

and

“Accurate diagnosis in kids is really tough and time consuming. Misdiagnosis in kids is really easy and can be done in 10 minutes. Accurate diagnosis in kids leads to helpful interventions that can greatly improve future life. Misdiagnosis in kids often leads to harmful medication and haunting stigma.”

and

“The stakes are high and the harms sometimes permanent. The best way to protect our children is to respect their difference and to accept uncertainty. I really love the idea of writing psychiatric diagnoses in pencil.”

This notion of conservative, careful and accurate diagnosis is a common theme in Dr. Frances’s writing, but in fact, it’s an empty exhortation, because the criteria are inherently vague and ill-defined.

Let’s consider the first criterion in the APA’s list:

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

The DSM-5 wording is almost identical, but adds two examples:  (e.g. overlooks or misses details, work is inaccurate).

To illustrate the problem, let’s imagine a conversation between two experienced psychiatrists, Dr. I. Druggem and Dr. Ak Curate.

Dr. Curate:      You’re diagnosing too many children with ADHD.
Dr. Druggem:  No, I’m not.  I always make sure that they meet the requisite number of criterion items.
Dr. Curate:      But you’re interpreting the criteria too loosely.
Dr. Druggem:  You’re interpreting them too tightly.
Dr. Curate:      Well consider that six-year-old boy you diagnosed last week.  Which criteria did he meet?
Dr. Druggem:  Inattention criteria a, b, c, d, and e.  He also met four of the hyperactivity-impulsivity criteria.
Dr. Curate:      So he met criterion 1(a) – “often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities”?
Dr. Druggem:  Yes, absolutely.
Dr. Curate:      How do you know?
Dr. Druggem:  Because I had his teacher fill out a checklist, and she checked that item.
Dr. Curate:      So the teacher said that he met this criterion.  Did she say how often is often?
Dr. Druggem:  No, of course not.
Dr. Curate:      How often is often?
Dr. Druggem:  I don’t know; I suppose two or three times a day.
Dr. Curate:      I think it would be perfectly normal for a six-year-old boy to make careless mistakes or lose his attention ten or even fifteen times a day.
Dr. Druggem:  No way.
Dr. Curate:      Yes way.

And the critical point here is that there is nothing in the DSM, or indeed in any psychiatric guideline, that can resolve this disagreement.  There is no way to say which psychiatrist is correct.  And the problem is compounded when we recognize that similar definitional difficulties arise when we ask what constitutes close attention versus not-so close; or careless mistakes versus other kinds of mistakes.  And when we recognize that the same difficulties arise with all 18 criteria, it is clear that the term “accurate diagnosis of ADHD” is a logical absurdity.  If one invents illnesses with no identifiable pathology, to be diagnosed on the basis of inherently vague checklists, the concept of true prevalence is meaningless.

So what psychiatry has created is a loose algorithm that can be expanded and contracted at will, without any blame or censure being assigned to the “diagnosing” psychiatrist.  But it’s even worse than that, because this arbitrarily flexible “diagnosing” is being conducted in a context where there are enormous incentives to make the “diagnosis”, and considerable penalties for declining to “diagnose”.

First in this regard are the pharma companies whose revenue correlates with the number of children “diagnosed”.  Secondly, the parents are off the hook with regards to the need to discipline or train their children effectively.  Thirdly, the “diagnosis” may entitle the child (or rather his parents) to a disability income.  Fourthly, the school may be eligible for additional funding.  Fifthly, the psychiatrists stand a very good chance of acquiring a long-term repeat customer.

So everybody wins – except, of course, the child, who loses, especially in the long term.  This is the monster that psychiatry has created.  And Dr. Frances played a cardinal role.

The problem is not over-diagnosing.  The problem is the spurious medicalization of problems that are not medical in nature.  And this was psychiatry’s contribution to the great psychiatry-pharma hoax, which they entered with eyes wide open.  The deal was simple.  We (psychiatrists) invent and legitimize the illnesses, and write the prescriptions; you (pharma) send lots of money, validations, and business our way.  And Dr. Frances is very knowledgeable about this matter.  In 1995, he and his partners John Docherty, MD and David Kahn, MD, wrote:

“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.”

This was a reference to The Expert Consensus Guideline Series: Treatment of Schizophrenia produced by Drs. Frances, Docherty, and Kahn (The Journal of Clinical Psychiatry, 1996, Vol 57, Supplement 12B) with a generous grant from Johnson & Johnson (owners of Janssen).  The quote is from an expert witness report by David Rothman, PhD, professor of Social Medicine at Columbia University College of Physicians and Surgeons, p 15-16.  The entire issue has been covered in great depth by Paula Caplan, PhD, here, and to the best of my knowledge, Dr. Frances has never publicly acknowledged any wrongdoing or issued any apology with regards to the matter.

FINALLY

Dr. Frances was a key player in the promotion of the psychiatric hoax.  As architect of DSM-IV, he had the opportunity to reverse the trend begun by Robert Spitzer, MD, with DSM-III, but instead, Dr. Frances not only stayed on the proliferation/expansionist track, but actually accelerated the pace.  His present hand-wringing concerning the mislabeling and over-drugging of children is not convincing.

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

 ADHD is not something a child has.  It is something a child does.

 

ADHD: A Destructive Psychiatric Hoax

INTRODUCTION

Earlier this year, Alan Schwarz, an investigative reporter for the New York Times, published his latest book:  ADHD Nation.

The blurb on the jacket states:

“More than 1 in 7 American children get diagnosed with ADHD—three times what experts have said is appropriate—meaning that millions of kids are misdiagnosed and taking medications such as Adderall or Concerta for a psychiatric condition they probably do not have.  The numbers rise every year.  And still, many experts and drug companies deny any cause for concern.  In fact, they say that adults and the rest of the world should embrace ADHD and that its medications will transform their lives.

In ADHD Nation, Alan Schwarz examines the roots and the rise of this cultural and medical phenomenon: The father of ADHD, Dr. Keith Conners, spends fifty years advocating drugs like Ritalin before realizing his role in what he now calls ‘a national disaster of dangerous proportions’; a troubled young girl and a studious teenage boy get entangled in the growing ADHD machine and take medications that backfire horribly; and Big Pharma egregiously over-promotes the disorder and earns billions from the mishandling of children (and now adults).”

And who could argue with any of that?  But the blurb continues:

“While demonstrating that ADHD is real and can be medicated when appropriate, Schwarz sounds a long-overdue alarm and urges America to address this growing national health crisis.”

And there, of course, is where we must part company.

When I first read the jacket blurb, I was curious as to what kinds of arguments Alan Schwarz would marshal to support the contention that ADHD is “real”, and that it sometimes warrants “medication”.  And let us be clear as to the meaning of the word “real”.  Nobody is denying that inattention, hyperactivity, and impulsivity can be real problems.  The issue at stake , however, is whether it makes any sense to conceptualize this loose cluster of vaguely-defined problems as an illness.  Usually when people say or write that ADHD is “real”, they mean that this cluster of problems listed in the APA’s catalog (DSM) is a genuine, bona fide illness – just like diabetes; and that people who “have” this so-called illness must take their “medication” in the same way that diabetics must take insulin.  So, the promise on the jacket that Mr. Schwarz would demonstrate that ADHD is a real illness seemed significant, and as I said earlier, I was particularly interested in whether he had anything new to add to this debate.

Here’s the opening page of the Introduction.

“Attention deficit hyperactivity disorder is real.  Don’t let anyone tell you otherwise.

A boy who careens frenziedly around homes and busy streets can endanger himself and others.  A girl who cannot, even for two minutes, sit and listen to her teachers will not learn.  An adult who lacks the concentration to complete a health-insurance form accurately will fail the demands of modern life.  When a person of any age has a combination of these struggles—severely enough to impair his daily functioning—with no other plausible explanation for them, then he could very well have a serious, if still somewhat mysterious, condition that medicine has decided to call ADHD.

No one quite knows what causes it.  The most commonly cited theory is that the hypractivity, lack of focus, and impulsivity of classic ADHD result from some sort of dysfunction among chemicals and synapses in the brain.  A person’s environment clearly plays a role as well: a chaotic home, an inflexible classroom, or a distracting workplace all can induce or exacerbate symptoms.  Unfortunately, as with many psychiatric illnesses, such as depression or anxiety, there is no definitive way to diagnose ADHD, no blood test or CAT scan that lets a doctor declare, ‘Okay, there it is’—all one can do is thoughtfully assess whether the severity of the behavior warrants a diagnosis.  (After all, we all are distractible or impulsive to varying degrees.)  One thing is certain, though: There is no cure for ADHD.  Someone with the disorder might learn to adapt to it, perhaps with the help of medication, but patients young and old are generally told that they will deal with their abnormal brains for the rest of their lives.” (p 1)

And there is it.  Let’s take a closer look.

“Attention deficit hyperactivity disorder is real.  Don’t let anyone tell you otherwise.”

The reality or otherwise of “ADHD” is the fundamental issue of this entire debate, and it is clear from this opening statement that Mr. Schwarz has not approached this question with anything resembling the kind of open-mindedness that one expects from an investigative journalist.

But it gets worse.

“A boy who careens frenziedly around homes and busy streets can endanger himself and others.”

Mr. Schwarz is clearly trying to create the impression that this kind of behavior is fairly typical of children who “have ADHD”, and he is also pointing out that the behaviors are serious.  What he doesn’t mention, however, and perhaps isn’t even aware of, is that physically dangerous activity – including running “into street without looking” – was one of the specific criteria for ADHD in DSM-III-R, but was diluted to “runs about or climbs excessively” in DSM-IV.  And in DSM-5, the word “excessively” was dropped.  Here are the actual items from the three editions:

DSM-III-R (1987):
“(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)

DSM-IV (1994)
Under the sub-heading Hyperactivity:
“(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)

DSM-5 (2013)
Under the sub-heading Hyperactivity and impulsivity:
“c.  Often runs about or climbs in situations where it is inappropriate.  (Note: in adolescents or adults, may be limited to feeling restless.) (p 60)

So, a boy who careens frenziedly around homes and busy streets would probably meet the standard in all three editions, but – and this is the critical point – there is no requirement in the latter editions of such extreme behavior to score a “symptom” hit.  Contrary to Mr. Schwarz’s implied assertion, a child does not have to engage in such extreme or dangerous behavior to meet any of the APA’s criteria for this so-called illness. And it needs to be noted particularly that since 1994, the only requirement under this item for adults and adolescents is that they experience feelings of restlessness!

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

“A girl who cannot, even for two minutes, sit and listen to her teachers will not learn.”

How can Alan Schwarz – or anyone else, for that matter – deduce that a girl who doesn’t pay attention to her teachers, can’t pay attention.  This is an invalid inference, but is standard procedure in psychiatry.

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

“When a person of any age has a combination of these struggles—severely enough to impair his daily functioning—with no other plausible explanation for them, then he could very well have a serious, if still somewhat mysterious, condition that medicine has decided to call ADHD.”

This again is standard psychiatric patter:  the flaw is contained in the phrase “…with no other plausible explanation for them…”

Anyone who has had even the slightest experience working with children and families can attest to the fact that there are always alternative psychosocial explanations, if one is prepared to look for them.  The reality, however, is that within the practice of psychiatry, these alternate explanations are almost never sought.

And the reason they are not sought is because psychiatry has effectively closed the door on these kinds of deliberations.  Within the psychiatric framework, if a child (or adult) meets the arbitrary and inherently vague criteria listed in the DSM, then he has a brain illness called ADHD.  So the notion of even looking for psychosocial explanations not only doesn’t happen, but would be seen within psychiatry as ridiculous.

In real medicine, if a person has pneumonia, then that is the explanation of his persistent cough, nasty phlegm, weakness, etc..  The notion of a physician in such circumstances casting around for an alternative psychosocial explanation would be pointless.  Similarly, psychiatrists, firmly wedded as they are to their spurious illness perspective, don’t look for ordinary human explanations of the problems they encounter.  The difference, of course, between psychiatry and real medicine is that the latter’s diagnoses are indeed genuine explanations of the presenting problems.  In psychiatry, the “diagnoses” are merely labels that psychiatrists assign to the loose clusters of vague problems, and have no explanatory value whatsoever.

