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The Web site sounds innocent enough: ADHDinfo.com. But it is sponsored by Novartis, the manufacturer of Ritalin. It opens with the question, What causes attention-deficit /hyperactivity disorder (ADHD) in school age children? It answers, "The exact cause of ADHD is not known. Scientists think that ADHD may be caused by an imbalance of chemicals in brain that help to control behavior." So your hyperactive child does not need better discipline; he needs a corrected biochemical imbalance. Our inattentive daughter does not need a more interesting classroom; she, too, just needs to get those pesky chemicals corrected.
Beneath the suggestion that biochemicals are the culprits, the drug company continues with seemingly wonderful news for overburdened parents, stressed schoolteachers, or rotten schools: Researchers have confirmed that ADHD is not caused by
Is it any wonder that the drugging of the nation's children is escalating? The drug companies are teaching society that no one is to blame and that no one needs to take responsibility for improving the behavior of children. Hardly anyone realizes that this constitutes a virtual abandonment of our children to the medical authorities and their drugs. Han anyone realizes that this disempowers the very people who are best positioned to save our children, both individually and collectively: the parents and teachers.
The Novartis Web site goes on to deny basic facts about stimulants, claiming, for example, that they do not stunt growth. They paint a picture of an enormous market for their products:
An estimated 3% to 5% of school-age children and 2% to 4% of adults have ADHD. As many as 2 million American children may have the disorder. It is estimated that every classroom in the United States has 1 to 3 children with ADHD.
No wonder teachers have gone into the business of diagnosing children. Every one of them has diagnosable kids in his or her classroom. The front page of Novartis's ADHDinfo.com has a headline and section titled "School Personnel: Do You Have a Child With ADHD in Your Class?" If you click on it, you will get information like the following: "Find what you need to know about your role in helping children taking medication for ADHD."
But even though ADHD is a biochemical disorder, you can have ADHD and yet become a household name, indeed, one of the world's greatest people. According to Novartis,
"you might be surprised to learn of some very famous people who had the disorder. All of the following are believed to have had ADHD:"
- Thomas Edison
- Babe Ruth
- Eleanor Roosevelt
- Albert Einstein
- Alexander Graham Bell
- Walt Disney
- Ludwig van Beethoven
- Winston Churchill
- Agatha Christie
Led by drug company public relations campaigns and advertising, over the last few years, there has been a massive increase in the prescription of stimulant drugs to children for the treatment of ADHD. Meanwhile, the controversy surrounding them has never been resolved if anything, continues to heat up. Perhaps in response to the efforts of reformers, the public is becoming more skeptical of medicating children. A recent survey found (Pescosolido et al., 2007 [1029]) that
"most respondents believed that psychiatric medications affect development (68%), give children a fiat, `zombie'-like affect (53%), and delay solving `real' behavior-related problems (66%). Most (86%) believe that physicians overmedicate children for common problems."
I have been documenting and publicizing these unfortunate realities for decades, and the American public is catching on. But to the authors of the survey study, these are false and stigmatizing attitudes. The ors come from the heart of the psychopharmaceutical complex, with study receiving funding from as seemingly diverse entities as the National Institute of Mental Health (NIMH) and Eli Lilly and Company. Ironically, drug promoter Peter Jensen (1989) [676], one of the authors of the report, has himself written about how stimulants can cause zombielike behavior in children (see subsequent discussion).
Meanwhile, the number of children involved is staggering. According to the Centers for Disease Control (CDC), estimates for the number of children afflicted with AOHO vary widely from 2% to 18%, with considerable variation in the numbers treated in different parts of the nation (Visser et al., 2005 [1299]). On the basis of 2003 data, the COC found that 11% of children had been diagnosed with AOHO at some time in their lives, including 6% of 4- to 8-year-olds, 13.5% of 9- to 12-year-olds, and 13.9% of 13- to 17 -year-olds. The COC further determined that 6.2% of boys and 2.4% of girls were currently being treated with medication for ADHD. Overall, 4.3% of children were being medicated.
One particular study in the American Journal of Psychiatry made an unusually low estimate for stimulant prescriptions to children and claimed, against all other estimates, that there had been no increase in rates over the past decade (Zuvekas et al., 2006 [1384]). I puzzled over what had motivated publication of the study. Then, some time later, I came on an unashamed, boastful explanation by editor Robert Freedman (2006) [488] about how the Zuvekas article was rushed to print to discourage the Food and Drug Administration from placing additional warnings on stimulant labels. The following is taken from an annual review by the editors of especially memorable events and achievements (Zuvekas et al., 2006 [1384]):
"This study, which was scheduled for publication several months later, showed that the prescription of stimulants to children had been remarkably stable over the past decade and that, if anything, too few children are treated. The final version of the April issue had already gone to our printer the morning that we decided this article needed to be published sooner than its scheduled time. Fortunately, because the printers were out to lunch and work had not yet started we could hold the issue for this article ... .The only article we could displace immediately was a review article by Kenneth Kendler, M.D., who told us that the needs of children should come first. The article appeared while the FDA hearings were ongoing, and the FDA decided not to issue a more severe warning about the safety and use of drugs that have a unique value in the treatment of childhood mental disorder."
How driven are the leaders in psychiatry to defend their drugs? Driven enough to stop the presses in their rush to publish an article, however idiosyncratic in its conclusions, to influence the FDA. The editors were driven enough to bump an article that instead urged that needs of children should come first. They seem to have no idea how their confessions make them look.
In a letter to the acting commissioner of the FDA in 2006, U.S. senator Charles E. Grassley [556], head of the Senate Finance Committee, expressed, concern about new data highlighting psychiatric and cardiovascular associated with stimulant drugs for the treatment of ADHD and about the lack of assessment of long-term risks in general for these drugs.
Grassley (2006) [556] cited reports that ADHD drug sales had skyrocketed with a threefold increase in sales between 2000 and 2004, from a total of $759 million to $3.1 billion, and that more than 2.5 million children under age 17 were taking the drugs. He demanded to know why the FDA was so lax in evaluating the risks of these drugs. It is not just the FDA; it is the entire psychopharmaceutical complex, including the scientific journal of the American Psychiatric Association.
Boys have always been the most frequently medicated with stimulant drugs. In 2002, an estimated 14% of U.S. boys were on stimulant (Vedantam, 2004 [1292]), a figure that has probably grown considerably since then. The Pharmaceutical Business Review noted that the United States, become a so-called mature market for ADHD drugs, with relatively little room for expansion. In reality, the drug companies hit up a whole new market within the United States-adults with ADHD.
The use of prescription medication for ADHD doubled 2000 and 2004 (Hitti, 2005 [622]; Elias, 2005 [401]), according to data compiled by Medco Health Solutions, one of the nation's largest prescription benefit managers. The increases were largest among adults age 20-44, especially women, but a 56% increase was also seen among children. According to Medco, nearly 1.5 million Americans age 20 and older (about 1% of the population) were using drugs for ADHD.
