“The Overdiagnosis of ADHD”

Philip Hickey, PhD
68
2029

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.

68 COMMENTS

  1. psychiatry is a hoax. But maybe the phrase ‘To every joke there is some truth’ applies. In an ideal situation, a psychiatrist might warn a patient of all dangers. He/she will not say that I won’t get this or that negative effect. He/she will tell me ‘this medication can kill you’. He/she will not say that something terrible will happen if I taper off a certain drug, and will not give me dire examples of ‘mad killings’ to warn me to take my drugs. The ‘doctor’ will tell me that the drug will probably cause massive brain damage and disability, and the doctor will not prescribe drugs to underage children, and sometimes, if I’m desperate enough, I’ll say I want medicine anyways. But yes, ‘psychiatry is a hoax’ created through repeated hypnotic suggestions. Like: ‘depression is a physical illness like diabetes’ ‘Mental illness is caused by a chemical imbalance’. Kindest regards, and thank you for your thoughts on the hoax of
    psychiatry, Even.

  2. Clear as a bell. Thanks Philip.

    Never for a moment should we forget that we are not dealing with ‘psychiatry’ here. ‘Psychiatry’ is an idea. We are dealing with psychiatrists. Those psychiatrists have pushed an agenda that has been a disgrace to any concepts (and they are only concepts) of medicine – especially high profile and active psychiatrists like Allen Frances.

    There is no justice or responsibility except for individuals. ‘Psychiatry’ has no feet to be put to the fire.

  3. Childhood immaturity? Childhood is immaturity!

    The problem with ADHD is obvious. You can’t expect everybody to be a born Fudd (PhD.). Education is so important in today’s world it’s easy to forget that there was a time not that long ago when the majority of USA citizens were uneducated, and basically illiterate. The uneducated majority of yesteryear, by today’s standard, would all be candidates for ADHD.

    When I was in grade school we had a teacher we used to take delight in playing pranks on. I heard that sometime later she went bonkers and spent time in the hospital, presumably because of us, her students. I guess the education system has fixed itself, in a sense, by driving its students bonkers. No need to blame the teacher for the failures of education when you can blame the student. What’s become of the world? Evil students no doubt.

    Thank you for this post, and keep ’em coming.

    • Allen Frances latest Huff Post piece is a little bit better than his usual fare. He’s taking on polypharmacy (multiple psychiatric drug use, or drug cocktails), something that we could use a lot more of, that is, exposure of the harm wrought by polypharmacy.

      His take on ADHD is more typical. There he’s going after over diagnosis, but he has still got little doubt that some ADHD, as he sees it, is legit. If, as I and others would have it, ADHD is a bogus “disorder” label, then it follows that all diagnosis of it would have to be over diagnosis.

      The problem is, whether you’ve got a lot of it, or a little of it, outcomes have been tended to be pretty atrocious. ADHD treatment, that is, stimulant use, as is, much like anti-depressant use, all too often serves as an iatrogenic route to even more severe “disorder” diagnoses and, potentially, to even more severe damage from drugging.

      • Of course, the problem is that when you have no actual objective criteria for a “diagnosis,” how would one ever tell if something is “overdiagnosed?” Just the use of that term sets my teeth on edge, because it presumes there would be a right level of diagnosis, and there is absolutely no non-arbitrary way to accomplish that. In the end, the ultimate result of any kind of diagnosis based on a spectrum is that the line of “disorder” will be pushed closer and closer to the line of the average, especially when there are folks with strong financial interests in moving the line in that direction. Same thing has happened with blood sugar levels, cholesterol levels, and various other tests (how many cases of “pre-cancerous cells” will never develop into cancer?) It works great for Big Pharma, but not so great for the recipients of this kind of “care.”

        —- Steve

  4. Philip, good to see you posting again.

    Thank you for exposing two-face / Janus (Frances) again. What a weird dude. I guess when you’ve built your reputation and career on fraudulent invalid diagnoses, it’s hard to fully admit how broken and meaningless the structures you helped create are.

