A Textbook Case

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

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,
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.

Go There >>
The Mislabeled Child

Go There Too >>
Move Over, DSM

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