Advertising plays a role in increased use of ADHD drugs, with the manufactures of Adderall XR (Shire) and Concerta (McNeil) advertising magazines geared to parents and the maker of Strattera (Eli Lilly [402]) advertising on television to promote the drug for adults. But the overall push to medicate America and the world comes from all the components of the psychopharmaceutical complex-drug companies and those in financial thrall, including physicians, medical organizations, medical journals, medical schools, and also health insurers, who prefer the costs of drugs to the higher costs of psychosocial and educational interventions. On the other hand, drug advocates, who see these trends as good, declared that the diagnosis of ADHD was missed in little girls due to the lack of hyperactivity but was showing itself among women as they grew older in the form of concentration deficits.
The convenience of once-a-day dosing for some drugs may also help increase sales. To make it even easier for parents to administer drugs to children, on April 6, 2006, the FDA approved a skin patch for the delivery of methylphenidate (Ritalin) to children. A patch sounds a lot less ominous than a drug. Called Daytrana, the patch can be slapped on the child's hip for up to 9 hours at a time. When taken orally, methylphenidate has a shorter duration of action (3-6 hours), typically requiring a second dose handed out by the school nurse during the school day.
The concept of ADHD and the use of stimulants to control the behavior schoolchildren is beginning to spread from America across the world as drug companies vigorously seek new markets for their products (Kean, 15, 2006 [748]).
Here is how the online Pharmaceutical Business Review saw the growing ADHD market and its future as of September 2005 (Focusing attention on ADHD, 2005):
"In April, the World Federation for Mental Health launched an international campaign to improve the diagnosis and treatment of children with ADHD. While awareness of ADHD is increasing, the condition is still associated with significant social stigma, especially in conservative societies like Japan. Meanwhile, research shows that the American ADHD market dwarfs all others in terms of revenues."
"While over 20 million children globally have been diagnosed with ADHD, it is estimated that only 5-10% of children suffering are ever actually diagnosed ... .Datamonitor research reveals that the American ADHD market overshadows all others, with 2004 revenues of over $2.5 billion-97% of ADHD drug revenues."
The Pharmaceutical Business Review goes on to say in a subhead, "Not Just an American Problem;" but that some conservative societies are more reluctant to drug their children. It laments, "Unlike the US, there is some reluctance to prescribe drugs to children in the EU." That is an important concept: Pharmaceutical marketing specialists see no reluctance in the United States on the part of parents to drug their children. "There is definitely a higher willingness to prescribe drugs and acceptance by families to have their children on drugs in the US, where parents in the EU generally prefer to try other non-drug interventions first."
The business review concludes on an upbeat note and an exhortation for everyone-parents, teachers, doctors, parents' groups, a media-to get behind the drugging of children:
"Despite the low rate of diagnosis, Datamonitor forecasts the global ADHD market to grow from $2.7 billion in 2005 to $3.3 billion in 2015. However, it is the success of awareness campaigns to encourage physicians, teachers, the media and parent support organizations to work together to ensure the proper treatment and management of children with ADHD and to reduce the public stigma of the disease and its treatment that will be a more telling statistic."
Can anyone doubt that the spreading of the ADHD diagnosis across America-and soon the world-has more to do with marketing than with treating a genuine disease?
Seemingly reputable sources like the New England Journal of Medicine bandy about statistics such as "ADHD is the most common childhood psychiatric disorder, affecting 4 to 10 percent of young people United States, with as many as half of them continuing to have symptoms into adulthood" (Kadison, 2005 [716]).
ADHD is the diagnostic justification for the often cavalier prescription of stimulants to young people and, increasingly, to older people as well. Although few professionals can recite the American Psychiatric Association (APA; 2000 [44]) diagnostic criteria as delineated in the Diagnose and Statistical Manual of Mental Disorders (DSM-IV-TR [44]), their existence creates a strong, albeit misleading, impression of validity diagnosis of ADHD.
In the last decade and especially in the past few years, prodrug interests have rallied behind the diagnosis of childhood bipolar disorder to justify prescribing adult mood stabilizers and even the highly toxic neuroleptic drugs to children. Between 1994 and 2003, there was a 40-fold increase in diagnosing bipolar disorder in children (Moreno et al., 2007 [947]), and trend has been escalating since then (Carey, 2007 [257]). Before the mid 1990s, doctors hardly ever diagnosed bipolar disorder in young children only rarely in adolescents; now they do it on a routine basis. The increase in the diagnosis of bipolar disorder has gone hand-in-hand with an equally huge increase in prescribing adult antipsychotic and mood stabilizing drugs to children. Moreno et al. (2007) [947] found 90.6% of the children received psychiatric medications, including 60.3% on mood , stabilizers and 47.7% on antipsychotics, with most on combinations.
At the annual meeting of the APA in Atlanta, Georgia, in 2005, a symposium was presented on Bipolar Disorder Management: A New Edition ("Bipolar Disorder," 2005). Physicians attending this particular seminar could get free credits toward maintaining their medical licenses and professional organization memberships. The program overview stated, "One the most significant gaps in our knowledge of how to diagnose and treat bipolar disorder relates to children and new findings will be presented." Even the psychological issues will be geared to drugs, according the program overview: "Psychological factors with an emphasis on reasons for non-compliance will be reviewed." Noncompliance refers to children or their parents refusing to take the drugs.
The program is straightforward in its call to start drugging children the absence of any scientific basis: "In the absence of treatment data, treatment of childhood bipolar illness is modeled on that of adults." Even if the child shows no signs of psychosis, the most toxic adult drugs are recommended: "For non-psychotic children, in descending order, treatment should be tried with lithium, divalproex, atypical antipsychotic, combining any of these approaches, and other anticonvulsants plus atypical antipsychotics or conventional antipsychotic."
The reference to "combining any of these approaches" indicates why so many children are now being treated with cocktails of several toxic chemicals at once; the drug company-paid "experts" at professional seminars are encouraging them. In my clinical practice, I am frequently faced with having to withdraw preadolescent and adolescent children from combinations of four or five medications, all of which causing them adverse mental and emotional reactions and doing much more harm than good.
In regard to bipolar disorder in children, the program booklet was summarizing the views of Gabrielle A. Carlson, Director, Division of Child and Adolescent Psychiatry, and Professor of Psychiatry and Pediatrics, Stony Brook University of Medicine, Stony Brook, N York. But Dr. Carlson has some other credentials that come out in the Disclosure Information section of the booklet. She is on the Speakers' Bureau of Abbot Laboratories and Eli Lilly and Company, and she gets research grants from Janssen Pharmaceutica Johnson & Johnson, Otsuka, and Shire Pharmaceuticals. The number of drugs she advocates for children reflects the numbers of drug companies that sponsor her efforts.
But-Carlson's list of drug company affiliations is hardly the longest among the other speakers. Frederick Goodwin - who lost his job as director of NIMH when my wife and I criticized his racist biopsychiatric initiatives in America's inner cities (Breggin et al., 1994b [220]) - lists himself as a consultant to six drug companies, a research grant recipient from nine drug companies, and a Speakers' Bureau member for seven drug companies. But even Fred Goodwin is not the record holder for pharmaceutical corporation affiliations. Another speaker, Terence Ketter, has even longer list. He is also a professor of psychiatry at Stanford University School of Medicine and an example of how drug company tentacles have a stranglehold on academic medicine.
