CHAPTER 1

There Is No Such Thing as ADHD

The hardest part about gaining any new idea is sweeping out the false ideaoccupying that niche. As long as that niche is occupied, evidence and proof andlogical demonstration get nowhere. But once the niche is emptied of the wrongidea that has been filling it—once you can honestly say, "I don't know," then itbecomes possible to get at the truth.

—Robert A. Heinlein, The Cat Who Walks Through Walls

I know I have very few standing beside me in my stance that there is no suchthing as ADHD. The vast majority of psychiatrists, psychologists, educators,parents, and others believe at their core that ADHD is truly a disorder. I'm notanticipating that this little book will change their minds. The ideas they haveare well substantiated by years of practice and documentation. The longer theseideas exist, the more valid they appear.

I contend that while perhaps well-meaning, this description of intense people ashaving a disorder is a farce. Millions of people have been taken in by it, andmost of them believe that their participation in the farce is in the bestinterest of their patients, their children, and themselves. It is with greatconviction that I tell you that labeling these people as disordered not only isan error, but also contributes to creating the dis-ease it intends to treat bywithholding the understanding and development of their true intense and giftednature.

THE DSM AND A CULTURE OF DISORDER

ADHD began as a construct in someone's mind. Psychiatrists see mental disordersor potential signs of mental disorder in every patient that presents to them.The very fact that a person goes to see a psychiatrist means that thepsychiatrist must find a diagnosis in order to bill for the visit. It's a rewardsystem. Find a diagnosis, get paid. It's that simple. The possible diagnoses arefound in the DSM, which is created by consensus of a group of people whoregularly get together and publish a book. This book contains descriptions ofevery mental disorder. By definition, if a condition is in the book, it's adisorder; if it's not in the book, it's normal. You can see how important thisone book is to the way we see ourselves in this culture.

The DSM is sometimes treated like the Bible of the psychiatric profession. Itstates its primary purpose is to provide a guide for clinical practice indiagnosing psychiatric disorders. Because we are forever learning aboutdisorders, the DSM goes through a continual review process, resulting in newversions being published every few years. The DSM-5 is scheduled to be releasedin May 2013.

As happens with manuals like this one, people who use it tend to anoint it withpowers beyond its intent. It is sometimes seen to define the entirety of mentalhealth and disorder. Common sense tells us that there is no way a singlereference book can include all the information needed to identify every type ofmental disorder that exists within the human population. We can also guess thatwith such a broad scope, there is at least a possibility that the criteriasupplied could be used to indicate disorder within what should be healthy humandifferences. But the glow around the book continues.

Before the first printing of the DSM, little had been done to categorize mentaldisorders. Each mental hospital had its own system. The federal government wasinterested in collecting statistics on mental disorders, but the lack of aunified system to categorize these disorders made the effort impossible. As aresult, the American Psychiatric Association (APA) took on the challenge toproduce a system that could be used nationwide. The first printing of the DSMwas based on input from both mental hospitals and the Department of VeteransAffairs. Considering the sources, there wasn't much emphasis on childhooddisorders or development.

In 1966 Dr. Samuel Clements wrote an article on minimal brain dysfunction inwhich he describes a number of learning or behavioral disabilities found inchildren with average to above-average intelligence. He identified the effect onmotor activity and attention span. The label "minimal brain dysfunction" likelyresulted from the fact that he believed the cause of these disabilities to beminor damage to the brain stem. This may have been the first formally accepteddescription of ADHD, although it has been recognized in one form or another bymental health professionals for at least a century.

By the time DSM-II was printed in 1968, the label had been adjusted to"hyperkinetic reaction of childhood or adolescence" with a one-line description:"This disorder is characterized by overactivity, restlessness, distractibility,and short attention span, especially in young children; the behavior usuallydiminishes in adolescence." This change reflects the APA's efforts to avoidlabeling a disorder according to the cause of the disorder, mostly because theyknew they were only guessing at the cause. There was no evidence of differencesin brain structure or functioning. By this time, Ritalin was already in use totreat hyperactivity.

MEDICATION GOES IN SEARCH OF PATIENTS

Once there was a description of ADHD as a mental disorder and a pharmaceuticaltreatment option available, the disorder seemed to go in search of patients.This practice is very different than the treatment of any other type of mentaldisorder. In the case of paranoia or schizophrenia, the patients bringthemselves to the doctor for treatment. ADHD goes in search of patients, muchlike many newly discovered and much-advertised physical ailments such asrestless legs syndrome. "Ask your doctor!" It should be no surprise that thepharmaceutical companies are paying for those ads. But are they also fundingADHD awareness?

