The Scientific American recently published an article suggesting that “cognitive and behavioral therapies that help young people reduce impulsivity and cultivate good study habits are costlier and take longer to administer [than ADHD drugs], but may be more efficacious over time”.

The article states;

A new synthesis of behavioral, cognitive and pharmacological findings emerged at the recent Experimental Biology meeting, held last month in San Diego, where experts in ADHD research and treatment gathered to present their work. Their findings suggest that behavioral and cognitive therapies focused on reducing impulsivity and reinforcing positive long-term habits may be able to replace current high doses of stimulant treatment in children and young adults…

Psychologist Claire Advokat of Louisiana State University has been looking at the effects of stimulant medications in college students to see what improves with medication and what does not. As expected, she found that people diagnosed with ADHD had lower grades and ACT (American College Testing) scores; they also dropped more classes than their peers. But she also found that these issues were not improved by stimulant medication treatment.

Instead, Advokat’s new findings indicate that the ADHD students naturally divided into those who had good study habits and those who did not, regardless of treatment. If students had good study habits, they did not need the medication to bolster their grades.

(The full article is available at http://www.scientificamerican.com/article.cfm?id=adhd-behavioral-therapy-more-effective-drugs-long-term&WT.mc_id=SA_CAT_MB_20120516 )

Temporarily putting aside concerns with the validity of ADHD as a diagnosable disorder, I welcome the long overdue recognition of what should be obvious. That is, cheap and messy drug interventions may immediately alter behaviour but there are no chemical short cuts to long-term academic success.

The following is an opinion peice by Professor Allen Frances first published in the New York Times on 12 May 20012  

At its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder.

But the association is still proceeding with other suggestions that could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal. The proposals are part of a major undertaking: revisions to what is often called the “bible of psychiatry” — the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. The fifth edition of the manual is scheduled for publication next May.

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.

Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.

D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.

Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.

The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.

Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.

New diagnoses in psychiatry can be far more dangerous than new drugs. We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance. No existing organization is ready to replace the American Psychiatric Association. The most obvious candidate, the National Institute of Mental Health, is too research-oriented and insensitive to the vicissitudes of clinical practice. A new structure will be needed, probably best placed under the auspices of the Department of Health and Human Services, theInstitute ofMedicine or the World Health Organization.

All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.

Allen Frances is a former chairman of the psychiatry department at Duke University School of Medicine and led the task force that produced D.S.M.-4.

A version of this op-ed appeared in print on May 12, 2012, on page A19 of theNew Yorkedition with the headline: Diagnosing the D.S.M..

http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html

Martin Whitely’s comment – Sharing the development of DSM5 as Allen Frances suggests could improve the process and moderate some of the excesses proposed for DSM5. All of that is good for American mental health consumers, however there is a more fundamental question that needs to asked in Australia. Why do we continue to follow America’s lead? Are mental health outcomes in the U.S. good enough to justify our continued devotion to the DSM model? Or is it time to go it alone? (For more on this topic see my blog for Australia Day 2011 at http://speedupsitstill.com/australia-day-question-why-slavishly-follow-american-psychiatric-association ) 

On May 2, 2012, the American Psychiatric Association announced changes to its proposed DSM5.¹  Psychosis Risk Syndrome, or as it was officially proposed to be called, Attenuated Psychosis Syndrome, has been dropped. This is great news because as has been highlighted on this website numerous times, Psychosis Risk Disorder was a flawed concept with the potential to be an iatrogenic health disaster. (Note: In coming weeks I will write an extended blog describing the history of Psychosis Risk Disorder and how this disaster was averted)

In addition most of the dangerous changes proposed for the already absurdly broad ADHD diagnostic criteria have been abandoned.  An additional four alternative ADHD criteria had been identified for inclusion in the DSM5. They were:

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).²

It is good news that these ridiculous additions have been removed along with the extremely worrying proposal to lower the bar for anyone over 16 years so that exhibiting 4 criteria of a subtype instead of 6 could be enough to get a diagnosis of ADHD.  However, the existing 18 diagnostic criteria have been reworded to be equally applicable to adults as well as children, reflecting the ADHD industries persistent and successful efforts to expand the adult market. (The revised proposed criteria are listed at the end of this blog)³

Another remaining concern is the proposal for an ADHD category titled Attention Deficit/Hyperactivity Disorder Not Elsewhere Classified must be removed.  This additional category reads: Attention Deficit/Hyperactivity Disorder (ADHD) Not Elsewhere Classified may be coded in cases in which the individuals are below threshold for ADHD or for whom there is insufficient opportunity to verify all criteria. However, ADHD-related symptoms should be associated with impairment, and they are not better explained by any other mental disorder.⁴ The inclusion of this additional category effectively enables clinicians to diagnose and prescribe without even the flimsy protection offered by the already extremely broad DSM4 diagnostic criteria. It cannot be allowed to stand unchallenged.

Continue reading “DSM5 Rollback Begins – Psychosis Risk Disorder gone and the revised proposal for DSM5 ADHD criteria not quite as horrific” »

A review of the medical records of 937,943 Canadian children showed that children born in December, the last month of their school year intake, were much more likely to be diagnosed and medicated for ADHD than their classmates born in January.