To demonstrate this, consider the two following hypothetical conversations.

Client’s parent:  Why is my son so distractible; why does he make so many mistakes in his schoolwork; why does he not listen to me when I speak to him; why is he so disorganized?
Psychiatrist:  Because he has an illness called attention-deficit/hyperactivity disorder.
Parent:  How do you know he has this illness?
Psychiatrist:  Because he is so distractible, makes so many mistakes in his schoolwork, doesn’t listen when you speak to him, and is so disorganized.

The critical point being that in psychiatry, the only evidence for the “illness” is the very behavior it purports to explain.  In other words:  your son is distracted because he is distracted.

Contrast this with a similar conversation in real medicine.

Patient:  Why am I so tired; why did my temperature spike; why am I spitting up such dreadful-looking phlegm?
Physician:  Because you have pneumonia.
Patient:  How do you know I have pneumonia?
Physician:  Because I can hear characteristic sounds through the stethoscope; your chest X-ray shows large quantities of fluid in both lungs; your sputum labs are positive for pneumococcus; and because everything you have told me is consistent with this diagnosis.  I can show you the X-rays if you like.

In this conversation, there is no circularity to the reasoning.  The pneumonia is the cause of the symptoms and constitutes a genuine and useful explanation.

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

“No one quite knows what causes it.”

Well actually, lots of people know what prompts children to “careen frenziedly around homes and busy streets”.  It is very simply that the discipline and self-control to refrain from this kind of activity has not been instilled at an appropriate age.  And it’s not “somewhat mysterious”.  It’s something that parents and grandparents have been dealing with probably since prehistoric times.  And the same goes for the other ADHD behaviors, misleadingly called “symptoms” in the DSM.

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

“The most commonly cited theory is that the hyperactivity, lack of focus, and impulsivity of classic ADHD result from some sort of dysfunction among chemicals and synapses in the brain.”

And just when we thought that the long-discredited chemical imbalance hoax was about to die!  Mr. Schwarz seems unaware that most leading psychiatrists are at the present time busy distancing themselves from this particular inanity, which was a mainstay of the psychiatric hoax for decades.  The very eminent and highly prestigious Tufts psychiatrist Ronald Pies, MD has even gone so far as to claim that psychiatry never promoted this hoax – an assertion that adds an entire new dimension to academia’s allegorical ivory tower.

Then Mr. Schwarz gets to the point:

“Unfortunately, as with many psychiatric illnesses, such as depression or anxiety, there is no definitive way to diagnose ADHD, no blood test or CAT scan that lets a doctor declare, ‘Okay, there it is’—all one can do is thoughtfully assess whether the severity of the behavior warrants a diagnosis.  (After all, we all are distractible or impulsive to varying degrees.)”

So despite the earlier vagueness, and despite Mr. Schwarz’s condemnation of what he describes as the over-diagnosis of ADHD, he is clearly a firm supporter of psychiatry’s contention that inattention, impulsivity, and general gadding about constitute an illness, if the behaviors cross some ill-defined threshold of severity.

This is another of psychiatry’s core fallacies, routinely promoted, not only in the successive editions of the DSM, but also in the defensive writings of psychiatry’s most prestigious promoters:  if a problem of thinking, feeling, or behaving crosses some arbitrary and vaguely defined thresholds, of severity, duration, or frequency, it becomes, through some alchemy known only to psychiatry, an illness.  The fact that no organic pathology has ever been identified is of no consequence.  If the problem is severe enough, then it’s an illness.

And the reason for this travesty is that within the looking-glass realm of psychiatric diagnosis, the cause of the problem is irrelevant.  This is the essential point of Robert Spitzer’s phenomenological approach as embodied in his DSM-III and in subsequent editions.  Why a person exhibits a problem is of no consequence.  If, in the case, say of “ADHD”, a child is inattentive, overly active and impulsive to the degree specified, albeit loosely, in the text, then he has the illness.  Whether he emits these behaviors because of lax parenting, inconsistent parenting, indulgent parenting, sibling rivalry, emotional abuse, or some other cause, makes no difference to the “diagnosis”.  In marked contrast to real medicine, where diagnosis and cause are virtually synonymous, in psychiatric diagnosis, the cause of the problem is immaterial.  If the child emits the behaviors in question, for any reason or cause, then he “has the illness”.  The “illness” in fact is nothing more than the presence of the vaguely-defined problem behaviors.  There is no requirement of neurological pathology, nor any evidence that the behaviors in question entail a neurological pathology.  DSM-III describes this approach as “…atheoretical with regard to etiology or pathophysiologic process except with regard to disorders for which this is well established and therefore included in the definition of the disorder.” (p xxiii), which is not the case with ADHD.

Far from acknowledging the obvious dishonesty of this “atheoretical” approach, DSM-III-R actually makes of it a virtue:

“The major justification for the generally atheoretical approach taken in DSM-III and DSM-III-R with regard to etiology is that the inclusion of etiologic theories would be an obstacle to use of the manual by clinicians of varying theoretical orientation since it would not be possible to present all reasonable etiologic theories for each disorder.” (p xxiii)

In reality, however, by ignoring etiological questions, the APA created the context in which “mental disorders” could be created at will on the basis of any human problem, and these “disorders” could be, and indeed are, morphed readily into “mental illnesses”, and, of course, as we see in Mr. Schwarz’s text, neuro-chemical imbalances.  Psychiatry has conveniently abandoned the notion that new diagnoses must be grounded on proven organic pathology.  Real doctors discover new illnesses through painstaking research and study – often taking years or even decades.  Psychiatry just makes them up and confirms their ontological validity by a committee vote.

For decades, psychiatry, confident in the knowledge that few people read the DSM,  simply lied with regards to the absence of organic pathology.  They told their clients, the public, and the media the blatant lie that the “chemical imbalances” existed and were the cause of the problems.  And – the biggest whopper of all – that the drugs corrected these non-existent imbalances.  They also routinely asserted that their “patients” would in many (or perhaps most) cases have to take the drugs for life.  And here again, Mr. Schwarz follows his psychiatric mentors, lock step.

“One thing is certain, though: There is no cure for ADHD.”

Again note the dogmatic arrogance.  Children who are inattentive, unruly, disobedient, and disruptive to the inherently vague degree specified in the DSM are incapable of acquiring an age-appropriate level of discipline!  How in the world could Mr. Schwarz know this?  As early as 1973, Huessy, Marshall and Gendron (Five hundred children followed from grade 2 to grade 5 for the prevalence of behavior disorder, Acta Paedopsychiatrica, 39(11), 301-309), showed that hyperactivity is not a stable pattern across time.  There is also an abundance of research going back to the 60’s that demonstrates clearly that children who are habitually inattentive, impulsive, and hyperactive  even to an extreme degree, can be trained readily to behave in a more productive and less disruptive fashion.  In fact, prior to the mid-60’s, no such research was needed, because parents and teachers routinely and successfully trained children to control their movements, and to pay attention to their studies and to their chores.  Indeed, parents and teachers accepted that this was an intrinsic part of their responsibilities.  But in 1968, with the publication of DSM-II, psychiatry’s “top experts” decreed that these problem behaviors constituted an illness that required specialist attention.  This “illness” was labeled hyperkinetic reaction of childhood.  The description ran to four lines:

“308.0  Hyperkinetic reaction of childhood (or adolescence)*
This disorder is characterized by overactivity, restlessness, distractibility,
and short attention span, especially in young children; the
behavior usually diminishes in adolescence.” (p 50)

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

“…patients young and old are generally told that they will deal with their abnormal brains for the rest of their lives.”

Despite decades of lavishly funded and highly motivated research, and despite the numerous enthusiastic, and subsequently discredited, claims to the contrary, there is not one shred of evidence that people who have been given the ADHD label have any brain pathology whatsoever.  In fact, no edition of DSM, including the present DSM-5, has ever included any kind of brain pathology as a criterion item for this so-called illness.  DSM-5 does include ADHD in the Neurodevelopmental Disorders section, but all that this entails is that the onset of the problem was in the developmental period.  There is no requirement of neurological pathology.  “The neurodevelopmental disorders are a group of conditions with onset in the developmental period.  The disorders typically manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.” (p 31)  Describing “ADHD” as a neurodevelopmental disorder strikes me as extraordinarily deceptive, in that most people would interpret the term “neurodevelopmental disorder” to entail some kind of neurological pathology.  What the APA has done here is convey the impression that there is a neurological pathology involved in “ADHD”, without having to produce evidence that this is the case.

THE “OVER-DIAGNOSIS” OF ADHD

Then Mr. Schwarz gets to the main theme of his book:  that ADHD is being grossly over-diagnosed, a theme incidentally that many psychiatrists have adopted in recent years in an attempt to rescue their crumbling profession from the criticisms of anti-psychiatry.  Watch how Mr. Schwarz does this:

“The American Psychiatric Association’s official description of ADHD, codified by the field’s top experts and used to guide doctors nationwide, says that the condition affects about 5 percent of children, primarily boys.  Most experts consider this a sensible benchmark.

But what’s happening in real-life America?

Fifteen percent of youngsters in the United States—three times the consensus estimate—are getting diagnosed with ADHD.  That’s millions of extra kids being told they have something wrong with their brains, with most of them then placed on serious medications.  The rate among boys nationwide is a stunning 20 percent.  In southern states such as Mississippi, South Carolina, and Arkansas, it’s 30 percent of all boys, almost one in three.  (Boys tend to be more hyperactive and impulsive than girls, whose ADHD can manifest itself more as an inability to concentrate.)  Some Louisiana counties are approaching half—half—of boys in third through fifth grades taking ADHD medications.

ADHD has become, by far, the most misdiagnosed condition in American medicine.

Yet, distressingly, few people in the thriving ADHD industrial complex acknowledge this reality.  Many are well-meaning—they see foundering children, either in their living rooms, classrooms, or waiting rooms, and believe the diagnosis and medication can improve their lives.  Others have motives more mixed:  Sometimes teachers prefer fewer troublesome students, parents want less clamorous homes, and doctors like the steady stream of easy business.  In the most nefarious corner stand the high-profile doctors and researchers bought off by pharmaceutical companies that have reaped billions of dollars from the unchecked and heedless march of ADHD.” (p 2-3)

But what Mr. Schwarz doesn’t mention, and perhaps isn’t even aware of, is that 69% of those “top experts” in psychiatry who “codified” the criteria for ADHD for DSM-5, and whose prevalence estimates Mr. Schwarz accepts implicitly, were also in the pay of pharma.

Nor does Mr. Schwarz seem to be aware that these same “top experts” who codified the criteria for ADHD have progressively liberalized the criteria for this so-called illness.  I have listed the DSM-IV (1994) relaxations in an earlier post.  The relaxations for DSM-5 (2013) were:

– the number of inattention “symptoms” required for adolescents and adults reduced from six to five (p 59)

–  the number of hyperactivity/impulsivity “symptoms” for adolescents and adults also reduced from six to five (p 60)

–  DSM-IV specified that some symptoms of ADHD had to have been present prior to age 7 (p 84).  DSM-5 relaxed this age-of-onset criterion to 12 (p 60).

It needs to be stressed that none of these relaxations were, or indeed could have been, based on empirical evidence or science.  There is no definition of ADHD other than that set down in successive revisions of the DSM.  The notion that the pharma-paid “top experts” compared ADHD-as-it-really-is with the description in the DSM, and found discrepancies, is simply not possible.  There is no ADHD-as-it-really-is.  There is no definition other than the one that the APA made up, and they can, and do, change it at will.  And, so far, the vast majority of the changes have been in the relaxation direction.