Who is paying for the seminar itself and the glossy 12-page booklet - this free opportunity for psychiatrists to get CME (Continuing Medical Education) credits? It was sponsored by an educational grant from GlaxoSmithKline. But the booklet appears to be distributed by the APA, whose seal, name, and address appear on the back cover, along with statement "Commercially Supported Activities". The seminar is part of concerted effort by the pharmaceutical complex, including APA, to push more drugs on America's children, in this case by first diagnosing them with bipolar disorder.
In 2005, the pharmaceutically oriented Journal of the American Academy of Child and Adolescent Psychiatry published guidelines for the diagnosis and treatment of bipolar disorder (Kowatch et al., 2005 [784]). Martha Hellander, a coauthor of the guidelines, declared, "These kids suffer so badly, and deserve to have evidence-based treatment as early in life as possible. Many respond quickly to mood stabilizing medication."
The phrase evidence based in psychiatry means nothing more nor less than "dictated by the psychopharmaceutical complex". There is no substantial evidence on which to base diagnosing children with bipolar disorder and drugging them with adult medications. In the vast majority of cases, the practice involves "off label" prescribing, that is, using medications outside the guidelines provided by the FDA drug approval process. Often it involves what can be called "off label diagnosing," that is, diagnosing outside the guidelines of the DSM [31]. These supposedly evidence-based treatment guidelines are typically written by authors with strong vested interests in drug companies (Taylor et al., 2005 [1241]). These authors see bipolar disorder in children as lifelong, meaning that the youngsters will become lifetime consumers of drugs.
Abboud (2005b) [5] of The Wall Street Journal did a good job exposing the rush to diagnose more and more children with bipolar disorder and to treat them with drugs. She pointed out that a small group of doctors are pushing the diagnosis to as early as age 4, when they begin prescribing adult mood stabilizers and neuroleptics such as Risperdal and Seroquel. On the basis of a huge health care information data base, the number of children diagnosed with bipolar disorder rose 26% from 2002 to 2004. As noted earlier, a more recent study (Moreno et al., 2007 [947]) found a 40-fold increase in the diagnosis from 1994-2003. This irrational exuberance about diagnosing children with bipolar disorder is the direct result of a drug company-inspired promotional campaign.
According to Abboud (2005b) [5], Joseph Biederman, a Harvard psychiatrist, believes that displaying violent outbursts and rages is likely bipolar, even in the absence of more classic symptoms. Biederman has long been a drug company henchman, coming to the fore whenever needed, for example, to produce research aimed at minimizing adverse effects of stimulants such as growth suppression and drug dependence. As Abboud noted, Biederman's group receives research funds from the makers of atypical neuroleptics, and Biederman is also a consultant to these companies, which manufacture the drugs being prescribed off label to these children.
Encouraged by the Biedermans of the psychiatric world, health care providers often diagnose bipolar disorder in children on the flimsy grounds of temper tantrums, irritability, or hyperactivity. In my practice, I have evaluated children who have been diagnosed bipolar when in fact they were normal children responding with typical childhood exuberance to a lack of parental control. In numerous cases, children have been continued on mood stabilizers and neuroleptics for a number of years by several consecutive doctors until coming to see me. After helping their parents learn and apply a program of consistent, rational discipline combined with unconditional love, most of the children have been easily withdrawn from the drugs, and they have gone on to live normal childhoods.
In my training and psychiatric practice spanning several decades, I rarely if ever saw a child who had been diagnosed bipolar. All that changed in the 1990s. Now I see them on a regular basis. In many cases, the diagnosis simply has no basis. In a number of cases, however, the children have undergone maniclike episodes; but in every single case, the episode could be traced to either antidepressant or stimulant toxicity. Although stimulants can cause psychosis and mania (Ross, 2006 [1108]), by far, the major cause of these drug-induced maniclike reactions have been the SSRIs and Effexor (reviewed in chapter 7).
Instead of being diagnosed with bipolar disorder, these children should have been diagnosed with antidepressant-induced mood disorder and easily treated by removing the causative agent. Instead, without removing the offending agent, these children are almost invariably also treated with mood stabilizers and neuroleptics. By the time I see them, they have lived on a drug-induced roller-coaster ride, driven up and do by competing toxicities.
At the same time, false claims are being made that these child have biological disorders. However, as Foltz (2006) [454] astutely conclude,
"Finally, at a fundamental level, there is no doubt that the brain is continually involved in our emotional and behavioral experience in every instant. Just as we cannot identify the neurological or neurochemical basis of resiliency, courage, love, or honesty in the brain, we cannot identify mania, delusion, anger, or oppositionality." (p. 154)
The ADHD and bipolar diagnoses also influence how millions of parents and teachers view the children in their care. Nowadays, nearly all parents and teachers have heard of hyperactivity and, more specifically, ADHD. Many teachers believe that they can diagnose it. To my increasing dismay, teachers have now begun to diagnose bipolar disorder in children.
Meanwhile, as noted earlier in the book, there is the beginning of a backlash, with a recent survey finding that 85% of those interviewed believe that doctors overmedicate children with depression and ADHD and that drugs are harmful to a child's development (Pescosolido et al., 2007 [1029]). More than half believe that psychiatric medications "turn children into zombies". One developmental pediatrician complained about the public's growing skepticism, instead proposing, "We need to view depression and ADHD like we do allergies. They are very treatable" (Marcus, 2007 [874]). In contrast, I am pleased that Americans are finally catching on, and hope I have made some contribution to that newfound enlightenment.
Unfortunately, frontline professionals are not catching up to public opinion. A 2004 survey demonstrated that school psychologists, who literally hold children at their mercy, continue to believe that ADHD has a proven "neurological/genetic, or otherwise, biological basis" (Cushman et al., 2004 [327], p. 187). They are not catching up, in part, because leaders in the field of psychopharmacology, in cooperation with their pharmaceutical industry patrons, continue to push medications, seemingly oblivious to their harmful effects (Leo, 2005 [831]).
Also along the bittersweet continuum, a New York Times article in December 2006 was titled "Parenting As Therapy for Child's Mental Disorders," in which doctors were advising that parents of children diagnosed with ADHD receive help with their parenting skills (Carey, 2006 [256]). Should it be news that parenting has something to do with whether or a child behaves in an undisciplined fashion? But the doctors are not really recommending improved parenting; they are recommending artificial regimens of reward and punishment called behavior modification. Children, of course, see through these manipulations as more adult tactics to control them. As I describe in Talking Back to Ritalin (2001c) [209] and The Ritalin Fact Book (2002b) [211], children respond quickly to a combination of meaningful direction and explanation from a caring therapist and, most important, a consistent parental plan for unconditional love and rational discipline.
The drug companies have had a few scares about their stimulant drugs the past few years but seem to have weathered them easily. In Canada, Adderall XR, a once-a-day formulation, was temporarily removed from the market in February 2005 (Branswell, 2005 [169]). The Canadian regulatory agency made the decision based on reports of sudden death and stroke in the United States, where 37 million prescriptions of Adderall and Adderall XR had been written since 1994. In response to the withdrawal of the drug, there was uproar from physicians and lobbying groups, leading to its reinstatement in August 2005. Canadian psychiatrist Umesh Jain, who condemned the removal of Adderall XR from the market, inadvertently testified to its addictive nature when he brought forward one of his patients to say, "I had a panic the way I would imagine a crack addict would have a panic if he just heard his dealer had gotten busted" (Branswell, 2005 [169]).
