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Tuesday 24 June 2014

YOUNG CHILDREN OVERDIAGNOSED WITH 'DISORDERS' FOR DISPLAYING LESS MATURE BEHAVIOUR!! - Canadian study shows - Courtesy of the CMAJ -“The potential harms of overdiagnosis and overprescribing and the lack of an objective test for ADHD strongly suggest caution be taken in assessing children for this disorder and providing treatment,”

Younger children in the classroom likely overdiagnosed with ADHD

Immaturity may lead to diagnosis of disorder

The youngest children in the classroom are significantly more likely to be diagnosed with attention-deficit/hyperactivity disorder (ADHD) — and prescribed medication — than their peers in the same grade, according to a study just published in CMAJ (Canadian Medical Association Journal).

ADHD, which is often treated with prescription medication, is the most commonly diagnosed behavioural disorder in children. Two recent studies have shown a link between the relative age of children and diagnosis of ADHD and prescription of medication. Younger children in the same grade as children who may be almost a year older may appear to be immature compared with their older peers. This apparent lag in maturity has been called the “relative-age effect” and influences both academic and athletic performance.

Researchers from the University of British Columbia were interested to see whether this relative age effect was present in Canada and looked at a large cohort of 937 943 children in British Columbia, a province where the cut-off for entry into kindergarten or grade one is Dec. 31. The research included children who were between 6 and 12 years at any point during the 11-year study conducted from Dec. 1, 1997 to Nov. 30, 2008.

Researchers found that children were 39% more likely to be diagnosed and 48% more likely to be treated with medication for ADHD if born in December compared to January. Due to the Dec. 31 cut-off birth date for entry into school in British Columbia, children born in December would typically be almost a year younger than their classmates born in January.

“The relative age of children is influencing whether they are diagnosed and treated for ADHD,” said lead author Richard Morrow, University of British Columbia. “Our study suggests younger, less mature children are inappropriately being labelled and treated. It is important not to expose children to potential harms from unnecessary diagnosis and use of medications.”

There are significant health and social ramifications of inappropriate diagnosis of ADHD. Medication to treat ADHD can have negative health effects in children such as sleep disruption, increased risk of cardiovascular events and slower growth rates. As well, younger children who have been labelled ADHD may be treated differently by teachers and parents, which could lead to negative self-perception and social issues.

“This study raises interesting questions for clinicians, teachers and parents,” noted coauthor and psychiatrist Jane Garland, University of British Columbia and BC Children’s Hospital. “We need to ask ourselves what needs to change. For example, attention to relative age of children for their grade and more emphasis on behaviour outside the school setting might be needed in the process of assessment.”

Although the prevalence of ADHD diagnosis and treatment is about three times higher in boys than girls, the effect of relative age applied to both. In fact, girls born in December and typically younger within their grade were 70% more likely to be diagnosed with ADHD than girls born in January.

“The potential harms of overdiagnosis and overprescribing and the lack of an objective test for ADHD strongly suggest caution be taken in assessing children for this disorder and providing treatment,” conclude the authors.

The ADHD medications included in the study were methylphenidate, dextroamphetamine, mixed amphetamine salts and atomoxetine.

MEDIA NOTE: Please use the following public links after the embargo lift:


Sunday 22 June 2014

The Pharma Chronicles: Prof Peter C Gøtzsche BMJ response re antidepressants increasing the risks of suicide in young people....

The Pharma Chronicles: Prof Peter C Gøtzsche BMJ response re antidepressa...: Peter Gøtzsche BMJ response by Prof Peter C Gøtzsche , Nordic Cochrane Centre, Rigshospitalet, Copenhagen:   'Re: Changes in antid...

'Re: Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study'

"The study is not reliable  

Lu et al. reported that suicide attempts in young people increased after the FDA warned in 2003 and 2004 that SSRIs can increase just that: the risk of suicidal behaviour in young people (1). They found substantial reductions in antidepressant use after the warnings and believe that this caused the increase in suicide attempts.  

This is contrary to what would be expected. The FDA’s large meta-analysis of 100,000 patients who had participated in placebo-controlled randomised trials found that antidepressants increase suicidal behaviour up till about the age of 40 (2), and in young people, the risk was doubled, as Lu et al. also report (1). This result was found despite the fact that many suicides and suicide attempts on active drugs were missing in the FDA analysis (3).   

