DSM-IV diagnostic criteria
Critique of DSM-IV Criteria in regard to decline of symptoms with age (Barkley,
More recent material: Other
Perspectives (Intro Page) Neurological Model
Drug Reactions (Breggin) Barkley's Model
Editor's Note, December 26, 2011:
I strongly urge the reader to obtain a copy of Anatomy of an Epidemic,
by Robert Whitaker. It provides overwhelming evidence, citing many
large studies done in the
U. S. and other nations, that drug treatment for psychiatric disorders
tends to worsen mental illness, and to turn brief, treatable episodes into
chronic mental illness.
January 2, 2002
I am adding some new material to the Turnertoys presentation on
ADHD, focusing on the theories of Russel Barkeley, Professor of
Neurology and Psychiatry at the University of Massachussetts Medical
Center. He takes pretty the opposite position to that of Peter
Breggin (for whom I provide sources and links below). Breggin sees ADHD
primarily as a normal response of children to the situations in which they
find themselves, as well as a symptom of a society that finds it easier to
control children chemically than try to understand why they behave as they
do, and also a result of faulty and indescriminate diagnosis.
Barkley has elaborated a theory of ADHD as a neurophysiological deficit in
children afflicted with it, and has defined the identifying symptoms in a
formal, theoretical way. Below are my discoveries in the literature and my
speculations as of a year ago.
4/22/06: This material is now embarassingly out of date, pending addition of
material already written. Maybe you shouldn't read it. Check back in a month
(year?) or two or three.
11/29/2009: I have found studies (in 2005-2008) while reading to prepare some
other writing that indicate a very large effect of intrafamilial conflict
on ADHD-like behaviors* in children. I have also had a little
experience treating children whose parents claimed that the kids were
hyperactive, hard to control, and could not focus. The parents in each of
these cases were separated and engaged in warfare with each other at long
distance, using the children as proxies. When the parents were convinced to
stop exposing their children to these conflicts, and aided in this by family
members who acted as go-betweens, or in 2 cases, by learning to behave
civilly in each other's presence and parent cooperatively, the change in the
behavior of the affected kids was so rapid as to seem magical.
*Since it is unlikely that there is anything like a unitary and distinct
syndrome of symptoms and causes that might be treated as a single diagnostic
entity called "ADHD", I have taken to referring to the
"disorder" simply as ADHD-like behaviors.
Click here for some new material
November 12, 2000
I have been wondering for some time: How can this "disease" have emerged from nowhere in such a
relatively short time? Is there an organic basis, involving, say, a newly
evolved or prevalent pathogen (such as HIV), or a toxin in the environment
we didn't have before? Is there something new in the child's environment we
are seeing but not recognizing as a factor? Were there such numbers of
messed-up kids all along, and we are just getting better at finding them?
Has a new industry emerged from a group who saw the market potential, and
who succeeded politically in establishing themselves? Has society's
definition of acceptable behavior changed, along with a loss of traditional
protocols for socializing children?
I was briefly involved in this area in 1971, when I was asked to
evaluate the use of amphetamines to treat a 10-year-old girl at a
residential institution where I worked as a psychologist. It was a rare
diagnosis then, but in 2000, ADHD could fairly be called an
With this article, I am beginning a series on ADHD, which will, I hope, grow
into a reference work of a scope similar to the section on PVC on this
website. I would like to try to make some sense of this, and I invite
you, our readers, to share whatever information I uncover. We will
certainly become more confused before we are enlightened. This will
take a while.
A Brief History (Another perspective
- new materials)
In the 1960's, some children were diagnosed as Hyperkinetic, Hyperactive, or as
having Minimal Brain Disfunction. Symptoms were impulsivity, poor attention
span, social difficulties, and excessive motor activity. It was a rare
diagnosis, and no scientist or clinician claimed to know the cause, although
many suggestions were put forward. By the early 1970's, 100,000 to 200,000
children were diagnosed with some variant of this problem, and were being
treated with drugs. Still, no one had any idea exactly what the disorder was. It
was found that stimulant drugs such as methylphenidate (Ritalin, Concerta, and
Metadate) or forms of amphetamine (Dexedrine and Adderall) could control the
symptoms in a small minority of children. Scientists admitted frankly that
there was no agreement concerning causal factors, or even precise diagnostic
criteria. If the child responded well to medication, he had the disorder;
if he responded poorly, he did not. Presenting symptoms were likely to be the
same in either case.
By the mid-1980's, the cluster of symptoms was being officially referred to
as ADHD, and diagnostic standards had been formalized in the American Psychiatric
Association's (APA) Diagnostic and Statistical Manual of Mental Disorders,
3rd ed. (DSM-III). In 1995, 10 to 12 pecent of all boys between the ages of 6 and
14 in the U.S. were diagnosed with ADHD and were being treated with Ritalin.
Presently, the diagnostic standards are those found in DSM-IV,
published in 1994.
The number of children diagnosed and treated for Attention Deficit
Hyperactivity Disorder now stands at about 5 million, according to one estimate.
A study in North Carolina found that 10% of children were receiving stimulant
drugs at home or in school. As many as 15% of boys between the ages of 6
and 14 in the U.S. have been diagnosed with ADHD and are receiving drug
therapy. The United States now consumes about 90% of world Ritalin
Three variations of ADHD are diagnosed:
Hyperactive-impulsive, affecting primarily boys; Inattentive, which includes a
higher percentage of girls; and combined.