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

And this is the central point.  To bemoan the over-diagnosis of ADHD is an empty, futile exercise.  Given the facts that:

– the criteria are impossibly vague and subjective, and
– pharma makes more money the wider the net is cast, and
– psychiatry shares in these profits through a variety of avenues, and
– the drugs are addictive, and
– schools receive additional funding for every ADHD child on their rolls,

“diagnosis” creep is inevitable.  “Diagnosis” creep is not some accident or some pharma-produced sabotage that has befallen psychiatry despite its best efforts to remain pure and undefiled.  “Diagnosis” creep is an integral component of the monster that psychiatry has consciously and deliberately created.  “Diagnosis” creep is an integral part of psychiatry’s expansionist agenda, and was facilitated enormously by Robert Spitzer’s atheoretical, phenomenological approach in DSM-III (1980).  Though, incidentally, in the case of “ADHD” it was occurring prior to 1980.  Here’s a quote from Ullmann and Krasner’s A psychological Approach to Abnormal Behavior,  Second Edition, (1975):

“The treatment of children who have received the label of ‘hyperactive’ has been a source of further controversy in both psychology and pediatrics…Drug therapy, particularly stimulants such as amphetamines, have become the popular form of treatment including up to 10% of all students in some school districts…” (p 496)

And even then, forty-one years ago, there were clear dissenting voices:

“The label plus the drug treatment brings the child into the mentally ill or sick category and the social and self-labeling that follow…The use of drugs enhances the belief in the efficacy of outside agents rather than attribution of change to one’s own efforts (an important element in the development of self control in children and responsibility in teachers).” (Op. Cit. p 497)

If should also be noted that the relaxation of criteria is not confined to “ADHD”.  DSM-5 also relaxed the APA’s definition of a mental disorder, effectively expanding the net for all their so-called diagnoses.

The definition of a mental disorder in DSM-IV (1994) was:

“… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.  Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.  Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as descried above.” (p xxi-xxii)

This definition can, I think, be accurately paraphrased as:  any significant problem of thinking, feeling, and/or behaving.  And indeed, it is extremely difficult to think of a significant problem of thinking, feeling, and/or behaving that is not listed within DSM.

The definition of a mental disorder in DSM-5 (2013) is similar to that quoted above, but contains additional verbiage, and one enormous relaxation of the definition.  To enable readers to judge this for themselves, here’s the DSM-5 definition:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.  Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.  An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual, as described above.” (p 20) [Emphasis added]

The word usually on the fourth line expands the potential range of psychiatric “diagnosis” enormously.  One might even say that it becomes so wide as to embrace the entire population.  The point being that in DSM-IV, the problems had to reach a certain level of significance or severity.  But in DSM-5, that requirement was effectively dropped.  Admittedly, both phrases are vague, but DSM-IV’s requirement that distress or disability be present, is obviously a more stringent standard than DSM-5’s assertion that distress or disability is usually present.  In effect, the severity threshold has been abandoned, and there is a clear invitation to practitioners to assign “diagnoses” to individuals with increasingly milder presentations.  And it needs to be stressed that this change was not based on any kind of scientific information or discovery.  This change was simply a decision by the APA to expand the prevalence of their so-called illnesses to virtually everyone on the planet.  It also needs to be stressed that this is not an empty issue, but has already been implemented in the case of “ADHD”.  Compare the severity criterion for ADHD in DSM-IV with that in DSM-5:

DSM-IV:
“D.  There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.” (p 84) [Emphasis added]

DSM-5:
“D.  There is clear evidence that the symptoms interfere with , or reduce the quality of, social, academic, or occupational functioning.” (p 60)

Here again, both statements are vague, but significant impairment in… is obviously a tighter standard than interfering with, or reducing the quality of….

Given all of these considerations, it’s extremely difficult to avoid the conclusion that the APA not only supports the wide expansion of this so-called diagnosis, but has actively pursued and facilitated this expansion for decades.

. . . . . . . . . . . . . . . . 

CONCLUSION

 Mr. Schwarz has done a good job of exposing pharma’s tactics and strategies.  Although much of this story is well-known and has been told before, he does present the scam in a detailed and readable form.  He also addresses the problem of parents pushing to get their children “diagnosed” and on drugs, and the undeniable fact that people do become addicted to these products.  He also exposes the link between CHADD and pharma.

Perhaps now he can take a look at the even bigger scam:  psychiatry’s spurious and destructive medicalization of literally every problem of thinking, feeling, and/or behaving, including childhood inattention, impulsivity, and general lack of discipline.

Pharma does indeed push their products using very questionable methods.  But they couldn’t sell a single prescription for methylphenidate or for any other psychiatric drug without psychiatry’s bogus and self-serving “diagnoses”.  And they couldn’t have increased their sales to the extent that they did, without the commensurate relaxation of the “diagnostic” criteria, that psychiatry knowingly and willingly provided.  Bemoaning the use of hurriedly-completed facile checklists is empty talk, unless one is also willing to turn one’s criticism against the DSM’s equally facile “symptom lists”, of which the checklists are simply mirrors.

Psychiatry is nothing more than legalized drug-pushing.  There is not one shred of intellectual or scientific validity to their so-called taxonomy.  They invent these so-called illnesses to expand their turf, and then liberalize the criteria to expand it further.

Under the guise of medical care, they routinely rob people of their sense of competence, their dignity, and in many cases, their lives.  They have radically undermined the concept of success-through-disciplined-effort, and have ensnared millions of people worldwide in their ever-expanding web of drug-induced dependency and self-doubt.  They are not the thoughtful and expert codifiers of genuine illnesses, as Mr. Schwarz contends.  Rather, they are drug-pushing charlatans and hoaxsters who have systematically and deliberately deceived their clients and the general public to enhance their own prestige and their incomes.

If there was ever a subject that called for thorough investigative journalism, psychiatry is it.

“The Overdiagnosis of ADHD”

INTRODUCTION

On May 23, the very eminent psychiatrist Allen Frances, MD, published on the HuffPost blog an article titled Conclusive Proof ADHD is Overdiagnosed.

The general theme, that various “mental illnesses” are being “overdiagnosed” is gaining popularity in recent years among some psychiatrists, presumably in an effort to distance themselves from the trend of psychiatric-drugs-on-demand-for-every-conceivable-human-problem that has become an escalating and undeniable feature of American psychiatric practice.  The assertion in Dr. Frances’s title – that the label “ADHD” is being applied to too many people – is obviously true. But the implicit assumptions – that there is a correct level of such labeling, and that the label has some valid ontological significance – are emphatically false.  But Dr. Frances affords no recognition to this aspect of the matter.

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

Anyway, let’s take a look at the article.  Here’s the opening statement:

“There are 3 possible explanations for the  explosion of the ADHD diagnosis during the past 20 years — with rates that have skyrocketed from only 3-5 percent of kids to 15 percent.

1) Diagnostic enthusiasts celebrate the jump as indication of increased awareness of ADHD and better case finding.

2) Diagnostic alarmists worry that we are making our kids sicker via environmental toxins, computers, an over-stimulating world, maternal drug use, or some combination.

3) Diagnostic skeptics attribute the change to the raters, not the rated — it’s not that the kids are sicker, it’s rather that the diagnosis is being made too loosely.”

So, Dr. Frances tells us that there has been an “explosion” of ADHD diagnosis during the past 20 years – i.e. since about 1996.  Rates of “diagnosis” have gone from 3-5% to 15%.  And this may indeed be the case.  But consider this.  DSM-III-R (1987) cited a prevalence rate of “…as many as 3% of children” (p 51).  DSM-IV (1994) cited “3%-5% of school-age children” (p 82).  So, from 1987 to 1994, when DSM-III-R was the diagnostic reference, the prevalence increased modestly.  But from 1994 to the present day – a period during most of which Dr. Frances’s own DSM-IV was the reference – the rate exploded (to use Dr. Frances’s own term) from 3-5% to 15%.  Could it be that the relaxation of the criteria in DSM-IV made it easier for a person to be given the ADHD label?

“DIAGNOSTIC” RELIABILITY

“There is no gold standard or biological test to prove precisely which view is correct and what would be the ideal rate of ADHD to best balance the risks and benefits of being diagnosed. I am strongly in the skeptic school. Long experience has taught me how great is the impact on diagnostic rates of even small changes in how any disorder is defined or appraised. And this is greatly amplified when heavy drug company disease mongering aggressively sells the disorder to doctors, parents, and teachers.”

The opening sentence here represents an interesting admission.  “There is no gold standard or biological test to prove precisely which view is correct…”  In other words, it is not possible to say definitively who “has ADHD” and who does not.  But wasn’t it the purpose of successive revisions of DSM to clarify this matter once and for all?  Wasn’t it the purpose of DSM to put “diagnostic” uncertainty in the past, and to provide strict, confirmable criteria that would resolve the diagnostic reliability question?  Hasn’t this been psychiatrists’ claim since the publication of Robert Spitzer’s DSM-III?   Even Thomas Insel, MD, former Director of NIMH, while dismissing the various DSM entries as mere “labels”, clung to the notion that they were reliable.  “While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.” (Transforming Diagnosis).  But now Dr. Frances tells us that at least the ADHD label doesn’t even have sufficient reliability to provide accurate prevalence rates.  Of course those of us on the anti-psychiatry side of the issue have been saying for years that the various items listed in the DSM are nothing more than loose collections of vaguely defined problems with no explanatory or ontological significance.  Whilst I don’t think there is any prospect of Dr. Frances joining the anti-psychiatry movement in the near future, it is gratifying to learn that he shares our views concerning the lack of reliability of the ADHD “diagnosis”.

Dr. Frances tells us that he is “strongly in the skeptic school”.  In other words, he believes that the increase in prevalence of this so-called illness from 5% to 15% is attributable, not to the children who are receiving the label, but rather to the labelers:  “…the diagnosis is being made too loosely.”

And to guard against any suggestion of self-incrimination or confession, Dr. Frances promptly distances himself from the perpetrators of such wanton laxness.  “Long experience”, Dr. Frances tells us, has taught him “how great is the impact on diagnostic rates of even small changes in how any disorder is defined or appraised.”  This is a particularly compelling issue, because a number of small (and some quite large) changes to the “ADHD” criteria were made by Dr. Frances and his team in the DSM-IV.

RELAXATION OF “DIAGNOSTIC” CRITERIA IN DSM-IV

I listed and discussed these changes in an earlier post on December 8, 2015, and the details need not be repeated her.  Suffice it to say that the criteria were eased to a very considerable extent, and readers can confirm this by referring back to my earlier post and to the two DSM’s.

So, given that Dr. Frances concedes that even small changes in criteria can have a great impact on “diagnostic rates”, isn’t it reasonable to conclude that the very marked easing of criteria in Dr. Frances’s own DSM-IV, published twenty-two years ago in 1994, was the major proximate cause of the rate increase over the past twenty years?  Surely Dr. Frances is aware that within a year of the publication of DSM-IV, virtually every community mental health center and other psychiatric facility in the country had trained their staff in the new criteria, and that as a direct result of this, untold numbers of children received this label (and the almost inevitably attendant drugs) who would not have received the label under the DSM-III-R criteria.

BLAMING PHARMA

And then with po-faced innocence, Dr. Frances has the gall to complain that the problem is “amplified when heavy drug company disease mongering aggressively sells the disorder to doctors, parents, and teachers.”  One can’t monger a spurious disease until it has been invented.  It was psychiatry who invented ADHD, and it was Dr. Frances who relaxed the criteria making it possible to apply this disempowering label to more and more children.  What pharma did was what pharma always does:  they used the marketing opportunities that psychiatry had obligingly and knowingly created for them.  Did Dr. Frances imagine that they would not avail of such opportunities?

Besides, for Dr. Frances to point the finger at pharma suggests a measure of ingratitude to the hand that fed him.  Remember, this is the same Dr. Frances who in 1995, in concert with his then colleagues Drs. John Docherty and David Kahn, reportedly received grants of about $515,000 from Johnson & Johnson to write “Schizophrenia Practice Guidelines” which specifically promoted Risperdal (a Johnson & Johnson product) as the first line of treatment for schizophrenia.  On July 3, 1996, Dr. Frances and his colleagues reportedly wrote to Janssen Pharmaceutica (a Johnson & Johnson subsidiary) concerning the preparation of Schizophrenia Practice Guidelines, ‘We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.’  For a full and compelling account of this sordid matter, see Paula Caplan’s very thorough exposé here.  This entire matter, incidentally, only came to light because Dr. Frances’s profitable and collaborative relationship with Johnson & Johnson happened to be mentioned in testimony in a Texas lawsuit against the pharmaceutical company.

