To Speed or Not to Speed

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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In what may turn out to be an early crack in the wall, the online psychiatric newspaper Medscape (which is entirely supported by drug manufacturers) has carried a brief critical article on ADHD by Dr William Wilkoff, a retired paediatrician in Maine, USA. Perhaps because of the climate they have to endure, Mainers, as they are known, are usually regarded as fairly unexcitable people, even a bit boring, but they see that as a strength. That would seem to describe the old chap to a T as he is decidedly unexcited about the rising tide of ADHD sweeping the US and many other countries. According to the CDC (or what’s left of it), 11.4% of American children aged 3-17yrs have been given the diagnosis, 15% of boys and 8% of girls, including 21% of 14yo boys and a ridiculous 23% of 17yo boys. Each year, well over a million children are added to the ranks. These days, whatever ails them at age 17 no longer disappears when they turn 18, as it used to, but they simply join the growing numbers of adults “living with ADHD,” as they say.

Dr Wilkoff points out that way back when he started his half-century of practice, what was then known as “minimal brain damage with hyperkinesis” hardly existed. During his career, it has “mushroomed” (his word) into an entire industry in its own right. His view is that what is seen as a genetic “disease” is actually just a selection from the huge range of behaviours shown by children as they react to circumstances in their lives. It’s not a disease at all, rather: “… an expression of a mismatch between a person’s capabilities (both physical and emotional) and their environment…” In particular, he points to sleep deprivation as a potent cause of the disturbed behaviour that leads to the label of ADHD. The fact is that modern children don’t sleep as much as children did in the past and, very often, they go to sleep in an agitated frame of mind because of what they’ve been watching on their various screens. That may be so but there is no doubting his basic point, that it is impossible for a genetic illness to go from nothing to nearly a quarter of all boys in under two generations.

In fact, the very idea of a novel biological illness called “ADHD” sweeping the world says that the people pushing this barrow have no idea how genes work to produce observable behaviour. They want to find a one-to-one connection between a category of behaviour they see as uniquely abnormal and some underlying biomarker or indicator of disease. We need to bear the following points in mind:

1. The diagnosis of ADHD is based on a loosely defined and highly subjective cluster of behavioural features which are very much dependent on the setting. What is seen as “disease” in one setting can be desirable in another, or completely absent, even in the same person. While the diagnostic criteria in the manuals look very objective and scientific, they’re not. For example, most of them rely on the word “marked.” What does that mean? It actually means “noted, indicated, specified,” as in “a marked man.” It does not mean “very, excessively, extremely” or any other adverbs. It gives a scientific gloss but it rubs off when we see how different people interpret the word.

2. It didn’t exist when I went to school, in a small country town at the height of the baby boom. There were 500 children in my primary school. I knew almost all of them, knew their families and so on. No child ever stood up in class and walked around or spoke out of turn. Same in high school, which was the regional high school, with 1100 kids when I finished Year 12. Because I worked as a postman during my holidays, I knew everybody. There were plenty who didn’t want to be at school, who left they day they could (end of Year 9) or after the state exams in Year 10, but they quickly found work and were fine. There were no psychologists in the town, no paediatricians, definitely no psychiatrists, what a joke that would have been. We’re now asked to believe that 15-25% of those boys should have been on drugs for a genetic mental illness that, left untreated, results in criminality, suicide, drug and alcohol addiction, family breakdown and other mental and social disorders. I don’t buy it.

3. Despite spending tens of billions over decades, nobody has ever found anything like a biomarker to indicate a primary biological cause for this “disorder.” There are no chemical imbalances, no genetic errors, no brain damage or anything. It exists today as it has always done, a cluster of signs that can only be seen with the eye of faith. Unbelievers just can’t see it.