The question has arisen concerning whether the use of
prescribed stimulants predisposes kids to later drug abuse. According to
Dr. Peter Breggin, Director of the International Center for the study of
Psychiatry and Psychology, Methylphenidate, amphetamine, and cocaine affect the
same neurotransmitter systems, and so use of Ritalin and similar drugs may
result in use of illegal stimulants. Nadine Lambert
has conducted research which showed that ADHD children medicated with stimulants
are more likely to start using illegal drugs than are other children.
However, a study by Biedermans, Wilens, et al
found that medication for ADHD reduced the likelihood of later substance abuse.
Letting young people speak for themselves in this matter (personal anecdotes
from young acquaintances), it is quite clear that Ritalin, at least, has become
a fashionable drug of abuse, although in some cases in a new and strangely
disciplined fashion. An
interesting article at a student-run website...
From November 16-18, 1998, the National Institutes of
Health convened the Consensus Development Conference on Diagnosis and
Treatment of Attention Deficit Hyperactivity Disorder. The Consensus
Statement (28 sec @ 28k; worth reading!) concluded:
*Although nothing is known regarding causes, ADHD is a real disorder.
*Stimulants, when used in a clinically rigorous and conservative fashion, can,
along with psychosocial therapies (behavior modification, parent training)
yield positive results, as measured in short-term studies.
*Present treatments address only core symptoms, and do little to improve
academic or social outcomes.
*Long-term assessment of the values of various treatments have not been
*There is no data on treatment of the inattentive type of ADHD, which tends to
affect more girls.
*Alternate treatments, ranging from dietary adjustments to
biofeedback, have been tried with various results. (See article
on this - large file, 34 sec @ 28k)
*Since knowledge of causation is only speculative, there are no strategies for
*Wide variation exists among practitioners with regard to diagnosis and
treatment, with primary care physicians diagnosing and prescribing medications
more readily than specialists. Read an example
*Adverse effects of medication are related to dosage.
*No clear neurological or physiological correlates of the disorder have been
identified. Brain scans and EEGs have been inconclusive.
Conclusions (for the time being):
There is probably a real disorder, mediated neurologically if not ultimately
of neurological origin, characterized by a deficiency of attentional control,
which afflicts a very few people. This condition most likely arises in
early childhood, responds to medication, and may be congenital. At
present, the medical and scientific communities have little idea as to
causation. This diagnosis, which properly belongs to this rare disorder,
has become a fashion, and it is applied, along with the treatment of fashion, to
a wide spectrum of behavioral clusters, many of which could not properly be
called symptoms at all, but rather a set of behaviors at an extreme of the
normal range of behavior for children, especially boys. (Read the DSM-IV
criteria with this in mind!) Alternately, behaviors labeled as ADHD are
likely very often to be a child's response to an environment which is highly
stressful, at school, home, or both. It seems intuitive and very
likely that drug companies, physicians, educational and other therapists, and
parents with disturbed or difficult children saw in this vaguely defined
disorder an opportunity to enhance their own self-interest. The result is
a huge cost to society in dollars and possibly permanently damaged children.
CLICK HERE FOR AN ENTIRELY
American Academy of Pediatrics. (2000a). Practice guideline: Diagnosis and
evaluation of a child with attention-deficit/hyperactivity disorder. Pediatrics,
105, 1158-70. Also available at http://www.aap.org/policy/ac0002.html
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders, Fourth Edition (DSM-IV). Washington, D.C.:
Barkley, Russell A (1997). ADHD and the Nature of Self-control (1997).
New York: The Guilford Press.
Breggin, P. (1998). Talking back to Ritalin: What doctors aren't telling
you about stimulants for children. Monroe, Maine: Common Courage Press.
Breggin, P. (1999a). Psychostimulants in the treatment of children diagnosed
with ADHD: Part I: Acute risks and psychological effects. Ethical Human
Sciences and Services, 1 13-33.
Breggin, P. (1999b). Psychostimulants in the treatment of children diagnosed
with ADHD: Part II: Adverse effects on brain and behavior. Ethical Human
Sciences and Services, 1, 213-241.
Breggin, P. (1999c). Psychostimulants in the treatment of children diagnosed
with ADHD: Risks and mechanism of action. International Journal of Risk and
Safety in Medicine, 12, 3-35. By special arrangement, this report was
originally published in two parts by Springer Publishing Company in Ethical
Human Sciences and Services (Breggin 1999a&b).
Breggin, P. (2000). Reclaiming our children: A healing solution for a
nation in crisis. Cambridge, Massachusetts: Perseus Books.
Lambert, N. (1998). Stimulant treatment as a risk
factor for nicotine use and substance abuse. Program and Abstracts, pp. 191-8.
NIH Consensus Development Conference Diagnosis and Treatment of Attention
Deficit Hyperactivity Disorder. November 16-18, 1998. William H. Natcher
Conference Center. National Institutes of Health. Bethesda, Maryland.
Lambert, N., & Hartsough, C.S. (in press). Prospective study of tobacco
smoking and substance dependence among samples of ADHD and non-ADHD subjects. Journal
of Learning Disabilities.
Zito, J.M., Safer, D .J., dosReis, S., Gardner, J.F., Boles, J., and Lynch,
F. (2000). Trends in the prescribing of psychotropic medications to
preschoolers. Journal of the American Medical Association, 283,