Chapter Four

Spitzer’s List

Here are the fourteen behaviors listed on the ADHD check list, quoted from the DSM.

“Diagnostic Criteria for 314.01 ADHD

Note: Consider a criteria met only if the behavior is considerably more frequent than that of most people of the same mental age. A disturbance of at least six months during which at least eight of the following are present:

1. often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to feelings of restlessness)
2. has difficulty remaining seated when required to do so
3. is easily distracted by extraneous stimuli
4. has difficulty awaiting turn in games or group situations
5. often blurts out answers to question before they have been completed
6. has difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension) e.g., fails to finish chores
7. has difficulty sustaining attention in tasks or play activities
8. often shifts from one uncompleted activity to another
9. has difficulty playing quietly
10. often talks excessively
11. often interrupts or intrudes on others, e.g., butts into other children’s games
12. often does not seem to listen to what is being said
13. often loses things necessary for task or activities at school or home (e.g., toys, pencils, books, assignments)
14. often engages in physically dangerous activities without considering possible consequences (not for the purposes of thrill seeking) e.g., runs into the street without looking

Note: The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-III-R criteria for disruptive behavior disorders. Onset before age seven. Does not meet the criteria for a Pervasive Developmental disorder.”

That’s it. Those are the fourteen items, of which your child only has to show eight. The symptoms need to show up before the child is seven years old, and should last for a period of six months for the child to qualify as ADHD. Wow!

We need to do some thinking about this list. Let me begin by drawing your attention to some details.

First, did you notice that eight of the fourteen items began with the word “often”? For example, “often loses,” “often fidgets,” “often blurts,” etc.

Whose “often” did the developers of this diagnosis have in mind when they chose these eight items? A general practitioner who sees a few kids? A pediatrician who sees a lot of kids for common medical problems? A child psychiatrist who sees a lot of kids for behavior problems? An adult psychiatrist who wouldn’t see a kid if his couch depended on it? How about a CHADD board member whose child is taking Ritalin?

What is required to answer the “often” question about a given behavior is experience and judgment. This is what parents pay a professional for: his or her experience in matters outside the normal person’s own expertise.

A second point. Did you notice that, of the six questions that did not begin with often, five of them began with “has difficulty”?

How much “having difficulty” does it take to qualify for a check mark? Again, it is a matter of experience and judgment. Again, it comes down to who is doing the diagnosing and what his or her qualifications are for doing so. The process should take more than simply owning a pencil and being able to read, shouldn't it?

Check list diagnosing totally ignores training and experience. In this check list approach, a teacher’s or day care worker’s opinion could carry the same weight as that of a qualified neurologist or child psychiatrist. That some parents accept a diagnosis from someone without training or experience, based on a list of fourteen vague criteria, and use that information to put their child on drugs, is beyond comprehension.

As Shakespeare might have put it, “He who depends upon diagnoses such as these, swims with fins of lead.”

ADHD Research

The problem of facile ADHD diagnosing is heightened by the fact that many millions of dollars are being spent on research intended to find the ultimate cause of the condition. Since this is clinical research, it involves comparing groups of children diagnosed with ADHD against normal children who haven’t been so labeled.

In all of the research projects on ADHD, the subject group is diagnosed by the check list. Since all fourteen of these items are matters of judgment, and all kinds of different people are making the judgments, the ADHD group they come up with is, scientifically speaking, insignificant. This means any differences observed between that group and the control group are also insignificant.

Despite this insignificance, whole careers have been built on ADHD research of this nature. Millions of dollars are being wasted in this fashion. But that is not the worst of it. Treatment is being justified on the basis of such flawed research. In the land of the blind the one-eyed man is king, even if he has a cloudy cataract.

But I’m not finished with this list yet. Look at the items again. Don’t you think almost any child could, without stretching things, be labeled ADHD? Tragically, the diagnosis is pathetically over inclusive. Do you know any fidgety children who can’t stay in their seat, or play quietly, who don’t listen when you speak to them, or have difficulty following instructions? Don’t most children blurt out answers, interrupt others, and chatter away?

Of course you do. Everybody does. Count them! That’s eight symptoms everyone exhibits. That means that just about any child – and I don’t care if he is your favorite nephew – qualifies for the diagnosis and will receive it, if he falls into the wrong hands.

Remember that the protocol says the symptoms must be present before the age of seven to make the diagnosis. Most every child, certainly those who are temperamentally energetic and intense, will show many of the behaviors on the list when they are of preschool age. It’s normal for young children to have these “symptoms.” So, the question then is, what do these behaviors really indicate?

Symptom or Adaptive Immaturity?

In my view, the significance of these so-called symptoms – and I prefer to call them behaviors – is entirely dependent on the age of the child. If I saw a four year old with these qualities, I would say to his or her mother, “this one’s a handful! How about we get to work on those temper tantrums for a start.” And with good parenting, I would expect the tantrums to cease in matter of two or three weeks.

This approach to difficult behavior is normal child rearing consultation. No way should it be called treatment of symptoms, in either the mother or the child. The behaviors on the ADHD check list, though they are called symptoms, are not symptoms in the way that a rash or a cough or a sore foot are symptoms. These behaviors are common, and they are normal in preschool children. When they are seen in older children, they are more appropriately called signs of immaturity.

It is important to draw this distinction. Getting over normal immaturity is a process that has a name. It is called growing up. No way is growing children up “treatment.” Children do not grow up by having a label pasted on their medical folder and taking prescription drugs such as Ritalin.

Children grow up when they are parented properly: that is nurtured and trained in a fashion appropriate for their temperament. This is a subject I shall return to and spell out in more detail later.

Before I go on to a discussion of Ritalin and its effects, let me close this chapter with a quote from the Drug Enforcement Agency Report – Methylphenidate, 1995.

“ADD has never been proven to be a disease or anything physical or biologic. Asked if it was or not, Paul Leber MD of the US Food and Drug Administration responded December 22, 1994 [stating] ‘that as yet no pathophysiology for the disorder has been delineated.’ The Drug Enforcement Administration responded on October 25th, 1995 [stating] ‘We are also unaware that ADHD has been validated as a biologic/organic syndrome or disease.’ ”

Despite such strong advice to the contrary, doctors go on making the diagnosis of ADHD and prescribing Ritalin, claiming that,”if I don’t do it, somebody else will.”

The next chapter is all about Ritalin, how it works, not why it works because nobody knows that. We shall also deal with Ritalin’s several varieties of side effects: mild, moderate, severe, and as yet unknown.