One hundred years ago it was rarely diagnosed in children. In the intervening time span the number and type of diagnoses has exploded. Moreover, the number and type of treatments have also exploded. The favored treatment usually involves powerful medications with serious side effects. Big Pharma has made a fortune from these medications and is constantly searching for new variations to patent and sell.
I'm talking about childhood cancer, but I bet you thought I was talking about childhood mental illness. After all, everyone in contemporary society knows that childhood mental illness is over-diagnosed, that drugging children is the preferred method for dealing with the normal problems of childhood, and that normal children are being treated with powerful psychotropic medications simply because they are quirky and authentic.
That's what author Judith Warner (Mommy Madness) thought, too, when she sold a proposal back in 2004 for a book that would explore the over-diagnosis of mental illness and overtreatment of children with psychiatric medication. She knew it for all the reasons listed above: childhood mental illness was rarely diagnosed in children 100 years ago; since then the number and type of diagnoses has exploded; the number and type of treatments has also exploded; the medications used to treat childhood mental illness are powerful and can have serious side effect; Big Pharma has made a fortune from these medications and is constantly searching for new variations to patent and sell.
But the same things apply to childhood cancer and no one is suggesting that childhood cancer is over-diagnosed, that chemotherapy is the preferred method for dealing with the normal problems of childhood, and that normal children are being treated with chemotherapy simply because they are quirky and authentic. The conclusions we have drawn from the dramatic increase in the diagnosis of childhood mental illness are wrong. Though childhood cancer was rarely diagnosed 100 years ago, that's not because it didn't exist. It's because we didn't have the tools to recognize it or any effective medications to treat it. Similarly, we need to consider the fact that childhood mental illness is not new, just as childhood cancer is not new; we just lacked the tools to recognize it and any effective medications to treat it.
In We've Got Issues; Children and Parents in the age of Medication, Judith Warner has written a brilliant and compelling book, a must read for anyone who for any parent who has a child who is miserable and struggling. It is also a must read for anyone who thinks he knows that childhood mental illness is over-diagnosed and over-treated. Parents who have dealt with mental illness in their children will find solace here, because someone has finally acknowledged that their childrens' "issues" are not the normal problems of childhood, that they struggled for years against putting their children on medications, and that their most fervent wishes for their children are not that they raise their grades from B's to A's in order to get into competitive colleges, but merely that they are able to live outside of institutions without hurting themselves or others.
Warner details how she came to write a book that is 180 degrees opposite what she initially intended. It happened because she talked to parents and psychiatrists and looked at what the literature actually shows. And Warner details how she and many others came to believe that childhood mental illness is a fraud perpetrated on society by Big Pharma:
The web of belief - let's call it the "naysayer" position ... is the new face of mental health stigma in our time. It is voiced as concern, as a desire to save children, as a wish to give childhood back to kids, but what it really is, most of the time is prejudice. And it's a poison.
People who share the views I used to espouse don't see themselves as prejudiced. They believe they are raising their voices in protest of a world that's gone mad, and, in particular, providing necessary push back against a pharmaceutical industry that's grown way too powerful, with the collusion of our government and far too many research scientists and clinical practitioners.
Warner is not naive:
I want to say here as strongly as I can that I agree that many aspects of today's world of childhood are toxic and that I deplore both the irresponsible marketing practices of Big Pharma and the failure of our government and research institutions to stand up against it...
But we must not confuse one issue with another:
That said, I also fiercely believe that the social climate of family life, the machinations of the pharmaceutical industry, and the lives of children and parents dealing with mental health issues have to be viewed as separate phenomena. Not because they aren't interconnected, but because if you let your feelings about industry and society cloud your vision of parents and children, you run the risk of not seeing them at all. (my emphasis)
We have used the wrong measurements to determine whether childhood mental illness is real (the rise in diagnoses, the rise in medications, the profitability of the treatment) and therefore we have reached the wrong conclusions. Children with mental illness always existed, we just never saw them because of prejudice, labeling ("mentally defective") and institutionalization. It would be a terrible sin if we continue not to "see" them today because of our feelings about contemporary society or our feelings about the pharmaceutical industry. Warner points out that real children and real parents are suffering terribly. We should not compound their suffering by pretending that it does not exist.
