Researchers Argue that ‘ADHD’ Doesn’t Meet DSM Definition of a Disorder

Peter Simons
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A new article, published in the journal Disability and Society, questions whether the diagnosis of ADHD meets the criteria for a disorder as set out in the manual used by the medical and psychiatric fields. The researchers argue that rather than using objective criteria, the definition of ADHD relies on subjective cultural values to define “abnormal” behavior. The diagnosis thus fails to meet the criteria, as stated in the DSM, that disorders must not be reducible to behavior that violates social norms.

“We argue that the current criteria draw into question whether ADHD/HD meets the manuals’ own definitions of a disorder,” the researchers write.

Photo Credit: Wikipedia Commons

The researchers – Justin Freeman at Syracuse University, NY, and Juho Honkasilta at the University of Jyväskylä in Finland – used a technique called critical discourse analysis (CDA) to investigate the language used to define the diagnosis of ADHD. For instance, the diagnosis of ADHD is listed as a “neurodevelopmental disorder” in the DSM-5, despite the research evidence suggesting that there is no neurological difference between those with the diagnosis of ADHD and those without the diagnosis.

Freeman and Honksilta argue that despite the lack of any organic or biological test for ADHD, it could still be a valid, useful construct if it “hangs together” logically. However, the criteria for the disorder appears to violate this requirement as well. They found that although the words “diagnosis” and “disorder” imply objective criteria, and the medical literature overuses the word “science” in describing ADHD, the actual language of the ADHD diagnosis is vague and subjective.

For example, each of the 18 symptoms of ADHD in the DSM-5 begins with the subjective, ambiguous specifier “often.” Thus, parents, teachers, and doctors are determining what constitutes “too much” inattention or “too much” activity for a child.

Additionally, the researchers argue that the omission of who is observing the child and judging the child’s behavior as excessive is inherently based on cultural values. They write that the criteria “Often unable to play or engage in leisure activities quietly” leaves out any context regarding why children’s leisure activities should be quiet in the first place.

Moreover, Freeman and Honkasilta suggest that normal childhood play is recontextualized, through the lens of adults who want to control and calm children, as a “disorder” and a “deficit.” Perhaps the most obvious example is that a criterion for ADHD in the DSM-5 is as simple as “feeling restless.”

Other criteria involve references to making others—people without the ADHD diagnosis—feel inadequate. For instance, included in the DSM-5 criteria are being “difficult to keep up with” and “wearing others out.”

ADHD has been the subject of controversy in the research literature of late, as studies purporting to show neurological components to the “disorder” have been discredited—in some cases, by the very researchers who popularized the diagnosis in the first place. Lancet Psychiatry, a premier research journal, recently devoted an entire issue to the debunking of one such study, which was acknowledged to be flawed in methodology.

At the same time, studies have found that more than 20% of high school boys are receiving the diagnosis, which is commonly associated with the prescription of potentially addictive stimulant medications. Concerns about overdiagnosis and overmedication are common in the popular and research literature regarding ADHD.

Indeed, this is not the first time that researchers have argued that the language of the disorder is vague, subjective, and serves the interests of parents, teachers, and the pharmaceutical industry—rather than the welfare of children. In fact, leading researchers have argued that the diagnosis does far more harm than good for children.

Freeman and Honkasilta also write that “the discourse of the manuals is intertwined with the everyday practices of schools and serve to legitimize status quo educational practices.” That is, the language used to construct the diagnosis is inseparable from the values of an education system requiring that children behave a certain way.

The researchers go on to state that the diagnosis of ADHD actually serves to reframe individual differences and cultural diversity as “mental illness.” Thus, according to the researchers, the existence of ADHD as a disorder enables the education system to continue ineffective teaching practices focused on the ideal “normal” child rather than changing to better help diverse children learn.

Freeman and Honkasilta note that the DSM-5 itself requires that a disorder not be comprised of cultural difference, or socially deviant behavior that is not harmful. The researchers therefore argue that given the cultural values implicit in the ADHD diagnosis, it fails this most basic definition. Going further, the researchers write that the “diagnosis” is actually dependent on adults in power insisting that children engage in both work and play in ways that are adult-like, which is developmentally inconsistent with common childhood behaviors.

The authors write that they are “alarmed by the DSM-5 and ICD-10 authors’ narrow view of what constitutes healthy or acceptable behaviors, such that they prescribe the manner in which individuals should play or sit.”