And in this general context, it should also be borne in mind that 56% of the DSM-IV Task Force had financial links to pharma. (Cosgrove et al 2006)

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

But let’s not dwell on the past.  Dr. Frances was never convicted of any offense for his role in the Johnson & Johnson scandal.  Nor was his medical license ever revoked.  Nor was he ever drummed out of his professional association.  Come to think of it, what are the criteria for being drummed out of the APA?  Given the scandals and disclosures of recent years, they must be rather lax.  But I digress.

ADHD AND CHILDHOOD IMMATURITY

Dr. Frances goes on to tell us some good news:

“Fortunately, there is one ingenious and compelling indirect way to determine whether rates of ADHD are inflated. Five large studies in four different countries have compared rates of reported ADHD in the youngest vs the oldest kids in classrooms. The studies converge on the inescapable finding that we are turning immaturity into disease.”

At this point, Dr. Frances turns the article over to Joan Lipuscek, MS LMFTA.  Joan Lipuscek is a child, teen and family therapist in Houston, Texas, with over fifteen years of experience.  Ms. Lipuscek outlines the five studies, all of which indicate that, in general, children who are younger than their classroom peers are more likely to be given the ADHD label. A  2010 US study, for instance, is reported to have found that :  “Children born 1-3 months prior to the grade cutoff date were found to be 27% more likely to be diagnosed for ADHD and 24% more likely to be medicated for ADHD compared to children born 10-12 months prior to the grade cutoff date.”  This is an interesting observation, of course, but the effect size (27%) doesn’t begin to explain the increase in labeling rates from 5% to 15% that Dr. Frances cited in his opening statement.  An increase from 5% to 15% is a 300% increase.

A more important point, however, is the implication in Dr. Frances’s paper that the “diagnosis” should not have been given to these children; that their juniority in the classroom should somehow have been considered an exclusionary factor.

So let’s see what the DSM has to say on age exclusions.  Here’s the pertinent sentence from DSM-III and DSM-III-R:

“In approximately half of the cases, onset of the disorder is before age four.” (p. 51) [Emphasis added]

So, clearly, as far as Dr. Spitzer and his Task Force were concerned, all children of school age were eligible for this diagnosis.

Dr. Frances, in DSM-IV, was a little more circumspect:

“It is especially difficult to establish this diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children and may include features that are similar to symptoms of Attention-Deficit-Hyperactivity Disorder.  Furthermore, symptoms of inattention in toddlers or preschool children are often not readily observed because young children typically experience few demands for sustained attention.  However, even the attention of toddlers can be held in a variety of situations (e.g., the average 2- or 3-year-old child can typically sit with an adult looking through picture books).  In contrast, young children with Attention-Deficit/Hyperactivity Disorder move excessively and typically are difficult to contain.  Inquiring about a wide variety of behaviors in a young child may be helpful in ensuring that a full clinical picture has been obtained.” (p. 81) [Emphasis added]

But the message is still clear:  children as young as two can be assigned this “diagnosis” provided that they “move excessively and typically are difficult to contain”, and that “a full clinical picture has been obtained”.  This latter exhortation is comforting, of course, but difficult to reconcile with the reality of the 15-minute “med check”.  But the critical point is that the only age parameters in the DSM criteria lists for ADHD are:  “Onset before the age of seven” (DSM-III), and “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years” (DSM-IV).  There is nothing in the system to even suggest that being the youngest in one’s class or being less mature than one’s peers has any bearing on the matter.  In fact, isn’t the criteria list essentially a definition of childhood immaturity?  To challenge the assignment of this “diagnosis” on the grounds that the child is merely immature misses the point.  Dr. Frances’s “discovery” that “we are turning immaturity into disease” is 48 years too late.  Turning immaturity into disease is precisely what happened in 1968 with the publication of DSM-II.  That edition of the manual contained the entry:  “308.0 Hyperkinetic reaction of childhood (or adolescence)” [p 12].  Psychiatrists then were as fond of putative brain disorders as they are today, and the children who were given the hyperkinetic “diagnosis” were also frequently described as having “minimal brain damage” (MBD), though no evidence of brain pathology was ever adduced.  By 1980, when DSM-III was published, the two concepts had fused. The Index to that edition contains the following entry:  “Minimal brain damage.  See Attention Deficit disorder” [p. 489].  And with the publication of DSM-III’s criteria list, the process of turning childhood immaturity into disease was complete.  DSM-IV’s primary contribution to this hoax, as pointed out earlier, was to liberalize the criteria, but made no attempt to reverse or even slow the process of pathologizing childhood immaturity.

In addition, all of the DSM criteria for ADHD are intrinsically vague and subjective.  As such, they are open to interpretation, and they constitute a tempting invitation to medicalize all and any problematic classroom behavior.  Is it Dr. Frances’s current contention that he and his Task Force colleagues couldn’t have foreseen that?  Dr. Frances had been a member of the DSM-III and DSM-III-R Task Forces, and had seen the effect that these documents had on psychiatric expansion and drugging.  Are we to believe that a scholar-practitioner of Dr. Frances’s caliber and experience is really that naïve?  Are we to believe that he was unaware of the controversy surrounding this issue?

This controversy is not new.  Here are three quotes from Ullmann and Krasner’s psychology text book A Psychological Approach to Abnormal Behavior, 2nd edition.

“This general type of hyperactivity is called ‘hyperkinetic reaction’ in DSM-II, in contrast to no mention in DSM-I.  Does this mention in DSM-II indicate the development of a new disease, the awareness and greater alertness of the professional to a disorder not previously of major concern, or the advent of a treatment method (drugs) for which practitioners sought more and more behaviors as being applicable?” [p. 496]

And:

“The treatment of children who have received the label of ‘hyperactive’ has been a source of further controversy in both psychology and pediatrics (Sroufe and Stewart, 1973).  Drug therapy, particularly stimulants such as the amphetamines, have become the popular form of treatment including up to 10 percent of all students in some school districts (Sroufe, 1972).

Investigators (Freedman et al, 1971; Wender, 1971; Fish, 1971) report that the stimulant drugs have been ‘beneficial’ in one-half to two-thirds of the cases in which they have been used.  However, the use of drugs with children brings up questions as to the conditions, goals, and effects of such treatment.  Critics of drug usage contend that diagnostic categories such as minimal brain dysfunctions are so vague and unspecific that many children who receive the label are actually reacting to specific environmental stimuli (uninspiring curriculum, ghetto schools, crowded classrooms, etc.)  (Battle and Lacey, 1972).  Thus the drugs are used (in much the same way as tranquilizers in mental hospitals) for management in the classroom or home.” [p. 496]

And:

“The label plus the drug treatment brings the child into the mentally ill or sick category and the social and self-labeling that follow (see Chapters 2 and 10).  The use of drugs enhances the belief in the efficacy of outside agents rather than attribution of change to one’s own efforts (an important element in the development of self-control in children and responsibility in teachers). [p. 497]

This was written in 1975:  forty-one years ago!

PSYCHIATRY’S BIO-BIO-BIO MODEL

Psychiatry, throughout its modern history (with the exception of its brief and circumscribed fling with psychoanalysis), has adopted and promoted a consistently bio-bio-bio approach to human problems.  Robert Spitzer, MD, architect of DSM-III and DSM-III-R, is often identified as the individual who codified this approach and embedded it solidly into psychiatric theory, research, and practice.  But here’s a little-known quote from the Introduction to DSM-III and DSM-III-R that lends at least a measure of doubt to that conclusion:

“The approach taken in DSM-III-R is atheorectical with regards to etiology or pathophysiologic process, except with regard to disorders for which this is well established and therefore included in the definition of the disorder.  Undoubtedly, over time, some of the disorders of unknown etiology will be found to have specific biological etiologies; others, to have specific psychological causes; and still others, to result mainly from an interplay of psychological, social, and biological factors.” (p. xxiii) [Emphasis added]

In the Introduction to DSM-IV, here’s what Dr. Frances wrote on the same topic:

Nothing.

That’s right – nothing!  The compellingly obvious notion that some of the problems listed in the APA’s catalog might actually stem from psychological factors was simply dropped from DSM-IV without explanation.  In my view, the most reasonable interpretation of this omission is that Dr. Spitzer’s earlier statement posed a threat to what has consistently been psychiatry’s primary agenda:  the medicalization of all problems of thinking, feeling, and behaving.

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

And here’s another interesting difference between III and IV.  Under the heading “The Distinction between ‘Mental Disorder’ and ‘Physical Disorder'”, DSM-III-R states:

“Throughout this manual there is reference to the terms mental disorder and physical disorder.  The term mental disorder is explained above. As used in this manual, it refers to the categories that are contained in the mental disorders chapter of the International Classification of Diseases (ICD).  The term physical disorder is used merely as a shorthand way of referring to all those conditions and disorders that are listed outside the mental disorders section of the ICD.  The use of these terms by no means implies that mental disorders are unrelated to physical or biological factors or processes.” (p. xxv)

DSM-IV’s statement, under the same heading, is similar, but with an important addition:

“The terms mental disorder and general medical condition are used throughout this manual.  The term mental disorder is explained above.  The term general medical condition is used merely as a convenient shorthand to refer to conditions and disorders that are listed outside the “Mental and Behavioural Disorders” chapter of ICD.  It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions, that mental disorders are unrelated to physical or biological factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes.” (p. xxv) [Bold face added]

Note the assertion:  “It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions…”

This is arguably the strongest and clearest endorsement of the bio-bio-bio approach that one could find in the psychiatric literature:  there is no fundamental distinction between mental disorders and ordinary physical illness.  This is the foundation for the mantra:  depression is a real illness, just like diabetes:  that unredeemed falsehood that psychiatrists have been telling their customers for decades.

PHARMA’S MARKETING IS BASED ON PSYCHIATRY’S HOAX

In his present article, Dr. Frances laments what he calls the overdiagnosis of ADHD.  And, indeed, the extent to which this fabricated disease is being foisted on our children for the sake of psychiatric prestige and profit is nothing short of a national scandal. But it pales into insignificance in comparison with the Great Psychiatric Hoax:  that all significant problems of thinking, feeling, and behaving, including childhood distractibility, are illnesses, requiring expert medical intervention and drugs.  And this perverse notion – that all significant problems of thinking, feeling, and behaving are biological illnesses – is the cornerstone of all pharma-psychiatric marketing:  you need our products because your brain is sick; your child needs our products because his/her brain is sick; your aging parents need our products because their brains are sick; etc.

And, as his own words clearly show, Dr. Frances has been a major player in the design, maintenance, and promotion of this hoax.  But now that the hoax is exposed, and even the mainstream media have come to recognize psychiatry’s venality, corruption, and spurious concepts, Dr. Frances is striving to distance himself from his former positions, and is re-inventing himself as the tireless champion of the “mentally ill” who has fought long and hard against the expanding tentacles of pharma and the slovenly prescribing practices of GP’s.

WHY PICK ON DR. FRANCES?

As my regular readers know, I have, in the past year or so, critiqued a number of Dr. Frances’s papers.  Some of my readers have written to me and asked why I bother to do this; that his excuses and self-promotions are unconvincing; and that there are more pressing matters to tackle.  And, or course, these are valid points.

But there is for me an over-riding issue:  that Dr. Frances isn’t just trying to exculpate himself.  He is also trying to exculpate psychiatry.  Dr. Frances’s consistent stance across several recent articles is that psychiatry is fundamentally good and sound, but that its concepts have been distorted and its “diagnoses” and “treatments” misused by others.  In my view, psychiatry is not something good and sound.  Rather, it is something fundamentally flawed and rotten.  And the fundamental flaw – the great lie – is that all significant problems of thinking, feeling, and behaving are illnesses. This is the very basis of psychiatry – the fundamental justification for medical intervention.  And it is a lie.  And it is irremediable.  Apart from those entries that are clearly identified as due to a general medical condition, illness is neither a valid nor a useful way to conceptualize the problems catalogued in the various editions of the DSM.  And when this hoax is thoroughly exposed, psychiatry will have lost its basis for existing.

