Dr. Allen Frances: "Saving Normal: An Insider's Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, And The Medicalization Of Ordinary Life"

MS. DIANE REHM

11:06:56
Thanks for joining us. I'm Diane Rehm. The diagnostic and statistical manual of mental disorders, the DSM, is used to determine treatment decisions, insurance eligibility, disability payments and special services. A 5th version of the manual has been approved by the American Psychiatric Association. Dr. Allen Frances chaired the task force that wrote the 4th edition.

MS. DIANE REHM

11:07:29
Now he's written a critical, new book titled "Saving Normal." He joins me in the studio to talk about what he calls out-of-control psychiatric diagnoses, DSM-5, big pharma and the medicalization of ordinary life. You can join us 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Good morning to you, Dr. Frances, thanks for being here.

DR. ALLEN FRANCES

11:08:05
Good morning.

REHM

11:08:08
Good to have you here. For the subtitle of your book, you have "Normal" and then you have "An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis" and so on. Why are you revolting?

FRANCES

11:08:34
I'm very concerned that the wrong people are getting too much treatment and the right people are getting too little treatment. Twenty-five percent of our population would qualify for psychiatric diagnosis in any given year and 50 percent, lifetime.

FRANCES

11:08:51
But most of those people, many of them at least, have a very marginal problem that probably shouldn't have been diagnosed and many people are getting medicine they don't need.

REHM

11:09:03
So you're saying that mental illness is now being too broadly defined?

FRANCES

11:09:11
And the real problem is that at the very same time people who are really sick are deprived of treatment, don't have adequate housing. A million psychiatric patients have wound up in prison for nuisance crimes that could have been prevented if they were properly diagnosed and treated. And one third of people with severe depression have no contact with a mental health clinician at all.

REHM

11:09:36
Okay, so you were chair of the DSM-4. We now have the DSM-5. Why didn't you revolt at the DSM-4? What's the difference between four and five?

FRANCES

11:09:55
I learned a very important lesson. We tried to be as conservative as you could be with absolutely modest ambitions and meticulous methods and we turned down 92 of 94 suggestions we received for new diagnoses.

FRANCES

11:10:13
But despite our efforts, there have been three epidemics of psychiatric disorders all occurring in kids since the DSM-4 was published.

REHM

11:10:21
Give me an example.

FRANCES

11:10:23
Attention deficit disorder has tripled. Autism has gone up by almost 40 times. Childhood bipolar disorder has gone up also by 40 times and adult bipolar disorder has doubled, all since DSM-4.

REHM

11:10:37
So how has that happened? Couldn't it be that society itself is placing more stress on both children and adults and therefore the number of people suffering has gone up?

FRANCES

11:10:55
Yeah, I don't buy that argument at all. I think human nature is remarkably stable and labels can change on a dime, that the increase in the rates of disorders doesn't come because people are sicker. It comes because we're labeling things in a much looser way.

FRANCES

11:11:11
And if you look at human history, our ancestors lived in much worse conditions than any of us are living in. And people in Iraq, Afghanistan, many parts of the world have stresses that we can't even imagine.

REHM

11:11:26
Is there a difference between how ADD was defined in DSM-4 and how it's defined now?

FRANCES

11:11:38
Well, let me be clear. We have a huge problem with ADD now that DSM-5 will make worse. An amazing Canadian study found out that using the current criteria, the best predictor of whether a kid has ADD is whether he's born in December or January. Get it? School year begins January 1st, the cut-off date.

FRANCES

11:12:01
The youngest kids in the class who are naturally going to be less mature and more active are being misdiagnosed. We're taking childhood and making it into a mental disorder and 20 percent of American teenage boys now qualify for ADD. Ten percent of them are on medication.

FRANCES

11:12:20
We should be spending the $9 billion we're spending on ADD medication, much of that should be going into the school system for more physical education and for smaller classes.