Finally, the researchers argue that, like homosexuality (which was considered a mental disorder by the psychiatric field until 1980), ADHD should be de-medicalized—and could be considered a normal variation on how humans, especially children, engage in the world.

 

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Freeman, J. E. & Honkasilta, J. M. (2017). Dictating the boundaries of ab/normality: A critical discourse analysis of the diagnostic criteria for attention deficit hyperactivity disorder and hyperkinetic disorder. Disability & Society, 32 (4), 565–588. https://doi.org/10.1080/09687599.2017.1296819 (Link)

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Peter Simons
MIA-UMB News Team: Peter Simons comes from a background in the humanities where he studied English, philosophy, and art. Now working on his PhD in Counseling Psychology, his recent research has focused on conflicts of interest in the psychopharmaceutical research literature, the use of antipsychotic medications in the treatment of depression, and the general philosophical and sociopolitical implications of psychiatric taxonomy in diagnosis and treatment.

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20 COMMENTS

  1. Of course ADHD is just a description of a cluster of behaviors and not an independent entity unto itself, just like the other alleged “psychiatric diseases”. The real headache is that the alleged “treatment” covers up serious conditions that actually have real treatments, like heavy metal poisoning.

    • yeah, it’s not that people don’t experience (and suffer) debilitating conditions. it’s that diagnostic labels function as unspoken convictions and the lab-created solutions are not the right response to non-medical conditions.

      that’s the problem: *non-medical conditions being treated (mistreated) medically*

  2. As a former high school teacher who saw the beginning of the ADHD tsunami before it swept across American schools I will always state that this is nothing more than something that was made up to benefit teachers and the drug companies.

    Psychiatry and the drug companies love to pathologize the normal, whatever that is, so that more people can be dragged kicking and screaming into their nets. PTSD is another example of a “diagnosis” that pathologizes something that is normal. Trauma is the normal response to terrible events or experiences that overwhelm people. To be overwhelmed emotionally and psychologically by terrible things is normal and is not pathology.

    So, kids are sick for life because they’re bored to tears by what is going on in school, or not going on as the case may be; and soldiers and people caught in natural calamities are sick because they become emotionally overwhelmed by the trauma they experience. This is just pure bull feces.

    If we began looking at the wonderful diagnoses in the wonderful DSM 5 we would most likely find that most do not make any sense at all. If you can vote to throw a diagnosis out of the DSM there isn’t any science at all associated with the damned book. Of course, the thing is created from diagnoses that were voted on by committee. The story that goes around is that many of these things were created by the upper middle class white men who made up the committees as they were washing their hands in the Men’s Room. A lot of science in that approach, yeseree!

  3. It is not just psychiatry who pathologizes medical conditions as regular doctors do it also. The problem is widespread across conventional medicine.

    What do we do to stop this from happening or can we?

    Sorry for this OT post but I am really angry about the situation.

    • No problem. I understand and agree with you totally. I just forget to mention doctors from other fields since I don’t often deal with them in daily life. We have a real problem with medicine in this country and I myself do not know what to do about it, other than standing up for yourself against any doctor who tries to bully you into doing things you don’t feel comfortable doing. My PCP tried to do that when we first got together until I stopped the conversation and told her, “You obviously do not understand the dynamic that will determine how we work together. Listen carefully: you give advice and I make the decisions. If you are not comfortable with this arrangement then we will not be able to work together.” It took a few times until she understood how we were going to work together.

  4. We are all born with “ADHD”. A young child’s curiosity, eagerness, and energeticness is merely the starting point, or the fertile soil which can yield a productive garden, if properly cultivated, rather than pathologized and drugged. Millions of years of evolution have given us huge brains capable of learning, during the course of childhood, endless ways to effectively adapt. But in the last 27 years, psychiatry has sabotaged this process for millions of kids, by tricking their parents/schools into thinking this wasn’t possible due to their supposed “brain disease”. This needlessly wastes their lives and their potential.

  5. nope. we aren’t all born with adhd.

    but we all were born on the planet in this catastrophic transmogrified condition: http://www.gordoncooper.com/wp-content/uploads/2013/01/Earth_at_Night_America.jpg

    the planet didn’t look like that 100 years ago. in addition to our catastrophically electrified earth we also have a catastrophically transmogrified atmosphere (GASP!!).

    we live inside of a gigantic electromagnetic box. electricity and telecommunications are not only environmental toxins but they’re also forces of destruction on the human form.

    take a look at heliobiology,

    https://ntrs.nasa.gov/search.jsp?R=19740020484

    http://www.thewisemag.com/astrology/solar-activities-and-us-part-three/

    as our environment continues to experience destruction (it’s happening now) humanity’s condition will worsen.

