A Matter of Personality

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Immaturity Is Now Officially a Disease

None Dare Call It Acting Out, Part II

Acting out
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In the beginning of Part I of this series, I looked askance at a recent newspaper headline claiming, "Survey: 1 in 10 U.S. children has ADHD." ADHD, of course, already has the longest history of any psychiatric disorder in terms of its basic validity being questioned; and not just by virulent anti-psychiatry nut-jobs like Tom Cruise, but by many in the field as well as people in all walks of life. Although it is probably true that there are children who do have brain pathology that causes the symptoms of ADHD, at the very least the condition is obviously way over-diagnosed. I am hardly the only one around who thinks that.

To review some definitions: The DSM (the diagnostic Bible of psychiatry) describes two sets of symptoms, or two subtypes if you like, that qualify a child (or an adult) for the diagnosis of Attention Deficit Hyperactivity Disorder. The first type is the inattentive form of the disorder. Such individuals are said to be often making careless mistakes on schoolwork, having trouble paying attention and listening when spoken to, not finishing assignments or chores, having trouble organizing and making a mental effort, losing things needed for tasks and activities, and being easily distracted.

The second type, hyperactive-impulsive type, are those who are often fidgeting, getting up from their seats when they should not, running or climbing inappropriately, having trouble playing quietly, acting as if on the go, talking excessively, blurting out answers to questions, having trouble waiting their turn, and interrupting and intruding upon others. 

The first problem with this formulation that jumps off the page is that the word often is not defined precisely. What percentage of the time does a child have to exhibit this behavior  What if the child exhibits the behavior in one context but not another? Should that count? It's entirely up to the clinician. They can set the bar as high or as low as they want to. Contrast that with the definition of a major depressive disorder, in which symptoms must be present almost all day almost every day (regardless of what is going on in the patient's environment) for at least two weeks. This still leaves some wiggle room because of the word almost, but it is far more precise.

The question of the environmental context in which symptoms occur, which is seriously under-evaluated by clinicians who frequently make the diagnosis of ADHD, is a very serious omission from the DSM criteria. For decades those physicians who think we need to diagnose this condition even more often than it already is have voiced the repeated mantra that when an allegedly ADHD child is in a video arcade and is able to focus intently on the game, with distracting buzzers bells and lights going off all over the place and throngs of other people walking all about in different directions, that the child's focus on the game in this situation is not the same thing as "concentration."  Really?

Leaving aside the fact that children diagnosed with ADHD are often able to demonstrate concentration in a variety of other environmental contexts, if what the child is doing at the arcade is not concentration, then what, pray tell, is it? Advocates for this point of view may say that concentration on video games is different than other forms of concentration because the flickering screen has hypnotic properties and the individual therefore goes into an altered mental state, but that is complete conjecture. 

Different brain parts are involved in different activities during the period in which concentration is maintained. If you are concentrating while reading a book, different parts of the brain will light up on a PET scan than if you are concentrating on an audiotape of the same material being read aloud.  That does not prove that retaining one's focus is a completely different skill in these two cases, although an individual can be naturally better at it in one context than the other. What scientific evidence do individuals making the patently absurd assertion that the child in a video arcade is not concentrating have to back it up? I will tell you: There isn't any. They just made it up. Repeat a lie often enough, and it becomes accepted as the truth. 

What about the DSM criteria of not following instructions and failing to finish work assignments. The DSM says that this behavior must not be due to "oppositional behavior."  How one can tell for certain whether or not a child who is not following instructions or finishing homework is being oppositional, one can only guess.

All of the characteristics of DSM ADHD are exhibited by almost all children naturally at one time or another.  If they have a lot of them frequently, their behavior may easily be due to their being chronically anxious or upset.  Disturbed and unhappy kids often have trouble sitting still.  Children who come from families with highly inconsistent and/or frankly abusive discipline can and often do show all of these symptoms much of the time.  Acting out, as defined it in Part I of this post, is a phenomenon well known to psychoanalysts and family therapists alike. 

I once read in a psychiatric newspaper that the symptoms of ADHD were indistinguishable from the behavior of children who are at the high end of the normal bell shaped curve for innate activity level.  The author advised that the following criteria be applied: Anyone who seemed to be in the top five percent on this curve should be considered to have ADHD.  That is like saying that all players in the National Basketball Association should be diagnosed with the disease acromegaly, an excess production of growth hormone, because they are all so tall.

Sometimes a single clinical anecdote, although possibly valid for only that case, can be an exception that brings a rule into question.  Actually, I have heard many clinical anecdotes that indicate that clear acting out or anxiety in children is easily and often confused with ADHD.  In this particular example, a colleague discussed a child he had treated for ADHD who had all of the symptoms of the disorder.  The problem behavior was pervasive, persistent, and prominent, and led to significant school impairment.