REHM

11:12:28
So what you're saying is that not only have definitions broadened, but that in response to those broadening definitions, doctors are handing out more medications. Doctors are handing out broader arrays of prescriptions for the same disorder that 20 years ago perhaps had a much smaller population to serve.

FRANCES

11:13:08
Yeah, what's happened is that 80 percent of psychiatry is no longer done by psychiatrists. Eighty percent of psychiatric medication is given out by non-psychiatric doctors.

REHM

11:13:18
How so?

FRANCES

11:13:20
The drug companies got tremendous incentives and tremendous resources to market. In 1997, three years after DSM-4, they prevailed on the government to allow them to market directly to consumers, something they can't do anywhere else in the world but New Zealand.

FRANCES

11:13:39
The courting of doctors has been intense and now the typical diagnosis is not made by psychiatrists after a careful evaluation. A typical diagnosis is made after seven minutes by someone with very limited training in psychiatry eager to get the patient out of the office, very influenced by drug salesmen and often having free samples.

REHM

11:14:02
Tell me how that diagnosis is made.

FRANCES

11:14:07
Poorly. A psychiatric diagnosis is an important moment in a patient's life. Done well, it leads to wonderful things, done poorly, it can be very, very harmful. I'd liken it to getting married, to buying a house, buying a car. A person shouldn't get a diagnosis and should not accept pills after a seven-minute evaluation.

FRANCES

11:14:29
Most people seeing a doctor on the worst day of their life will get better just through natural resiliency, time, resources from family and the community and what we're doing is jumping ahead, giving diagnoses carelessly to people who don't really need them.

REHM

11:14:47
But how is the doctor making this diagnosis? What kinds of questions? What kinds of presentation is the parent making? There are lots of things that go into a diagnosis surely?

FRANCES

11:15:03
There should be, but usually there aren't. The insurance company requires that the doctor makes a diagnosis and give a code after the first visit or else he won't be paid for it. So everything conspires to really loose, really fast diagnoses that are made off the top of the head. If something can be misused in the diagnostic system it will be misused.

REHM

11:15:27
Give me another example in addition to ADD where you think this DSM-5 is going to take us even further than it's already gone.

FRANCES

11:15:41
Well, first of all, let me make clear DSM-4 has taken us further than it should be. This is not a problem of the future. We have a problem right now that the DSM-5 will make worse. The rates of autism have gone up almost 40 times in the last 20 years.

FRANCES

11:15:57
It's not because of vaccinations. It's not because there's more autism in the population. It's because autism has become the key to getting school services, smaller class sizes, individual attention. Autism, we put in Asperger's in DSM-4. That's part of what led to this tremendous increase. But it was a clinical diagnosis. We never imagined that it would be so closely coupled to school services.

REHM

11:16:21
But at the same time, look at the population at the other end of the age spectrum. You've got Alzheimer's increasing by I don't know what percentage, but a lot because the population is aging. In the same way, you have the incidence of Parkinson's disease on the increase because of aging.

REHM

11:16:55
Couldn't it be that there are now more problems in society creating this, you know, whether it's in utero, whether it's after a child is born, conditions that lead to a greater incidence of autism and at the other end of the spectrum Alzheimer's?

FRANCES

11:17:24
Well, I think Alzheimer's is strictly related to age and as we get to live longer, we run the risk of Alzheimer's. I think with autism it's almost impossible to believe that we've had a 40-fold increase in the behaviors that would be diagnosed.

FRANCES

11:17:42
It makes much more sense to see this as the result of the fact that educational decisions in the school systems are being based by the requirement that the diagnosis be present. It would be much better to de-couple educational needs from clinical diagnosis.

REHM

11:18:00
What do you mean by that?

FRANCES

11:18:03
In order to get special school services, individual attention, smaller class sizes, a kid has to have a diagnosis of autism. When you give a benefit because of a diagnosis, that diagnosis will increase. The rates will go way up. I want kids to have school services, but it shouldn't be based on a psychiatric diagnosis which was created by researchers and clinicians with no expertise in school services.

