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Chapter One Symptoms in Search of a Diagnosis Why did they give him Ritalin for diabetes? Mother of a hyperactive child later diagnosed with subclinical diabetes after years of drug treatment It's one of the biggest frauds ever perpetrated on the educational system, on parents, on their children. Every medical person involved should be held accountable for it ethically. Dr. Michael Valentine, school psychologist, on the labeling of millions of children as hyperactive HAS YOUR CHILD BEEN LABELED HYPERACTIVE? IF SO, you're not alone. According to doctors, there's an epidemic of hyperactivity in America today. Three to 5 percent of all U.S. schoolchildren, and more than 10 percent of elementary school-age boys, currently take Ritalin or other drugs for hyper behavior, attention deficits, and impulsiveness.     These children are labeled hyperactive by family practitioners, neurologists, and psychiatrists. Some of them are initially "diagnosed" by teachers, school counselors, or nurses. There's only one problem with this scenario: Hyperactivity is not a disease. It's a hoax perpetrated by doctors who have no idea what's really wrong with these children . ARE YOU SKEPTICAL? IF SO, I'M NOT SURPRISED. THE MEDICAL community has elevated attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) to the status of diagnoses, and most people believe that these are real diseases. They aren't--and doctors who label children ADD or ADHD don't have a clue as to what's really ailing them.     Why? Because hyperactivity and attention deficits are merely symptoms .     What's the difference between a symptom and a diagnosis? Here's an example. Let's say you come down with a chronic cough. Should your doctor say, "You have a coughing disorder," and prescribe cough drops--without worrying about whether you have lung cancer, strep throat, or tuberculosis? Or if you develop a swollen leg, should your doctor diagnose it as "a lump," and give you an aspirin, without determining whether that lump is a tumor, an insect bite, or gangrene?     Of course not. Yet this is how doctors "diagnose" hyperactivity. Is your child overly active? Does he run around too much? Does she fidget in class? Then your child is one of two million hyperactive children and needs to take amphetamine-like drugs--possibly for life. Likewise, if your child makes careless mistakes, doesn't seem to listen, doesn't finish schoolwork, loses things, and is easily distracted and forgetful, then he or she has attention deficit disorder and also needs drugs. Yet just as hyperactivity is merely a symptom, so are attention problems. The unanswered question, obviously, is, "What is causing your child to be hyperactive?" Or, "What is causing your child to have attention problems?"     It's a critical question. Children with early-stage brain tumors can develop symptoms of hyperactivity or poor attention. So can lead- or pesticide-poisoned children. So can children with early-onset diabetes, heart disease, worms, viral or bacterial infections, malnutrition, head injuries, genetic disorders, allergies, mercury or manganese exposure, petit mal seizures, and hundreds--yes, hundreds --of other minor, major, or even life-threatening medical problems. Yet all of these children are labeled hyperactive or ADD.     Furthermore, hundreds of thousands of perfectly normal children are labeled hyperactive or attention disordered, even though there's nothing at all wrong with them. These children are lumped in with the truly ill children I mentioned above, and all are medicated willy-nilly with potent and potentially dangerous drugs.     In short, huge numbers of healthy children are being drugged for no reason--and huge numbers of sick children are taking Ritalin to cover up the symptoms of undiagnosed and untreated medical problems. The latter is particularly tragic in light of the fact that most truly hyperactive and attention-disordered children have treatable or even curable medical conditions. The subtle behavioral changes that underlie these conditions require equally subtle diagnostic techniques, not a checklist and a pill.     Of course, most doctors do acknowledge that "a few" cases of hyperactivity and attention disorder are caused by diagnosable medical disorders. In the course of the fifteen-minute evaluation most hyperactive or attention-disordered children receive, doctors generally do a cursory check for some of these causes--hearing and vision problems, for instance. But because they believe that hyperactivity itself is a diagnosis, few doctors rule out all of the medical problems that can cause a child to be hyper or inattentive.     Labeling a child hyperactive or ADD, without finding out the underlying causes of the hyperactivity, can have many consequences--almost all of them bad. Warren: Hyper or Sick? I met Warren when he was eight. A previous doctor who labeled Warren hyperactive had started him on Ritalin, and his parents came to me for a second opinion.     