  6. I won’t even bother to read this trash. What on earth is Mad in America doing? Anyone with any ounce of common sense knows that “ADHD” is pure fiction and that the DSM is the nefarious anti-Bible. Psychiatry is a great curse upon the world. Who will stand up to the Goliath of the psycho-pharmaceutical industrial complex? Who will slay the dragon of psychiatry?

    • Maybe MiA is trying to educate the DSM deluded? I hope they do de-medicalize ADHD, because grown adults forcing children to take amphetamines is something only really sick people would think is a good idea.

      “The researchers argue that rather than using objective criteria, the definition of ADHD relies on subjective cultural values to define ‘abnormal’ behavior.” Isn’t this basically the truth for all the voted into existence DSM disorders? For example, just after my child tested in the 100th percentile on his state standardized tests, which is of course “abnormal.” First thing I got was a call from the school social worker, not congratulating me, but wanting to get her grubby little hands on my “abnormal” child.

      But drugging up all the intelligent children isn’t really going to benefit humanity, and I think that’s basically what the ADHD diagnosis is all about. Thankfully, I’d taught my children to behave in a mutually respectful manner, so the school social worker was incapable of coming up with any behavioral complaints.

      I do agree with you, Slaying, “‘ADHD’ is pure fiction and … the DSM is the nefarious anti-Bible. Psychiatry is a great curse upon the world,” yet once again. Soon, I imagine, they’ll have to start murdering everyone they can get their hands on, if they’re not already which I think they are, to cover up the globalist banksters’ fiscally irresponsible debt based monetary system and their own crimes, just like they did in Nazi Germany and communist Russia. History does repeat itself, over and over and over again, unfortunately. Here we come, WWIII, just like I knew would happen just after 9/11/2001.

      “Those who don’t know history are doomed to repeat it.” It’s a shame our history books have been filled with lies, and US history classes consist solely of memorizing dates, rather than being filled with wisdom from the ages. Gosh, I wonder who financed this miseducation of the American public, including the psychiatric industry? It couldn’t possibly be the globalist banksters, could it?

  7. “Freeman and Honkasilta note that the DSM-5 itself requires that a disorder not be comprised of cultural difference, or socially deviant behavior that is not harmful.”

    And how exactly does that differ from any other “disorder” in the DSM? If the DSM really required that a “disorder” not be comprised of cultural difference or deviant behavior, it would be a VERY thin manual! It would, in fact, be essentially EMPTY!

    —- Steve

  8. On the Lancet study (Subcortical Volume Differences in ADHD, Hoogman et.al, Pub 15.2.17)
    Hi all, my immediate impression having looked at the methodology, subject selection and stats is a very unprofessional ‘usual Lancet rubbish’. I must disclose that I have fallen out with both editors of the Lancet and BMJ about overdramatising findings to gain readership and maintain their high impact factors, as exemplified by the MMR (Lancet) and Statin (BMJ) stories. I did suggest to the 2 that next time I would complain to the Press Complaints Commission. They also got upset with me as I suggested that critical analysis of their papers was better in the Daily Mail (whose health editor is very good). I would stick to the Nature journals, and NEJM.

    On the study specifics, this was a brave attempt to get big numbers, but with all the attendant problems of an international multicentre study, which have been described in before (I was involved in the Intercept study on the suicide protection potential of Clozapine in psychosis). A snapshot process of subjects of a large variety of ages, will come up with overlap between subject / control findings, all very predictable. I think they were hoping to get separation in basal ganglia areas but couldn’t, so focussed on the hippocampal / amygdala changes instead. They forgot to mention that the Hippocampus and Amygdala are the most plastic of brain organs, readily reducing in volume in response to persistent high stress and Hypercortisolaemia (caused by all kinds of conditions, both physical and mental adversity, including mixed abuse by elders).

    The IQ difference between subjects and controls is interesting, I am sure the authors are regretting not controlling for this in their initial subject selection, as it totally moves the focus to this statistically more robust finding. I was pleased to find that ADHD drugs did not seem to make a blind bit of difference, and is used simply for sedation and school room control, and might explain hippocampal / amygdala loss due to these children struggling to use their preferred way of learning, and getting stigmatised by teachers and peers. School would be a horrible experience for them (need a good naturalistic study on this I think).