    It’s incredible that now 15% of American kids are getting labeled as “having ADHD”. I had no idea that it had gotten that bad. What a bunch of fricking bullshit. There is no discrete illness called ADHD. I work with kids all the time and it’s obvious that you can’t arbitrarily subjectively measure the behaviors and utterances of the kids and reliably say that some have this disease called ADHD and others don’t. Problems with attention occur on a continuum and vary in different settings over time, and there is no evidence they represent a unitary disease nor that they are caused by brain chemistry or genes.

    • You know this and I know this. I taught high school for fifteen years and never ran into a student that I would label with something like this. So, how do we get parents to come to this?

      I know people that are rational on all the rest of the stuff that we talk about here but when I bring ADHD up and how invalid it is inevitably someone will say, “But I know a situation where the kid really does have this!” I just throw my hands up and leave. I attended a lecture where I work on ADHD and when I stood up and shared the fact that this was never talked about until the early 80’s I was promptly told that without a doubt ADHD is a valid disease and that I shouldn’t be trying to lead people astray, for the good of the children of course! When I asked them how this could have just cropped up out of the clear blue all of a sudden they had no explanation, they just told me how wrong I was in believing that it isn’t a disease. I’ve just about given up on it.

      • I see ADHD as one of the most bogus diagnoses of them all and certainly does such harm to the self-esteem of children. Attention is a skill set that can be strengthened through practice. I help children to learn better self-control, how to tolerate boredom and how to play the rules of school which include politeness and respect to teachers and peers but not interrupting others, waiting one’s turn, etc. Play therapy with dolls or puppets, chairs and chalkboard can be useful in recreating the classroom and solving “acting out issues”. Helping children engage in learning often means parents spending a lot of time with their children reading and doing homework so that they can learn how to manage their time, take good breaks, etc. It is important to praise children for being patient and taking their time doing homework and managing their time. There is no skill in a pill, parents need to take the time to teach their children skills not medicate for quick solution. Eating healthy, exercise, managing t.v., video game and phone time are all part of raising healthy children. I tell parents they are the CEOs of their family. Parenting is the most important role in society in my opinion. Psychiatrists and NPs stay out of medicating children who need adults around them to guide them in their development.

        • Couldn’t agree with you more. The only thing I’d add is that schools are often the worst enemy of this kind of kid, because they are as dull as dull can be, but it doesn’t have to be that way. We used homeschooling and alternative schools for our very active, bright, easily-bored boys and had no complaints about “ADHD” and actually very few complaints about ANYTHING. It wasn’t easy, but who said raising kids was supposed to be easy? The dumbest thing we can do is tell kids, “Oh, well, the reason you aren’t paying attention is because you can’t because your brain won’t let you.” Instant off-the-hook excuse for the kid, his parents, and his teachers, when the reality is, paying attention, like anything else, is a skill that can be learned. They may find it harder than other kids, and they may never be great at it, but they can learn to be better than they are and at the same time learn that you can overcome any shortcoming in time if you work at it, which may be the most important lesson of all.

          — Steve

      • But Philip, 15% of kids having ADHD only leaves about 5-10% of the junior population free for having other disorders, like Intermittent Explosive Disorder, Misbehaving Syndrome, Call of Duty Overplaying Disorder, Sibling Rivalry Disorder, Drapetomania, etc.

        Oh wait… these things can be co-morbid. Haha how could I forget that!

  5. On the subject of ADHD (not Doctor Frances) 2012″ Why French Kids Don’t Have ADHD” https://www.psychologytoday.com/blog/suffer-the-children/201203/why-french-kids-dont-have-adhd

    Raising children is very difficult, specially today.”Mom Whips Child For Breaking In House… Goes To Jail” http://wild1063.iheart.com/onair/big-daddy-afternoon-jumpoff-2862/mom-whips-child-for-breaking-in-14845429/

    The law of supply and demand is at play.
    •“No one explains where this disease [ADHD] came from, why it didn’t exist 50 years ago. No one is able to diagnose it with objective tests. It’s diagnosed by a teacher complaining or a parent complaining. People are referring to the fact that they don’t like misbehaving children, mainly boys, in the schools. The diagnosis helps tranquilize the parent, tranquilize the school system. It offers them the sense that they are doing something about the problem, that they are dealing with it in a rational, scientific way. It’s a kind of pharmacological magic.” Szasz