By focusing on what are, by comparison, relatively minor and remediable matters, Dr. Frances is deflecting attention from the major and irremediable matter:  that psychiatry is a hoax.

Psychiatry is a destroyer of people, both individually and in terms of our cultural resilience.  They have replaced the success-through-collaboration-and-personal-effort ethos of Western society with their intrinsically disempowering broken-brains-need-pills philosophy that has infected every facet of modern life.

ADHD:  The Hoax Unravels

At the risk of stating the obvious, ADHD is not an illness.  Rather, it is an unreliable and disempowering label for a loose collection of arbitrarily chosen and vaguely defined behaviors.  ADHD has been avidly promoted as an illness by pharma-psychiatry for the purpose of selling stimulant drugs.  In which endeavor, they have been phenomenally successful, but, as in other areas of psychiatry, the hoax is unraveling.

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

In 2001, the American Academy of Pediatrics published Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder Here’s a quote:

RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).

The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances.”

Clearly, this recommendation is pushing the drugs (evidence good), and is downplaying the usefulness of behavioral interventions (evidence fair).  The reference to behavioral interventions “…as an adjunct…” doesn’t inspire a great deal of confidence in their use as the primary intervention.  And, indeed, this is how “treatment” of “ADHD” has developed in the intervening years:  pills for all, and occasional behavioral programs, many of which were geared towards accepting one’s “illness” and promoting “medication compliance”.

And all of this in a context in which ADHD was being fraudulently promoted by psychiatry, and by its pharma partners, as a neurochemical imbalance which was corrected by stimulant drugs.  Here’s what the eminent Harvard psychiatrist Timothy Wilens, MD, wrote on the matter in the article Paying Attention to ADHD in Family Circle magazine on November 20, 2011:

“ADHD often runs in families.  Parents of ADHD youth often have ADHD themselves.  The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations.”

“Contrary to what most parents think, medication is one of the most important treatments for ADHD and is essential for long-term success of these kids.” (p 65)

The above quotes were clearly aimed at mothers, were designed to break down parental resistance to drug-taking, and are typical of what psychiatry generally has been saying on this subject for decades.

Dr. Wilens is an Associate Professor of Psychiatry at Harvard, and works as a psychiatrist at Massachusetts General Hospital.  In 2014 he was named Chief of Staff in Child and Adolescent Psychiatry.  So promoting the chemical imbalance hoax has certainly not harmed his career.

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

In recent years, psychiatrists have been experiencing increased scrutiny and criticism from the media, the general public, and some legislators, for the “pill for every problem” approach.  In this context, the American Academy of Pediatrics, in 2011, published an updated set of guidelines for ADHD under the title ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents  In this revised document, their recommendations for treatment are divided into three parts:  preschool children (4-5); elementary school children (6-11); and adolescents (12-18).  Here is a quote from each section:

Action statement 5a: For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.

Action statement 5b: For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence -based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).

Action statement 5c: For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.

Note in particular that for preschool children, the recommended “first line treatment” is behavior therapy administered by the parent and/or teacher, and the pills are recommended only if the behavioral interventions are not effective, and the problem is moderate-to-severe.  This is a sea-shift from the earlier guidelines.

Note also that for older children, pills and/or behavioral therapy are recommended, “preferably both”.  Here again, behavioral interventions are being emphasized a good deal more than was the case in 2001.

Later in the guidelines document, the authors clarify what they mean by behavior therapy:

“Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior. The training involves techniques to more effectively provide rewards when their child demonstrates the desired behavior (eg, positive reinforcement), learn what behaviors can be reduced or eliminated by using planned ignoring as an active strategy (or using praising and ignoring in combination), or provide appropriate consequences or punishments when their child fails to meet the goals (eg, punishment). There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectations for each task as they are mastered to shape behaviors.  Although behavior therapy shares a set of principles, individual programs introduce different techniques and strategies to achieve the same ends.” [Emphasis added]

Note that what’s being recommended here is that the parents be trained in the ordinary, time-honored principles of effective parenting.

And remember, this was in 2011 – five years ago, but the shift in the pediatric guidelines has not resulted in a significant shift in practice.

In response to this inertia, on May 3, 2016, the Centers for Disease Control and Prevention (CDC) issued a press release titled More Young Children with ADHD Could Benefit from Behavior Therapy.

Obviously the CDC considers ADHD to be a disease, but if you can bear with the medicalization wording, here are some interesting quotes:

“The American Academy of Pediatrics recommends that before prescribing medicine to a young child, healthcare providers refer parents to training in behavior therapy. However, according to the Vital Signs report, about 75% of young children being treated for ADHD received medicine, and only about half received any form of psychological services, which might have included behavior therapy.” [Emphasis added]

Note that what’s being stressed here is the need to refer parents to behavioral training.

“Parents of young children with ADHD may need support, and behavior therapy is an important first step.  It has been shown to be as effective as medicine, but without the risk of side effects. We are still learning about the potential unintended effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to first refer parents of children under 6 years of age with ADHD for training in behavior therapy before prescribing medicine.” [Emphasis added]

“CDC is calling on doctors, nurses, and allied health professionals who treat young children with ADHD to support parents by explaining the benefits of behavior therapy and referring parents for training in behavior therapy.” [Emphasis added]

In addition to the press release, the CDC also provided a press telebriefing in which reporters were able to put questions to senior CDC officials.  One of the questions was from Ariana Cha with the Washington Post.  Her question was:

“Hi.  I had a quick follow-up question about the — about insurance.  And when you say that these should be covered, are you also talking about kind of the gold standard, which is A.B.A. [Applied Behavior Analysis]  Therapy, which is incredibly expensive and usually used for autism but also to address a lot of the same behaviors that you see in ADHD?”

Two CDC officials responded.  First was Anne Schuchat, MD, Principal Deputy Director for CDC:

“No, you know, the treatments are quite different.  And I’d like Dr. Georgina Peacock to comment on that because we don’t believe the same interventions for autism should be used for children with ADHD.”

And then Georgina Peacock, MD, MPH, FAAP, Director, Division of Human Development and Disability:

“So we are talking about behavioral therapy, but this particular behavioral therapy is parent training.  So parents learn skills that help promote positive behaviors in their children.  There’s also a strengthening of the relationship between the parent and the child.  And some of the other things, some of the examples of things that happen, is parents learn about limit setting.  They learn about applying appropriate consequences for inappropriate behaviors and learn about how to improve communication between the parent and the families.  That’s the type of behavioral therapy that we are talking about and the American Academy of Pediatrics recommends for families.” [Emphasis added]

It is clear from these responses that the CDC is not conceptualizing these recommendations as the provision of some kind of specialized treatment to the children, but rather as training the parents in the basic principles and practices of effective parenting.

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

In other words, as we “mental illness deniers” have been saying for years, the problem does not reside in the child in the form of some hypothesized brain dysfunction.  Rather, the problem is the direct result of ineffective discipline, training, and correction on the part of caregivers.  And the truly ironic thing is that older people, with no particular training in psychology, psychiatry, social work, counseling, etc., have been saying this for decades, shaking their heads in sadness and disbelief as they watch their children and grandchildren accept pharma-psychiatry’s hoax, and feed the serotonin-disruptive drugs to their children in ever-increasing numbers.  Grandparents – nature’s own trainers in parenting skills – have been effectively silenced by pharma-psychiatry’s spurious, self-serving insistence that these kinds of misbehaviors constitute a brain illness which needs the attention of medically-trained experts.  These unsubstantiated assertions undermine parental confidence, open “uncooperative” parents to accusations of child neglect, and create an environment in which the levels of mastery and self discipline that were the norm for children fifty years ago, are rapidly becoming the exception.

Even CHADD, not noted for challenging the ideology of their pharma benefactors, makes some concessions in this direction.  Here’s a quote from their About ADHD document:

“Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.”

This, incidentally, is a truly delightful example of typical psychiatric mental gymnastics.  Let’s take a closer look.

“Problems in parenting or parenting styles may make ADHD better or worse…”

Now, as is well known, ADHD is defined by the presence of six or more habitual behaviors from either or both of two checklists of nine items each.  So if it is being conceded that “problems in parenting” can make ADHD worse, this can only be in terms of a deterioration on one or more of the criterion items.  But since all the criterion items are continuous variables, this inevitably entails a recognition that problems in parenting can push a child past whatever threshold of severity or frequency is required to constitute a “hit”.  Which in turn entails the fact that problems in parenting can produce the six or more hits required to make the “diagnosis”.  In other words, problems in parenting, by CHADD’s own admission, can cause ADHD.  Obviously the drafters of the document realized that they had opened this door, and immediately tried to slam it shut by countering even their own logic with their customary mantra-like assertion:  “ADHD is clearly a brain-based disorder”, the proof of which will be forthcoming any decade now!

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

And incidentally, the American Academy of Pediatrics guidelines includes a section on the adverse effects of stimulant drugs.  Here’s a quote:

“An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations and other psychotic symptoms.”

In 2009, Mosholder et al conducted a study on the incidence of these kinds of events and found:

“A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In approximately 90% of the cases, there was no reported history of a similar psychiatric condition.”

Eleven cases in 743 person-years (i.e. one in 68 person-years) sounds like a small effect.  But in any given year, about 3.5 million American children take a stimulant drug for ADHD.  And if we assume that each of these children takes the pills for an average of six months (almost certainly an under-estimate), this amounts to approximately 25,700 drug-induced psychosis/mania incidents each year in the US alone.  To the best of my knowledge, no large-scale, systematic study of the outcome of these incidents has been undertaken.

. . . . . . . . . . . . . . . . 

SUMMARY

The 2011 pediatric guidelines, reinforced as they were by the CDC’s recent press release and telebriefing, represent a formidable broadside against psychiatry’s promotion of ADHD as a brain illness residing within the child.  If this “illness” can be “cured” by improved discipline/correction on the parents’ part, isn’t it eminently reasonable to conclude that ineffective discipline was the precipitating cause of the problem in the first place?  We can be sure that pharma-psychiatry are already working on counter-measures to neutralize the impact of these documents, and we should not expect the bastions of bio-bio-bio psychiatry to crumble overnight. But as Andrew Lloyd Webber and Tim Rice put it so lyrically back in 1968:

“But if my analysis of the position is right,
At the end of the tunnel there’s a glimmer of light”
(Joseph and the Amazing Technicolor Dreamcoat)

On all sides the hoax is unraveling, and psychiatry has  no response other than the repetition of the same unsubstantiated assertions, laced generously with PR, obfuscation, and the assignment of blame to others for their own errors and deceptions.

 

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.

The Inherent Unreliability of the ADHD Label

I imagine that everybody on this side of the issue knows by now that the eminent psychiatrist Jeffrey Lieberman, MD, Chief Psychiatrist at Columbia, and past President of the APA, called Robert Whitaker “a menace to society.”

This outburst of petulance – the latest in a string of similar deprecations – occurred on April 26, 2015 during an interview with Michael Enright on CBC (Canadian Broadcasting Corporation) radio’s “The Sunday Edition.”  The grounds for Dr. Lieberman’s vituperation were that Robert had dared to challenge some of psychiatry’s most sacred tenets!

In the subsequent discussion, it was noteworthy that nothing emerged that would justify characterizing Robert as a menace to society, and the general consensus seemed to be that the eminent doctor was just having one of his little rants.