FRANCES

11:18:26
Educational decisions about who gets what service in schools should be based on educators using educational tools to make decisions about what's best.

REHM

11:18:36
Dr. Allen Frances, he's professor emeritus and former chair of the Psychiatry and Behavioral Science Department at Duke University. His new book is titled "Saving Normal." Short break.

REHM

11:20:05
And welcome back. Here in the studio, Dr. Allen Frances. He is professor emeritus, former chair of the psychiatry and behavior science department at Duke University. He was chair of the DSM-4 Task Force. He's written a new book titled "Saving Normal: An Insider's Revolt Against Out-of-Control-Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life." And now joining us from his office in Pittsburgh is the chair of the DSM-5 Task Force, Dr. David Kupfer. Good morning to you, sir. Thanks for joining us.

DR. DAVID KUPFER

11:21:04
Good morning, Diane. How are you?

REHM

11:21:05
I'm fine, thank you. Talk about why a new version of the DSM is being published now?

KUPFER

11:21:14
Well, it's been actually almost 20 years since the last DSM, the DSM-4 was published. And there has been a lot of both information improvement and, if you will, diagnostic criteria science advances, that it seemed very appropriate to begin a process sometime ago to update the DSM. And so the intent is to more precisely diagnose mental disorders. There are a number of things, as we approach this milestone, that we believe the DSM-5 will represent the best clinical guide -- and it is a guide for diagnosis.

KUPFER

11:22:04
And a number of those changes that we have made have been within the context knowing that many of the areas that can withstand, if you will, improvement in more precise diagnostic criteria are along the childhood and adolescent continuum. And so consequently, the entire book has been organized along developmental lifespan within each chapter.

REHM

11:22:30
All right. And knowing that you have been listening since the top of the hour to the comments of Dr. Frances, can you talk about or respond to his concerns that both the DSM-4 and the DSM-5 are contributing to what he calls a false epidemic of Attention-Deficit Disorder and Autism?

KUPFER

11:23:07
Yes. Well, first of all, you and I can't really predict, if you will, how the DSM-5 will influence the prevalence and incidence of these particular disorders. We have been very much aware of what has happened since the advent of DSM-4. And so consequently we've paid a tremendous amount of attention in looking at the diagnostic criteria for Autism Disorder, Autism Spectrum Disorder and ADHD.

KUPFER

11:23:40
And having spent a good bit of time reviewing those diagnostic criteria, we've made some major changes with Autism. And we believe that the field trials and what has been done already in using the new sets of criteria of Autism Spectrum, clearly lead to more precise diagnostic criteria, lead to better levels of determining, if you will, levels of severity that we had previously. And at least the data to date shows that children that need services are getting the services that are appropriate.

KUPFER

11:24:25
The prevalence of the overall disorder for Autism Spectrum is not leading us to another very, very large rise. And I would say that as long as clinicians are using the precise criteria that will be in the DSM-5, I believe that we have the best clinical approach to making the diagnosis for Autism Spectrum Disorder.

REHM

11:24:51
All right.

KUPFER

11:24:52
And I would say the same thing abide certainly for ADHD, as the committee reviewed both all of the information concerning young people with ADHD as well as adolescents and adults with ADHD.

REHM

11:25:08
Now if I may, let me ask you also about Dr. Frances' concern that now big pharma is taking advantage of these criteria as set out in the DSM and using that to advertise directly to the public creating in their minds the idea that they must go to the doctor with a child who may have been born in December and January, who may be younger than classmates, who may be a bit on the overactive side and to find within seven minutes that that child has ADD.

KUPFER

11:26:11
Well, the first thing to say, of course, is that the DSM is a guideline for clinical diagnosis. It is not a guide -- a treatment guidebook. And therefore there are no recommendations specifically that lead to pharmacologic interventions or behavioral interventions. I do think that, again, the use of the definitive criteria is the best approach in well-trained clinicians. One of the things that we are doing again in DSM-5 is making it electronically available with references. We are expecting that it will be a much better educational tool. It will be clearer.

