A Critical Thinker’s Views on ADHD and the DSM

By Philip Hickey, Ph.D.
May 2, 2012

The November/December issue of The National Psychologist carried an article by Dathan Paterno, Psy.D., called “A divergent view on ADHD,” an interesting piece in which Paterno expressed the view that ADHD is not a brain illness, but rather “…a set of skills that needs to be trained.”

He also stated that the most likely cause was ineffective parenting.

Predictably, the article attracted some negative comment. In the January/February issue there were two critical replies — one from Myles Cooley Ph.D.; the other from Jan Nix, Ph.D.

The letters are very similar. Both castigate Paterno in scathing terms and pour censure on The National Psychologist for daring to print such material! What’s interesting is that Cooley’s and Nix’s letters read more like dogmatic refutations of heresy than a scientific discussion.

In addition, Cooley cites the 2002 International Consensus Statement on ADHD (PDF). I took a look at this, expecting to find something learned and scholarly.

Instead, it is little more than dogmatic condemnation of “heresy” signed by 86 mental health professionals. A spurious document signed by 86 individuals is still a spurious document. Cooley makes no mention that the so-called Consensus Statement has been criticized at least twice in the peer- reviewed literature by a total of 36 authors at least as eminent as the 86 Consensus authors. (A critique of the International Consensus Statement on ADHD, Timimi, S., Moncrieff, J., et al, 2004, and Does the International Consensus Statement on ADHD Leave Room for Healthy Skepticism? by Jureidini, J., Taylor, D.C., 2002). It has also attracted negative comment from David Cohen, Ph.D., (professor of Social Work at Florida International University, Miami) and D.B. Double, a British psychiatrist (consultant psychiatrist Norfolk and Suffolk NHS Foundation Trust and honorary senior lecturer Norwich Medical School, University of East Anglia).

Even a cursory reading of the so-called Consensus Statement suggests not only that the authors are blatantly partial to the bio-pharma viewpoint, but also — and more importantly — missed the central issue. They labor the point that ADHD “exists.” Nobody is arguing that ADHD does not exist. Of course children misbehave in these ways. The question is: How do we conceptualize this misbehavior?

People of an evangelical persuasion conceptualize it as sin: Moral laxness in the family has allowed the devil to enter and the child lacks the moral stamina to resist temp- tation, which leads to this kind of misbehavior.

People who accept the ontological status of the APA’s so-called diagnoses conceptualize the misbehavior as an illness — not an ordinary illness, mind you — but rather a mental illness. Within this group there exists a growing subgroup that conceptualizes the misbehavior specifically as an illness of the brain.

And, of course, there are behaviorists, like myself, who conceptualize this misbehavior as behavior — pure and simple. We seek explanations within the framework of stimulus, response, reinforcement, etc. — the same framework that helps us conceptualize and understand behavior generally.

I’m not suggesting that one way of conceptualizing this misbehavior is as good as another. Far from it. In my view the behaviorist perspective is the most parsimonious, the most elucidative and the most supported by the evidence.

The “mental-illness-that-morphed-into- a-vaguely-defined-neurological-illness” explanation has in fact no explanatory value. Consider the following hypothetical conversation:

    Parent: “Why is my child so restless and inattentive?”

    Psychiatrist: “Because he has an illness called ADHD.”

    Parent: “How do you know he has this illness?”

    Psychiatrist: “Because he is so restless and inattentive.”

The reasoning is entirely circular. The only evidence for the “diagnosis” is the very behavior it purports to explain. The posited neurological deficits would, of course, break the circularity, but in order for us to take this seriously, advocates of the neurological illness theory need to come up with a neurologically-based diagnostic procedure. So far, there is none.

Another flaw is highlighted by the question of faking. If I wanted to fake pneumonia, I might read up on the symptoms, then go to an emergency room and report these symptoms, perhaps cough a little, etc… and the staff there would probably take me very seriously. But they would also order some lab tests, monitor my vital signs, etc., and after a while they would come back to me and tell me that I didn’t have pneumonia.

Contrast this with ADHD. If a parent coaches a young child to emit the items on the APA’s checklist, and the child emits these behaviors on a fairly regular basis — then the child has ADHD. All of the criteria for ADHD are behaviors. There is no deeper etiology that can distinguish “genuine” cases from fakes. In fact, the distinction is meaningless. Here again, a definitive neurological test would resolve this problem, but despite active promotion of the neurological illness concept for the last 30 years, there is still no test. As long as all the criteria for this so- called diagnosis are behavioral, the most reasonable place to seek its cause is in the behavioral dynamics of the child and his significant others.

One could critique the illness concept, indeed the entire spurious DSM nosology, at length. But the point I wish to make is that Paterno’s ideas are perfectly reasonable — more reasonable than the illness theory — and The National Psychologist should be commended — not censured — for printing them. Indeed, there is widespread and growing opposition to the American Psychiatric Association’s (ApA) medicalization of virtually all human problems.

A front page story in the January/February issue of The National Psychologist reported significant opposition among the American Psychological Association and the British Psychological Society to the proposed DSM-5 changes, opposition aimed directly at the medicalization question.

What’s particularly interesting is that it has taken the APA and the BPS so long to identify and engage this issue. The spurious and increasing medicalization of ordinary human problems has been going on since DSM-II and received its major acceleration from the ApA’s definition of a mental disorder in DSM-III: “…a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress … or disability … or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.” (DSM-III; xxii)

If you read it carefully, what this actually says is: any significant human problem. The ApA has been building its sandcastle on this spurious foundation ever since, and the APA and the BPS have been walking lock-step. I’m glad to see the development of some opposition, however belated. But the issue is not DSM-5. The issue is DSM, with its bogus diagnoses, the only purpose of which is to legitimize the drugging of an ever-increasing segment of the population.

A check on ProPublica (http://projects.propublica.org/docdollars/) reveals that Russell Barkley, Ph.D., lead author of the so- called Consensus Statement, received just under $80,000 in consulting and speaking fees from Eli Lilly in 2009 and that at least 11 other authors were receiving significant sums from pharmaceutical companies between 2009 and 2011.

Dogma and vituperative condemnation are the true enemies of genuine understanding. We are fortunate to have a newspaper that prints opposing positions. DSM, with its medicalization of all human problems, has become a destructive Juggernaut in our society and owes its success in large part to the blind obedience of its adherents and their willingness to stifle voices that refuse to sing along.

Philip Hickey, Ph.D., is a retired psychologist. He has worked in prisons, addiction units and community mental health centers. He may be reached by email at phil.hickey1@gmail.com. He blogs at: http://behaviorismandmentalhealth.com.

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