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

But in all the furor, it was largely ignored that, in the same interview, Dr. Lieberman had said something else, which in my view warrants additional discussion.  He was conceding the general point that sometimes people are given prescriptions for psychiatric drugs needlessly.  This is at about minute 25:35 on the recording.  Michael Enright asks:  “you could be over narcotizing?”, and Dr. Lieberman replies:

“Absolutely.  I had an experience with my own son.  I have two sons.  My older son was going to nursery school, and they said he’s not paying attention and were concerned.  ‘You should have him tested.’  We had him tested.  The neuropsychologist said, ‘Well there’s some kind of, you know, information processing problems, you should see a pediatric psychiatrist.’  I said, “Well, I am a psychiatrist, but I’ll take him to see a pediatric psychiatrist.’  We took him to see a pediatric psychiatrist, spent twenty minutes with him, and he started, you know, writing a prescription for Ritalin.  I said, ‘Why?’ and he said ‘Well, he’s got ADHD.’   I said, ‘I don’t think so.’

So, long story short, he ended up graduating from University of Pennsylvania, law school at Columbia, he’s in a top law firm.  So, yes, it happens, and part of that is social pressure.”

I could not find a transcript of the interview, so I made the above transcript myself, and I have checked it several times for accuracy.  In reading the passage, five points come to mind.

Firstly, the “diagnosis” was made in twenty minutes.  This is not actually surprising.  In my experience it is pretty much the norm.  But for years, Dr. Lieberman has been extolling the professionalism and thoroughness of psychiatry, but nevertheless, dropped this admission into the interview without comment or criticism.

Secondly, Dr. Lieberman, as an eminent psychiatrist, had no difficulty resisting the pressure to accept the prescription.  For many families, this is not the case.  Indeed, during my career, I worked with a number of parents who had been threatened with child custody suits if they didn’t get their child examined by a psychiatrist and “on Ritalin”.

Similar pressures exist with children in foster care.  If the child displays any kind of problem behavior, including distractibility/over-activity, a psychiatric consultation is mandated, a prescription is written, and there is no one to speak up for the child, or to challenge what is being done.

Thirdly, I think it’s noteworthy that Dr. Lieberman rejected the prescription.  If ADHD is an illness, and a licensed pediatric psychiatrist diagnosed this illness, and the same licensed pediatric psychiatrist wrote a prescription, shouldn’t Dr. Lieberman have played safe and given his child the pills?  After all, they’re safe and efficacious!  Surely it would have been wiser to play safe rather than risk depriving the child of needed medication.  Or could it be that Dr. Lieberman’s faith in the efficacy and safety of these products stopped short of actually giving them to his own child?

Is Dr. Lieberman aware that many parents who refuse psychiatric “medication” in this way are reported to Social Services for neglecting the child’s medical needs?

Fourthly, Dr. Lieberman’s son was “diagnosed with ADHD” by a pediatric psychiatrist while in pre-school, but didn’t take the pills.  Nevertheless, he graduated from Columbia law school and is now an attorney at a “top law firm”.  That’s food for thought.

Fifthly, and most importantly, Dr. Lieberman’s disagreement with the pediatric psychiatrist highlights one of the major weaknesses in the psychiatric system:  its intrinsic unreliability and subjectivity.

Let’s take a look at what Dr. Lieberman and the other psychiatrist were disputing.  Obviously I don’t know when this interaction occurred, but if we put it around 1990, then DSM-III-R  would have been in force.  Here are the criteria for ADHD from that manual (p 52):

A.  A disturbance of at least six months during which at least eight of the following are present:

(1)  often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)
(2)  has difficulty remaining seated when required to do so
(3)  is easily distracted by extraneous stimuli
(4)  has difficulty awaiting turn in games or group situations
(5)  often blurts out answers to questions before they have been completed
(6)  has difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension), e.g., fails to finish chores
(7)  has difficulty sustaining attention in tasks or play activities
(8)  often shifts from one uncompleted activity to another
(9)  has difficulty playing quietly
(10)  often talks excessively
(11)  often interrupts or intrudes on others, e.g., butts into other children’s games
(12)  often does not seem to listen to what is being said to him or her
(13)  often loses things necessary for tasks or activities at school or at home (e.g., toys, pencils, books, assignments)
(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 

Note:  The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-III-R criteria for Disruptive Behavior Disorders

B.  Onset before the age of seven.

C.  Does not meet the criteria for a Pervasive Developmental Disorder.

Note:  Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.

My Random House Webster’s College Dictionary gives the following meaning for the word criterion:  “a standard of judgment or criticism; a rule or principle for evaluating or testing something.”

Even a cursory glance at the APA’s criteria shows that they are entirely unsatisfactory for this purpose.

Take the first item from the list:  “often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)”  There are several factors that prevent this item from serving as a criterion in the above sense of the term.

Firstly, children’s behavior (and indeed adults’ behavior) varies from time to time and from place to place.  A child might, for instance, be fidgeting in one classroom and not in another; or only in the period immediately preceding lunch.  Where and when should the rating be made?

Secondly, the word “often”, which occurs also in seven other items, is not operationally defined and will inevitably mean different things to different people.  An “old-fashioned” person who believes that children should sit still and pay attention, might consider one or two squirmings excessive; while a more liberal teacher might set the bar a good deal  higher.

And how in the world can anyone reliably assess an adolescent’s “subjective feelings of restlessness”?

Similar observations can be made about all the items.

The point here is:  what were Dr. Lieberman and the pediatric psychiatrist disagreeing about, and how could such a disagreement be resolved?  The other psychiatrist might have said:  “your son is easily distracted by extraneous stimuli”;  or:  “your son often talks excessively”.  Dr. Lieberman could reply:  “no he isn’t”; “no he doesn’t”.  And that’s it.  There is no way to objectively resolve such a dispute.  There is no fact or observation to which one or other of the parties could point, that would clinch the matter. And that’s a fundamental problem, because ultimately all psychiatric “diagnosis” is tainted by this kind of subjectivity.  In the final analysis, a person “has a mental illness” because a psychiatrist says so!

In the situation described by Dr. Lieberman, apparently his view prevailed, and from his statements in the radio broadcast, it is clear that he believes his view was correct.  But this is a meaningless position, because the only criteria that exist to resolve the disagreement are inherently unusable for this purpose.  Nor is DSM-5 any better.  This latest edition of the manual contains 13 of DSM-III-R’s 14 “criteria” (with some minor verbal changes), and some additional items which are no less vague.

What Dr. Lieberman apparently took from his interaction with the pediatric psychiatrist  is that sometimes pills are over-used.  But the message he should have taken was that what psychiatrists call ADHD is nothing more than a loose collection of vaguely-defined behaviors, whose purpose is to foster psychiatry’s self-serving hoax that these behaviors constitute an illness, which requires to be “treated” with stimulant drugs.

ADHD:  A Destructive and Disempowering Label; Not an Illness

In recent years, we’ve seen an increasing number of articles and papers from psychiatrists in which they seem to be accepting at least some of the antipsychiatry criticisms, and appear interested in reforms.  It is tempting to see this development as an indication of progress, but as in many aspects of life, things aren’t always what they seem.

Last month (June 2015), The Lancet Psychiatry published a paper online in their Personal View series.  The paper is titled Childhood: a suitable case for treatment?, and the authors are Ilina Singh and Simon Wessely.  Dr. Singh is Professor of Science, Ethics & Society at King’s College London, and is cross-appointed to the Institute of Psychiatry.  Dr. Wessely is professor of psychological medicine at the Institute of Psychiatry, King’s College London, and President of the Royal College of Psychiatrists.

The article opens with an abstract:

“We examine the contemporary debate on attention deficit hyperactivity disorder, in which concerns about medicalisation and overuse of drug treatments are paramount. We show medicalisation in attention deficit hyperactivity disorder to be a complex issue that requires systematic research to be properly understood. In particular, we suggest that the debate on this disorder might be more productive and less divisive if longitudinal, evidence-based understanding of the harms and benefits of psychiatric diagnosis and misdiagnosis existed, as well as better access to effective, non-drug treatments. If articulation of the values that should guide clinical practice in child psychiatry is encouraged, this might create greater trust and less division.”

And already there are some red flags. Firstly, the title Childhood: a suitable case for treatment? evokes the kind of concerns often expressed on this side of the issue, that the creation of the “ADHD diagnosis” is essentially a systematic and self-serving pathologization, on the part of psychiatrists, of normal childhood activity.

Also, the term “medicalization” which occurs twice in the quote, is usually used on this side of the debate to indicate the spurious assertion that a non-medical problem (in this case, childhood distractibility/impulsivity) is a disease.  But this is not how the term is used by Drs. Singh and Wessely.  As becomes evident later in the paper, they clearly endorse the disease assertion, and use the term “medicalization” merely to indicate the assignment of the “diagnosis” to individuals who don’t actually have the “disease”.

BIOMARKERS

The authors discuss biomarkers, and point out that:

“Psychiatry has yet to discover, let alone use, well established biomarkers in diagnosis and treatment…”

But they continue:

“It is also worth considering that biomarkers do not resolve the ethical concern about the diagnosis of ADHD as a violation of childhood: should this particular set of childhood behaviours or capacities be labelled a medical disorder requiring observation or intervention? This aspect of the problem of diagnostic uncertainty in ADHD is not about whether or not the diagnosis is correct; it is more fundamentally about whether or not medical diagnosis is the right thing to do. From this perspective, biomarker evidence might contribute to better (that is, more accurate) diagnosis of ADHD, but clinicians might also get better at doing the wrong thing.”

This is a complicated paragraph, with, I suggest, some muddling of issues.

First, let’s consider the notion of biomarkers.  In general medicine, a biomarker is a biological factor that establishes, usually with a high level of confidence, that a particular illness or disease is present.  For at least the past five decades, psychiatric research has been preoccupied with discovering the biomarkers for the various “mental illnesses” listed in the DSM.  Despite the highly motivated nature of this research, the quest has been a dismal failure.

The central question at stake in this context is:  Do the various behaviors used in the DSM to define “attention deficit hyperactivity disorder” constitute an illness?  The only way that this question can be answered definitively is to identify a biological pathology, and show that this pathology is present in all the individuals concerned.

At the present time, the “mental illness” known as ADHD is defined by the presence of a certain number of vaguely-defined habitual behaviors from a DSM checklist, and there is no logical reason to believe that the individuals who exhibit the requisite number of habits have any kind of illness.  All of the habits in question, even if present to a severe degree, can be adequately understood in fairly ordinary psychosocial terms.

But if it were to be clearly established, through honest, transparent, and replicated research, that the habits in question do, in fact, stem directly from some neurological pathology, then the matter would be resolved, and attention deficit hyperactivity disorder would indeed be a real illness, amenable to investigation, diagnosis, and treatment within the medical model, and it would probably be given a name that reflected the biological pathology rather than the behavioral consequences.

To what extent it would constitute “a violation of childhood” is an interesting, but secondary, issue.  Leukemia, spina bifida, meningitis, polio, etc., all violate childhood, but that fact has no bearing on whether or not they can legitimately be considered illnesses.

CASE STUDY

The authors present a brief composite, anonymized case study.  John is an eleven-year-old boy who was assigned a diagnosis of ADHD at age 9 and takes Concerta (methylphenidate) every day.

Then the authors comment:

“Responses to this case presentation are likely to mirror the differences of opinion found among John’s caregivers.  Some might argue that John’s childhood represents a life of containment: across different institutional contexts, John’s behaviour is carefully managed, allowing few opportunities for the kind of liberal self-fashioning imagined by Trimble [Steven Trimble, educator, naturalist, and co-author of The Geography of Childhood]. The sociologist Erving Goffman called this process the “bureaucratisation of the spirit”.  Others will point out that adult guidance and management are essential to child flourishing; indeed, these form part of society’s obligations of care for a child.  Some of this care involves inculcation into social norms through institutions erected for this purpose.”

And

“Such arguments, which have been the mainstay of the debate over the diagnosis and treatment of ADHD, are unlikely to unlock the stalemate of disagreement.”

And this, to my mind, is misleading.  The mainstay of the debate is whether or not the loose collection of vaguely-defined habitual behaviors listed in the DSM constitute an illness.  Whether the behaviors in question should be considered problematic or variations on normal is an interesting and important topic.  It has probably been the subject of debate since the dawn of civilization, and will likely continue to occupy our descendants for centuries to come, but it is not the “mainstay of the debate over the diagnosis and treatment of ADHD”.