KUPFER

11:26:58
And we do believe that if it is used appropriately we hope that clinicians will find that they will get a much better assessment to then make more precise treatment recommendations, whether those treatment recommendations be pharmacologic or behavioral or psychotherapeutic.

REHM

11:27:19
But, Dr. Kupfer, considering the fact that most doctors these days have very, very little time to spend with a patient, and most doctors are not psychiatrically trained, and yet have these medications available to them, are you at all concerned that young kids may be being too soon and too much medicated by ordinary physicians who are not investigating fully whether a child has ADHD or is actually Autistic?

KUPFER

11:28:14
I am concerned that all clinical evaluations, whether they be for psychiatric purpose or whether they be for medical purposes such as the diagnosis of diabetes or hypertension, be conducted in a such a way that there is sufficient time and training and expertise to make the right diagnosis. What I suggest, that you well know, we are talking about what are the resources available and how are we, in a sense, allowing ourselves as a society to conduct the diagnostic work ups that we need for what may turn out to be chronic medical and psychiatric problems.

REHM

11:28:58
But the question becomes, I mean, Dr. Kupfer, it's almost mind blowing that these centers for disease control has reported that the rates of autism have jumped to 1 in 50 children. And that becomes 40 times greater than it was 20 years ago, and up from 1 in 80 just last year, and 1 in more than 1100 just years ago. So it begs the question, are these diagnoses been made too readily available by individuals who may not be completely trained to make such a diagnosis, even if you are providing these textbooks online or providing the information they can look for and access immediately on the computer?

KUPFER

11:30:20
Yes. I am going to say the following, which is that if various type of surveys are conducted where only one or two questions might be asked, we might wind up saying that the rate of, for example, obesity or hypertension is 80 percent of the population. When we've conducted so far with the new sets of DSM-5 criteria for autism spectrum disorder, we have not seen the levels of prevalence that had been reported by the CDC.

REHM

11:31:01
One Tweet reminds us that the DSM has, shall we say, made some mistakes in the past, that homosexuality was finally removed from the DSM as a mental health disorder. How long did that take, Dr. Kupfer?

KUPFER

11:31:32
Well, it did not take that long, if you will, and it was removed quite a bit ago in terms of the DSM. So it was certainly not part of the DSM-4 and obviously it would not be part of the DSM-5.

REHM

11:31:48
1972 doesn't seem all that long ago. My concern is that people hearing this program, people hearing that the criteria for ADD is going to be expanded, people hearing that the diagnoses for Autism is going to be expanded may be looking at their children differently when a doctor who is not trained as a psychiatrist and who has not gone through that really thorough examination makes such a diagnosis and hands out a pill. What is in the DSM to stop that doctor?

KUPFER

11:32:47
The main thing is that based on the DSM-5 that will come out, the criteria for ADHD and the criteria for Autism Spectrum Disorder will not be expanding. If anything, we believe that what we have learned from the past has led us to put clearer levels of distress impairment and levels of severity. And so therefore if anything, the expectation over the next few years is that the diagnosis in terms of the number of people with these disorders will not necessarily go up.

KUPFER

11:33:29
I do want to say one thing about the DSM-5, if I have a moment...

REHM

11:33:33
Surely.

KUPFER

11:33:33
...which is to say that it is going to be a living document. We are not going to wait 20 years to be able to make adjustments if there are any, if you will, unintended consequences. I agree with my colleagues in the past that unnecessary epidemics can be avoided. And the lack of precision and the lack of training often lead to, if you will, a different set of expectations and perceptions, both on the public's part and unfortunately also in the eyes of clinicians and schools. And we would like to avoid that as much as possible in the future.

REHM

11:34:19
Dr. David Kupfer. He is chair of the DSM-5 Task Force. I know you have to leave us, Dr. Kupfer. I want to thank you for joining us.