It is therefore a highly convincing finding that antidepressants increase the risk of suicide in young people, and randomised trials are far more reliable than the before-after analysis that Lu et al. presented, which seemed to find the opposite result. There must therefore be major problems with their research ..."

Wednesday 11 June 2014

The Normalization of Difference in Our Children Dave Traxson - June 9, 2014 - Courtesy of dxsummit.org

CLICK ON LINK FOR : dxsummit.org/archives/2117
ODD and ADHD are not evidence based medical conditions,as there is huge geographical variation, but are 
'socially constructed' concepts.

The Normalization of Difference in Our Children
Dave Traxson       June 9, 2014

How in a Progressive Society we use this to Minimize the Excessive and Erroneous Diagnostic Labeling of Childhood Behaviors.

A starting point for all my professional involvements with children to help engage them positively in the process, is what I call the Normalising Conversation. This is an ongoing process which develops with the work with a child and is revisited regularly to reinforce their normality rather than abnormality

I start by asking if they understand the difference between a Psychiatrist and a Psychologist, as this can often be a cause of confusion and distress, due to their perceived negative labeling by significant people in their lives. I start by explaining that one is a doctor who treats the mind, when people are temporarily unwell, in various ways using a range of clinical therapies or drugs.

I then say a Psychologist is not a Doctor and talks to normal people, in various settings such as schools or offices, who are having typical ‘ups and downs.’ I explain that everybody around them has ‘ups and downs’, even their head teacher, their boss, their parents, their favourite musician or celebrity etc. Wherever possible I illustrate this by using the real names of these significant people, which I elicit from them and talk about their possible ‘ups and downs’ in a jokey but reframing way.

Sometimes you can visibly see their breathing slow down as they become reassured by what I am saying and this is, I strongly believe, is the power of a Normalising Conversation.
Why are normalising conversations important?

– to reduce pathologising and erroneous labeling of childrens’ normal range of behaviours.

- to demonstrate clearly that their current behaviour pattern falls within a normal range and is definitely not abnormal in nature.

- to motivate them to revise their thinking and/or ‘mind set’, to consider alternative explanations and to visualise an achievable preferred future.

- to promote inclusive and solution focussed approaches to their situation.

- to fundamentally reduce the number of children who proceed down the ‘conveyor belt’ of diagnostic stigmatisation and consequently the over-prescription of psychotropic drugs to children.

- to enhance life opportunities and positive outcomes through our childrens’ improved wellbeing and mental health.

- to avoid giving children any of the plethora of new diagnostic labels to hang around their necks as a toxic and false categorisation of their unique humanity.

- to re-evaluate treatment responses in various countries and the impact this has on an individual or on societal values and outcomes.

So instead of starting by categorising children, so frequently, as having clinical ‘disorders’ of the mind or personality, we need to see them as being fundamentally unique and different human beings with the opportunities for positive change in a life that is all ahead of them.

Rather than thinking that these human variances of behaviour and mood are distributed on the ‘normal distribution curve’ that we are all used to see being used to justify the spread of different attributes we are more likely to see a ‘normal scatter diagram’ of scores or views around a continuum line of difference. Standard deviations are not a helpful concept for behaviour patterns that are by no means standard in nature.

A normal curve may well work for height and other physical features but is unlikely to be a successful explanation of such complex and interactive dimensions as ‘intelligence’ or ‘deviance’ from behavioural norms or expectations. Indeed Psychology’s leading role in the use ‘the normal distribution curve, over the last century, has been a cause of deep regret to many humanistic psychologists who have ethical concerns about the inappropriateness of such a divisive and limited construct and how it has been used in the guise of IQ to segregate children who may well have been better educated within a full spectrum and inclusive provision.

