ADHD: A Destructive and Disempowering Label; Not an Illness

Philip Hickey, PhD
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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), 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.

 

21 COMMENTS

  1. i want to add- i always look forward to reading your articles here on mia. yours are some of my favorites. clear, broken down well. and you see the issues as black and white, as i do. there is no room for people who say “in certain cases the medications are helpful, the diagnosis is correct…” all lies. all built on lies. hope i live long enough to see the day the house of cards built by psych/big pharma comes crashing down…

    erin

  2. As numerous educators and critics have stated, our school system remains based much upon the idea of preparing or “conditioning” students for work in factories, assembly lines, corporate office cubicles, or other subservient positions in life.

    We see the foregoing in most schools where children are still forced to sit rigidly in rows looking at the backs of the heads of others, bells ring to enforce their strictly regimented schedule, they are forbidden to speak freely for very long periods of time, they must do rote memorization of uninteresting things they feel will be of no use to them in the future, they are required to do hours of often tedious homework every night, etc…

    Obviously, countless children inherently find the above conditions to be extremely oppressive or intolerable. Vast numbers of them are then labeled ADHD and put on dangerous drugs, when it is clearly our school system that has failed them!

  3. It’s sad to see this tired conversation about ADHD’s validity continuing in academic circles. To my mind, believing ADHD exists is tantamount to believing the earth is flat or the universe is 4,000 years old. There would be no debate about this fiction without the profit to be made from drugs.

    I have been reading “The Life and Death of Planet Earth.” A rather grim book, it describes how the increasing complexity of post-industrial civilization may reverse as fossil fuels are depleted over the next few centuries, or if massive climate change occurs over the next few millenia.

    This makes me wonder what will eventually bring down the house of cards that is the modern DSM diagnostic system. Will it be:

    A) Public outrage over the lies psychiatrists are telling which finally force the abolition of the DSM? This could occur in the next several decades.

    B) A global economic collapse caused by oil, coal, and gas becoming increasingly unaffordable, along with renewable alternatives not scaling up in time? In this scenario, medications could no longer be produced on an industrial scale, and there would be little reason for DSM diagnoses to continue to exist. This could happen in the next few centuries.

    C) Either 1) A new ice age, which is possible based on current models (we are in a warm period between ice ages right now) or 2) A massive amount of global warming before the next ice age…. either one of which could bring modern industry to its knees? This would again mean no more medications and the collapse of much of modern psychiatry. This might occur in the next few thousand years.

    D) Something else entirely or some combination of the above?

    Unless nuclear power and/or renewable energy can sustain the modern economy indefinitely – which is possible, but not inevitable from my reading – the myth of psychiatric diagnoses’ validity will collapse, and there will come a day when medications are no longer available at scale. Taking the long view, it’s probably not if but when and how this will occur. I hope that it is option A.

    • I think that it comes down to how things go from the top. What the elite decide to do and how much they can get away with.

      I think that it’s not just psychiatry treatments that are in trouble, western medicine as a whole is starting to develop a credibility problem because of pharmaceuticals.

      We also have science progressing to the point where maybe people start living a lot longer ? And if that’s too many people ?

    • To add, something a little more down to earth is the fact that many of the drugs that were perscribed back when I was intimately familiar with the shortcomings of psychiatry are now off patent.

      I didn’t realise things like Zyprexa are now off patent. Remeron etc etc.

      It’s easy to see how once anyone can make these drugs the purely money making corrupting influence is greatly lessened. Drug company’s are obviously going to be less incentivised to pervert the system in their favor if someone might just buy the clone instead.

  4. Thank you for writing this excellent analysis and for bringing the Lancet article to my attention. Having read some of Dr. Ilina Singh’s previous work (‘I Bambini e le Droghe’: The Right to Ritalin vs the Right to Childhood in Italy, and the hopeful study mentioned in this article: http://www.theguardian.com/society/2012/oct/15/adhd-study-reveals-childrens-views) I am disappointed that Dr. Singh has succumbed to dogmatism. I can only hope that she moves beyond this way of thinking about ADHD in the future.

  5. “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.”

    Is anyone surprised? Since the DSM and its labeling protocol is an artificial construct, voted into existence by people with perverse and questionable motives, why should anyone expect the human genome to oblige and produce a genetic marker for ADHD or anything else, for that matter? And without a doubt, the mission of mainstream psychiatry is to pathologize every normal human trait or feeling. What used to be called shyness is now social anxiety; grief over the loss of a loved one is no longer viewed as a normal response to a loss but a condition warranting drugging, and even obstructive sleep apnea, a purely physical condition, is listed in the DSM. And as we know, the “treatment” is worse, much worse, than the “disease;” the stimulant drugs used for ADHD are extremely deleterious to the developing brain and are often the trigger of a “bipolar” diagnosis, now to be treated by a cocktail of neurotoxins. I am in full agreement that mainstream psychiatry has much to be ashamed of.

    That said, I do not agree with the assertion that the concept of ADHD is spurious or that symptoms such as inability to focus, poor short-term memory, distractibility or lack of organizational ability are fictitious. The symptoms are quite real for those experiencing them and the response should be finding effective non-drug, non-coercive interventions. Plenty of studies (some noted on MIA) document improvements in ADHD outcomes based on dietary interventions (elimination of sugar, gluten and food additives; nutrient supplementation with vitamins and minerals). In the “Brain Maker,” Dr. David Perlmutter, who strongly decries the drugging of children with ADHD, states:

    “….ADHD should not be viewed as a distinct disorder, but rather as a symptom of various other issues. …ADHD is simply a manifestation of an inflammation gone awry due to triggers like gluten and the downstream effects of a sick microbiome.” In a similar vein, in Nutrient Power, William Walsh describes his nutrient protocols for ADHD (among other conditions) and offers a very helpful prognosis for this condition, based on vitamin and mineral supplementation. That is the direction we need to go in; not deny the problem.