    • Counterargument to children in France with ADHD….”French Kids Do Have ADHD: An Interview” https://www.psychologytoday.com/blog/here-there-and-everywhere/201209/french-kids-do-have-adhd-interview….”Moliere described ADHD in his play L’Étourdi ou Les Contretemps (The Blunderer) in 1655. However, the concept of ADHD, or “Trouble déficit de l’attention/hyperactivité”(TDAH), as a serious disorder is still not fully accepted in France. However, ADHD impacts the functioning of 3.5% of the population of France (Lecendreux, et al. 2011). In addition, ADHD is just as prevalent in other countries as it is in the U.S. (Faraone, et al. 2003).

      I interviewed Elias Sarkis MD, a board-certified child and adolescent psychiatrist and Distinguished Fellow of the American Psychiatric Assocation, to learn more about the prevalence of ADHD in France. Dr. Sarkis lived in France for 10 years, and graduated from medical school at Universite de Lille in Lille, France. He is now the medical director of Sarkis Family Psychiatry and Sarkis Clinical Trials in Gainesville, Florida. His website is http://www.sarkisfamilypsychiatry.com.

      Dr. Sarkis returns to France on a regular basis. He said that ADHD does most certainly exist in France. Not only are there clinical studies showing the prevalence of ADHD in France, but Dr. Sarkis also has a friend, a psychiatrist, whose child has ADHD. His friend’s daughter had lifelong difficulties in school, had an unplanned pregnancy, and then dropped out of school. Her mother is now watching her child so she can return to school.

      Dr. Sarkis said that in France there is a “strong negative cultural belief against medication” for children with psychiatric disorders. However, he said, children with ADHD continue to suffer the consequences of the disorder. Regarding the impact of undiagnosed and unmedicated ADHD in France, Dr. Sarkis said, “the reality is that there are French kids in prison, a high rate of tobacco use, and kids dropping out of school”.

      Dr. Sarkis said said that if a French child with ADHD receives “excellent parenting, high structure, and clear expectations from parents” it can mitigate behaviors, However, it is “at the price of the child experiencing increased anxiety and internalizing problems”. For those children who are not able to receive excellent parenting and high structure, ADHD behaviors can be extremely impairing.

      In France it is difficult for parents to get an evaluation and treatment for their ADHD child. It takes 8 months for a child to get an appointment with a specialist, and it can take another 8 months before a child is prescribed medication (Getin, 2011).

      Fortunately, Dr. Sarkis said, the concept of ADHD as a serious, treatable disorder is gaining strength in France. Parents are learning more about ADHD via the Internet, and there are more centers being established to help treat this debiliating disorder. “

  6. Hi Philip, thanks for the worthwhile article.

    I think that if a child didn’t suffer from “the symptoms of ADHD” then it would have something wrong with it. All children spend time staring out the window daydreaming at school – school can be really really boring.

    I’m sure there are genuine conditions brought on by processed food or too much “healthy food” that make childrent restless, but this is malnutrition not ADHD.

  7. I wondered if Dr. Frances ever apologized for taking pharmaceutical money to do the schizophrenia practice guidelines. Apparently he did in a 2015 blog where he stated:

    “…it was very unwise to do guidelines with drug industry funding. Even though they were fairly done, accurately reported, and contained built in methodological protections against industry-favorable bias, the industry sponsorship by itself created an understandable appearance of possible bias that might reduce faith in the sound advice and useful method contained in them. It was an error in judgment on my part that I apologize for. I have learned from my mistake and hope others do as well.”

    He still does not publicly admit that there’s no way to protect against industry bias when a special interest funds your research. And, of course, he does not acknowledge that the guideline was not fair, sound, or useful, even with the information available at the time.

