A Textbook Case

Scrutinizing the mental health bible's take on attention deficit disorders

| June 8, 2006


Though America's medical professionals are diagnosing children with attention deficit disorders at breakneck speed, doctors are nevertheless hard-pressed to provide a solid definition of what exactly the illnesses are. That shouldn't be too surprising, however, considering that the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) 'lists no fewer than 18 different behavioral symptoms' for attention deficit hyperactivity disorder (ADHD), Contexts reports in its Spring issue (not available online). Such a scattershot approach by the DSM IV -- one of the most important texts to those who mete out psychiatric diagnoses -- has some clinicians and clinical organizations worried that scores of children are being misdiagnosed. Indeed, some think its structure and approach are faulty, causing misdiagnosis and clinical confusion.

Context cites sociologist Adam Rafalovich, who reports that doctors themselves are often unsure of their own diagnoses when it comes to ADHD. With so many symptoms that qualify one for an ADHD diagnosis and no ranking system to ferret out the significant from the incidental, doctors are on their own. Some, the article reports, have begun to distinguish between 'primary' and 'secondary' symptoms, thereby acknowledging a critical difference between neurological and environmental factors that the DSM IV does not address.

Drs. Brock and Fernette Eide, writing for The New Atlantis, raise similar concerns, arguing that the nation's system of diagnosing and treating children with behavioral difficulties has relied too heavily on ADHD diagnoses and psychotropic medication. Such diagnoses, they point out, stem from a flawed diagnostic paradigm: 'Understanding why a particular child is struggling with attention involves more than simply documenting certain behaviors,' which is as far as many diagnoses go. Yet the DSM IV offers no further guidelines, and 'because these various factors are not adequately considered in the DSM, they are seldom considered by practitioners when diagnosing ADHD.'

Leading the charge in the reformation of the DSM IV are psychodynamically oriented psychologists, who believe that diagnosis must draw from people's social context as well as their symptoms. In order to provide a viable alternative to the symptom-based diagnostic methods of the DSM IV, four psychodynamically oriented organizations recently published the Psychodynamic Diagnostic Manual (PDM) as a complement to the DSM IV. Advocates hope the new manual will 'encourage the next generation of therapists to start thinking about clients as something more than a collection of symptoms,' reports Garry Cooper in Psychotherapy Networker.



The DSM IV -- whose preparers, TheChronicle of Higher Education ($$) reports, have 'undisclosed financial ties to the pharmaceutical industry' -- isn't going anywhere fast, as it is a deeply entrenched resource in the field. Clinicians, professional organizations, and many others are now wondering, however, if the manual doesn't lack a broader perspective that could assist in providing better diagnoses and healthier children. If we do, as Dr. Brock and Fernette Eide suggest, 'tend to classify the child as 'sick' rather than seeking to understand what makes many healthy children struggle,' then it could be time to diagnose our system of diagnosis itself.

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