Along with conduct disorder and oppositional defiant disorder, ADHD was originally considered one of the "disruptive behavior disorders" in the DSM-III-R (APA, 1987 [37]). In the DSM-IV [43], an attempt is made separate ADHD from the other two disruptive disorders, at least when ADHD manifests itself primarily as inattention, rather than hyperactivity. The DSM committee found that while disruptive behavior and attention problems often occur together, some ADHD children are not hyperactive and disruptive (Fasnacht, 1993 [420]).
Despite any attempt to separate them, the three diagnoses often overlap each other, and research projects often refer to them as one group: the DBDs. The DSM-IV [43] observed that "a substantial portion of children referred to clinics with Attention-Deficit/Hyperactivity Disorder also have Oppositional Defiant Disorder or Conduct Disorder". An NIMH study similarly concluded that pure conduct disorder or pure oppositional disorder are "relatively rare" (Kruesi et al., 1992 [792]), with most cases qualifying for an attention-deficit disorder diagnosis. All this casts doubt on the meaningful existence of any one of the diagnoses. It adds up to saying that a kid in trouble is a kid in trouble or that a kid in conflict with adults is a kid in conflict with adults, regardless of how you list and categorize the problems or behaviors.
The DSM-IV [43] does not discuss the definition of disruptive behavior disorder. The DSM-III-R [37] stated that DBD children are "characterized behavior that is socially disruptive and is often more distressing to others than to the people with the disorders". The so-called illness consists of being disruptive to the lives of adults-a definition tailored for controlling children, while exonerating adults.
The DSM-IV (1994 [43], 2000 [44]) distinguishes between two types of ADHD: one marked by inattention and the other by hyperactivity-impulsivity. The official standard for ADHD requires any six of nine items under each category. For hyperactivity-impulsivity, the first four items, in descending order, include the following:
The first four items in the list for diagnosing the inattention form of the disorder include the following:
The list appeals to teachers, containing virtually every behavior that s them or demands their attention. Its marketing success is based on this redefinition of relatively normal classroom behaviors, especially among bored or poorly managed children, into a disorder treatable by drugs. The same list of behaviors in children could be used to identify, nor a disease in the children, but incompetent or overstressed teachers, boring classes, and poor classroom discipline.
Barkley (1981) [99], a man who has done more to suppress America's children than perhaps any other psychologist, stated, "Although inattention, over-activity, and poor impulse control are the most common symptoms cited hers as primary in hyperactive children, my own work with these children suggests that noncompliance is also a primary problem" (p. 13). In other words, an underlying "primary" problem with these children is their refusal to comply with adult authority. They are disobedient!
What does Barkley suggest as his approach to disobedience? Not improved disciplinary practices and unconditional love to guide the children and to win their cooperation. Barkley uses his observation as an authoritarian justification for oppressing and controlling children with drugs.
It is not surprising that many children are "noncompliant" with Barkley. Although not a medical doctor, he has been a leader among those who minimize adverse drug effects while exaggerating their benefits. He not only pushes medication; he exclusively blames the children for conflicts they are having with family and school. As he put it, "There is, in fact, something 'wrong' with these children" (p. 4). In his written words, one can hear echoes of confused, frustrated, potentially abusive parents yelling at their children, "There is something wrong with you!"
By indicting the children as having "something wrong" with them, Barkley deflects parents and teachers from the need to examine improve their own attitudes and behavior toward the children in care. Although the behavior of children is enormously responsive to adult interventions and although the distress of children often results directly from the actions of adults in their lives, in Barkley's mind the role of the adults can be ignored. The adults, in effect, get a free pass. They have little or no role in causing or ameliorating the emotional suffering a disturbing conduct of the children in their care.
While this "free pass" may relieve some parents and teachers of feeling guilty, it undermines their sense of responsibility and efficacy in the lives of the children. By making parents and teachers believe that have no control over the lives of the children in their care, drug advocates like Barkley disempower them. Mistakenly convinced that they cannot exert influence over the children in their care, parents and teachers readily abandon them to authoritarian diagnosticians and drug pushers like Barkley.
To the contrary of Barkley's oppressive attitudes toward childen, any adequate, rational, and caring approach to helping children view them in the context of the family and the school. Only by look the whole picture of the children's lives can we understand why the distressed or distressing and how we, as responsible and caring ad can better meet their needs.
The symptoms or manifestations of ADHD often disappear when the children have something interesting to do or when they receive a little adult attention. This is agreed on by most or all observers and indirectly finds its way into the DSM-IV [43], where it is specified that the symptoms may become apparent when the child is in settings "that lack intrinsic appeal or novelty". The so-called disorder may also be minimal or absent when "the person is under very strict control, is in a novel setting engaged in especially interesting activities, is in a one-to-one situation," including being examined by the doctor. Most advocates of ADHD as a diagnosis also note that it tends to go away during summer vacation.
If the list of criteria for ADHD has any use, it identifies children who are bored, anxious, or angry around some of the adults in their lives or in some adult-run institutions such as a particular classroom or family setting. These so-called symptoms should not red flag the children as suffering from psychiatric disorders. They should signal to adults that renewed efforts are required to attend to the child's basic needs (for a discussion of basic needs, see Breggin, 1992a [191]).
When a small child, perhaps 5 or 6 years old, is persistently disrespectful or angry, there is always a stressor in that child's life-something which the child has little or no control. Sometimes the child is not being respected. When treated with respect, children tend to respond respectfully. When loved, they tend to become loving.
While the source of the child's upset may ultimately be more complicated, often, its roots are observable in the first family session with the child and parents. Commonly the parents are too fearful or distracted to apply rational discipline and let the child run wild. They have lost all sense their own moral authority, and consequently, the child no longer treats them with respect. Often the parents cannot agree on a rational plan, subjecting the child to contradictory commands. Sometimes the child is being abused outside the home or is simply unable to fit into the highly structured, boring environment typical of many classrooms. Too often, psychiatrists have instructed the parents that the problem lies in the child therefore they should not bother to examine how they relate to their offspring or what may be happening to their child in the outside world.
Small children do not, on their own, create severe emotional conflicts m themselves and with the adults around them. When older children end up generating severe conflict, it usually comes from a long history of prior conflicts with adults. Children are not born bored, inattentive, undisciplined, resentful, or violent, but the stigmatizing psychiatric labels imply that they are. Indeed, fabricated theories about the genetic origin of so-called ADHD are created for the purpose of proving the argument children are born with problems that, in reality, they develop in response to their environments.
In my experience, children labeled ADHD are usually more energetic more spirited, or more in need of an interesting environment, than their parents and teachers can handle. One of the early advocates of hyperactivity as a diagnosis describes them as unusually dynamic bundles of energy (Wender, 1973 [1335]). They sound like prototypes of health, vigor, and youth. Yet they are being diagnosed with a psychiatric disorder-a label that will follow them into adulthood, forever stigmatizing them in their own eyes and in the eyes of others.