    Just to be clear, in using the ADHD abbreviation, I am not endorsing the validity of this label; I am using it strictly as a frame of reference.

    • I think the position of Hickey is that the “symptoms” mislabeled ADHD are quite real in various degrees and kinds, but that the ADHD concept is still spurious, meaning that ADHD does not represent a reliable illness organization or syndrome occurring at more than a chance level across a population.

      So, ADHD can be totally spurious and nonexistent – i.e. the false concept that a unitary illness called ADHD exists and can be “treated” – but the actual experiences of childhood attention problems caused by many different factors, from which ADHD is falsely concretized, do still exist in all their degrees and kinds, and can be quite amenable to non-drug treatments as you suggested.

  6. “is 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.”

    “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.”

    I think I’m on the side of the authors of that reviewed article on this one. I think the problem is (ignoring at this point all the other problems like the fact that the “ADHD” behaviours likely don’t have one etiology anyway) – what constitutes an illness? While in terms of physical illnesses this used to be a very clear cut thing (which thanks to pharma’s disease mongering is not the case anymore) “mental illness” has always been a more tricky thing. At some point we arrive at something that can be defined just as a normal human variability in temperament, personality, resilience to various forms of stress etc.. Not to mention social factors which define what is healthy=acceptable and what is not. I think the authors of the reviewed article may be accidentally asking the question of “is there such a thing as mental illness?” at least in case of ADHD. People are different and these differences will be reflected in biology – it’s only a matter of looking closely enough. But if these differences divide people into “sick” and “healthy” in terms of their mental function – that’s a different question altogether and I think that’s kind of what the authors are starting to contemplate.

  7. I don’t think people’s fight should be about labels per se. Labels are useful for categorisation and research. It is when people misunderstand them, that problems arise. It’s when people internalise them so deeply that they see almost everything in their lives through the prism of their labels and forget they are first and foremost people with challenges and problems (and problems in living) that they cause self harm. When others, due to their ignorance, see the labelled the same way, they make life for the labelled difficult.

    Labels are descriptive and should be seen as such.

    If someone has a better alternative to labels that can be practically implemented, that’d be great. But I don’t see that happening. All I see is people who are angry, and though they may have justifiable reasons for their anger, it won’t do much.

    Also, psychotropic drugs do help some people. And if it’s making them focus better, it’s up to them to take them. What’s required is honesty. Psychiatrists should tell their patients what side effects the drugs may cause, and what their long term consequences may be. Not everyone has bad experiences on them. Some do, some don’t, some see the trade off between side effects and their non-drugged lives, as something they are willing to accept.

    Do labels not have negative consequences? Do they not make some others prejudge people? Sure, there are many instances where they do.

    Do I wish we could do away with labels? Sure. But what practically implementable alternatives are you willing to show us?

    What we can do is talk, write and educate people about the negatives of labels, and how they can make others be judgmental without even knowing what their purpose is. Psychiatrists and psychologists should take part in doing this as well. It is in the interest of their clients and ultimately in the interest of their own profession to clear these things up.

    • We are pathologizing childhood through the ADHD label. There is only one way to get rid of these labels…snip, snip, snip. First by acknowledging that they are not diseases, and second by encouraging dispensing with the tag altogether. The label serves two purposes. It provides an excuse in billing the government for treatment, on the one hand, and it justifies the use of psycho-active chemicals (institutes treatment), speed in the case of ADHD, on the other. There is a great deal of making mountains out of molehills in psychiatry, and in few instances are those mountains any higher than in that of ADHD. I say stand up to the mountain, snip, snip, snip, and it’s a molehill, no disease, again. You can’t do that by not making a distinction between real disease and phony disease (i.e. labels). Once this is so, phony disease labels can go the way of other fads and historical relics. Which way is that? Snip, snip, snip. Into the paper shredder.

      • Diseases or not. Impairment in functioning is a condition for any sort of treatment (or “treatment” if you want to call it that). If some people benefit from taking psychotropics in order to enhance their functioning, I do not see a problem with that.

        Fine. You’ll put them into the paper shredder. Suggest an alternative to help people in distress. Listening and talking will only do so much. Drugs will also only do so much. A combination will also only do so much. That doesn’t mean that it does not benefit some. It also doesn’t mean that a person should rely on the mental health system to solve problems in living, thinking and feeling. In fact, he should rely on them to a certain extent and sort out many other things by learning and adapting to challenges in life by himself as much as possible.

        • Presumption of “sickness” or “impairment in functioning” (with or without “benefit” of “psychotropic”) is just that, presumption.

          I would suggest we don’t pathologize childhood so much primarily because it all too often leads to a pathologized adulthood, and anybody has probably got better things to be doing with life itself than convalescing. However, if you’ve got nothing better to do, convalesce away.

          Distress is a fact of life. What distress is not is disease. I would suggest that the mental illness industry isn’t the knight in shining armor, in such instances, that it would make itself out to be. While stress disables some, it enables others. Perhaps we should be looking at what it is that makes for such a difference in coping and managing rather than just opting whole hog for labeling (i.e. stigmatizing) certain people.

          What’s more, cutting back on the offensive labeling of childhood makes a great deal of sense, at least, to me. I think they call it, non-labeling that is, “mental health”, or “mentally healthy”. Labeling itself though is referred to as a “mental health crisis”, and to my way of thinking, that “crisis” is less than desirable. This “mental health crisis” hunt has got us to the point where “mental health experts” are saying 1 in 5 people in the USA have one. Stop labeling children, and you have that much of a less contagious “crisis” situation.