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That's especially true because many parents harbor the not so secret fear that if they were better parents they could have prevented it or found a way to make it better without medication or psychotherapy.
"On the other side of the spectrum are the parents and kids who thinks every disappointment should be cured with a pill."
This is exactly the poisoned prejudice that Warner is decrying. Everyone "knows" that lots of parents and kids think every disappointment should be cured with a pill, yet no one actually knows very many if any real parents who behave that way.
For example, you seem very sure that lots of children are taking antidepressants (20 out of 30 is "some" classes). Do you have any idea at all how many children are currently taking antidepressants? How about how many children have depression? Any idea what number of children tried to commit suicide last year?
I suspect that the answers are no, no, and no, yet you are "sure" that normal children are being over-treated. So if you have no actual knowledge of the problem, how can you be so "sure"?
I take issue with the validity of your analogy. First of all, i sure hope childhood cancers are not misdiagnosed with the same frequency that mental illnesses are! Second, i suspect that most untreated childhood cancers will cause death much more quicly than childhood mental illnesses. Although i certainly am not about to downplay the seriousness of mental illness, and i understand that it most certainly can cause death.
As a young adult, i was diagnosed with all sorts of things, some of them just matters of degree or professional judgment (dysthymia versus major depressive disorder), some of them completely off-the-wall (bipolar disorder with no evidence of mania, schizoaffective disorder by a man who told ME that i was in fact hearing voices -- i wasn't, borderline personality disorder by anyone with whom i happened to disagree). I sure hope that my situation doesn't represent that of most mental patients. But i know that it's not unusual, either... There was a slate.com article about unreliability of psychiatric diagnosis. http://slate.msn.com/id/2144123/ Sorry, Dr. Amy, i don't have any journal articles to cite for you. =)
Children are particularly difficult to diagnose because a lot of them tend to present with similar symptoms such as irritability or inability to control rage. My question is, why diagnose at all? Why not wait? You can ferret out underlying issues and work with the child to control emotions without a diagnosis.
Unfortunately, there are plenty of psychiatrists who take shortcuts (How the hell else is it even possible to diagnose someone in a fifteen-minute interview?), and if a kid has previously been diagnosed with something like childhood bipolar disorder (which isn't actually in the DSM yet, but that doesn't mean it's not diagnosed), some doctors will go out of their way to look for and see symptoms of bipolar disorder.
A separate issue is the use of atypical antipsychotics, which first of all, have not yet even been clinically shown to improve depression in ADULTS. (I'm not entirely sure about this; someone please correct me if i'm wrong.) And yet, more and more, they are being prescribed to _children_ with mood disorders. These drugs have demonstrated risks (diabetes, obesity), and their benefit has not yet been demonstrated.
Sometimes nothing works and you have to turn to a treatment of last resort. I get that. But one in 329 FIVE-YEAR-OLDS being treated with antipsychotics? I have a hard time believing that's strictly necessary. (Statistic from Philip Dawdy's website Furious Seasons.)
I know that childhood mental illness is a real, devastating problem. When i was a crisis line volunteer, i spoke to parents of out-of-control kids. I also spoke with a mother who had tried medicating her child, but the child found the side effects intolerable, so they stopped the meds; the doctor said, You are noncompliant, so i cannot help you with your child. When i consulted with the clinician on duty, my supervisor, he told me the same thing. We have got to do better for these kids.
It is no secret among conscientious, thinking mental health professionals that there is something of a crisis within this profession. I find it extremely concerning that you would disparage those of us who seek to rectify this unfortunate situation. Perhaps you have a unique perspective on this issue that you are not sharing.
By the way, i'm still not stalking you, yet; i was looking up something having to do with mammograms (reading a chapter on radiography) and there you were! And i couldn't resist one extra click... and they make it so freaking easy to register. Are you all over the web or what?! =) Later.
"As a young adult, i was diagnosed with all sorts of things, some of them just matters of degree or professional judgment (dysthymia versus major depressive disorder), some of them completely off-the-wall (bipolar disorder with no evidence of mania, schizoaffective disorder by a man who told ME that i was in fact hearing voices -- i wasn't, borderline personality disorder by anyone with whom i happened to disagree)"
Were you a normal "quirky" kid whose lazy parents started medicating you because they thought it would turn you from a B student into an A student? Or were you a child with real psychiatric issues that were not properly identified initially?
