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a recent meta-analysis that demonstrated there is no educational/learning benefit for children being treated with psy- chostimulants,” it is completely senseless to risk not only the well-being of the medicated children but the health of the commu- nity of children at large by continuing to permit the indiscriminate distribution of these dangerous drugs. a recent meta-analysis that demonstrated there is no which psychiatry seeks acceptance by medicine in general. educational/learning benefit for children being treated with psy- Insiders know it is more of a political than scientific document." chostimulants,” it is completely senseless to risk not only the Dr Lawrence Diller, discussing the process by which the DSM- well-being of the medicated children but the health of the commu- IV criteria were decided, offers this illustration of how shockingly nity of children at large by continuing to permit the indiscriminate political the process was. "The main study group had determined distribution of these dangerous drugs. that only five of nine symptoms would be required to qualify for a diagnosis of 'ADHD: hyperactive/inattentive subtype' [that is, a Lack of Reliability of Diagnosis ‘combined' version of the disorder]. But then the supervisory The "reliability" of a diagnosis refers to the degree to which it is DSM-IV task force astonishingly overruled this decision and dependable; that is, the degree to which we can rely on the fact increased the number of symptoms required to six! Presumably that the diagnosis will be the same regardless of who is doing the they were concerned that five criteria were too few and might assessment or where the assessment is being done. For example, result in too many children being diagnosed with this type of a broken arm is diagnosed through X-rays and there is a high like- ADD, but the arbitrariness of their action has little to do with lihood that if you visited 100 orthopaedic physicians with the science.""! same X-ray, all 100 would make the same diagnosis. "Broken In Western society, which often deifies physicians, it can be arm" is a highly reliable diagnosis. In contrast, "ADHD" is an truly shocking to people to realise that this popular psychiatric almost completely unreliable diagnosis. diagnosis was invented by a group of folks "There are no objective diagnostic criteria for sitting around the table, not by a group of ADHD—no physical symptoms, no neurologi- scientists discovering something in a cal signs, and no blood tests... No physical test laboratory. can be done to verify that a child has The result of the DSM process is a diagnos- "ADHD'."** tic category, ADD/ADHD, which is completely The suggestion that 100 clinicians would "There are no arbitrary and based solely on behaviours. The likely come to no consensus on a child Foye A F diagnostic criteria raise obvious questions diagnosed by anyone as "ADHD" is borne out objective diagnostic about validity (discussed in the next section), by the shocking differences in international criteria for ADHD— but the description of the "symptoms" is also prevalence rates. "[T]he prevalence of ADHD no physical symptoms, hopelessly subjective and therefore inherently in the UK is generally estimated at 1% or less, no neurological signs unreliable. In order to be diagnosed as having whereas it is at least 10-12 times greater than v ADHD, a child must have either six out of a that in Australia and the US."’ and no blood tests... list of nine symptoms of "inattention", or Shockingly, this means that if you flew 12 six out of a list of nine symptoms of "ADHD" children from Perth to London No physical test can be "hyperactivity-impulsivity". The symp- and had them assessed, the statistical : toms "must have persisted for at least 6 likelihood is that only one would be a done to verify that a months to a degree that is maladaptive "confirmed" diagnosis. Factually, then, child has ‘ADHD"." and inconsistent with developmental level" (italics added). However, there is no objective guideline for assessing the requi- site degree of maladaptation; it is left to the discretion of the individual clinician. Even more outrageous, every one of the 18 "symptoms" of ADHD is qualified by the Even within countries, wide variations word "often". What constitutes "often" in prevalence rates preclude the reliability fidgeting, or "often" having difficulty of the diagnosis. For example, an analysis of the use of stimulant organising tasks and activities? There are no objective guidelines. drugs for ADHD in the US found that "Southern youngsters were To one evaluator, a child who is fidgety every day might seem about 71% more likely than kids in the Northeast or West to get normal; but to another evaluator (perhaps a childless one), a child the "disorder" is either grossly overdiagnosed in the US, Australia and Canada, or grossly underdiagnosed in the UK (and most of the rest of the world). In either case, it is not a diagnosis that can be depended upon; it lacks reliability. the drugs, and Midwesterners were 51% more likely".* fidgeting a great deal on two occasions might constitute "often". A closer look at the diagnostic criteria and an understanding of The reliability problems don't end there. the DSM process highlights some of the reasons for this "Even aside from ‘often’, the rest of the definition is riddled unreliability. Laypeople assume there is some scientific or with ambiguous and vague terminology. Which mistakes are objective process in the identification of disorders. This is ‘careless’ ones? What constitutes being spoken to ‘directly? What typically true in medicine, but it is often not true in psychiatry. constitutes 'difficulty' in organising things? Who decides what The American Psychiatric Association publishes the "bible" of activities require ‘sustained mental effort’? What is ‘easily’ dis- psychiatric diagnoses, the Diagnostic and Statistical Manual, tracted? When does a small movement qualify as a ‘fidget’ or a which is currently in its fourth edition (DSM-IV). An observer at ‘squirm’? Who determines when 'remaining seated is expected’? the 1987 APA DSM hearings made the following disturbing When is running or climbing or talking 'excessive'?"* comment: "The low level of intellectual effort was shocking. Some of the most mainstream US proponents of the medical Diagnoses were developed by majority vote on the level we model of ADHD, believing that it is a valid medical disorder, would use to choose a restaurant. You feel like Italian, I feel like have acknowledged the lack of diagnostic reliability. In 1998, the Chinese, so let's go to the cafeteria. Then it's typed into the National Institutes of Health held a Consensus Development computer." A prominent American psychiatrist, a former chief of | Conference on Diagnosis and Treatment of ADHD and heard the National Institute of Mental Health's Center for the Study of testimony from a number of "experts", virtually all of whom Schizophrenia, put it this way: "DSM-IV is the fabrication upon supported the medical model. At the end of the conference, panel "There are no objective diagnostic criteria for ADHD— no physical symptoms, no neurological signs, and no blood tests... No physical test can be done to verify that a child has 'ADHD"." 14 = NEXUS www.nexusmagazine.com FEBRUARY — MARCH 2005