If we normalise behaviour without patronising clients and unduly minimising the significance of certain behaviours then we have millions of people in society, as they naturally mature as individuals, feeling they are thought to be normal and not abnormal, by those around them. So institutional social control via Psychiatric institutions and/or prison for the normal range of behaviours is avoided. This may include minor ‘offenses’ such as finding a ‘roof over your head’ by squatting or ‘fending for yourself’ by retrieving and  eating packaged food which is still edible from shop bins and means that less people are potentially ‘retraumatised’ by the system we have in place to deal with their personal distress. We would automatically be more holistic in the way we look at the complex interactive variables that occur in a child’s life such as childhood trauma, attachment difficulties, family breakdown or violence, environmental stressors, and intrapersonal issues all of which may be contributing to the way the child is behaving at that particular point in time.

The range of societal responses, around the world, is enormous to these issues. Let’s take ADHD and psycho-stimulant medication as one example – in Italy and France 0.15% of children are medicated, in the U.K. it is at least 1.5% with many seeking an increase and in America it is at least 15% with many there saying that 25% of all children there will need medication for a mental health condition. This systemic lunacy illustrates that the behaviours we are defining as abnormal are not a true medical phenomena but are instead socially constructed and developed for another more controlling agenda than the welfare of children.
Indeed this rapidly expanding situation is, in my opinion, the biggest Child Safeguarding issue of our time and dwarfs some of the other important issues that are regularly featured in our media and courts.

If our shared intent is to be a caring, progressive society that actively promotes the mental health and wellbeing of individuals at all levels then this is where we need to start. “Communication is the art of intent,” is a great unattributed quote that I have found very helpful in my career and so the Trillion Dollar Question, for that is the potential cost to society of getting it wrong, is what do we collectively want to communicate to the future about the way we have deliberately chosen to treat our children today?

Is it an agenda of Inclusion in a Fair Society or Exclusion and Stigmatisation?

Is it a Comprehensive Education and Health Care System for all or an elitist schooling and medical health system for the ‘chosen few?’

Is it mental health and wellbeing for individuals and society as a whole or mental illness with the focus on ‘within person’ causation?

Is it a future of hope and creatively addressing difficulties or despair and categorising differences into arbitrary divisions for us all?
These choices are real and some societies are on very different philosophical and practical journeys to our own hence giving us all an opportunity to reflect and learn.

Where do we want to start this new journey as a society and what is our collective aspirational destination for children in particular?

The debate continues. Please participate.

Acknowledgement: Thanks to Lucy Johnstone for her ideas about Psychological Formulation and ‘Retraumatisation’ of clients.

Tuesday 3 June 2014

Mental Suffering and the DSM-5 Stijn Vanheule - Courtesy of dxsummit website - Posted 3-06-14

Mental Suffering and the DSM-5
Stijn Vanheule


In his writings on the topic of diagnosis, the French philosopher and physician Georges Canguilhem makes a crucial distinction between pathology and abnormality, thus paving the way for the studies of his student Michel Foucault on the topics of psychiatric power and biopolitics. In Canguilhem’s view, decision making about normality and abnormality is generally based on two factors. One starts from the observation that there is variability in the ways human beings function: individuals present with a variety of behaviours just as their mental life is characterized by a variety of beliefs and experiences, of which some are more prevalent than others. Then, a judgment is made about (ab-)normality; this tends to be based on a norm or standard against which all behaviours are evaluated and considered as deviant or not.

At this level, two possibilities open: a judgement is made based on either psychosocial criteria or statistical norms.

If the judgement is based on psychosocial criteria, it is the extent to which the individual’s functioning fits his environment that is assessed. Following this logic, behaviours are ‘normal’ if no-one is particularly concerned about it or if they don’t cause the others inconvenience. This line of reasoning might seem plausible, but it is based on the idea that individuals must adapt to their context: “To define abnormality in terms of social maladaptation is more or less to accept the idea that the individual must subscribe to the fact of such a society, hence must accommodate himself to it as to a reality which is at the same time a good”. As social conventions change across time, identical modes of human functioning will be judged differently. The case of homosexuality illustrates this well: in the early 20th century it was mainly seen as a moral aberration; and in the works of early sexologists homosexuality was classified as a perversion. This gave rise to the medicalized idea of homosexuality as a mental disorder. However, following much protest in the 1970s, homosexuality was gradually accepted as a sexual preference, alongside heterosexuality.