Warren was a normal, sturdy boy. He looked healthy except for his pallor, which contrasted strikingly with his mother's rosy complexion. His medical reports offered few clues about the roots of his impulsiveness, restlessness, and inattention. He'd had some breathing problems, episodes of partial hearing loss during ear infections, and a heart murmur--all conditions considered benign by previous doctors--but his records contained no significant red flags.     According to Warren's mother, he was cranky and sniffly as a baby, but his symptoms cleared up as he aged. However, shortly after a move to a new house, Warren changed for the worse.     "I can't remember that he ever balked at going to school," his mother told me. "He brought home good report cards. He never had any trouble with his teachers. Now he's in trouble all the time."     I asked her what was happening at school.     "He's in squabbles and scrapes with kids who used to be his good friends. He pesters his teacher. And he isn't learning anything in school. He's even backsliding. His handwriting and his spelling were better last year than they are now."     Warren's teacher was the first to bring up the word "hyperactivity." Warren wasn't destructive, she told his mother, but he constantly disrupted the class. If he wasn't raising his hand dozens of times an hour to ask an endless stream of questions, he was bouncing out of his chair to sharpen pencils, get a drink, or just wander around. He forgot his homework assignments. He ground his teeth while doing class work. He squirmed. He had trouble doing math problems he'd mastered days earlier.     "She told us to take him to a specialist in hyperactivity," Warren's mother said. They did, and the doctor prescribed Ritalin. Warren's parents worried about the drug's possible side effects, but the doctor convinced them that Ritalin would solve their son's academic and behavioral problems.     "We thought, well, if it would do any good ... but it didn't."     No surprise. After an extensive three-day workup, I was able to diagnose Warren's real problem. By day two, I'd unearthed several clues. First, Warren was color-blind. Second, his electroencephalogram (EEG) showed abnormal but nonspecific brain wave patterns. A test called an electronystagmography (ENG) also produced abnormal results. These test results, taken together, told me that something serious was wrong with Warren's brain, but they didn't tell me what the problem was.     The next day, I discovered the answer: A carbon monoxide assay revealed a blood saturation of this deadly gas at the dangerous 20 percent level. Carbon monoxide was displacing the oxygen in Warren's bloodstream, drastically reducing the supply of oxygen to his brain. His fidgeting, falling academic performance, and purposeless hyper behavior were all symptoms of low-level carbon monoxide poisoning.     Warren's patents immediately called the gas company and had their heating system overhauled. They also started driving Warren to school, rather than having him ride for several hours a week on an old school bus with a faulty exhaust system.     Repeat studies three weeks later showed that Warren's carbon monoxide level had dropped to 3 percent. Already, his teachers and his parents were seeing dramatic changes in his behavior. Within six months, Warren's EEG was normal, and his color blindness--not hereditary in his case but due to toxic exposure--was resolved.     It took three days of evaluation, and many studies, for me to identify Warren's problem and rule out the hundreds of other conditions that could have caused his symptoms. Was it worth it? Warren's parents certainly thought so. His previous doctor's "diagnosis" may have been faster, but it was wrong--and Ritalin certainly wasn't a cure for carbon monoxide poisoning. Symptoms in Search of a Diagnosis Do all hyperactive children suffer from carbon monoxide poisoning? Of course not. As I've noted, hundreds of different disorders can cause the symptoms that doctors call hyperactivity or attention deficit disorder. Some are common, some are rare, and some happen only once in a blue moon. These disorders have different causes, different prognoses, and different treatments. And that's exactly my point.     If a hundred different disorders can cause fidgeting, academic problems, overactivity, sleep problems, and attention disorders, then how can doctors pretend to treat all hyperactive or attention-disordered children with a single drug? The approach is even more illogical when you consider that this drug, Ritalin, merely masks symptoms without addressing what's causing them.     An even more dangerous trend is letting elementary school teachers "diagnose" hyperactivity and ADD, a frighteningly common practice these days. Here's how it works. A teacher, frazzled by Johnny's disruptive behavior, calls Johnny's parents to a meeting. Flanked by a school psychologist or principal, the teacher advises the parents that Johnny needs to be taking Ritalin. The parents take Johnny to a doctor, who in essence rubber-stamps the teacher's "diagnosis," often without even conducting a physical examination.     