Medication for ADHD is a multibillion-dollar industry. It's clear that thepharmaceutical companies have a lot to gain from an increase in diagnosis. It'salso becoming clear that they have the resources to influence the outcome.

In 1987 CHADD (Children and Adults with ADHD) was founded to support people withADHD. According to a transcript from PBS NewsHour's Merrow Report, CHADD wasfunded by Ciba-Geigy, secretly receiving almost $800,000 between 1991 and 1994.I've been involved with CHADD for years. I still am, and this hit me like a tonof bricks. The CHADD website states:

CHADD was founded in 1987 by a small group of parents of children with AD/HD andtwo treating psychologists in Plantation, Florida (near Miami). These parentscame together because they felt frustrated and isolated, and there were fewplaces to turn for support and information about AD/HD.

However, they also state that pharmaceutical donations received by CHADD as ofJune 30, 2009, included support from Eli Lilly, McNeil, Novartis, and Shire US.This constitutes 39.5 percent of CHADD's total revenue, or about $1.5 million,in 2009. This fact by itself is not as troublesome as the fact that thesearrangements were kept secret for so long.

The use of stimulant medication to treat ADHD in children in the United Stateshas grown from 2.4 percent in 1996 to 3.5 percent in 2008. That's a half millionmore children on drugs. The drug is introduced to parents as a safe treatmentplan. Indeed it's not very hard to find supporting articles and studies showingthat taking stimulants under a doctor's supervision for treatment of ADHD issafe. But the very same people will also tell you that stimulants are deadly.The list of potential serious side effects of stimulant use contains paranoia,anxiety, depression, tachycardia (increased heart rate), dizziness, high bloodpressure, increased sweating, decrease in appetite, sleeplessness, and more. Oneside effect usually attributed to consistent abuse or a serious overdose isamphetamine psychosis. This is similar to the symptoms of schizophrenia. Vividauditory hallucinations and paranoid delusions are caused by the brain's fearcenter being overstimulated. This couldn't happen when the drug is prescribed bya doctor and administered as directed, right? Wrong! My son was only ten yearsold when he began to experience auditory hallucinations while taking aprescribed stimulant for treatment of ADHD. There are other stories aboutchildren taking medication for ADHD as prescribed and under a doctor's care thathave had even more serious side effects, including death.

I'm not one of those antidrug advocates. I believe in better living throughchemistry; it's just that this should be done with a solid understanding of therisks. Drugs should be used only when there are no other options. To prescribesuch strong psychotropic drugs to children for an illness that cannot be provenseems irresponsible, particularly if the intent of the prescription is only toimprove performance in school.

There's no question that the pharmaceutical companies that manufacture themedications used to treat ADHD stand to benefit from an increase in prevalence.The only remaining question is how much misinformation has been distributed andwhat part drug manufacturers are playing in today's increase in ADHD diagnosis.

WHY SCHOOLS AND PARENTS SEEK DIAGNOSIS

The symptoms in the diagnostic criteria for ADHD fall into three categories ofbehavior: inattention, hyperactivity, and impulsivity. The chart below shows thesymptoms matched with what the implied "normal" behavior should be.

Based on the expectations of "normal," what does this sound like to you? It mayjust be me, but this sounds like a schoolteacher's dream student. This "normal"child sits still for extended periods of time, speaks when spoken to, ispatient, and doesn't lose or forget things. The "normal" child is even quietwhen engaging in leisure activities. The best part of this for the teacher isthat this "normal" child maintains focus on anything they are directed to dountil they are directed to do something else.

It's no wonder that ADHD is usually diagnosed at age seven and a half. By thistime the child has entered second grade, and the expectations are set. Teacherstypically have thirty or more students in a classroom and a lot of material tocover. That would be possible if every student fit the description above of"normal." So the kids that are the furthest from this idealized description ofthe perfect student are singled out as being the problem. It seems that there isno attempt to question the system that expects young children to sit still andstudy attentively all day, every day.