The child was treated with a stimulant, and had an excellent response.  He calmed down considerably.  Then, the child and his mother disappeared for over a year from my colleague's practice.  They then returned as suddenly as they had disappeared.  The mother asked that the child again be put on the stimulant, because the child was showing all the same symptoms.  The doctor asked what had happened during their absence from his clinic. 

The mother said that she had moved out of state.  Knowing the importance of follow-up questions, my colleague inquired about whether the child was treated with the medication by another doctor in the state she had moved to.  She replied that the child had not needed to take anything.  He had been calm and doing quite well in school without medication the entire time they were away.  The symptoms had only arisen again when they had moved back. 

On further questioning, the mother told a hair-raising story of their ultra-violent living situation in my colleague's town.   She had left the bad situation when she moved, and returned to it when she moved back.  The child's symptoms appeared in the violent context, but not when he was removed from that situation.

Note that the mother did not even tell the psychiatrist what was really going on in their home until confronted with two quick and drastic changes in the level of the child's symptoms.  While the medication was helpful in this case, clearly the horrific environment in which this child found himself - one that would over time create for this child far more problems than just trouble sitting still - needed to be addressed.  It was far more important than the child's symptoms. The fact that "biological" psychiatrists often have no time to even ask about environmental issues is nauseating. 

This type of clinical anecdote shows, assuming that the child did indeed have all of the symptoms of ADHD, that one of three things must be true.  First, the doctor may not have applied the appropriate diagnostic criteria.  I have no reason to think so in this particular case.  Second, perhaps no doctor can tell from symptoms alone if ADHD behavior is due to an underlying disorder or is a reaction to a discordant family environment.  The third possibility is that the underlying disorder itself is really in most cases a normal psychological reaction to a problematic environment.

So what does the recent literature say?  Well of course I will cherry pick studies somewhat, but these particular studies raise very serious questions indeed.

For instance, we now have very strong evidence that immature kids are more likely to be diagnosed with ADHD than mature kids.  If accurate, I guess we now have definitive evidence that immaturity is now officially a disease.   Unfortunately, the two articles I am about to describe appeared in a relatively obscure journal, the Journal of Health Economics, so they were not widely publicized.

In these two studies that show rather dramatically that immaturity is very likely being mislabeled as ADHD, both found nearly identical data about the diagnosis of ADHD in school children. In these articles, two independent  research groups (Evans, Morrill, & Parente, 29, 2010 657-673; Elder, 29 2010, 641-656) used four different data sets in different states.

They compared the rate of diagnoses of ADHD in the younger children in a particular grade with the rate of the diagnosis in the older children in the same grade. This can be done using their birthdates.

When I was in school back in the stone age, the school year used to be divided into two semesters, with some children starting school in the middle of the year. At that point, the first graders that started earlier would then be called A-1's while those that started later in the year would be called B-1's. With this system, there was only a six month spread between the younger members of any particular class and the older ones.

Somewhere along the line someone decided to eliminate this system and have all the children born during an entire year - commencing on a certain "cut-off date" - start school at the same time. This means that the youngest members of one single grade school class can be up to a year younger than the oldest students. Especially in the early grades, this undoubtedly means that the younger children in the class will be, on average, considerably less mature than the older ones. In turn, this means that the average attention span and ability to sit still is likely to be considerably lower in the younger group.

In Elder's study, roughly 8.4 percent of children born in the month prior to their state's cutoff date for kindergarten eligibility - who typically become the youngest and most developmentally immature children within a grade - were diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. The study also found that the youngest children in fifth and eighth grades were nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD! The results of the second study were quite similar.

Translated into numbers nationwide, as a colleague of mine summarized, this would mean that between 900 thousand (Elder) and 1.1 million (Evans et al. 2010) of those children under age 18 in the US diagnosed with ADHD (at least 4.5 million) are misdiagnosed.

Even this conclusion would presuppose that the older children were being correctly diagnosed, which is one hell of an assumption! It is also quite possible, considering what this data means for the diagnosis itself, that a lot of active and relatively inattentive or immature but otherwise normal kids in the older half of their classes are being labeled with a supposedly biogenetic disease.

And these numbers do not take into account all the children who are misdiagnosed because they are in actuality distracted and jittery due to chaotic, neglectful or abusive home situations. We're talking a lot of misdiagnosed children here.

If you don't believe the latter paragraph, consider a study by Strohschein, (2007, "Prevalence of methylphenidate use among Canadian children following parental divorce." Canadian Medical Association Journal, 176(12), 1711-1714). It showed that children of parents in the midst of getting a divorce were almost twice as likely to be put on Ritalin - a stimulant - as children whose parents were staying together. As we all know, people who have ADHD genes to pass to their kids are all genetically predisposed to get a divorce. (For those readers who may be unfamiliar with concept of snarky sarcasm, that last sentence was a good example of it).