I understand that teachers can be tremendously burdened by impulsive, overactive, disruptive students. Teaching these children can be a nerve-racking and frustrating experience. In effect, many of these children are completely unteachable, and Ritalin does restrain some of them to the point that they can sit and learn. But allowing teachers to "diagnose" hyperactivity and doctors simply to rubber-stamp the teachers' recommendations to put children on Ritalin is an extraordinarily risky situation.     To illustrate just how misguided this practice is, consider the following two scenarios. Case 1: James At six years old, James is driving his adoptive parents crazy. He wets the bed. He bounces off the walls at home and at school. He's confrontational and destructive and has wild tantrums when he's crossed.     James also exhibits pica--that is, he eats nonfoods such as dirt and paste. He grinds his teeth. He's been placed in a special education class because he can't attend or behave well enough to keep up with other students. His teacher recommends Ritalin.     James is a classic case of hyperactivity. But Ritalin and counseling won't treat the medical conditions my evaluation reveals.     First, tests reveal toxic lead levels that are crippling James's brain cells. In addition, he suffers from fetal alcohol syndrome (FAS), a tragic consequence of prenatal alcohol exposure. Children with mild cases of FAS often show no obvious physical signs, and in James's case, there is only one subtle physical clue--abnormal epicanthal folds over his eyes. The real clue comes from his family history: James's biological mother had a long history of both drug and alcohol abuse.     James needs immediate treatment to lower his toxic lead levels, and his family needs to determine the source of the lead he's ingesting and remove it. James also needs a different special education class, with teachers knowledgeable about FAS children's disabilities. Case 2: Debby Debby, age five when I see her, is tiny and delicate. Her mother, however, describes her as a "mean little kid" who has temper tantrums and screaming fits. As a baby, she cried continuously, slept very little, did not nap, and banged her head on her crib. Now in school, she's run away from kindergarten twice. Her teacher despairs over her out-of-control behavior and recommends medication. Debby's first doctor agrees.     Fortunately, Debby's mother demands a second opinion. My examination leads me to call for a cardiac consultation, which uncovers a defective blood vessel between Debby's heart and lungs, preventing a normal flow of oxygenated blood to the brain. Surgery corrects this serious and potentially fatal condition. Almost immediately, Debby's behavior improves, her tantrums stop, and her teachers begin praising her academic achievement. Now ask yourself: Did Debby's teacher and James's teacher make correct diagnoses when they suggested that these children were hyperactive and needed Ritalin?     The answer obviously is no. Ritalin treatment wouldn't have corrected the lead poisoning that was continuing to damage James's already malfunctioning brain. And Ritalin would merely have masked symptoms of a disorder that could eventually have killed Debby. The Problem That Doesn't Just Go Away Once a teacher or doctor identifies a child as hyperactive or attention disordered, the next step is almost a forgone conclusion: a quickie medical evaluation and a prescription for Ritalin or similar drugs. When these drugs do work, they work in the extremely limited and temporary sense that children taking them tend to be calmer, more focused, and easier to live with, at least in the short term. But, as I explain later, these drugs are far from benign, and their benefits are questionable.     The real tragedy, however, is that masking children's symptoms merely allows their underlying disorders to continue and, in many cases, to become worse. Contrary to popular belief, hyperactive children don't simply outgrow their symptoms. Instead, many grow into troubled teens and adults.     About half of all children labeled hyperactive do well in adulthood. Many of them originally suffered from time-limited physical disorders in childhood (developmental seizures, for instance); when the disorders cleared up, so did their hyperactivity. Others were never hyper in the first place but merely normal, active children (see Chapter 8). The outlook for the other 50 percent of children labeled hyperactive, however, is grim.     Salvatore Mannuzza and colleagues, studying adults labeled hyperactive in childhood, found that they were far more likely than control subjects to hold low-paying jobs and to be high school dropouts, and that a large minority of them regularly committed irresponsible and violent acts. Eric Taylor and colleagues found that hyperactivity-- even in children who showed no early evidence of serious behavioral problems --was a risk factor for problems in late adolescence, frequently leading to violence, other antisocial behaviors, social problems, and school failure. And H. R. Huessy and colleagues, following eighty-four hyperactive children for up to a decade, found that their rate of institutionalization for delinquency was twenty times that of the general population. Numerous studies also show that children labeled as having both hyperactivity and conduct disorder--a fancy psychiatric term for stealing, lying, and acting out--are at extremely high risk of drug abuse, teenage pregnancy, and criminality in adolescence and adulthood.     