4. We are told that ADHD has high levels of “comorbidity” with a number of other mental conditions (see CDC link above). About 80% of children reach criteria for one or other psychiatric diagnoses, such as “behaviour or conduct disorder,” anxiety, depression, ASD etc. This is where the eye of faith takes over what should be a reliable or scientific process: there is so much overlap of the symptoms that it’s possible to slice and dice them any way the interviewer wants. One person sees the child as having ADHD; next one says “Oh no, that’s ASD,” while the third says “Actually, it’s both.” Poor concentration is absolutely typical of anxiety and of depression. One child withdraws and tries to hide, the next acts the clown and distracts the other children while the third argues with the teacher. That’s personality but the underlying cause is anxiety or depression – or boredom.

5. There is not a single symptom of ADHD which cannot be better explained as anxiety. However, psychiatrists don’t like anxiety, they think it’s not real. Moreover, they don’t know about Ockham’s razor. This ancient principle says that the number of explanatory entities must not expand beyond the minimum needed to do the job. I don’t have to invoke ghosts if the wind can make the door slam. I don’t have to invoke two separate “diseases” called ADHD and anxiety if all the symptoms can be attributed to anxiety. And they can but if you rely on questionnaires and don’t ask the questions nobody wants to be asked, like “Are you a nervous person?” you’ll never find the core problem.

6. “Ah yes,” they say, “but what about the tablets? You can’t deny they work.” They certainly do something, no argument about that, amphetamines are very powerful psychoactive drugs. It’s not widely known but these drugs were behind the Wehrmacht’s stunning successes in the early parts of World War II. In a detailed historical study, Norman Ohler showed how amphetamines were handed to all front line troops, which is how they stayed awake and kept pushing ahead when the defending troops were falling down exhausted [1, also my review here]. They were used by the Allies to help bomber pilots stay awake on long trips but they had another effect, as well. When anti-aircraft fire was intense, many pilots panicked, dumped their bombs and turned back. Up to 40% of bombs were wasted this way but if the pilots had taken amphetamines, they held course to the target. That is, they weren’t bothered by fear. Amphetamine users say the same thing: “Why do I take them? They make me feel ten foot tall and bullet proof, that’s why.” That is, stimulant drugs suppress anxiety. If anxiety causes poor concentration, which it does, then amphetamines will improve it. The fact that people improve does not say there is a separate “disease process” in responders. That’s the classic mistake known as Argumentum ex iuuantibus, or arguing backwards from a treatment effect. The Romans knew all about it but everybody seems to have forgotten the lesson these days.

7. Historically, the drug effect on children was discovered by chance, which is more or less normal for psychiatry. In 1937, a psychiatrist running a clinic for children gave a group of them amphetamine for apparently no other reason than that was about all he had. Half of them became quieter and more focussed and, from that microscopic start, has grown the mighty ADHD industry, now extending its imperial reach to adults. It is wholly a matter of luck for the manufacturers, and the psychiatrists who have grown rich on it, that the drugs had just that effect but the industry is a fad built on artfully manipulating the fears of middle class parents.

8. Recent studies show that the drugs produce only a temporary improvement in performance but no long term improvement in real measures, such as ability to learn or organise material [e.g. 2]. Their main effect is that people feel better but their results hardly budge. We can readily explain that as a reduction in performance anxiety. Long term outcomes show no reliable difference except people who have been prescribed stimulants before 18 are more likely to abuse drugs as adults.

9. People don’t like the drugs. 40% of teenagers stop them within a year and many more take them irregularly. Trouble is, they often don’t tell anybody and their supplies continue, so they quickly leak into the black market. Stimulant drugs open a huge door to the otherwise hidden world of the drug scene, luring innocents down the path like a latter-day Pied Piper.

10. Prepubertal children who continue the drugs through to early adulthood will be on average 25-30mm (an inch) shorter than children who don’t take them. If every child were told this, which they’re not, most would refuse drugs.