KUPFER

11:34:34
Well, thank you very much for having me, Diane.

REHM

11:34:36
Indeed. And you're listening to "The Diane Rehm Show." I understood there was to be no interaction between the two of you, Dr. Frances. What's your reaction to what you heard Dr. Kupfer say?

FRANCES

11:34:56
The problem is the DSM-5 has introduced a number of new diagnoses that are very -- possibly will become topics for epidemics. And it's reduced the thresholds for a number of existing diagnoses.

REHM

11:35:12
For example.

FRANCES

11:35:13
ADHD, it's reduced the number of criteria items and it's raised the age of onset from seven to twelve. It'll be much easier for kids and adults, especially adults to get the diagnosis of ADHD. It's introduced the concept that grief can be easily turned into major depressive disorder. If you've lost the person you love most in the world and two weeks later you experience sadness, loss of interest, trouble with appetite and sleeping and less energy, in DSM-5 that can be major depressive disorder.

REHM

11:35:49
I had understood perhaps from many, many years ago that that grieving period could last as much as a year and be within normal range. You're telling me now that if I go to the doctor, God forbid, after I lose someone close to me two weeks later, that doctor is going to say I need to give you medication?

FRANCES

11:36:20
And a drug company salesman can convince him using DSM-5 as his text that his is a legitimate diagnosis two weeks after losing a loved one.

REHM

11:36:30
What's happening to feelings that all of us have? Are they to be neutralized by medication?

FRANCES

11:36:41
Well, the problem is we're medicalizing things that are part of everyday life. In DSM-5, if you have cancer and you worry too much about the physical symptoms that you're experiencing, it will be the doctor's choice, and he can easily give you the diagnosis of Somatic Symptom Disorder. One-sixth of people with cancer will get an added psychiatric diagnosis of Somatic Symptom Disorder merely because they worry about their symptoms. One-fourth of people with chronic pain will be diagnosed as Somatic Symptom Disorder.

FRANCES

11:37:17
I'm 70 years old. My memory's getting worse. That could very easily be mild Neurocognitive Disorder. My grandchildren have temper tantrums. That could be Disruptive Mood Dysregulation Disorder. And I have more.

REHM

11:37:34
Dr. Allen Frances. He is the author of a new book titled "Saving Normal: An Insider's Revolt." We'll take your calls when we come back.

REHM

11:40:02
And the full title of Dr. Allen Frances' new book is titled, "Saving Normal: An Insider's Revolt Against Out-Of-Control Diagnosis, DSM-5, Big Pharma And The Medicalization Of Ordinary Life." We're going to open the phones now, first to Black Mountain, N.C. Good morning, Cindy.

CINDY

11:40:32
Good morning, Diane. Thank you very much for having this subject on your show. I have a comment and a question.

REHM

11:40:39
Surely.

CINDY

11:40:42
My younger daughter has Asperger's syndrome and my baby brother has Asperger's syndrome. My granddaughter has full-blown autism. I'm very discouraged when I hear things that blame their diagnosis on the DSM-4 (sic) and that since it was published the diagnosis of Asperger's has increased exponentially. I've heard this on several shows. Isn't it possible that when the DSM-4 was published the increase in diagnosing a child with Asperger's was because it just became easier to spot it and treat it?

CINDY

11:41:30
When my daughter was diagnosed she was eight years old. Nobody in her school had ever heard of it. And that's it.

FRANCES

11:41:41
Well, Cindy, I'm really pleased to hear that you're getting the treatment and the care you need and that it's worked for you. We expected the rates to go up about three or four times. And I think the destigmatization has been helpful in bringing people needed services that they otherwise wouldn't have gotten. But there's been a big overshoot. And you couldn't possibly have 40 times as many people. I think you may be in the category of those who were helped by it, but lots of people have been harmed. And it's a very stigmatizing diagnosis that's being given out very loosely.