Moreover, study after study shows that treating hyperactivity with Ritalin does nothing to change this dismal long-term prognosis. At one time, doctors optimistically thought that after a decade or so of Ritalin treatment, behavior-disordered kids would somehow snap out of it and turn into happy, well-adjusted adults. No such luck: In 1987, the Interagency Committee on Learning Disabilities reported to Congress:     A distressing finding in recent years is the increasing awareness of the limitations of psychopharmacological treatment in [ADHD]. ... It was hoped that two to three years of early treatment would provide sufficient performance increments and enhancement of self-esteem to carry the child over the pubertal transition. Data from a number of longitudinal studies, however, have shown that this is often not the case. Subsequent to discontinuation of drug therapy at approximately age 13, levels of social functioning and interpersonal skills continue to be lower for [ADHD] adolescents and young adults than for their age-matched normal peers. This finding is especially true for that subgroup who displayed assaultive or aggressive behavior in childhood. Adolescents and young adults may carry over one, two, or three of the symptoms of [ADHD], and those who carry over multiple symptoms seem to be at higher risk for substance abuse .     The textbook Developmental Neuropsychiatry notes that "clinicians treating large numbers of hyperactive children who were receiving adequate amounts of stimulants and whose medication was well monitored found that over the years, in spite of medication, many problems continued. By adolescence, these stimulant-treated hyperactives were still failing in school and continued to be behavior problems; many had developed antisocial behaviors, as well as experiencing social ostracism. ... [T]he children continued to be in various degrees of trouble, and other methods of management as well as (or instead of) stimulants were required."     The poor outcome of children labeled hyperactive is not surprising. Why? Because their underlying medical conditions were never addressed--and because many medical conditions that can cause hyperactivity also cause social problems, academic difficulties, and even criminality. To cite just a few examples: * High lead levels, even in the absence of clinical lead poisoning , place children at great risk for both school failure and delinquency. * High mercury levels can cause agitation and cognitive problems. * Manganese toxicity is linked to aggression and criminality. * Iron-deficiency anemia can lead to poor job performance, despondency, fatigue, and often aggression and irritability. * B vitamin deficiencies, common in teens and young adults, can lead to symptoms of subclinical beriberi, including hostility and violent outbursts. * Hyperthyroidism can cause fear, hostility, and demanding, hypercritical behavior, all of which can lead to job and social failure. * Individuals with Tourette's syndrome, a genetic disorder that can cause hyperactivity, have high rates of antisocial or even criminal behavior. * Temporal lobe seizures, sometimes almost continuous and often too subtle to be detected by eye, can cause violent outbursts, restless movements, and bizarre behavior. * The fluctuating blood sugar levels seen in subclinical diabetes can cause fugue states, in which individuals commit unexplained and sometimes violent acts. * Cardiac conditions can reduce the supply of blood, oxygen, and nutrients to the brain and, over time, can cause the death of brain cells. This results in impaired thinking and aberrant behavior. * Some drugs, both prescription and illegal, can cause the brain to atrophy, leading to disturbed cognition and behavior.     Many of the hundreds of disorders that cause childhood hyperactivity and attention problems grow worse, not better, with age. Brain cysts, seizure disorders, metabolic disorders, genetic defects, and heart disorders, for instance, usually don't just go away. Instead, they cause more (and often more serious) symptoms in adulthood. Although some children have temporary conditions that can be cured by a move to a less toxic environment, recovery from an infection, or dietary changes, many others aren't so lucky.     