Many and probably most so-called ADHD children are receiving insufficient attention from their fathers, who may be separated from the family, too preoccupied with work and other things, or otherwise impaired in their ability to parent. In many cases the appropriate diagnosis dad attention-deficit disorder (DADD; Breggin, 1991b [189]; Breggin et 1994b [220]). A 2007 study in the Journal of the Canadian Medical Association confirms what I have written about for years. Strohschein (2007) analyzed data from Canada's National Longitudinal Survey of Children and Youth from 1994 to 2000. Among those children whose parents remained married, 3.3% received Ritalin at some time during the 7-year period. Among those whose parents divorced, 6.1% (almost double) were placed on Ritalin during the period. In partial confirmation of her findings, Strohschein cited several other studies indicating that single-parent households have a higher rate of children on stimulant medication. In my clinical experience, conflict associated with divorce, both before and after the actual separation, invariably causes severe stress in children. The children's distress is a normal reaction; but if brought to a health-care provider, the children are almost always given a psychiatric diagnosis, anything from ADHD or oppositional defiant disorder to an anxiety or mood disorder. Usually, the source of the problem-parental conflict and suffering-is largely or completely ignored, and instead the child is diagnosed and medicated. Sadly, this misguided psychiatric response reinforces the belief commonly held by children that they are somehow at fault, and even to blame, for the fighting among their parents.
After the divorce, when living in a single-parent home, usually under the care of the mother, boys in particular become difficult to handle. They suffer from acute and then chronic DADD. Many of these children in such great need of male attention that even a once-a-week counseling session with a fatherly therapist is very helpful to them. However, the therapist becomes far more effective if able to increase the involvement of the father in the child's life and to help both parents reconcile their differe1 sufficiently to develop a consistent and loving plan for raising their children. The therapist can also help the mother identify other males in the child's life who may wish to take a more active role. In my practice, if the father is participating in the child's life, I work with the mother and the children family, helping to provide support for her parenting decisions.
Young people are nowadays so hungry for the attention of a father that it can come from any male adult. Seemingly impulsive, hostile groups of children will calm down when a caring, relaxed, and firm adult male is around. Arlington High School in Indianapolis was canceling many its after-school events because of unruliness, when a father happened to attend one of them (Smith, 1993 [1192]):
That evening there was an odd quietness on [the father's] side of the auditorium. It turned out that when he would tell his group to settle down, some students would second him. One said: "That's Lena's father. You heard him. Be quiet; act right." (p. 5)
Since then, the school has begun to enlist volunteer dads to help supervise after-school events.
At other times, the so-called disorder should be called TADD: teacher attention-deficit disorder. Owing more to problems in our educational system than to the teachers themselves, few students get the individualized educational programs that they need.
Overall, in our society, parents and teachers receive too little support for their tasks, which are among the most difficult in society. The average parents receive more training in how to breathe during the delivery of their children than they will receive in how to relate to their offspring over the ensuing 18 years. The average teacher has difficulty keeping himself or herself afloat amid the pressures of teaching poorly disciplined children in overcrowded classes. The teacher has little time to individualize his or her instruction to particular educational needs and even less to develop relationships with students. Nevertheless, as burdened as parents and teachers may feel, they should not try to escape their responsibilities by drugging children. Instead, they should find the support they need to continue improving their skills, while also working toward improving their schools and families.
In 1993 [112], neurologist Fred Baughman Jr. noted that studies have failed to confirm any definite improvement from the drug treatment of ADHD-labeled children. Baughman cited estimates of the frequency of ADHD, which varies from 1 in 3 to 1 in 1,000. He therefore asked, Is attention-deficit hyperactivity disorder, after all, in the eye of the beholder?
The eye of the beholder theme echoes Diane McGuinness (1989) [906], who has systematically debunked ADHD as the emperor's new clothes. In a chapter in The Limits of Biological Treatments for Psychological Distress, she observed,
"The past 25 years has led to a phenomenon almost unique in history. Methodologically rigorous research ... .indicates that ADD [attention deficit disorder) and hyperactivity as `syndromes' simply do not exist. We have invented a disease, given it medical sanction, and now must disown it. The major question is how we go about destroying the monster we have created. It is not easy to do this and still save face." (p. 155)
According to Vatz (1993) [1291], "attention-deficit disorder (ADD) is no more a disease than is `excitability.' It is a psychiatric, pseudomedical term".
Frank Putnam (1990) [484], a director of one of NIMH's research units, applauded "the growing number of clinicians and researchers condemning the tyranny of our psychiatric and educational classification system". Putnam found that it is "exceedingly difficult to assign valid classifications [to children, and yet] children are by far the most classified labeled group in our society". He warned against "the institutional prescriptions of a system that seeks to pigeonhole them".
In recent years, the "inattention" aspect of the ADHD diagnosis received increasing emphasis in an effort to spread the net wider to include girls who display no hyperactivity. Educators Thomas Cushman and Thomas Johnson (2001) [326] have examined the multiple causes of inattention in children including stress, feelings of sadness, temperament, nutrition, and genuine medical disorders. They examine sources of so-called inattention in the ecological environment of the school. Finally, they challenge the basic concept of "inattention". In my own clinical experience children who display "inattention" on academic tests or in school may have a marvelous capacity to involve themselves wholeheartedly in projects they enjoy and have learned how to master.
The notion of a specific ADHD syndrome is further undermined by the tendency to give the same child a combination of several diagnoses. This reality appears throughout the psychiatric literature. Dulcan and Popper (1991) [384] observed that multiple diagnoses for a single child are common and that hospitalized children average four diagnoses at once. Like proverbial cookie cutter, the diagnoses chop the child into various predesigned shapes that bear little or no resemblance to the child's underlying psychosocial problems, family or school conflicts, and unmet needs.
Without fully exploring the implications, Dulcan and Popper (1991) [384] also pointed out that the diagnosed behaviors may turn out to be assets in adulthood:
"Certain individuals may even learn to turn childhood deficits such as excessive sensitivity (separation anxiety), unrelenting stubbornness (oppositional defiant disorder), or uncontrolled activity and enthusiasm (attention deficit hyperactivity disorder) into strengths in adulthood." (p. 2)
Unfortunately, Dulcan and Popper (1991) [384] missed the point. The child does not have deficits to begin with. The deficits lie within the inability of the adults and their institutions to meet the child's needs and to guide his or her energies into positive forms of expression. Indeed, the requirements we place on children for conformity and docility in the classroom are antithetical to success in a competitive, mentally demanding adult world. Furthermore, once the child is labeled as having a disorder or deficit, the view of the child's behavior becomes entirely negative. Instead of channeling the energy, it is viewed as an illness to be eliminated. Time after time, parents come to me preoccupied with their child's supposed deficits, such as ADD and dyslexia, without any corresponding focus on the child's assets, such as computer skills, social abilities, and imagination. Worse yet, when the child is drugged, the potentially positive traits are driven underground and potentially destroyed by a combination of toxicity and stigmatization.
A study led by NIMH's Alan Zametkin et al. (1990) [1376] received a great deal of publicity for finding increased brain metabolism in PET scans of adults with a history of ADHD in childhood. However, when the sexes were compared separately, there was no statistically significant difference between the controls and ADHD adults. To achieve significance, the data were lumped together to include a disproportionate number of women in the controls. In addition, when individual areas of the brain were compared between controls and ADHD adults, no differences were found. It is usually possible to massage data to produce some sort of statistical results, and Zametkin et al.'s study is a classic illustration.
