THE huge increase in the number of children and young people diagnosed with attention deficit hyperactivity disorder has stirred up a hornet’s nest. Many are questioning the appropriateness of medicating children—some barely out of infancy—with drugs such as methylphenidate (Ritalin). But there is an equally serious problem with the diagnosis itself. The loose criteria used to diagnose children as having ADHD are remarkably close to those used to diagnose adults as “psychopathic”. And the British government is drafting plans to lock up people diagnosed as psychopathic to prevent crimes they might commit.
We are at risk of perpetrating a serious breach of basic human rights. If the plans go ahead, people in Britain will be incarcerated on the basis of fallible clinical judgement, not anything they have done. The risk is that merely unruly children, once they have been judged to have ADHD, will be on a downward slope toward institutionalisation. And those judgements will be presented in courts and other tribunals under the guise of science.
ADHD is diagnosed, for want of a better word, by a psychiatrist observing behaviour, and comparing it with a checklist of behavioural traits. In the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), defining symptoms include “often does not seem to listen when spoken to directly” and “often blurts out answers before questions have been completed”. If a child shows more than six of the diagnostic symptoms, they will be described as having more severe ADHD.
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This hardly constitutes an objective medical diagnosis. There is no evidence that ADHD results from brain malfunction. Neither laboratory tests, physical examination nor general medical condition has been shown to help in the clinical assessment of this disorder. Just as US Supreme Court Justice Potter Stewart said of pornography, you are supposed to “know it when you see it”.
“Antisocial personality disorder” in adults, meanwhile, is defined in DSM-IV as “disregard for and violation of the rights of others” occurring with three of seven behaviours—for example impulsiveness, deceitfulness and lack of remorse—and with a “conduct disorder” diagnosed in childhood.
“Psychopathy” is more a legal than a psychiatric term, but it is closely linked to the notion of an antisocial personality disorder. Popular “tick-test” questionnaires used by forensic psychiatrists to diagnose psychopathy aim to detect personality attributes such as “glibness” and “need for stimulation or proneness to boredom”. It is not hard to imagine some interviewers inducing glibness or boredom in their subjects.
As with ADHD, neither genetics, physical brain damage or a biological marker plays any part in the diagnosis of personality disorders. In fact, there is a startling overlap between the assessment and diagnostic criteria for personality disorders and for ADHD.
British law defines such disorders as untreatable, and under the Mental Heath Act 1983 no one can be detained in hospital for an extended period unless their condition is treatable, as most psychiatric disorders are. If a person is detained for assessment and their condition is deemed untreatable, they must be released.
This loophole has rightly been criticised for years. In December 2000, the Department of Health and the Home Office jointly published a consultation paper suggesting two changes. Those with psychiatric disorders who are considered untreatable and dangerous would be confined, and those receiving treatment in the community would be forced to take their medication or risk incarceration. It would be possible to detain someone who had not (yet) committed an offence.
Locking up people without due process of law has always been considered a breach of human rights. Locking up psychopaths has always been the job of the criminal justice system—based on the psychopath’s criminal actions. Now the government proposes a new approach: lock up the psychopath based on what they might do.
The decision will depend on reports from psychiatrists—based on a tick test. When suspects fail the test, they are very likely to be locked up, in establishments somewhere between prisons and special hospitals. They will stay locked up until some time in the indeterminate future when someone else thinks they are no longer a risk. If even one person is locked up to prevent a crime they weren’t going to commit anyway, an injustice will have been done.
Where shall we start looking for potentially dangerous psychopaths? There is a thriving research industry that aims to predict who may offend. It is pointing the finger at children diagnosed with ADHD.
In a 1996 paper entitled “Early identification of chronic offenders: who is the fledgling psychopath?” Donald Lynam, an associate professor of psychology at the University of Kentucky, states that “Children who had both hyperactivity, impulsivity, attention deficit and conduct problems were at risk of serious adult antisocial behaviour and personality disorder” (Psychological Bulletin, vol 120, p 209). In her book Boys will be boys (Double-day, 1991), Myriam Miedzian concluded that “ADHD is a predisposing factor in antisocial personality disorder.” Some claim they can quantify the risk—for example saying that hyperactive boys aged between 9 and 17 are six times more likely to be involved in criminal activity.
In Britain, the number of children prescribed drugs for ADHD rose from 600 in 1994 to 114,000 in the first nine months of 1999. If there really has been such a huge increase in the incidence of ADHD, where are the emergency epidemiological studies looking for causes so that it can be prevented?
Estimates in the US put the proportion of children with ADHD at between 3 and 5 per cent. Some claim that as many as 65 per cent of these will go on to develop serious behavioural problems, including criminal activity.
These figures include an offshoot of ADHD called “oppositional defiant disorder”. This is characterised in DSM-IV as “often argues with adults”, “often actively defies or refuses to comply with adults’ requests or rules”, “often deliberately annoys people” and “often blames others for … misbehaviour”. This is medicalisation gone mad. It is not—yet—widely diagnosed in Britain.
If it had been around a century ago, Mahatma Gandhi could easily have been diagnosed as having ODD. If the psychologists are right that ADHD and associated syndromes predict psychopathy, and if the government gets the powers it wants without extra safeguards, then we are going to need some pretty big detention centres for all these potentially dangerous people.