FRANCES

11:42:17
Every week I get a bunch of emails from parents whose lives have been devastated, whose kids have been harmed by a diagnosis given out carelessly that didn't make sense. So--

REHM

11:42:27
But if medication helps then how is that harmful?

FRANCES

11:42:33
Well, autism doesn't have a medication, but the school services can help. And the problem is to get them to the people who really need them. So we need to be providing more services to people who really need them, and less services to people who don't. And there's been a big overshoot.

REHM

11:42:49
All right. To Cleveland, Ohio. Michelle, you're on the air.

MICHELLE

11:42:55
Hi, Diane. Hi, Dr. Frances. Thank you for taking my call.

REHM

11:42:58
Surely.

MICHELLE

11:42:59
I just have a comment. I'm a mental health professional, licensed in both Florida and Ohio. And Dr. Frances, I completely agree with you. The number of children out there that are getting diagnosed with really severe, severe diagnosis and then given medication, stunts their emotional growth. And we are producing adults--soon-to-be adults that will have no coping skills whatsoever, but believe that they simply need to take a medication. Cognitive behavioral therapies are incredibly effective. And I have met very few conservative psychiatrists that just recommend therapy.

MICHELLE

11:43:40
They're prescribing Seroquel. They're prescribing Xanax. And these are for young children and teenagers. And it's just so disappointing and unfortunate because in 10 years and in 15 years these are going to be our adults that are basically going to have no coping skills or strategies of life skills. And it's just so discouraging as a professional out there.

FRANCES

11:44:07
Well, I think it's very important that we treat the people who need it and protect the people who don't from treatment that's not necessary for them. We've taken individual difference, developmental lags and we've turned these into medical and mental disorders, often at great expense to the patient. It's so easy to give a diagnosis. It can take five minutes. But that diagnosis can haunt a family and haunt the person for a lifetime. So what I'm asking for is accurate diagnosis. The people who need it are being ignored. The people who don't need it are being excessively diagnosed, excessively treated. I agree with you completely.

REHM

11:44:46
Here is an email from Treva, who says, "In the 1920s my grandmother visited the doctor for stomach problems and she was sent to have all of her teeth removed. I believe what her doctor did was the best he knew at the time, but looking back from today's perspective what a travesty. I wonder how this age is going to be judged in the future? My 13-year-old son recently observed he was the only boy in his circle of friends who was not on medication for their behavior.

FRANCES

11:45:41
This is what makes me sad and scared. Hippocrates, the father of medicine, said, "First do no harm." Antipsychotic medications have brought in $18 billion of revenue, lots of that for kids. Kids gain a pound a week on antipsychotic medications, going from 110 pounds to 122 pounds in three months, with the risk of diabetes, of later heart disease, possibly a shortened life expectancy. Now, antipsychotics are wonderful drugs for those who need them, but because of the drug company marketing, because of the loose diagnosis, because half of this medicine is being given by non-psychiatrists, we're flooding kids with medicine that has obvious immediate harms and possibly long term consequences.

FRANCES

11:46:35
We need, as a society, to get more cautious in diagnosis and more tolerant of individual difference.

REHM

11:46:43
All right. To Mitchellville, Md. Hi there, Hank.

HANK

11:46:47
Hi, how are you?

REHM

11:46:48
Fine, thanks. Go right ahead, sir.

HANK

11:46:52
Yes. My question is this, I know that about probably 20 to 25 years ago there was instituted what is called the autism waiver, in which families could apply for funding, not having to pass a means test in order to get services for their children, particularly preschool children. And I'm wondering how that funding source may have contributed to the increase in diagnosis of autism.

FRANCES

11:47:22
Psychiatric diagnosis has become way too important, too important in school decisions, too important in disability decisions, too important in the court. Whenever a diagnosis determines something outside its competence, the diagnosis will be done loosely. And I think that's the problem with the overshoot in autism. That we should be basing school decisions on school needs, not on a clinical diagnosis created by people who don't know the first thing about school services.

REHM

11:47:51
So you're turning the responsibility over to teachers?