Since the behaviors associated with ADHD do not constitute an organic disorder but, in most cases, a manifestation of conflict between children and adults, it is unreasonable to expect that a biological cause will ever be found. Put another way, since the adults have more influence over the origins and resolutions of the problem, it is irrational to seek a biological defect in the child. Golden (1991) [540] put it simply:
"Attempts to define a biological basis for ADHD have been consistently unsuccessful. The neuroanatomy of the brain, as demonstrated by neuroimaging studies, is normal. No neuropathologic substrate has been demonstrated." (p. 36)
Meanwhile, the emphasis on possible genetic and biological causes of upset behaviors in children ignores research confirming their psychosocial origins (see earlier in the chapter and Breggin, 1992a [191]; Green, 1989 [559]).
The neurobiological basis for ADHD remains a cornerstone of the argument for diagnosing and drugging children, even as the search for scientific evidence continues to flounder (Seitler, 2006 [1153]; Stolzer, 2007 [1217]). The search for a genetic and biological cause of ADHD can never succeed use the biopsychiatric researchers are looking in the wrong place. When a child lacks self-discipline or feels bored and frustrated by school tasks, the fault does not lie in the child's biology but in the adult world's failure to discipline and to engage the child. There are an infinite number of psychosocial and educational approaches to helping the kind of children who get falsely labeled with ADHD, but these better methods will never be fully implemented until the diagnosis of ADHD and the use of toxic chemicals have been abandoned by the psychiatric and educational establishment (Timimi, 2004 [1255]).
Through the 1990s, the United States used 90% or more of the world's Ritalin. The pattern is changing now, however, as drug companies seek new markets. Drug company marketing has led to increasing worldwide use of the ADHD diagnosis with the prescription of stimulants (Kean 2005 [747], 2006 [748]).
Similarly, males used to be given 90% of the Ritalin in the United States, but drug company promotion of stimulants for inattention has led to more and more girls being diagnosed and prescribed medication. Nonetheless, boys still remain the main target of psychiatric drugs that aim at eliminating or subduing their more rambunctious or difficult behaviors. Aside from feeling bored or in conflict with adults, why would boys ordinarily tend to act resentfully and rebelliously toward the authority of their mothers and female teachers? The simplest answer is that the culture trains them to be disrespectful toward women in general. In fact, many grown men continue to resent "being told what to do" by women. In some authoritarian societies, the adult male continues to demand unquestioned authority over women.
A multiplicity of factors contribute to the conflicts and confusion little boys. Respect for authority in general is on the decline in society. Boys are culturally encouraged, and even trained, to suppress their tender ("feminine") sides. Meanwhile, the culture too often encourages the feel and to act domineering and hostile toward girls and women. These lessons are imprinted through TV and other entertainment media and reinforced in sports and on the playground as well as in some families.
In our modern society, girls also receive increasingly confusing sages about assertiveness, and more and more of them are being diagnosed with one or another DBD. Often, they are children with special enterprise and boldness.
Founded in 1987, Children and Adults with Attention Deficit Disorders (CHADD) has now expanded its horizons to include adults, as well, with ADHD20. Founded and led by parents who have children labeled with attention deficit disorders, from the beginning, its unofficial policy has been "we are not to blame". CHADD's official policy views these children as suffering from genetic and biological problems. In the words of CHADD president Sandra F. Thomas (1990) [1253], "Our kids have a neurological impairment that is pervasive and affects every area of their life, day and night."
CHADD leaders claim that their children's emotional upset and anger is in no way caused by family conflicts, poor parenting, inadequate schools, or broad social stressors. In a CHADD brochure titled Hyperactive? Inattentive? Impulsive?, a headline announced, "Dealing with parental guilt. No, it's not all your fault" (CHADD, n.d.). After stating that ADHD is a neurological disorder, the brochure went on to explain,
"Frustrated, upset, and anxious parents do not cause their children to have ADD. On the contrary, ADD children usually cause their parents to be frustrated, upset, and anxious." (p. 1)
There could be no more blatant example of child blaming and parental exoneration.
CHADD has followed the model of its adult counterpart, the National Alliance for the Mentally Ill (NAMI; Breggin, 1991b [189]). Parents who belong to NAMI usually have grown offspring who are severely emotionally disabled, and they promote biochemical and genetic explanations, drugs, electroshock, psychosurgery, and involuntary treatment. The organization also tries to suppress dissenting views by harassing professionals who disagree with them (Breggin, 1991b [189]). NAMI has developed an affiliate, NAMI-CAN-the National Alliance for the Mentally Ill, Child and Adolescent Network (Armstrong, 1993 [67]). Both NAMI-CAN and CHADD believe in what they call BBBD-biologically based brain diseases.
Parent members of CHADD and NAMI have developed enormous influence by joining forces with biologically oriented professionals, national mental health organizations, and the drug industry. But where is the money coming from to support high-pressure lobbying, media campaigns, and upscale national conventions at hotels like the Chicago Hyatt Regency? Pathways to Progress, CHADD's (1992) convention program, stated,
"CHADD appreciates the generous contribution of an educational grant in support of our projects by CIBA-Geigy Corporation."
CIBA-Geigy (now Novartis) manufactures Ritalin, the stimulant that, at the time, held the lion's share of the ADHD market.
I have been able to obtain a complete list of contributions to CHADD by CIBA-Geigy. The escalating totals are as follows:
| 1989 to year ending June 30, 1992 | $170,000 |
| Year ending June 30, 1993 | $50,000 |
| Year ending June 30, 1994 | $200,000 |
| Year ending June 30, 1995 | $398,000 |
In 1995, CHADD also had smaller grants from Abbott Laboratories ($37,000) and Burroughs Wellcome ($18,000). Abbott is the manufacturer of the stimulant pemoline (Cylert), used to treat ADHD. Burroughs Wellcome makes several medications used in pediatric medicine, including well-known antibiotics and cold medications. They also make the highly stimulating antidepressant Wellbutrin.
CHADD's dependence on drug companies continues unabated. According to CHADD (2007), obtained from its Web site, "total pharmaceutical donation support of CHADD as of June 30, 2006 was 28% of CHADD's budget ($1,401,000)". Not included in this total are contributions foundations influenced by the drug companies such as Eli Lilly. The complete list of pharmaceutical supporters includes the manufacturers of most stimulants: Cephalon (Provigil, not approved for treating ADHD), (Strattera), McNeil (Concerta), New River (lisdexamfetamine dimesylate, a newly approved drug marketed in collaboration with Shire), Novartis (Ritalin in various forms), Shire (Adderall; Daytrana), and UBC (Metadate). Except for corporations making stimulants, CHADD received no other pharmaceutical industry support. CHADD is a committed group.
Does all this money influence CHADD to defend drug company interests, rather than the genuine interest of parents and their children? When the FDA served notice that it might put a new warning onto the label of stimulant drugs concerning cardiac risks in children, CHADD responded with a February 2006 press release warning that the decision was "premature" and calling for the usual "further research" (Goodman, 2006). CHADD concluded, "For many persons, ADHD medications are an important part of a comprehensive treatment program." In the press release, did CHADD describe itself as a drug company-funded advocacy group? No, it called itself "the nation's leading advocacy and family support organization representing people with attention-deficit/hyperactivity disorder (ADHD)".