Sometimes, the conditions plaguing these children worsen so dramatically that physicians finally detect them--for instance, when a previously undiagnosed brain tumor in a hyperactive child becomes life-threatening. More often, however, the unwell child simply becomes an unwell adult, his or her symptoms masked by a succession of prescription drugs (and often by illicit drugs and alcohol as well) while a smoldering disease continues to cause damage. Often, drug abuse becomes a secondary problem that increases the hyperactive individual's chances of job failure, social problems, and encounters with the law. The hyperactive person, having never felt truly "good," has no clue that he or she is chronically ill. All he or she knows is that a marijuana joint, a bottle of Scotch, or a snort of cocaine makes the symptoms go away--for a little while. Why the Hyperactivity Label Is So Popular You might ask, at this point, why doctors are content to label children hyperactive or ADD without evaluating them for all of the medical conditions that can cause hyperactivity, impulsiveness, and inattention. After all, the job of the doctor is to diagnose. Furthermore, in medical school, doctors learn about dozens of syndromes that can cause hyperactivity. And, in their daily practice, doctors see the results of simply labeling children hyperactive: chronic academic and social problems, troubles with the law, failure, and tragedy. Why are so many diagnoses being overlooked, in a population so desperately in need of help? There are, in my opinion, two reasons--and neither of them reflects well on the medical profession. The Growth of Managed Care     Medicine isn't what it used to be. Twenty years ago, most doctors made medical decisions based on only one standard: what was best for the patient. With generous insurance policies underwriting virtually all medical treatment without much question, doctors were free to make diagnostic decisions with only their parents' interests in mind. And there was no question about where a doctor's allegiance lay: with the patient.     Today, however, with most doctors working under managed care plans, the questions are more complex and the ethics more murky. Doctors are now working for two masters, their patients and their managers, and the goals of those two groups are often in conflict. In fact, many if not most managed care programs are actually set up to punish doctors who offer careful and thorough care, and to reward those who skimp.     For instance, many managed care plans are capitated. This means that the doctor receives a set fee each year for treating a group of patients. If these patients have minor and easily diagnosed problems, the doctor will be sitting pretty at the end of the year, with money left in the bank and possibly a nice bonus from the bosses at the managed care program. But the doctor unlucky enough to get lots of patients with complex, expensive problems requiring extensive evaluations, testing, and consultations will be in trouble. This doctor, if he or she insists on providing the best of care for each patient, can actually wind up paying for patients' care. Furthermore, conscientious doctors can wind up being let go by managed care companies unhappy with patients receiving "too much" care.     As one doctor commented in Medical Economics , "It used to be that the harder you worked and the more care you provided, the more money you earned. Under capitation, it's the opposite. The more you limit, the more you're paid. You want to be the patient's advocate, but the system makes it awfully hard."     An increasing number of Americans are subject to managed care plans. In 1973, when President Nixon signed the HMO Act, only a few thousand people were members of HMOs. "By the end of 1994," managed care consultant Thomas Garvey notes, "HMOs had 51.1 million members--about 20 percent of the population." And by the year 2000, Garvey predicts, "Managed care entities will boast more than 100 million members and will dominate health care services in the United States." Already, when all forms of managed care (and not just traditional HMOs) are included, more than 70 percent of Americans with health insurance belong to managed care groups.     As the HMO population grows exponentially, the number of children labeled as hyperactive and put on Ritalin is growing right along with it--from about 150,000 in 1970 to approximately 2 million today. In my opinion, it's no coincidence that the number of children labeled hyperactive or ADD started skyrocketing at about the same time managed care took over the medical industry. Under managed care, the pressure for doctors to treat patients quickly is intense. The ten-minute office visit is the gold standard, and many procedures must be approved by nonmedical business managers who frown on diligent and appropriate diagnostic efforts. This new system puts pressure on even the most conscientious doctors to cut corners.     What does this mean to a hyperactive patient? It means, realistically, that a family practitioner has about ten or fifteen minutes to diagnose the child. It also means that the doctor has disincentives, not incentives, for ordering tests or referring the child to specialists who could identify neurological, cardiac, metabolic, infectious, or genetic disorders. In short, it means that the odds of getting a careful differential diagnosis are slim.     