11. Sustained concentration, which is demanded in schools and many jobs today, isn’t natural. It has to be learned, and there are thousands of factors that can contribute to the outcome. If you want to know what the “natural” state of human attention is like, watch baboons or other monkeys eating on the ground. They look around, grab a bit of food and shove it in their mouths, look around, get a bit more, look around… Monkeys that don’t look around for the many dangers they face don’t survive to breed. This was almost certainly the case with early humans. We are naturally alert animals. Children (and most adults) pay attention to what they like and fidget with things they don’t like. That’s normal. In my day, we walked several kilometres to school or rode our bikes so we’d already exercised before we started the first class. For teenagers, bursting with energy, sitting still in a boring class while the teacher drones away at the board is torture.

12. Human behaviour is infinitely variable. We have no way of predicting how a child will react to life events. For example, the parents in one family bicker and squabble in front of the children. One child reacts by withdrawing into a fantasy world, the sibling reacts with defiance and arguing. That’s normal. The idea of an “equal emotional environment” is pure fantasy. The same events can have different outcomes, but also, the same outcomes can have different causes. One child argues due to anxiety, the next argues for laughs, to make the teacher look stupid. One child withdraws due to boredom, the next withdraws due to misery over its disturbed home life. That’s common sense. We cannot just select a cluster of undesirable behaviours and say they are a “disease” with a single biological cause. Take crying, for example: there are people who cry a lot. Some cry through misery, some cry through fear, some cry due to joy while others cry with any intense emotion, including boredom. We cannot put them in a group and say they have “Generalised Crying Disorder,” call it a unique genetic disease and put them all on a drug. That’s ridiculous. Thirty years ago, psychologist Richard Bentall (then at Liverpool University) mocked the idea of categories of “illness” based on behaviour alone when he proposed that happiness should be made into a new disorder called Major Affective Disorder, Pleasant Type [3]. He followed the DSM system and was able to show that happiness met all their criteria for a mental disorder.

We could go on but it gets boring and I start to fidget. ADHD doesn’t exist, either as a unitary entity that can be carved meaningfully out of the range of human behaviour, and it doesn’t exist as a biological entity. It doesn’t have a single cause and it isn’t a single thing. There is no brain damage in people labelled ADHD, no genetic defect, no single personality defect or anything. It is just part of the range of human behaviour where a particular person in a particular setting reacts to what is going on in a particular way. We are all born with a huge range of potential behaviours; the ones that come to dominate our lives are shaped by family, society, events, personality and so on. The outcome to a particular event can change next week or it can become cemented in place by the reaction of the surroundings (commonly known as the Law of Effect).

As Dr Wilkoff didn’t quite say, the idea that there is a unitary biological illness called ADHD has reached its use-by date, it has ceased being of any value and is now destructive. We could have predicted this, some of us actually did, because the entire concept, this huge and immensely profitable industry, is based on a false understanding of human mental function. Specifically, it is based in the spurious positivist notion that we can’t talk meaningfully about human mental function, therefore we have to talk about biology, and biology-talk will tell us all we need to know. Biology is not a substitute for an articulated theory of mind or a model of mental disorder. When it’s put like that, it’s so naïve, so wilfully dumbed down, that it would just about make you cry. But then you’d have Generalised Crying Disorder and would need to see a psychiatrist for the latest breakthrough in psychiatric drugs.

References:

1. Ohler Norman (2015): Der totale Rausch: Drogen im Dritten Reich. Kiepenheuer & Witsch : Köln. English translation by Shaun Whiteside: Blitzed: Drugs In Nazi Germany. Allen Lane: London, 2016.

2. Bowman E et al (2023). Not so smart? “Smart” drugs increase the level but decrease the quality of cognitive effort. Science Advances 9, doi: 10.1126/sciadv.add4165

3. Bentall RP (1992). A proposal to classify happiness as a psychiatric disorder. Journal of Medical Ethics, 18: 94-98

For an interesting commentary on the dumb “equal environments” notion, see the (fairly long) essay by psychologist Jay Joseph in this week’s Mad in America: The 110 Year Schizophrenia Genetic Research Train Wreck.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.