Sociology influences medicine more than we like to admit. One only needs to look at the history of psychiatric disorders—a term used broadly here to incorporate developmental dis­orders—to see how “normal” in one era is often deemed “abnormal” in another, and how the di­viding line between these two ends is often wa­fer thin.

Research advances are certainly key to what we claim as being a disorder, but politi­cal and social influences also play their part. Autism is an excellent case in point; the cutoff for “abnormal” has shifted from recognizing se­verely affected individuals only (30 years ago) to a more moderate position (20 years ago) and now to a point somewhere in between (today).

Variations aren’t just seen over time, but also between geographical locations. The proportion of children receiving a par­ticular diagnosis can vary dramatically be­tween states, for instance. Without ques­tion, the social and political influences of different jurisdictions are major drivers of this variation.

That’s not to say that people receiving these diagnoses don’t warrant assistance from health professions—they clearly do— but rather that our decisions about normal and abnormal are not as objective as we pretend.

Enter “sluggish cognitive tempo”

Consider the case of a possible new de­velopmental disorder called sluggish cog­nitive tempo, identified by U.S. research­ers and discussed at length in a recent New York Times article.

The disorder is characterized by be­havioral symptoms such as drowsiness, daydreaming, mental confusion, physical lethargy and apathy, and appears to be an offshoot of attention deficit/ hyperactivity disorder (ADHD).

Whereas some children may have atten­tional deficits because of hyperactivity (the child who is “bouncing off the walls”), slug­gish cognitive tempo is used to describe kids whose attentional deficits are due to low levels of mental energy.

The case for sluggish cognitive tempo representing a new disorder has been gath­ering pace over the past five years, so much so that the Journal of Abnormal Child Psy­chology dedicated most of its January issue to research related to the subject. Indeed, in the issue, the journal claimed to have “laid to rest” any questions over the exist­ence of the disorder, and that the cluster of symptoms is well on the way to being rec­ognized as a legitimate disorder.

Cause for controversy

Still, the proposal for sluggish cognitive tempo to be recognized as a disorder has been met with derision from many within the scientific community. Allen Frances, a former chair of the task force that delivered a previous revision of the Diagnostic and Sta­tistical Manual (the so-called psychiatrist’s bible), has been among the most vocal crit­ics. In a recent article, “No Child Left Undiag­nosed,” he wrote: “‘Sluggish Cognitive Tem­po’ is a remarkably silly name for an even sillier proposal…[It] may possibly be the very dumbest and most dangerous diagnos­tic idea I have ever encountered.”

These are fighting words, and there’s no hint of a backdown.

I am more circumspect than Dr. Franc­es in my evaluation of sluggish cognitive tempo, but there are two aspects that cause me concern. The first is about clinical need. The point of a diagnosis is to identify peo­ple who require assistance from health pro­fessionals, and then use that diagnosis to inform treatment. At this point, research hasn’t demonstrated that children with these behaviors require assistance from health and education professionals. Is slug­gish cognitive tempo just pathologizing normal variation in childhood behavior?

My second concern is the unclear influ­ence of pharmaceutical companies on this line of research. Pharmaceutical giant Eli Lilly has a long-standing association with Professor Russell Barkley, one of the key re­searchers in the sluggish cognitive tempo field, and the company has already funded drug trials in this area. This may be a com­pletely innocent relationship driven by a mutual desire to help children. But, at the very least, it’s a bad look.

Higher standard of evidence

Disorders of the body are typically di­agnosed based on clear biological obser­vations. A diagnosis of diabetes, for exam­ple, is based on fasting blood sugar levels, and a diagnosis of kidney disease is based on a suite of urine tests. We don’t have that luxury with disorders of the mind. Diagno­ses are based on behaviors, which makes it an inherently subjective task that will al­ways attract vehemently opposing views. For this reason, the field must demand the highest levels of scientific evidence show­ing this cluster of symptoms characterizes a group of children who require assistance from health professionals.

At this stage, sluggish cognitive tempo is not even close to reaching these stand­ards.

Andrew Whitehouse is Winthrop Profes­sor, Telethon Institute for Child Health Re­search at University of Western Australia

DISCLOSURE S TATEMENT

Andrew Whitehouse receives funding from the National Health and Medical Re­search Council, the Australian Research Council, and the Autism Cooperative Re­search Centre.

By Andrew Whitehouse