    • Dear Marie,

      Its interesting what you say about pharmaceutical money and I hope I’m not wandering off topic here : I was told by a gp today that my cholesterol was 6 (uk) and that I should be on a statin. With difficulty I checked 6 (uk) and this is exactly average. By coincidence I found a heart attack calculator on the Internet (from 2001) and when I entered my dimensions the result was very low risk. When I increased the cholestetol to 7 (uk) it was still low risk.
      (But my ratio was good anyway). Obviously there’s been “medicalisation” since 2001.

      I suppose people do have a choice whether they take the statins – but maybe not an informed choice.

      (Psychiatric “medications” are a lot worse).

      • Yes, statins are one of the most pushed drugs today by GP’s. They’re even advocating that people that are at no risk at all at this point in time go on them as “maintenance”. The problem with statins that few people realize and that few doctors tell people are that they can affect the muscles in your hips and legs and cause bad enough problems that you can’t walk on your own without the use of canes, crutches, or wheelchairs. They are no telling people the entire truth about these drugs. Plus, they are one of the most expensive drugs on the market today.

        I ran into the same problem with a doctor insisting that I was going to take them and I fired him after only one visit as a new patient.

        • Hi Stephen,

          I switched PCPs this year and had a physical with the new doctor. When he told my cholesterol was way over the ideal 200 level, I cringed as I feared hearing the “S” word.

          Much to my pleasant surprise, the guy said that because of my otherwise ideal ratios, the research he consulted was conflicted on whether I needed to be on stains or not. So he left it up to me and obviously, you all know what I decided. 🙂

          There is no doubt in my mind that my previous PCP would have wanted me on them yesterday. Obviously, I am quite happy with the switch.

          • Good point. I’d forgotten that. You have to wonder with all this early onset dementia and Altzhiemer’s that we experience these days. We are a pill consuming society and I don’t think that anything is going to change that now.

            People think I’m strange because I won’t take all kinds of “medicines” but I grew up in a family where the older women were educated in the use of plants as medicines.

            We were expected to take care of medical problems at home if at all possible. When I was little you didn’t see people running to the doctor’s office all the time. You only went for emergencies. I was not allowed to take medicines from doctors. I almost died from strep throat one time when I was in high school because of this intense dislike of the “modern drugs”. These days patients are herded like cattle into the waiting rooms of offices, where you wait for hours for the doctor to see you.

            My present doctor is always trying to send me off to some kind of specialist or put me on some kind of medicine and I just politely decline. She’s finally learning to only suggest and then let me decide if I want what she’s offering. Many doctors don’t know how to deal with a patient like me.

          • Stephen,

            I think statins might have some uses but as a general maintenance drug I think they do more harm than good. A lot of doctors avoid taking them themselves.

  8. Are the FDA approval and the licensing of doctors the source of the problem, rather than a protection?

    So is there a problem in that the drug manufacturing and the providing of doctor services are a for profit industry, and that most of the time it is just serving the desires of the parents? I say yes.

    So what do we do? How can we protect the personhood of the children, and in the face of parents who are committed to politically exerting an ownership right because this is the basis of their adult identity?

    Should there have to be a court involved and the child represented by an attorney, before there can be any substantial medical procedures or drugging?

    We have now laws against child abuse. These make no exception for when that abuse is performed by a licensed doctor, a therapist, or a parent. It is just a matter of interpretation. So I say these laws should be enforced on doctors, therapists, and parents, and maybe on Big Pharma too.

    We have mandatory reporting laws for cases of suspected child abuse. There is no exception in these for abuses committed by doctors, therapists or parents. It is just a matter of interpretation as to what is abuse. I say we should use this, that is report, but also prosecute those who fail to report.

    Those in our society who support the middle-class family control the land, the capital, and the politics. Those of us who do not support it are kept on the margins, and delegitimated. So most survivors are afraid to even think about opposition. I say this pertaining to survivors of the middle-class family and to survivors of the psychiatric system. To me these are the same. So this situation will not change until we start standing up for ourselves.

    Always the fate of children, and the fate of adults too, is in the hands of the broader society. Every society inscribes upon it’s members. Okay, but never before in history has their been anything like the middle-class family, where adults are encouraged to deliberately assert themselves by going into a Barnes and Nobel’s and purchasing a pedagogy manual and then by making some babies and then by using them for display and bragging. And then each time the FDA approves a new drug, what this means is that it is approved for parents to get their kids put on it and brag about it.