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

“If a child’s spirit and freedom are potentially at stake, then we should care about evidence that children such as John are routinely misdiagnosed (that is, diagnosed with non-existent disorders), and we should ask what evidence exists about the consequences of misdiagnosis. So, what are the chances that John has been misdiagnosed?”

Note the confusing reference to “non-existent disorders”, which again sounds like a challenge to the medical status of ADHD, but in fact, as is clear from the context, means only that John doesn’t have the “illness” in question.

DISCUSSION

The authors address the questions of misdiagnosis and its consequences at some length, but this discussion is entirely within the bounds of mainstream, conventional psychiatry.

“Of course, to reject the possibility that ADHD diagnosis for John might be both valid and beneficial would be a mistake.”

There’s not much ambiguity there.

“But if John has been misdiagnosed (that is, diagnosed with a disorder when no disorder exists), then what can we anticipate for him?”

Drs. Singh and Wessely point out some of the difficulties involved in answering this question:

“No research base yet exists to address the adverse consequences of ADHD nondisease diagnosis. The design of such a study would be a challenge, in view of the ambiguity surrounding ADHD diagnosis.”

In fact, the design of such a study would be more than a challenge; it would be impossible!

ADHD is defined by the presence of a certain number of vaguely-defined habitual behaviors in the DSM checklist.  In such a context, the notion that John has ADHD and James doesn’t is meaningless, because each of the vaguely-defined items is open to interpretation and bias, and there is no way to reconcile discrepancies.

If it were discovered that the problems collectively labeled ADHD were in fact caused by an identifiable brain pathology, then the issue becomes moot.  Children who have the pathology, have the illness, and those who don’t, don’t.  In the absence of such a discovery, any attempts to refine or sharpen the criteria are futile.  Absent a clear marker of the so-called illness, attempts to identify and refine diagnosis are simply the perpetuation of error and bias.

And, as the authors themselves have pointed out, no such findings of pathology have been discovered.

But Drs. Singh and Wessely are mired in the traps of psychiatric dogma and complacency.

“For example, most people would agree that in the USA, use of medications to treat ADHD in children is excessive.  Fewer people know that the USA has problems of both overdiagnosis and underdiagnosis of ADHD.”

How can they know – how can anyone know – that ADHD is over-diagnosed or under-diagnosed in the US, or anywhere else for that matter, since the criteria, as the authors themselves acknowledge, are inherently ambiguous?  If a psychiatrist in Atlanta, Georgia, says that John “often fidgets with or taps hands or feet or squirms in seat” and another psychiatrist in London, England, says no he doesn’t, what fact or argument could settle this matter?  How can we say which psychiatrist is over-diagnosing and which is under-diagnosing?  How often is “often”?  What kind of hand or foot movements constitute a fidget?  What kind of movements constitute a squirm?  And similar unresolvable ambiguities are inherent in every DSM checklist item.

The DSM checklist purports to be a diagnostic tool.  The idea is that if one applies the checklist to children, those who have the “disease” will be so identified, and those who do not have the “disease” will be screened out.  But, as the authors of the paper acknowledge, they don’t know the nature or pathology of the disease. So all that they’ve got is the checklist.  Tinkering with the checklist items in an effort to improve “diagnostic” accuracy is an exercise in self-deception, because there is no yardstick by which this accuracy can be assessed,

It comes to this:  ADHD is a label, arbitrarily and unreliably applied to children who are presenting problems in the classroom, to legitimize drugging them into something resembling manageability and compliance, while at the same time exposing them to the dangers of stimulant drugs.  Dressing it up in disease language is a hoax.

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

“We are asking for a more reasoned, less emotional approach to the problem of ADHD diagnosis and medicalisation. To properly investigate the consequences of psychiatric diagnosis and nondisease diagnosis, the impetus to immediately drive a moral stake in the ground must be restrained, to allow intuitions to be weighed against evidence.” [It is clear from the context that the authors are using the unusual term “nondisease diagnosis” to mean:  assigning a diagnosis of a disease to a person who doesn’t actually have the disease in question.]

But what kind of evidence can be adduced in this matter?  The authors are implying that there is a fundamental distinction between correct diagnosis of ADHD (i.e., cases where the child actually has the “disease”) and incorrect diagnosis (where the child does not have the disease, but is given the label “mistakenly”).  Calling for an investigation of the consequences of incorrect diagnosis vs. correct diagnosis is an exercise in futility, because there is no way to distinguish the one from the other, and there never will be unless/until an underlying explanatory brain pathology is identified.

Psychiatry has created and promoted the self-serving fiction that childhood distractibility/impulsivity and various other human problems are illnesses that need to be “treated” with neurotoxic chemicals and other brain-damaging interventions.  Suggesting at this very late stage in the proceedings that overuse of the ADHD “diagnosis” may be causing harm, and calling for more research on the “prevalence, causes, and consequences” of this “overdiagnosis” is just another way of endorsing and perpetuating the hoax.

The critical issue here is not that there have been errors of “over-diagnosis”.  The critical issue is the spurious medicalization of virtually every conceivable problem of human existence, including childhood distractibility/impulsivity.  This was not an error.  This was, and still is, the deliberate and self-serving policy of organized psychiatry, financed by pharma, and pursued avidly with disregard for logic, fact, or human integrity.

So why should “the impetus to…drive a moral stake in the ground” be restrained?  Psychiatry is the profession that routinely lies to its clients.  Psychiatrists tell their clients the blatant falsehood that they have chemical imbalances in their brains, and that they must take the drugs to correct these imbalances.  Psychiatry is the profession that allied itself with pharma’s fraudulent research and promotional efforts.  Psychiatry as a profession is, I suggest, morally bankrupt, and moral judgments are called for.

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

“But the diverse commitments entailed in the broader debate over diagnosis and treatment of this disorder have perpetuated reductive arguments and have scattered energy unproductively. If the goal is to answer the difficult questions that surround ADHD with evidence rather than with speculation, then a more collaborative agenda of research and public engagement is needed.”

Decades of generously-funded and highly-motivated psychiatric research have failed to establish that the habitual behaviors labeled ADHD stem from any kind of neurological pathology.  Nevertheless, Drs. Singh and Wessely persist in the notion that ADHD is a disease, and that more research is needed.  They call for evidence rather than speculation, while at the same time explicitly endorsing the standard psychiatric position, which is founded entirely on speculation, unsubstantiated assertions, and disregard for the evidence.

And finally:

“The days when doctors were the sole arbiters of the boundary between normal and pathological states have long disappeared, if those days ever existed at all.”

This is a lofty sentiment, but does not reflect the reality.  Psychiatrists, both collectively and individually, do indeed see themselves, and behave, as the sole arbiters of the boundary between normal and pathological, and, at least here in the US, they have five editions of the DSM to prove it.

 

Book Review: Parenting Your Child with ADHD: A No-Nonsense Guide for Nurturing Self-Reliance and Cooperation, by Craig Wiener, EdD

I have recently read this book, and I think it would be extremely helpful for parents, teachers, and counselors who work with children in this area.

Here are some quotes:

“…ADHD [is] something that your child does rather than something that she has.”

“The first thing to realize is that while you and other adults see your child’s ADHD behavior as a problem to overcome, for your child, ADHD behavior holds solutions to the difficulties that he faces on a daily basis. When your child encounters adversity, ADHD behavior somehow mitigates the situation. When you identify what gives his ADHD behavior its staying power, you will have gained valuable insight into why such behavior repeats so frequently. You will also be taking a giant step forward in knowing how to eliminate it.”

“Groups are breeding grounds for ADHD behavior, because children often have problems accommodating when they must function in groups. In group settings, individuals are typically less important than the group as a whole, so they may feel neglected in comparison to one-on-one interactions, in which they have more influence and importance. It comes as no surprise, then, that one-on-one interaction results in less ADHD behavior in comparison to when a child is part of a group. This is why your child might have been doing okay before he started preschool or kindergarten.”

“When your child feels neglected or denied in a group, ADHD behavior can be quite effective in getting people to shift their attention back to him.”

“Your child’s ADHD behavior may have any of the following beneficial effects: it may garner attention for her, it may get others to make accommodations for her, it may help her avoid certain situations, it may help her acquire something she wants, and it may antagonize others for doing things she does not like. Any one of the five “A”s can increase the frequency of ADHD behavior. Sometimes these reinforcements even work in combination to drive particular behaviors, strengthening them that much more.”

“ADHD behavior generally remits as soon as the child hears the word “yes.” Loved ones will frequently offer relief when hearing a child complain or create problems. This can occur when your child overreacts, shows frustration, becomes self-critical, or behaves in any number of ways that indicate distress. When a child is diagnosed with ADHD and considered impaired, the tendency is for the adults in her life to lower their expectations and offer support.”

“The accommodated child will often ask questions about matters that she can easily resolve on her own. She enjoys the fact that you drop everything to address her concerns. Playing dumb or foolish can increase assistance because it’s difficult to impose requirements, hold her accountable, or ask her to contribute when you have doubts about her competence. Her staying ineffectual can keep you preoccupied with her, and it becomes your responsibility to solve her trials and tribulations. Often she will complain, ‘Why didn’t you remind me?’ when you failed to run interference for her. The side effect when you and others ‘pick up the slack’ is that she remains unskilled.”

“If your child frequently sabotages your shopping, shop for essentials and the items you want first. Buy what she likes at the end. If she wants you to buy snacks, for example, say, ‘We can get the snacks before we leave, if we’re still interested in shopping.’ Even if this makes your shopping trip less efficient (e.g., instead of working through the aisles in order, you pass the snack aisle at first and return to it later), her behavior may improve.”

“Most ADHD interventions recommend that schools adjust to the needs of the child with ADHD. If the school does not make the recommended changes, parents are encouraged to pressure administrators until the adjustments occur. However, insisting that the school make all the adjustments comes with an important risk: your child may not learn to adapt to others’ ways and adjust to the world the way it is.

As is evident from the above quotations, Craig does not conceptualize ADHD as an illness.  Rather, he presents these kinds of behaviors as ways in which the child copes with difficulties that he or she might be experiencing for various reasons.

The book is written in plain, jargon-free English, and is filled with down-to-earth, practical advice, suggestions, and detailed illustrations.  Craig encourages parents to scrutinize their own actions and perspectives, not from a blaming perspective, but rather to explore ways in which the parent-child interactions might be reinforcing the very behaviors that are causing concern.

Craig’s suggestions and examples are presented thoughtfully, and without patronization, and I think most parents, even those whose children have never been labeled ADHD, will be able to see something of themselves in the pages.

I, and I suspect most people who have worked in this field, have heard many parents say:  I’m at the end of my rope.  I don’t know what I can do with this child (or words to that effect).  Well here’s something that any parent can do:  get a copy of this book; read it; and give the suggestions a try.

. . . . . . . . . . . . . . . . 

Disclosure:  I have no financial links to this book or to any books/materials that I endorse on this website

The ADHD Label and Mortality

On February 26, 2015, The Lancet published online an article by Soren Dalsgaard et al titled Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study.

The article describes a Danish study that was designed to assess “ADHD-related mortality in a large cohort of Danish individuals.”

The researchers describe their methods as follows:

“By use of the Danish national registers, we followed up 1·92 million individuals, including 32 061 with ADHD, from their first birthday through to 2013. We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, family history of psychiatric disorders, maternal and paternal age, and parental educational and employment status, by Poisson regression, to compare individuals with and without ADHD.”

Data for the study was obtained from The Danish Civil Registration system, The Danish Psychiatric Central Register, and the Danish National Patient Register.

