ADHD Once Again

    Do not think about, write about or deal with  human behavior without determining the effects of incentives. It’s not their money, of course they’ll waste it.

     Wherein we see that an eminent psychiatrist thinks psychotropic medication is a swell idea for others but not for his son.

The Inherent Unreliability of the ADHD Label
By Philip Hickey, PhD

I imagine that everybody on this side of the issue knows by now that the eminent psychiatrist Jeffrey Lieberman, MD, Chief Psychiatrist at Columbia, and past President of the APA, called Robert Whitaker "a menace to society."

This outburst of petulance – the latest in a string of similar deprecations – occurred on April 26, 2015 during an interview with Michael Enright on CBC (Canadian Broadcasting Corporation) radio’s "The Sunday Edition."  The grounds for Dr. Lieberman’s vituperation were that Robert had dared to challenge some of psychiatry’s most sacred tenets!

In the subsequent discussion, it was noteworthy that nothing emerged that would justify characterizing Robert as a menace to society, and the general consensus seemed to be that the eminent doctor was just having one of his little rants.

But in all the furor, it was largely ignored that, in the same interview, Dr. Lieberman had said something else, which in my view warrants additional discussion.  He was conceding the general point that sometimes people are given prescriptions for psychiatric drugs needlessly.  This is at about minute 25:35 on the recording.  Michael Enright asks:  "you could be over narcotizing?", and Dr. Lieberman replies:

"Absolutely.  I had an experience with my own son.  I have two sons.  My older son was going to nursery school, and they said he’s not paying attention and were concerned.  ‘You should have him tested.’  We had him tested.  The neuropsychologist said, ‘Well there’s some kind of, you know, information processing problems, you should see a pediatric psychiatrist.’  I said, "Well, I am a psychiatrist, but I’ll take him to see a pediatric psychiatrist.’  We took him to see a pediatric psychiatrist, spent twenty minutes with him, and he started, you know, writing a prescription for Ritalin.  I said, ‘Why?’ and he said ‘Well, he’s got ADHD.’   I said, ‘I don’t think so.’

So, long story short, he ended up graduating from University of Pennsylvania, law school at Columbia, he’s in a top law firm.  So, yes, it happens, and part of that is social pressure."

I could not find a transcript of the interview, so I made the above transcript myself, and I have checked it several times for accuracy.  In reading the passage, five points come to mind.

Firstly, the "diagnosis" was made in twenty minutes.  This is not actually surprising.  In my experience it is pretty much the norm.  But for years, Dr. Lieberman has been extolling the professionalism and thoroughness of psychiatry, but nevertheless, dropped this admission into the interview without comment or criticism.

Secondly, Dr. Lieberman, as an eminent psychiatrist, had no difficulty resisting the pressure to accept the prescription.  For many families, this is not the case.  Indeed, during my career, I worked with a number of parents who had been threatened with child custody suits if they didn’t get their child examined by a psychiatrist and "on Ritalin."

<insert>

    Giving drugs to children is so ingrained in the culture that failing to conform to the norm is regarded as punishable by jail. Diagnosed in nursery school—seems a bit early.

Similar pressures exist with children in foster care.  If the child displays any kind of problem behavior, including distractibility/over-activity, a psychiatric consultation is mandated, a prescription is written, and there is no one to speak up for the child, or to challenge what is being done.

Thirdly, I think it’s noteworthy that Dr. Lieberman rejected the prescription.  If ADHD is an illness, and a licensed pediatric psychiatrist diagnosed this illness, and the same licensed pediatric psychiatrist wrote a prescription, shouldn’t Dr. Lieberman have played it safe and given his child the pills?  After all, they’re safe and efficacious!  Surely it would have been wiser to play safe rather than risk depriving the child of needed medication.  Or could it be that Dr. Lieberman’s faith in the efficacy and safety of these products stopped short of actually giving them to his own child?

Is Dr. Lieberman aware that many parents who refuse psychiatric "medication" in this way are reported to Social Services for neglecting the child’s medical needs?

Fourthly, Dr. Lieberman’s son was "diagnosed with ADHD" by a pediatric psychiatrist while in pre-school, but didn’t take the pills.  Nevertheless, he graduated from Columbia law school and is now an attorney at a "top law firm."  That’s food for thought.