Applied to the DSM-5 it can be concluded that some disorders, particularly those diagnosed in children, remain strongly based on judgement in lieu of norms that are imposed onto the individual. For example, the criteria for diagnosing ADHD exclusively build on third party opinions about the individual and use common sense ideas about desired behaviours in specific contexts (e.g. school) as the standard against which behaviours are evaluated. Indeed, diagnostic criteria for ADHD include characteristics like “Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction),” “Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)” and “Often has difficulty waiting his or her turn (e.g., while waiting in line)”. In the DSM-5, and other relevant literature, these diagnostic criteria are rarely discussed, leaving all interpretation as to a) what is meant by the term ‘often,’ and b) why specific behaviours are deemed problematic, down to the judging diagnostician. Thus, it is the professional’s personal opinion that functions as the norm against which an individual is evaluated. In other words, because strict scientific standards for making such evaluations do not exist, it is the belief system of the diagnostician that determines the standard. This can provoke over-diagnosis [6], especially if particular professionals are inclined to problematize particular behaviours.

The other option for evaluating the (ab-)normality of human mental functioning is to refer to statistical norms. Canguilhem indicates that this kind of judgement is rooted in the work of the Belgian mathematician Adolphe Quetelet (1796-1874), who aimed to study human functioning through a new discipline he coined ‘social physics.’ His underlying thesis was that social scientists should study the variability of human characteristics, ranging from physical qualities to aspects of psychological and behavioural functioning. Quetelet aimed to map how people generally function, thus giving rise to a mode of thinking ‘in which normality’ is considered in terms of the statistical normal distribution. In this line of reasoning normality implies a mode of functioning that closely adheres to the mean or median in statistical distribution. Abnormality, in its turn, implies a mode of functioning that strongly deviates from the average: individuals with an extreme score in terms of the normal distribution are abnormal. From a Foucauldian point of view, this statistically-based evaluation of human behaviour engenders a bio-political approach to human functioning: based on a marked deviance from the average, individuals are subjected to disciplinary practices that aim to engender (self-)control.

Nowadays, certain psychological testing practices function according to the same logic: an individual’s score is compared to cut-off values that are listed in so-called norm tables. Such tables are composed of scores obtained by administering the same test in large populations (clinical and/or non-clinical). To evaluate the individual’s test score, professionals often only compare it to the distribution of scores in the general population, and thus determine whether it deviates from the norm or not. According to Nikolas Rose psychological tests provide “a mechanism for rendering subjectivity into thought as a calculable force.” In his view psychological assessment and evaluation practices provide a technology, starting from which contemporary man inspects and perfects himself, and likewise scrutinizes and manages others. Through the lens of psychological testing, we began to think of ourselves as manageable machinery. Assessment instruments map individual differences, appraise them in terms of statistical or other social norms, and engender “techniques for the disciplining of human difference” .

Canguilhem argues that in the diagnosis of pathology, by contrast, the subjective experience of human suffering is the hallmark. Indeed, for diagnosing pathology, one cannot start from societal or statistical norms. “Pathological implies pathos, the direct and concrete feeling of suffering and impotence, the feeling of life gone wrong”. Such a diagnosis of pathology does not build on the opinions of experts, but on patients’ appraisal of their own distress. Moreover, it does not neglect the heteronomy in the patient’s functioning [22], but examines how heteronomy is experienced.

By referring to the experience of distress in the definition of mental disorders, the DSM-5 takes into account pathology. Yet as one examines specific DSM-5 disorder criteria one sees that for certain conditions the subjective experience of distress is not necessarily crucial. For example, none of the diagnostic criteria for ADHD refers to the experience of distress by the child or adult for whom the diagnosis is considered . In the diagnosis of other conditions, like Major Depressive Disorder, the subjective experience of distress is taken into account more strongly. In our view, the quality of psychiatric diagnosis would be greatly enhanced if pathos, as mentioned by Canguilhem, were mandatory to all diagnostic decision making.

Excerpt from the paper: Vanheule, S. & Devisch, I. (in press). Mental suffering and the DSM-5: a critical review. The Journal of Evaluation of Clinical Practice. http://onlinelibrary.wiley.com/doi/10.1111/jep.12163/abstract.

Full paper available upon request.