The teacher, wanting to help the child who is not in step with the good studentsin the class, indicates to an administrator or a parent that this child may havea disorder. This is usually done in a formalized meeting around a table full ofteachers, school counselors, and administrators. It can be pretty intimidating.The parent or parents are bombarded with tales of the child's problem behaviors,missing assignments, and other proof that there is indeed a problem. Asuggestion is made that perhaps it isn't bad parenting. Perhaps there is amedical explanation. The parents usually agree that the child should see adoctor as soon as possible. They are then assured that once the child has adiagnosis, the school will be much more able to help the child.

Many of us can see something of ourselves in the list of symptoms used todiagnose ADHD. However, the criteria are more stringent than that. A diagnosisof ADHD must be based on more than just a list of behaviors. The condition mustalso cause impairment in two or more settings such as home and school. Since theDSM doesn't offer a definition of "impairment," we'll fall back on thisdefinition found online at www.thefreedictionary.com as a point of reference:

Impairment: The condition of being unable to perform as a consequence ofphysical or mental unfitness; "reading disability"; "hearing impairment"

Based on the requirement of impairment in two or more settings, it's easy to seewhy ADHD has traditionally been considered a childhood disorder. The impairmentsare usually related to expectations of behavior and performance in school. Sinceschools are dealing with so many children in a single classroom, they simplywork better when all the children are on the same program and no one childrequires greater-than-average attention. When school activities come home in theform of homework, the impairment comes home, too. Once we're no longer students,the "disorder" seems to go away. But did the underlying condition really goaway? Was a side benefit of graduation a cure from ADHD?

Let's say, for example, that a man with ADHD is impaired at home and at work. Athome the impairment is related to paying bills on time. The task is boring andso he puts it off and the bills stack up. Then one day he discovers online billpay. Since he enjoys his computer, the task is quick and easy, and he now payshis bills on time. Since the impairment no longer exists at home, is he cured?

Another criterion required for a diagnosis is "clinically significantimpairment" in social, academic, or occupational functioning. The DSM doesn'tprovide a definition of clinically significant impairment, but it is safe toassume that "clinically significant" is being used in comparison to"statistically significant." For example, a 5-point difference in IQ may bestatistically significant in a study, but it wouldn't be considered clinicallysignificant since we wouldn't expect a 5-point difference in IQ to have aprofound effect on functioning. Clinical significance requires subjectivejudgment on which "impairments" are important and which are not. While oneperson may consider an impairment clinically significant, another with the samelevel of functioning may disagree on the level of impairment.

It seems unlikely that a true disorder would be cured or eliminated by onlinebill pay or graduation from school. It is also troublesome to have a disorderdefined by a subjective measure of impairment, particularly if the impairment isrelated to a situation that is temporary. I propose that the underlyingcondition is still there, but the negative aspects of some of the traits onlysurface under certain conditions.

NOT ALL DISTRESS OR DIFFERENCE IS MENTAL DISORDER

These people, my people, are different. They do experience some distress andthey are impaired in some situations. That does not equal mental disorder.Stephanie Tolan has a beautiful story called "Is It a Cheetah?" which can befound on her website www.stephanietolan.com. In the story she uses the cheetahas a metaphor for children with different abilities. She explains acts oflashing out or empty eyed staring as expressions of frustration, comparing themto a cheetah in captivity throwing itself at the bars of its cage or giving up.She compares the cheetah cage at a zoo to the classroom. This environmentdoesn't give them the opportunity to show what they are really capable of, sothey are not recognized as special, gifted students, and they may bemisunderstood as not really trying or even disabled. If this sounds a lot likeADHD, you are beginning to see the light.

There are statistically significant differences that aren't considered disorderssuch as giftedness. On the scale of intelligence, the bottom 2 percent areconsidered mentally retarded and therefore subject to a diagnosis of mentaldisorder. However, the top 2 percent are considered mentally gifted and notsubject to a diagnosis of mental disorder. The difference between the two is theexpected outcome. Mental retardation is expected to produce less-than desirableoutcomes while giftedness is expected to produce better than-average outcomes.

It's understandable that intense people would be under consideration asdisordered when viewed by people looking for mental disorder. They aredifferent. But, as we see in the example of mentally gifted persons, differentdoesn't necessarily mean disordered.

Neurodiversity

A new concept of neurodiversity proposes that differences in neurologicaldevelopment in humans is just as important to the health of the human race asbiodiversity is to the health of an ecosystem. Neurodiversity takes into accountdifferences in the way different people process information including sound,textures, light, images, and even movement. Although the concept ofneurodiversity is associated with a particular view of autism, it applies aswell to intensity.