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.
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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)
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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.
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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.