    In traditional societies and primitive societies it is not anything at all like this.

    Nomadic
    http://freedomtoexpress.freeforums.org/how-to-stop-child-drugging-t270.html

  9. I saw Dr Francis speak at the Madinamerica film festival a few years back. I give him credit for coming and speaking to an audience obviously opposed to his position and his record. He very openly declares over medication and over diagnosis as problems, but immediately pivots to the idea that there are people who “really” need these meds but aren’t getting them. He pointed to the number of mentally ill prisoners as evidence for this. He apparently believes that the only people who “really” need meds are the few of us left who aren’t taking them.
    It seems to me that DSM IV was his opportunity to define who “really” need meds. We see how that turned out. If Dr Francis has some secret new diagnostic tool up his sleeve he should let the rest of us in on it.

    • If you look at my psychiatric record for the first 4 years you could think I really needed meds. But then I came off the strong meds more than 30 years ago and the weaker meds disappeared of their own accord.

      The consultant psychiatrist treating me went out of his way to cover up the disability and suicidal reaction to the meds and the recovery as a result of coming off them.

      He was also a teaching and researching psychiatrist that would have mislead many young doctors and would have killed some of his patients.

    • Psychiatry not only destroys the people it arrogantly alleges to serve. This aberrant medical and allegedly scientific “speciality” destroys fellow human beings so brutally and relentlessly. It coercively and enforcedly drugs and damages physically, psychologically, emotionally, spiritually, socially, financially. The hopes, dreams and aspirations for future happiness and fulfilment are destroyed. Those so terribly injured and robbed of all self esteem may be too wounded to ever return to the society from which the hubris of psychiatry has exiled them. Their families and those who love them also have their lives and hopes destroyed in parallel.
      This more global human destruction is well conceptualised by reference to the words quoted by J. Robert Oppenheimer at the first atomic explosion in Los Alamos: –

      “FOR I AM BECOME DEATH, THE DESTROYER OF WORLDS”.

      It is that awful.
      Psychiatry has become medicine’s Enron and with it brought shame on my own profession.

      • Agreed.
        Before psychiatry brutalized me I was a six-figure-salaried-executive. Psychiatry kidnapped me, locked me up, drugged me and left me so totally traumatized I have been unable to return to the workforce since. Now, 12 years down the track I have been fully off meds for around six years and cope well, but still have incredibly debilitating reactions to any stress whatsoever.

        That they are drugging LITTLE CHILDREN and stuffing up their entire lives is unforgivable…that they are doing it to so many is, as you say, a crime of ENRON scale…bigger, even.

        Keep up the good work exposing these crimes, Philip.

      • “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.” I, too, couldn’t agree more.

        • Don’t we have duty of care to young doctors (some of whom we have taught , or used to teach ourselves) who may be considering entry into psychiatry training programs? How can we prevent the waste and sacrifice of their vocation if they are to be subjected to the type of propaganda illustrated by the “Stop Bashing Psychiatry” campaign launched in the UK earlier this year, and if they are to be used to perpetuate the current failed paradigm?
          They surely need to be aware of what catastrophic harms they will be coerced into inflicting upon their “patients” if their career decisions are to be informed and consented.
          If such awareness leaves a cadre of the committed to enter and revise with care, compassion and differentiation between science and science-fiction in psychiatry, then of course we should afford them our respect as well as all possible help and support. T.

  10. I definitely understand the anger towards psychiatry but again, 80% of all psych prescriptions are prescribed by non psychiatrists. And many people end up on AD withdrawal boards thanks to their PCP prescribing psych meds for normal responses to stressful events in a person’s life. Even if psychiatry was banned which is never going to happen (another discussion), it wouldn’t solve the problem of the gross over prescription of these meds.

  11. This article leaves me wondering how Dr. F is able to diagnose ADHD in three-year olds, whose attention spans are bound to be short, because their brains are developing. Does he flip a coin? Consult the Ouija Board? See the Oracle at Delphi? This is all very mysterious to me.