The eleven year study of British Canadian children aged six to twelve, titled Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children¹, confirms the ADHD late birthdate effect found in two recent smaller US studies described in my previous blog post.

The late birthday effect in the massive new Canadian study was very significant. Boys who were born in December were 30% more likely to have a diagnosis and 41% more likely to have a prescription for ADHD than their peers born in January.

The effect was even stronger for girls.  Girls born in December were 70% more likely to have a diagnosis and 77% more likely, to have a prescription for ADHD than their peers born in January.

British Columbia children exhibited the general worldwide trend that ADHD diagnosis and prescribing rates for boys are approximately three times greater than for girls.²  This is consistent with the traditional wisdom that girls grow up faster than boys.

Drugging boys to make them behave more like girls in class demonstrates just how empty modern educational ‘philosophies of inclusion’ are.  But many girls are also chemically punished for their childishness when compared to their older classmates.

Obviously younger children are more likely to be immature with the youngest kindergarten children having 20% less life experience than their oldest classmates. However, it should not be lost that children develop at different rates.

If a child is less mature than other children their own age, or even younger, they are not diseased, they are different.  Classing relative immaturity as a disease to be treated with amphetamines, is a barbaric abuse of a child’s right to grow at their own pace.

If, as the ADHD Industry frequently claims, ADHD is a neurobiological disease, a child’s birth date should have no bearing on their chances of being diagnosed and ‘medicated’.  Yet the ADHD Industry will respond as it always does and ignore or spin yet another inconvenient truth revealed in this study.

 Related Media:

Martin Whitely interviewed by Greg Carey, Radio 4BC, Brisbane 20 March 2012. http://www.4bc.com.au/blogs/4bc-blog/adhd-misdiagnosis/20120320-1vh3e.html

Sue Dunlevy, Immature Children prone to ADHD Tag, The Australian, 20 March 2012 http://www.theaustralian.com.au/news/health-science/immature-children-prone-to-adhd-tag/story-e6frg8y6-1226304525855

For more related information see Pseudoscience supporting ADHD and How is ADHD Diagnosed?

The world’s most popular independent online news service, The Huffington Post, recently published two significant blogs suggesting that Western Australia and France offer lessons on how to tackle the global ADHD epidemic.

Taming the ADD Epidemic

The first co-authored by Emeritus Professor of Psychiatry at Duke University and the former chair of the DSM-IV development task force Doctor Allen Frances and myself was titled Taming the ADD Epidemic. (available at http://www.huffingtonpost.com/allen-frances/add-epidemic-_b_1293556.html)

The blog outlines the experience of Perth, Western Australia, the world’s first ADHD hotspot to see a massive downturn in child prescribing rates.  It describes how the implementation of tighter prescribing accountability measures that I advocated were followed by a 60-70% fall in Western Australian child ADHD prescribing numbers¹ and a 51% fall in self reporting of teenage amphetamine abuse.²

Dr Frances kindly concludes, “There are two potential tools that would allow us to tame the current ADD fad: 1) narrowed and more carefully applied diagnostic criteria and 2) rigorous quality controls over stimulant prescription. DSM-5 will lead us in just the wrong direction on the first; Mr. Whitely shows us the way on the second.”

Why Bébé (French for Baby) Doesn’t Have ADHD

The second by family therapist and author Marilyn Wedge, Ph.D.  offers her theory as to why in the ‘United States, approximately 5 percent of school-aged children have been diagnosed with ADHD and are taking pharmaceutical medications. [Where as] In France the percentage is a mere 0.05 percent.’  (available at http://www.huffingtonpost.com/marilyn-wedge-phd/adhd_b_1310973.html )

Continue reading “Huffington Post looks to Western Australia and France for the way forward on ADHD” »

Western Australian Mental Health Minister Helen Morton has released draft legislation that would please the One Flew Over the Cuckoo’s Nest fictional Nurse Ratched. 

Under the laws proposed by Minister Helen ‘Ratched’-Morton.

• Children as young as 12 may be able to consent to Psychosurgery, ECT and Sterilisation (without parental permission).
• Social workers, Occupational Therapists, Registered Nurses, Midwives and other authorised Mental Health Practitioners (with minimal mental health training) may be able to detain and treat people suspected of having a mental illness for up to 3 days (potentially a week under certain circumstances).
• Police will be able to apprehend any individual they suspect of having a mental illness and of being a danger to themselves, the public or property, enter any premises, conduct body searches and seize any articles from the individual suspected of having a mental illness.

The legislation places the burden of proof on patients to prove they are well, rather than on authorities to prove they are ill.  It provides inadequate protections to vulnerable individuals and often reverses the responsibility to prove a case from the “judge come jailer” to the “jailed”.

A copy of my submission opposing the legislation is below. The draft legislation is available at Draft_for_Mental_Health_Bill_2011_v3.sflb.ashx  and the Western Australian Mental Health Law Centres submission is available at http://www.mhlcwa.org.au/frms/HealthBill.htm

  Continue reading “12 year olds to consent to Psychosurgery, ECT and Sterilisation (without parental permission) under proposed Western Australian laws” »