A decade ago, when the managed care movement was still in its early years, a Georgia parent advocacy group found that of 102 children put on Ritalin, only 2 received an evaluation that met even the cursory standards recommended by the manufacturers of the drug. With managed care in full swing now, it's likely that the number of children getting thorough evaluations is even smaller. An Obsession with Lumping     For centuries, doctors have obsessively sought the roots of disease, and this process of discovery continues. In recent years, for instance, researchers have discovered that Lyme disease causes some cases of arthritis, that bacteria cause many ulcers, and that heart valve defects are to blame for many anxiety attacks.     Learning the causes of the symptoms in these cases--not just continuing to label them arthritis or ulcers or anxiety--dramatically improves doctors' ability to help their patients. I call this type of medical progress "splitting," because it splits large, vague groups of symptoms into ever more accurate diagnostic categories. And when you know what you're treating, you know how to treat it correctly . For instance, patients with bacteria-caused ulcers are no longer put on useless bland diets, given years of medication, or referred to psychotherapy for stress. Because we now know what's wrong with these patients, we don't waste their time and money on worthless treatments.     Unfortunately, splitting is losing ground to a new and opposite trend in medicine. I call it "lumping," or the grouping of many symptoms together into handy but diagnostically worthless categories. (Some doctors call them "wastebasket diagnoses.") Lumping is particularly popular in modern psychiatry--not a surprising fact, since psychiatry has always been the least scientific of the medical specialties.     Thus, we have a "disease" called "depression," which in reality is a group of symptoms (sadness, loss of appetite, etc.) that can be caused by anything from thyroid disorders to brain tumors. Likewise, we have a "disease" called "anxiety disorder," which actually can result from a host of conditions ranging from inner-ear problems to medication errors. Lumping, which has spread quickly from psychiatry to other medical specialties, leads to one-size-fits-all treatments such as Prozac and tranquilizers, rather than to real diagnoses, real treatments, and real cures.     Hyperactivity and ADD, when spoken of as diagnoses rather than symptoms, are classic examples of lumping. Completely normal children can exhibit enough behaviors to earn a label of hyperactivity or attention deficit disorder and a prescription for Ritalin. So can children with pesticide poisoning, brain cysts, parathyroid disorders, or hundreds of other conditions. Do all of these children have the same "disease"? Hardly.     Attention deficit hyperactivity disorder, or ADHD, is actually the latest in a progression of meaningless labels tacked onto children with behavior disorders (or normal but active behavior). In the early 1900s, doctors did a good job of diagnosing such children, given the limitations of medical technology at the time. Then psychiatry took over, first lumping all of these children into the category of "minimal brain damage." When they couldn't identify what that damage might be, the psychiatrists switched to "minimal brain dysfunction." Next came "hyperkinetic reaction," followed by "attention deficit disorder with (or without) hyperactivity." Now, of course, the psychiatric profession has given us "attention deficit hyperactivity disorder," or ADHD. And when children aren't hyperactive enough to qualify as ADHD, doctors simply remove the "H" and label them as ADD. Gerald Coles commented in The Learning Mystique , "Rather than moving toward ever greater precision, they're constantly sweeping over the disasters of last year's conception."     As Professor Richard Vatz notes, "Attention deficit disorder is no more a disease than is `excitability.' It is a psychiatric, pseudomedical term." Yet the labels ADHD and ADD, invented by psychiatry and codified in its Diagnostic and Statistical Manual of Mental Disorders (DSM), are now almost universally accepted by neurologists, pediatricians, and general practitioners--not as starting points for diagnoses, but as diagnoses in and of themselves.     The current mantra of these physicians is that hyperactivity and ADD are distinct disorders, much like chicken pox or cancer, that can be identified using a cookbook list of symptoms originally concocted by the psychiatrists who authored the DSM. As you can see from the following checklist, the DSM has made "diagnosing" these purported disorders a cinch. Doctors simply need to choose from a Chinese menu list of symptoms--pick six from column A, and six from column B. And if a child doesn't quite fit the categories, many doctors are willing to label him or her a "borderline" case.     Thus, millions of children with hundreds of diseases, or no diseases at all , are lumped into a single category: hyperactivity. All get the same treatment: Ritalin or another drug. And all get the same diagnosis, which is to say, none at all. A Quick Word About the DSM Normally, I wouldn't bore you by talking about a tedious medical reference book. But unlike most medical books, the DSM--a huge (800-plus pages) book dubbed the "psychiatric Bible"--plays a major role in whether or not your child receives real treatment. It's a dangerous book, and you need to know about it.     