Here’s the authors’ summary of their findings:

“During follow-up (24·9 million person-years), 5580 cohort members died. The mortality rate per 10 000 person-years was 5·85 among individuals with ADHD compared with 2·21 in those without (corresponding to a fully adjusted MRR of 2·07, 95% CI 1·70–2·50; p<0·0001). Accidents were the most common cause of death. Compared with individuals without ADHD, the fully adjusted MRR for individuals diagnosed with ADHD at ages younger than 6 years was 1·86 (95% CI 0·93–3·27), and it was 1·58 (1·21–2·03) for those aged 6–17 years, and 4·25 (3·05–5·78) for those aged 18 years or older. After exclusion of individuals with oppositional defiant disorder, conduct disorder, and substance use disorder, ADHD remained associated with increased mortality (fully adjusted MRR 1·50, 1·11–1·98), and was higher in girls and women (2·85, 1·56–4·71) than in boys and men (1·27, 0·89–1·76).” [Emphasis added]

So, essentially, the authors identified a cohort of almost 2 million people, 32,061 of whom had been assigned a “diagnosis of ADHD”.  During the follow-up period the death rate per 10,000 person-years was 5.85 in the ADHD group vs. 2.21 for the remainder.  These figures yield an adjusted risk ratio of 2.07.  In other words, the individuals who had been labeled ADHD had approximately double the mortality risk as those who had not been so labeled.

But many of the individuals who had been labeled ADHD had also been assigned the labels “oppositional defiant disorder”, “conduct disorder”, and “substance abuse disorder”.  These additional labels were also associated with increased mortality.  When the excess mortality associated with these additional labels was adjusted out, the ADHD individuals were found to have a 1.50 mortality risk ratio compared with individuals in the cohort who had acquired none of the psychiatric labels mentioned.

DISCUSSION

The central problem in research of this kind is in the general concepts rather than the specific details.  In their final paragraph, the authors state that:

“ADHD is a common neurodevelopmental disorder known to cause impairment across the lifespan”

and indeed the entire article is written from a medical perspective, as if ADHD were a bona fide illness like pneumonia or kidney failure.

Note the perfect example of psychiatric “logic” in the above quote:  ADHD causes impairment.  So if a parent were to ask the authors why her child is so distractible, impulsive, and hyperactive, she will receive the reply:  because he has ADHD; ADHD causes the distractibility, impulsivity, and hyperactivity.  But if she presses the issue and asks how the psychiatrist knows that the child has ADHD, the only possible answer is because he is so distractible, impulsive, and hyperactive.  The only evidence for the so-called disorder is the very behavior that it purports to explain.  Labeling a child ADHD explains nothing.  Its only purpose is the legitimatization of drugs.

ADHD is nothing more than the loose cluster of vaguely defined behaviors listed in the DSM and the ICD.  The APA describes these behaviors as “symptoms”, but this is a misnomer.  In real medicine the illness does indeed cause the symptoms, and provides an explanation for the symptoms.  Pneumonia, an infection of the lung, causes coughing, exhaustion, and nasty-looking phlegm.

But in ADHD, as in all so-called psychiatric illnesses, this is not the case.  In psychiatry, the “symptoms” are the “illness”.  There is no causative disease entity behind the “symptoms” as there is in real medicine.  In psychiatry, the so-called symptom list, with all its vagueness and polythetic variability is the illness.  And in particular, despite psychiatry’s routine claims to the contrary, there is no neurological pathology common to all, or even most, of the individuals who acquire this label.

The fact that the authors refer to ADHD as a neurodevelopmental disorder probably reflects the fact that in DSM-5, this “diagnosis” is in the section headed “Neurodevelopmental Disorders”.  But this is very misleading.  Most people on hearing that ADHD is a neurodevelopmental disorder would assume that a neurological pathology is implied.  This is emphatically not the case.  The chapter on Neurodevelopmental Disorders in DSM-5 begins:

“The neurodevelopmental disorders are a group of conditions with onset in the developmental period.  The disorders typically manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.  The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence.”

As the reader can see, there is no requirement of proven, or even suspected, neurological pathology.  All that’s required is that the individual be functioning below par (for any reason) in one or other of these areas.  The use of the term “neurodevelopmental disorders” is deceptive, and is another example of psychiatric assertion as a substitute for truth.

In the present study, the ICD lists were used to identify the ADHD group.  Here are some of the items on this list that might have a bearing on accident-related mortality.

  • unduly high distractibility…
  • undue lack of persistence at tasks…
  • very often runs about or climbs excessively in situations where it is inappropriate…
  • often has difficulty waiting turns…
  • excessive motor restlessness…
  • excessive levels of off-task activity…

It doesn’t take a great deal of imagination to see how children and adults whose habits and behaviors attract these kinds of descriptions might have a higher accident-related mortality than individuals who do not function in these ways.

“Unduly high distractibility”, for instance, is an obvious causal factor in motor vehicle accidents.  People who are distractible – i.e. who have not acquired the habit of screening out extraneous stimuli – will, other things being equal, have a higher accidental death rate than people who do screen out extraneous stimuli.

Similarly, “often has difficulty waiting turns”.  A great many traffic accidents are caused by people who become impatient in a line of traffic, and pull out to pass when it is not safe to do so.  And “excessive levels of off-task activity” would certainly include texting while driving – a known killer.

By defining ADHD by the presence of these behaviors, psychiatrists have, in effect, guaranteed that the group of people identified will have excess accident-related mortality.

In effect, all that Soren Dalsgaard et al have established is that people who engage in impulsive, high-risk behavior have a higher mortality rate than people who don’t.  That’s all there is to it.  The injection of ADHD, the “common neurodevelopmental disorder” adds nothing to the understanding of the matter, and in fact, serves to distract from the critical issue:  that we need to train children to pay attention, and not to be impulsive in matters that involve safety.

AND INCIDENTALLY

Under the heading Acknowledgements, the article states:

“This study was supported by a grant from the Lundbeck Foundation.”

Four of the five authors, Drs. Dalsgaard, Østergaard, Mortensen, and Pedersen, are affiliated with the Lundbeck Foundation Initiative for Integrative Psychiatric Research.

And, predictably, the study generated a good deal of media attention.  Here are some media quotes:

Risk for Dying Young Increased With ADHD Diagnosis, Study Finds Psychiatry News:

“The results, published in Lancet, showed that of the 32,061 individuals with a diagnosis for ADHD, 107 died before the age of 33—a rate that is twice that for persons without the disorder, even after adjusting for factors that increase risk for premature death such as history of psychiatric disorders and employment status.”

A.D.H.D. Diagnosis Linked to Increased Risk of Dying Young The New York Times:

“People with a diagnosis of attention deficit disorder are at higher risk of dying young than those without the disorder, usually in automobile crashes and other accidents, suggests research reported on Wednesday, from the largest study of A.D.H.D. and mortality to date.”

“The risk was even higher in people who received a diagnosis at age 18 or later, the study found — possibly because of the severity of such cases, the authors wrote.”

A new study shows there’s a strong link between ADHD and premature death Vox Topics:

“When the researchers followed the group for the next three decades to learn about how they fared, they came to some startling conclusions. Compared to people without ADHD, those who had the disorder were twice as likely to die prematurely — and much more accident prone.” [Emphasis added]

People who are distractible and impulsive have a higher death rate from accidents.  That’s a startling conclusion!

ADHD linked to greater risk of dying young Science Nordic:

“People with ADHD face a risk of premature death 1.5 to 8 times greater than those without the disorder. That’s the conclusion of a new study involving 32,000 Danes with ADHD and more than a million Danes without the disorder.”

Study Finds People with ADHD More Likely to Die Prematurely Psychology Today:

“ADHD is more than just a learning disability or mental health condition. It does far more than just inhibit learning or make children more ‘difficult.’ According to one new study, it greatly increases its sufferers’ odds of dying young.”

ADHD Greatly Increases Risk of Premature Death Psychiatric Advisor:

“In an associated comment to the study, Stephen Faraone, PhD, Director of Child and Adolescent Psychiatry Research at SUNY Upstate Medical University in New York, wrote, ‘For too long, the validity of ADHD as a medical disorder has been challenged. Policy makers should take heed of these data and allocate a fair share of health care and research resources to people with ADHD. For clinicians, early identification and treatment should become the rule rather than the exception.'”

Note the very nice example of psychiatric logic:  because individuals who are distractible and impulsive have a higher mortality rate, then their label – ADHD – must be valid!  People who ride motorcycles routinely also have a higher than average accident-related mortality rate.  Should we therefore conclude that riding motorcycles is a “valid” illness?

AND ON A PERSONAL NOTE

Recently my wife and I were taking our grandsons home   My wife was driving.  Our 6-year-old grandson was asking her lots of questions.  After a while I suggested that he ease up on the talk, and let his grandmother concentrate on driving.  He agreed readily.  “Otherwise,” he added, “we could have an accident, and we’d all be killed.”

Such startling wisdom – out of the mouths of babes.  As I’ve said many times, critiquing psychiatry is not quantum physics.

Book Review:  A Disease Called Childhood, by Marilyn Wedge

Avery, a member of Penguin Group USA, has recently published A Disease Called Childhood, by Marilyn Wedge.  Marilyn has a PhD in psychology and works as a family therapist.

In 2014, fully 11% of American children had received a “diagnosis” of attention deficit hyperactivity disorder (ADHD).  It is widely believed by these children, their parents, the press, the public, and government agencies, that this loose collection of vaguely defined behaviors constitutes an illness – specifically a chemical imbalance in the brain, which is corrected by stimulant drugs.

Dr. Wedge’s book is a timely reminder that the “science” on which this perspective rests is highly questionable, and that there are alternative perspectives and alternative ways of working with children.

Here are some quotes from the book:

“From my point of view, behavioral problems such as aggression, disobedience, or other behaviors commonly associated with ADHD, such as inattention and hyperactivity, are signs that something is wrong in a child’s life – either extreme trauma, like abuse or poverty, or something more typical, like a lack of discipline or a difficult family transition.  Children are not fully developed mentally or behaviorally.” (p xii)

“There is another aspect of ADHD that worries me.  As stimulants have come to be prescribed for ever larger numbers of children, our society’s very perception of childhood has changed.  Instead of seeing ADHD-type behaviors as part of the spectrum of normal childhood that most kids eventually grow out of, or as responses to bumps or rough patches in a child’s life, we cluster these behaviors into a discrete (and chronic) “illness” or “mental health condition” with clearly defined boundaries.  And we are led to believe that this “illness” is rooted in the child’s genetic makeup and requires treatment with psychiatric medication.” (p 17)

“A serious problem for teachers is that an ADHD diagnosis exempts a child from having to take accountability for his behavior.” (p 91)

“Each individual has a unique story that ultimately reveals the true reasons for troubled behavior.  A child’s individual story is both a clue to the cause of his troubles and a signpost that guides us to help him.” (p 113)

“And in our medicalized society, deviating from the norm tends to be interpreted to mean there is something “biologically wrong” with the child.” (p 123)

“Using medication to suppress the life story of a child who is suffering from trauma subjects him to yet another form of maltreatment.” (p 137)

“If we realize that children can be overactive and impulsive for any number of reasons, we can avoid reducing their behavior to a simplistic diagnosis of ADHD.” (p 195)

“When parents provide limits and don’t give in to whining and screaming, children learn patience.  They learn to tolerate a little bit of frustration, which is an important skill in life.  Living with structure from an early age, children find comfort in rules, and parents naturally maintain and evolve these rules as the child develops.” (p 202)

“Medical researchers have not yet found a biochemical cause for ADHD on which they agree.  Despite sixty years of heavily-funded research, there is no laboratory test that indicates the presence or absence of ADHD in a child.” (p 217)

“The brain has become the scapegoat for all sorts of childhood problems.” (p 218)

A Disease Called Childhood is a carefully researched and highly readable book.  The author outlines the history of the ADHD “diagnosis”, and draws attention to the flawed research, and questionable promotional tactics that have spuriously pathologized and drugged millions of children, not only here in the US, but also overseas.

Marilyn Wedge draws unstintingly, and with evident compassion,  from her wealth of professional experience, and stresses the supreme importance of getting to know our children and providing the love and structure that they so desperately need.

I strongly recommend this book for parents, teachers, and physicians who write prescriptions for this so-called illness.  The book will also be helpful for anyone who is concerned about the extent to which pharma-psychiatry is systematically pathologizing human existence.

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Disclosure:  I have no financial links to this book or to any books/materials endorsed on this site.