Fifthly, and most importantly, Dr. Lieberman’s disagreement with the pediatric psychiatrist highlights one of the major weaknesses in the psychiatric system: its intrinsic unreliability and subjectivity.

Let’s take a look at what Dr. Lieberman and the other psychiatrist were disputing.  Obviously I don’t know when this interaction occurred, but if we put it around 1990, then DSM-III-R  would have been in force.  Here are the criteria for ADHD from that manual (p 52):

    A disturbance of at least six months during which at least eight of the following are present:
        Often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)
        Has difficulty remaining seated when required to do so
        Is easily distracted by extraneous stimuli
        Has difficulty awaiting turn in games or group situations
        Often blurts out answers to questions before they have been completed
        Has difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension), e.g., fails to finish chores
        Has difficulty sustaining attention in tasks or play activities
        Often shifts from one uncompleted activity to another
        Has difficulty playing quietly
        Often talks excessively
        Often interrupts or intrudes on others, e.g., butts into other children’s games
        Often does not seem to listen to what is being said to him or her
        Often loses things necessary for tasks or activities at school or at home (e.g., toys, pencils, books, assignments)
        Often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking

Note:  The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-III-R criteria for Disruptive Behavior Disorders

   2. Onset before the age of seven.

3. Does not meet the criteria for a Pervasive Developmental Disorder.

Note:  Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.

My Random House Webster’s College Dictionary gives the following meaning for the word criterion:  "a standard of judgment or criticism; a rule or principle for evaluating or testing something."

Even a cursory glance at the APA’s criteria shows that they are entirely unsatisfactory for this purpose.

Take the first item from the list:  "often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)"  There are several factors that prevent this item from serving as a criterion in the above sense of the term.

Firstly, children’s behavior (and indeed adults’ behavior) varies from time to time and from place to place.  A child might, for instance, be fidgeting in one classroom and not in another; or only in the period immediately preceding lunch.  Where and when should the rating be made?

Secondly, the word "often", which occurs also in seven other items, is not operationally defined and will inevitably mean different things to different people.  An "old-fashioned" person who believes that children should sit still and pay attention, might consider one or two squirmings excessive; while a more liberal teacher might set the bar a good deal  higher.

And how in the world can anyone reliably assess an adolescent’s "subjective feelings of restlessness"?

Similar observations can be made about all the items.

The point here is:  what were Dr. Lieberman and the pediatric psychiatrist disagreeing about, and how could such a disagreement be resolved?  The other psychiatrist might have said:  "your son is easily distracted by extraneous stimuli";  or:  "your son often talks excessively".  Dr. Lieberman could reply:  "no he isn’t"; "no he doesn’t".  And that’s it.  There is no way to objectively resolve such a dispute.  There is no fact or observation to which one or other of the parties could point, that would clinch the matter. And that’s a fundamental problem, because ultimately all psychiatric "diagnosis" is tainted by this kind of subjectivity.  In the final analysis, a person "has a mental illness" because a psychiatrist says so!

In the situation described by Dr. Lieberman, apparently his view prevailed, and from his statements in the radio broadcast, it is clear that he believes his view was correct.  But this is a meaningless position, because the only criteria that exist to resolve the disagreement are inherently unusable for this purpose.  Nor is DSM-5 any better.  This latest edition of the manual contains 13 of DSM-III-R’s 14 "criteria" (with some minor verbal changes), and some additional items which are no less vague.

What Dr. Lieberman apparently took from his interaction with the pediatric psychiatrist  is that sometimes pills are over-used.  But the message he should have taken was that what psychiatrists call ADHD is nothing more than a loose collection of vaguely-defined behaviors, whose purpose is to foster psychiatry’s self-serving hoax that these behaviors constitute an illness, which requires it to be "treated" with stimulant drugs.

<end>

   I guess the “illness” disappeared sometime after kindergarten.

Government Job or Respect–Which’ll It Be?
Cheerio and ttfn,
Grant Coulson, Ph.D.
Author, “Days of Songs and Mirrors: A Jacobite in the ‘45.
Cui Bono–Cherchez les Contingencies

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