FRANCES

11:47:59
It certainly makes more sense for educators to decide educational needs, than for a pediatrician who sees a kid for 10 minutes, giving a diagnosis and have that be determinate.

REHM

11:48:12
Okay. So if the kid on the third row is acting out, acting out, acting out, a teacher may not want a child who is acting out, but who is otherwise totally normal.

FRANCES

11:48:32
And the problem is the class sizes are way too big. Lots of schools don't have physical education so kids can blow off steam. We shouldn't be spending $9 billion on drugs, medicalizing normal kids. We should be giving them a better school experience.

REHM

11:48:49
All right. Let's go to Julie in St. Louis, Mo. Good morning.

JULIE

11:48:54
Hi, thank you so much for taking my call, Diane.

REHM

11:48:57
Sure.

JULIE

11:48:57
I just want to say that I so appreciate the level of discourse you bring to the radio.

REHM

11:49:02
Thank you.

JULIE

11:49:02
I'm calling as a parent of a child with autism. We got our diagnosis after a two and a half hour evaluation by a very reputable neurologist. And Dr. Frances' claim that the diagnosis has increased in frequency as a result of the DSM is, I think, reaching. I think there are many things that contribute to the significant increase in the diagnosis. And I have to tell you, as a parent, believe me when I tell you, there is no way we sought this diagnosis. And there is no way that we saw any advantage in acquiring this diagnosis, in terms of educationally speaking or otherwise.

JULIE

11:49:46
Believe me, it's not something that parents are looking for, to give their children some sort of an academic edge, you know, by getting services. And it certainly was not given to us with a wink and a nod saying, okay, here you go. Now, your child's going to have a leg up at school. It's just really, to me, improbably and sort of fantastic.

FRANCES

11:50:11
Well, I think we introduced Asperger's in DSM for precisely the reasons you're suggesting. It's a very helpful diagnosis that's useful in many situations. The problem is the overshoot. And there's no way that there could possibly be a 40 times increase. So your experience is perfect for you and I wish it were always like that, but in other situations the diagnosis is being used too loosely, in a way that stigmatizes kids.

REHM

11:50:38
All right. To Houston, Texas. Good morning, David.

DAVID

11:50:44
Good morning. Thank you for having me.

REHM

11:50:47
Surely. Go right ahead, sir.

DAVID

11:50:49
I just want to speak--well, let me say Amen to what both of you are saying. I'm a school psychologist. I've been on faculty at Baylor College of Medicine and Texas Children's Hospital here in Houston. Let me give you a report from the trenches. And I'll limit myself just to the diagnosis of autism. It not only is true, Diane, that a physician untrained in psychiatry can make that diagnosis, I have people in my department that are 26 years old with a masters degree and it's legal for them to make the diagnosis of autism.

DAVID

11:51:16
So this problem that Dr. Frances is pointing to, of people wanting the services, is only compounded by people that are very narrowly trained making diagnoses. And when I train interns I call it name-that-tune problem. Of course, most of them are too young to remember the game show. But these young school psychology trained people will see one or two things, toe walking. Maybe they'll see a little hand flapping. And boom, they want to rather certainly and proudly say, oh, that's autism. And I'm having to fight these kids and say, whoa, whoa, whoa, it's got to be like the big dipper, it's got to have all the stars before that's the constellation.

DAVID

11:51:58
This individual differences concept that Dr. Frances talked about is so critical.

FRANCES

11:52:03
Yeah, we have to let kids be kids. So I think some of the callers obviously have kids who need help and it's wonderful that they're now getting it, but I think lots of kids are mislabeled because they're the slightest bit different than someone else.

REHM

11:52:17
David, I don't understand how a 26-year-old who is not even trained in psychiatry or even perhaps psychology is allowed to make such a diagnosis. Where does that permission come from?