And the alarming studies - and the press reports that describe them - just keep on coming.

We heard a story in the news just a few months ago about a study that was reported to be proof positive that ADHD was a genetic disease, and therefore could not possibly ever be a behavioral problem resulting from dysfunctional family interactions. 

The study that was widely reported under a headline implying this genetic "proof" of ADHD and disproof of family problems was published in a medical journal called the Lancet on September 30. 

In the study, the genes of 366 children 5 to 17 years of age who met diagnostic criteria for ADHD but not schizophrenia or autism and 1047 matched controls not diagnosed with the condition were studied. Researchers found that compared with the control group without the ADHD label, children with the disorder were twice as likely - approximately 15% vs 7% - to have something called copy number variants (CNVs).

CNVs are sections of genes in which there are variations from the usual 2 copies of each chromosome, such that some individuals will carry just 1 (a deletion) and others will have 3 or more (duplications).

Of course, even if the presence of CNV's were serious proof that ADHD is invariably a genetic disorder - and it is not for reasons I will mention shortly - this would mean that a whopping eighty five percent of kids diagnosed with ADHD did not have the disorder! That is one serious rate of misdiagnosis.

The presence of CNV's does not prove genetic origins for most cases of ADHD at all, although they may quite possibly predispose some individuals to develop deficits in the neural networks of their brains. As you can see from the above data, 7% of normal kids have them.

Second, a high percentage of the kids diagnosed with ADHD who did have increased rates of CNVs also exhibited learning disabilities. In ancient times when I was in training, problems with attention were thought to be a side effect of learning disabilites such as dyslexia.

Last, the presence of higher numbers of CNV's (in the regions of chromosomes in which the study authors found them) is not specific to ADHD, but is also seen in autism and schizophrenia. This study could win the Oscar for" Most Highly Exaggerated Claims of Significance of Data in a Research Study."  Shame on the press for going along with the ruse.


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Other problematic studies and their conclusions have reported without question by the lay press.  For instance, an article in Health Day on June 14, 2011 carried the headline, Too Little Sleep in Preschool Years May Predict ADHD: Study suggests link between behavior in kindergarten and sleep loss earlier in life.

In this case, the study being described on the website had not yet even made it into a journal, which means no peer review (review of the experimental design and conclusion by independent experts) had yet taken place. It was going to be presented at a meeting of the American Academy of Sleep Medicine. On the other hand, fellow blogger the Last Psychiatrist (TLP) says he believes, only half in jest, that peer review these days is about equal to proofreading. Still, Health Day was jumping the gun a bit, no? Why?

The authors of the study reported, "Children who were reported to sleep less in preschool were rated by their parents as more hyperactive and less attentive compared to their peers at kindergarten." However, inattention and hyperactivity in the preschool years was not a predictor of sleep duration in kindergarten, the researchers added.

Their conclusion: "These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention."

So does sleep deprivation lead to a mental disorder? That seems to be the implication. But that couldn't be it, could it? Surely these scientists could not possibly believe that correlation is evidence of causation in this particular instance?

How about children of those parents who don't insist on a regular bedtime for their sleep-deprived children? Do such parents suddenly become firm disciplinarians when their kids reach kindergarden? Might they also let their kids get away with murder in other ways? Do children who get to pick their own hours and are therefore up half the night start to act out? Might they also get a little rambunctious and CRANKY? Ya think? Just asking.

Here's is one last, perhaps even stranger article. It might fall under the category of Now You See It; Now You Don't.

The following headline appeared in the December 2010 Edition of Clinical Psychiatry News:

"ADHD Diagnosis 'Extremely Transient' Over 1-Year Period."

The article describes what J. Blake Turner, Ph.D. found when he analyzed serial assessments of 8,714 children and adolescents. At the annual meeting of the American Academy of Child & Adolescent Psychiatry, he reported that, "Generally, the loss of the diagnosis" was more likely than its persistence over a relatively short period of time.

Roughly 1,200 total cases were identified initially - a fairly astonishing percentage of the sample in and by itself. In the four studies looked at, loss of the ADHD diagnosis occurred in 55-75% for the "inattentive" type of ADHD, 55-65% for the "hyperactive" type, and 18-35% for the "combined" type during the year the subjects were studied.

The disappearance of the diagnostic criteria did not usually result from a small change in those kids who barely met the criteria in the first place - the kids described in the study lost on average five different ADHD symptoms!

Do neurodevelopmental disorders disappear like this over such short periods? I think not. Are the majority of children diagnosed with ADHD merely reacting to stressful environments?   You be the judge.

David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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