The adult counterpart of CHADD, NAMI (National Alliance Mental Illness), has had equal success in its political efforts. It, too, is closely aligned with biological psychiatry and accepts money from the drug companies. Eli Lilly recently disclosed the recipients of $11.8 million in largesse for the first quarter of 2007 (Johnson, 2007 [693]). NAMI alone received a whopping $544,500.
In November 2005, the medical director and CEO of the APA wrote a letter to all members, including this author, urging us to become "professional supporters" of NAMI for the price of $75 per year (Scully, 2005 [1148]). When one organization sends out a mailing urging you to join another organization, you know they are partners. NAMI is an extraordinarily influential member of the psychopharmaceutical complex.
A CHADD Educator's Manual was written with the collaboration of professionals, including Russell Barkley (Fowler, 1992 [480]), the psychologist whose aim is to crush "noncompliance". It makes clear the intention to diagnose (and subsequently drug) children who fail to conform to strict discipline:
"Attention Deficit Disorder is a hidden disability. No physical marker exists to identify its presence, yet ADD is not very hard to spot. Just look with your eyes and listen with your ears when you walk through places where children are-particularly those places where children are expected to behave in a quiet, orderly, and productive fashion. In such places, children with ADD will identify themselves quite readily. They will be doing or not doing something which frequently results in their receiving a barrage of comments and criticisms such as `Why don't you ever listen?' `Think before you act'. `Pay attention'."
Note that "children are expected to behave in a quiet, orderly and productive fashion". There is no hint that adults should be expected to teach children discipline and to provide them with places in which they are motivated and enabled to behave in a quiet, orderly, and productive manner.
I have documented cases of parents who were forced to medicate their children by their spouses, the state, or their public school (Breggin, in press). By far the greatest threat to children and their parents lies within the public schools. They are being turned into triage centers to select out children for medication treatment. Parental consent will be steamrollered (Jackson, 2006b [659]). The system is euphemistically called mental health screening. In some states, there are proposals to begin with preschoolers and infants.
The impetus is the federal government's New Freedom Commission which supports both early mental health screening in the schools and the Texas Medical Algorithm Project, a pharmaceutical company attempt to enforce guidelines necessitating the use of its products. Minnesota pediatrician Karen Effrem (2005 [395], 2006 [396]) is leading the fight against proposed TeenScreening in our schools. Meanwhile, Effrem's state is moving toward toddler screening, and even infant screening, where legislation has been introduced calling for the "socioemotional" screening of toddlers before admission to kindergarten.
Columbia University is the strongest force in promoting TeenScreen around the nation. Evelyn Pringle (2007) [1057], writing for Independent Media TV, reported on how Columbia's TeenScreen program is run by Lauri Flynn, the former executive director of NAMI, the drug company-sponsored organization that has led the push for drugging adults and children. Flynn distinguished herself in the late 1980s by leading personal attacks against me because of my criticism of psychiatric medication. Over the years, NAMI has received multimillions from donors like Janssen, Novartis, Pfizer, Abbott Labs, Wyeth-Ayerst, Bristol-Myers, and its largest benefactor, Eli Lilly, which for years has given at a clip of over $1 million a year. The Columbia TeenScreen program was developed in collaboration with NAMI and therefore with America's pharmaceutical industry. TeenScreen is a pharmaceutical marketing program aimed compelling unlimited numbers of children and youth to take psychiatric drugs.
If these screening programs become fully implemented, "millions more children will be pushed into becoming lifetime consumers of psychiatric drugs. The engorged psycho-pharmaceutical complex will spread its tentacles over family and school alike. Meanwhile, the whole process will gradually become increasingly involuntary. Given that our children need attention to their real educational and family needs, and not diagnosing and drugging, these mental health screening programs are worth fighting against!" (Breggin, in press).
Children are given stimulant drugs for ADHD during a period of time in which they are developing their psychological and social skills, and, indeed, their very identity. What does it mean to a child, and later to the grown adult, to be told that his or her brain has crossed wires or a biochemical imbalance? What are the repercussions of children hearing that medication is necessary for them before they can behave in a "normal" manner that conforms to the standards of their family or school?
In my clinical work, it is enormously satisfying to see the reactions of children when I tell them, "I know you've been told by other doctors that you have ADHD and bipolar disorder, and that you need drugs; but none of it's true. Like any kid, you need help in learning to control your behavior. You're a wonderful child and you're going to be fine. We're all going to work together to help you grow up." Parents describe seeing their children look happy for the first time in years on the way home in the car after the first session. Some have told me that within hours their children have started singing or joking for the first time in years as a result of my reassuring them that there's nothing wrong with them and that, with the help of their parents, they can learn to control their own behavior.
It is far more demoralizing for a child to be told that his or her brain is defective than to be called bad. This is because the diagnosed child gets the same message - "you are bad" - plus a message that he or she is a hopeless freak, a person with an abnormal brain and mind. I never tell children they are bad, but they often find relief in hearing, "You don't have anything wrong with your brain; your parents haven't until now figured out how to help you stop behaving so badly. But you can see just from today in our family session how easy it is for you to calm yourself down with only a little help from me. You and your parents will soon be able to do that without my help."
As the list of criteria demonstrates, ADHD is one more DBD-another way a child gets labeled as a source of frustration or disruption. This is true even in regard to some of the criteria for the inattention aspect of the disorder. As Golden (1991) [540] observed, "The behavior is seen as being disruptive and unacceptable by parents and teachers, and the child socially handicapped as a result."
Dulcan (1994 [383]; see also Whalen et al., 1991 [1338]) summarized some of harmful moral, psychological, and social effects on children who are prescribed stimulant medications such as Ritalin and Adderall:
"indirect and inadvertent cognitive and social consequences, such as lower self-esteem and self-efficacy; attribution by child, parents, and teachers of both success and failure to medication, rather than to the child's effort; stigmatization by peers; and dependence by parents and teachers on medication rather than making needed changes in the environment." (p. 1218)
An unpublished report (Jensen et al., n.d. [676]), circa 1989, "Why Johnny Can't Sit Still: Kids' Ideas on Why They Take Stimulants," was based on research conducted by physicians Peter Jensen, Michael Bain, and Allen Josephson. Jensen is an experienced researcher from the Division of Neuropsychiatry at Walter Reed Army Institute of Research. Using interviews, child psychiatric rating scales, and a projective test titled Draw a Person Taking the Pill, the authors systematically evaluated 20 children given Ritalin by their primary care physicians. The researchers concluded that taking the drugs produced (a) "defective superego formation" manifested by "disowning responsibility for their provocative behavior (b) "impaired self-esteem development"; (c) "lack of resolution of critical family events which preceded the emergence of the child's hyperactive behavior," and (d) displacement of "family difficulties onto the child".
Many of the children thought they were bad and were taking the pill to control themselves. They often attributed their conduct to outside forces, such as eating sugar or not taking their pill, rather than to themselves. Jensen et al. (n.d.) [676] warned that the use of stimulant medication "has significant effects on the psychological development of the child" and distracts parents, teachers, and doctors from solving important problems in the child's environment.