    Finally the authors provide their own criticism; the need to concentrate on longitudinal structural imaging to look at brain maturation in these different conditions. This is best done at a single centre, and needs much smaller, but carefully selected group of subjects and controls. However, there are ethical issues involved in annual MRI screening, including confounding study results. This is being done by NIH in early onset psychosis.

    Ethically, my fear is how politicians and the general public would interpret the finding of ‘smaller brains in ADHD’ This has the (sickly) smell of Eugenics and Social Darwinism, with the potential to reduce reasonable adjustments to help these children learn in their preferred way. Also, when selecting for apprentice schemes and jobs, could a diagnosis of ADHD based on MRI scans limit success in employment, limit driving licences being given? What happened in Germany in the late 1920’s (A life not worth of life) is not that long ago.
    Shola

  9. A lot of what these authors say is as taken directly out of my mind. I’ve been working with so called ADHD children and teens since I was 15. First of all, it is not natural for humans to sit still in a classroom and stare at a teacher preaching and a black board for hours at a time, so there is no wonder that a lot of children can’t sit still, and start seeking other activities. It doesn’t mean that these children can’t learn, are less intelligent, or god forbid have to be drugged so we can handle them. In most cases these children often are more intelligent than the so called “normals”, but learn by more practical means such as actually hands on work, or more practical approach to the same subjects as “so called Normals”.

  10. Yes Aurebu I agree; during my course leading to the PGCE, I noticed teaching academics being resistant to using PBL (Problem Based Learning), and very resistant to randomised allocation of cohorts to different teaching modes. They came up with the same excuses I have heard from psychotherapists, including CBT therapists facing challenge from Behaviour Activation therapy.

  11. There is another fundamental issue with the DSM, particularly with a description like ADHD. That is the problem of reification, belief in an entity rather than a process or reaction. https://www.mja.com.au/journal/2009/191/11/cough-disorder-allegory-dsm-iv

    Many paths lead to a syndrome of poor attention, fidgetiness and impulsiveness. Put any of us under stress and in situations of sleep deprivation, and in a class where we may have a learning difficulty…

    Nonetheless as a child psychiatrist, I have to say that stimulants like methylphenidate do give some children a lot of benefit. But that is a much smaller group than receive them. Prominent original proponents of the diagnostic construct – Eisenberg, Conners, Kagan – all vehemently denounced the overdiagnosis epidemic.

    The stimulants work as performance enhancers. But at what cost? A team of athletes will do brilliantly on anabolic steroids, the bulk of a school class will concentrate to a teacher’s delight on stimulants. The communist Ceausescu regime facilitated the widespread doping of their Olympic athletes on anabolics, but lesser known is they did the same with Ritalin as standard for the children with academic ability – in the belief Romania would be the smart nation as well as covered in Olympic glory.

    But the athletes bodies fall apart decades later. What about the children’s brains? We don’t actually know. The long term studies have not been done. One longitudinal birth cohort study (the Raine Study in Western Australia) showed raised diastolic blood pressure and poorer academic results after 8 years of continuous stimulants versus other children with ADHD behaviours who had minimal or no medication. But then a confounding factor could be parents who chose not to medicate may have focussed more heavily on non-drug ways of helping concentration etc.

    To parents I talk about stimulants providing windows of opportunity to do non-drug things to help a child who cannot concentrate, and inform parents that we don’t know the long term outcomes. Best to focus the pills just on schooldays alone. But then there are families who don’t cope and family support agencies don’t cope with them either – so yes in the end “ADHD” is in many cases a system-wide societal problem of insecure attachment in insecure nature deficit neighbourhoods submerged in insecure media along with empty carb food and under-exercised bodies with video-game addled, sleep deprived brains, placed in under-resourced or rigidly structured school environments where students cannot just go for a quick run around when they need.

    If there was early in-utero and neonatal brain insults then there is more likely a “real” case of ADHD. Some families pass on a temperament of novelty-seeking energy. But it aint simple. A full biopsychosocial perspective must accompany this rather simplistic 4-letter acronym.

  12. Has anyone tried background music of various types instead of Ritalin in a classroom setting.
    We all use it in our offices when doing non patient contact work, it easily replaces caffeine and junk food.
    Declaration of interest – I am an avid listen of Classic FM in the UK.
    Is it worth an cohort RCT or before and after study?