The DSM is published by the American Psychiatric Association, and is revised every few years. Simply put, it's a guidebook to what psychiatry considers to be mental illnesses. It lists hundreds of labels for such illnesses, followed by lists of the symptoms needed for a patient to qualify for each label. These labels are now accepted as diagnoses by hospitals, medical journals, and insurance companies, as well as most physicians.     Many of the doctors your child is likely to see--not just psychiatrists but also general practitioners, pediatricians, and neurologists--rely almost exclusively on the DSM when determining what's wrong with your child. Most school psychologists also have well-thumbed copies of the DSM, which they use in making their own "diagnoses." These professionals rely on the DSM because most of them believe, naively, that the DSM is a well-supported, scientifically based work. However, nothing could be farther from the truth.     In fact, DSM is as much a political document as a medical document. New versions are compiled every few years by powerful psychiatrists who quibble over what constitutes a mental illness and what doesn't. "Diagnoses" are regularly voted in or out. (Homosexuality, for instance, was a disease in DSM-II but was voted out in DSM-III. Self-defeating personality disorder was a disease in DSM-III-Revised but deleted in DSM-IV. And narcissistic personality disorder was in, then out, then back in again!) Furthermore, the symptoms for virtually all DSM diseases change from revision to revision. Thus, your hyperactive child might be mentally ill according to one DSM and perfectly normal according to the next edition six or seven years later. Needless to say, this sort of thing doesn't happen with real diseases such as pneumonia or measles.     In addition to its political nature, DSM has two obvious and dangerous flaws. First, as I've said, it's the source of the pat labels doctors give patients in lieu of diagnoses. For instance, using DSM, I can label patients as having "impulse-control disorder not otherwise specified" or "oppositional defiant disorder" or "hypersomnia," prescribe a drug for each condition, and collect my fee--without ever examining these patients to find out why they're impulsive or aggressive or sleepy. This is, of course, exactly what is happening to children labeled hyperactive or attention disordered.     The other major flaw of DSM, related to the first, is that it labels virtually everything as some type of disorder. Thus, a child who sees a DSM-oriented doctor is almost assured of a psychiatric label and a prescription, even if the child is perfectly fine. In their book, Making Us Crazy , Herb Kutchins and Stuart A. Kirk note that under DSM, symptoms of mental disorder include--to name just a few--"frustration, anger, difficulty concentrating, restlessness, increased appetite, weight gain, often losing one's temper, being easily fatigued, muscle tension, ... having extremely frightening dreams, being inappropriately sexually seductive, theatricality, showing arrogance, lacking empathy, being preoccupied with being criticized, and difficulty making everyday decisions." And individual DSM labels include so many vague criteria that almost anyone can qualify. Psychologist Paula Caplan noted that when a psychology professor gave students lists of DSM symptoms for several disorders, the students found that 75 percent of the class fit the criteria for "borderline personality disorder," and 100 percent of the men fit the criteria for "premenstrual dysphoric disorder"!     The result is no surprise: Researchers are concluding that almost everyone is crazy. The National Institute of Mental Health, using DSM criteria, announced in May 1996 that "24.1 percent of the population, or 48.2 million Americans, have some kind of mental disorder within a 12-month period ." In short, according to DSM, a quarter of all people in America were crazy last year! And many of those people, according to psychiatrists, had hyperactivity or attention deficit disorders--disorders now said by their most zealous fans to affect up to 33 percent of all Americans.     This willy-nilly labeling of virtually everyone as mentally ill is a serious danger to healthy children, because virtually all children have enough symptoms to get a DSM label and a drug. And, of course, DSM labeling is a danger to ill children, whose true diagnoses remain undiscovered and untreated.     Most important, however, DSM is dangerous because doctors are using the book as a substitute for clinical judgment and diagnostic skills. If a doctor tells you that your child has a "DSM diagnosis" of ADHD, ADD, conduct disorder, oppositional defiant disorder, depression, or anxiety, find another doctor who relies on real medical knowledge and evaluation rather than on this diagnostic cookbook. (Continues ...)