DAVID

11:52:40
Well, let me be fair to the person, the degree in Texas is called the LSSP and the license emanates from the same board that licensed me as a fully doctoral level psychologist. But the problem is in schools, this licensed specialist in school psychology, this credential can be obtained with a masters degree only, and as I say, in fairness to them, they are trained in school psychology, but even school psychology is such a narrow focus that these kids are getting a broad-based education in psychopathology or even the problems of developmental issues, etcetera. And they're just making these diagnoses way too quickly and then they're being pressured to make them, as Dr. Frances alluded to, by the people wanting, unnecessarily the services.

DAVID

11:53:33
I agree with Dr. Frances. I'm thrilled when we can give services to children that are adequately and appropriately diagnosed, but it is an epidemic that my psychology friends and I talk about, that these 26, 27-year-olds are diagnosing. Look, I'm in one school district, one small school district in Texas. I'm one of five psychologists. I have five autism evaluations per week, referrals that is.

REHM

11:53:59
Wow. That's quite a story. And you're listening to "The Diane Rehm Show." Thanks for your call, David. And let's go to San Diego, Ca. Good morning, Jillian.

JILLIAN

11:54:15
Good morning, Diane. Thank you for having me.

REHM

11:54:18
Sure.

JILLIAN

11:54:18
I would like just to comment. I've been listening to the show for the last 40 minutes and I really just want to provide a viewpoint from a pediatric practitioner's perspective.

REHM

11:54:30
Sure.

JILLIAN

11:54:30
I’m a pediatric nurse practitioner and I work in primary care pediatrics. So I do see a lot of these children on a daily basis, mainly for well-child checks, lots of times with a lot of concerns as far as inattention, depression, behavioral problems. And I just wanted to say that as a practitioner, we definitely do not, you know, see a patient in our officer--at least personally I do not and I know most all of the providers that I work with that do prescribe for ADHD, really take this very seriously. They use a lot of different, I guess, resources. They take a lot of information. They see these children over multiple visits. And we do not, by any means, see a patient in our office, have a parent say, my child isn't paying attention, and hand out a pill.

JILLIAN

11:55:29
That is just not how it works in our practice.

REHM

11:55:33
Well, I'm--

JILLIAN

11:55:33
And I can't speak for other--

REHM

11:55:34
Sure.

JILLIAN

11:55:34
--provides, if they do that, but--

REHM

11:55:36
Sure.

JILLIAN

11:55:36
--I just want to make sure you give us our due course. We have--

REHM

11:55:39
Absolutely.

JILLIAN

11:55:40
--definitely, you know, see these children a lot and just because a criteria is changing in a book, I'm not going to be more likely to diagnose this child. We definitely take a lot of time and a lot of care into when or if a child would need medication.

REHM

11:55:57
I'm glad to hear that.

FRANCES

11:55:59
And good for you. I just wish that the rest of the country were following that practice.

REHM

11:56:03
And here's a tweet which says, "My Texas school district encourages an ADHD diagnosis before kids can receive services for dyslexia and learning abilities."

FRANCES

11:56:24
That's the problem.

REHM

11:56:29
So where are we going with this, Dr. Frances?

FRANCES

11:56:31
I think lots of things should happen. This is a complex problem. It won't have a simple solution. I think we should be tightening up diagnosis, there should be big, black box warnings in DSM-5 for those diagnoses that are being loosely delivered. I think it's very important to tame the drug companies. It's like tobacco. If they can advertise, they will take advantage of that freedom. They don't have the freedom to advertise to consumers anywhere else except New Zealand. Stop them from advertising.

REHM

11:57:02
And it's important for parents to ask questions.

FRANCES

11:57:07
Parents should never accept a diagnosis on faith.

REHM

11:57:13
The book is titled, "Saving Normal: An Insider's Revolt Against Out-Of-Control Diagnosis, DSM-5, Big Pharma And The Medicalization Of Ordinary Life." Dr. Allen Frances is the author. Thanks for being here.

FRANCES

11:57:35
Thank you.

REHM

11:57:35
And thanks all for listening. I'm Diane Rehm.
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