Jensen et al. (n.d.) [676] concluded, "Research investigating children's perceptions of the meanings of stimulant medication, as mediated by the family context, adult and child attributions, and the child's developmental level, are long overdue." Unfortunately, Jensen never published the paper and instead went on to a lucrative and influential career as one of the nation's most uncompromising advocates of drugs for children.
Our children relate to us mostly through home and school and, in some families, through church, scouts, and other community organizations. In each place, we need a new dedication to their basic needs, rather than to treating presumed psychiatric disorders. Above all else, our children need a more caring connection with us, the adults in their lives. This link is now being forged in some school systems that have begun to abandon the large, factorylike facilities of the past in favor of a "small is beautiful" philosophy.
There are many advantages to smaller schools, but perhaps the most significant one is this: They allow teachers to get to know their students well enough to understand them personally and to meet their basic educational and emotional needs. At the same time, small schools and classes meet the teachers' basic needs for a satisfying, effective professional identity. Conflict can be more readily resolved as ideally it should be-through mutually satisfying solutions-rather than suppressed through medical diagnosis and pharmacological behavior modification.
Some smaller, more child-oriented schools have shown that the DBDs can virtually disappear. There is no better evidence for how the environment powerfully shapes the behavior that results in children being psychiatrically diagnosed.
In a July 14, 1993, New York Times front-page report titled "Is 11 Better? Educators Now Say Yes for High School," Susan Chira [278] reported,
"Students in schools limited to about 400 students have fewer behavior problems, better attendance and graduation rates, and sometimes higher grades and scores. At a time when more children have less support from their families, students in small schools can form close relationships with teachers."
Chira (1993) [278] suggests that teachers in these schools have the opportunity "building bonds that are particularly vital during the troubled years of adolescence". Even students from troubled homes respond to smaller, more caring schools. "They are shining stars you thought were dull," said a New York City teacher. "If you're under a lot of pressure and stress, they help you through that," said a student. "They won't put you down or put you on hold" (Chira, 1993 [278]).
Leila Abboud (2005a) [4], the Wall Street Journal writer who disclosed the facts behind the diagnosis of childhood bipolar disorder, also examined nondrug approaches to helping children. Abboud opened by pointing out, "With persistent concerns about using powerful psychiatric drugs in children, there is growing interest in counseling techniques troubled kids that aim to change destructive behavior." The successful, tested methods she described always started with the adults in the child's life. Parent management training, developed by Yale child psychologist Alan Kazdin, involves 5-15 weeks of teaching parents how to manage their child's behavior through role-playing and a disciplined system of rewards and punishments. The Incredible Years, developed by psychologist Carolyn Webster-Stratton, has a data base of over 8,000 professionals trained in the program. Parents usually attend 3 months of group sessions structured around videos of how to deal with difficult children. There is a module for teachers as well. Multisystem therapy, developed at the Medical University of South Carolina, centers around intense interventions in the families of high-risk juveniles in trouble with the law who might otherwise be sent to residential facilities. In addition, I have described a variety of approaches to helping children through their families and schools in my books Reclaiming Our Children (2000b) [206], Talking Back to Ritalin (2001c) [209], and The Ritalin Fact Book (2002b) [211].
Children respond so quickly to improvements in the way that adults relate to them that most children can be helped without being seen by a mental health consultant or therapist. Instead, the therapist can consult with the parents, teachers, and other concerned adults. In my clinical practice, I often see children only once or twice with the parents. After that, I work with the parents by themselves to help them to develop more consistent, rational methods of disciplining the child, along with unconditional love and attention to educational needs. If the parents are willing and able to learn new ways of approaching their children's needs, obvious positive changes in the children become apparent within a few day and weeks.
Many psychotherapists routinely help children without actually seeing them in their offices. As "adult therapists," they help their adult patients become more loving or disciplined parents through the routine work of psychotherapy, indirectly transforming the lives of their children. The children get better sight unseen. These therapists may not identify themselves professionally as child psychiatrists or child therapists; but they are doing far more good for children than those professionals diagnose and medicate them.
Children are not born with emotional disorders; they are born into emotionally disturbing living conditions. I have reviewed some of research literature linking disturbed home environments, child abuse, and other factors to emotional disturbances in children (Breggin, 1991b [189], 1992a [191]). A study by Biederman et al. (1995) confirmed that there correlation between adversity in the child's life and a diagnosis of ADHD. Adversity includes such things as severe marital discord, low social class, large family size, foster parent placement, and mental illness or criminality in the family.
Salyer et al. (1991) [1120] provided a discussion with citations to literature concerning the role of environment in causing a variety of childhood disorders. The focus of their article is learning disability (LD). They pointed out that families with children labeled LD are less cohesive and more chaotic, with less educational stimulation and more economic difficulty. Families with so-called LD children tend to provide less support and less independence, while emphasizing control. In the same vein, they pointed out that even with known biological and genetic disorders, such as brain damage, "the psychosocial environment was found to be the most important predictor of the child's later level of functioning (p. 238).
Green (1989) [559] provided a comprehensive review showing that virtually every childhood disorder can be produced by environmental trauma and stress. The whole range of childhood disorders, from autistic behavior to hyperactivity and violence, can be caused by the environment. The message from this seems clear-cut: Adults, through their control over the environment, are in a position to provide harmful or healing alternatives to children.
When adults provide them a better environment, children tend to quickly improve their outlook and behavior. Sometimes children can benefit from learning how to help to ease the conflicted situation, but it is futile to ask young children to contribute in a positive fashion to resolving family problems unless the adults are simultaneously learning the same conflict resolution skills.
By the time children reach adolescence, self-destructive patterns can become so internalized or entrenched that their parents may be unable to reach them. In addition, rebellious teens may be unwilling or unable to rend to positive changes in their parents. As a result, some teenagers can benefit from individual counseling, especially if their parents are also getting help. But for the overwhelming majority of preadolescent children, therapeutic interventions can be directed almost exclusively at the adults in their lives, including the parents and teachers.
If children are brought into a therapy setting, they should never be given the idea that they are diseased or defective. They should never be told that they are the original cause of the conflicts they are having with their schools and families. The focus of child psychiatry should not children, but parents, families, schools, religious institutions, and the wider society. What is most needed is greater adult responsibility for children in all spheres of life, from the personal attention of a parent or teacher to the social reform of our family, school, religious, and social life.
Children can benefit from guidance in learning to be responsible for their own conduct, but they do not gain from being blamed for the trauma and stress that they are exposed to in the environment around them. They need empowerment, not humiliating diagnoses and min-disabling drugs. Most of all, they thrive when adults show concern and attention to their basic needs as children. These needs include self-esteem, love, discipline, and education. These needs cannot be filled by adults who want to diagnose and drug the children. They can only be fulfilled by adults who are willing to open their hearts to children and to learn new and better ways to approach troubled and troubling young people as individuals.
We have lost sight of these truths in America and have become all too willing to hand over our so-called problem children to experts with credentials that permit them to recommend or prescribe drugs. Our problem children reflect our problems as adults; in each and every case, it is up to us to find ways to provide what our children need in order to become responsible, self-disciplined, successful adults.