That was a dumb question on my part. Obviously, you need a diagnosis to get the treatment paid for by insurance. But using that rationale to dictate diagnosis is illogical and doesn't address the source of the problem (that is, the power of insurance companies to dictate what gets paid for).
Dr. Amy, i was not the type of child that you talked about in your article. I used my own example to illustrate that diagnosis is hard even in an adult, and some providers suck at it. What i was getting at is, most of the time it's even harder to diagnose a child.
All too many kids are being prescribed medications with serious known risks, whose benefits are unclear, based on a diagnoses that are questionable in the first place!
I am not arguing that mental illness does not occur in children, or that clear cases of bipolar or other disorders in children do not exist, or that children should never be given psychotropic medications.
(To answer your question, i was eighteen before i ever saw a mental health professional; i had some underlying emotional issues that led to my self-injury and suicidal ideation, and i was also just immature. Some perspective from a grown-up might have helped me. I was treated as "sick" from the get-go, when a large part of my problem was simply that growing up is hard. Part of the professionals' problem, i suspect, was that they just couldn't get past the self-injury; i hope that kind of misunderstanding within the profession has changed by now. Part of it was that i could rationalize things so well that they didn't realize that i wasn't feeling _anything_ because of my depression; i found that cognitive behavioral therapy suddenly made complete sense once i could feel! And another part, i think, was that dealing with sick people all the time had narrowed the doctors' perspectives, made them cynical and tired. But anyway. I'm irrelevant to this discussion. =)
If that is the case, then i will just point out that there are in fact valid criticisms of how often childhood mental illness is diagnosed and the way it is dealt with by the psychiatric community, and those criticisms are based in knowledge and compassion... and then i shall join you in your incredulity at those who deny the existence of childhood mental illness. And now i'm all done really!
Good post.
"It's good to question where medicine is going and how treatments affect patients, but there has to be leeway for those who actually need that treatment or who actually have the disorder. "
I think that Warner is on the mark when she points out that those who deny the existence of childhood mental illness are ideological purity ahead of the well being of actual children. Most people who "know" that normal children are being "drugged" under the guise of a false mental illness diagnosis don't know any actual normal children who are being drugged and don't know any children with mental illness. They blithely assume that because they don't "see" any children with mental illness (because they aren't even looking), such children do not exist.
I blogged not long ago about my son's ADHD:
http://www.open.salon.com/blog/froggy/2010/01/29/adhd_is_real
Along with living with ADHD in my house, I attend lectures, read books, talk to my son's many doctors, and educate myself as much as I can. According to brain researchers at OHSU, the primary component to predicting ADHD is genetics.
Genetics.
My husband, my brother, my husband's brother, and by all likelihood my father (undiagnosed) have ADHD. Guess what? My son does too. So does my nephew, though my sister-in-law refuses to do anything about it.
I wish I had a dollar for all the times I've wracked my brain, trying to imagine what I did wrong (other than being born into the wrong family and perhaps marrying the wrong man). I wish I had a dollar for all the times I've watched the "normal" kids sail through school, making friends and doing their work with nary a problem. I wish I could explain the pain of having my child come home from school with no friends, another trip to the office, or feeling weird for having to go to the resource room.
I cannot redesign the entire American school system to suit my child. One on one tutoring in a rubber room? Fantastic. I'm all over it. Wanna pay for it? I didn't think so. I can't homeschool--I need to work.
ADHD is real. Psychiatric meds work, at least somewhat. And I have never, ever, met a parent of a child with ADHD or other mental issues who has given medication lightly, or who has given medication without trying EVERYTHING else first.
Thank you Dr. Amy.
"ADHD is real. Psychiatric meds work, at least somewhat. And I have never, ever, met a parent of a child with ADHD or other mental issues who has given medication lightly, or who has given medication without trying "
You are absolutely right! You should take a look at Warner's book. It is filled with stories like yours.
"According to brain researchers at OHSU, the primary component to predicting ADHD is genetics.
Genetics."
One of the things that Warner wrote that particularly resonated with me is that people whose children don't have ADHD, Asperger's depression etc. consciously or unconsciously take credit for it! They credit their "superior parenting" when all it's entirely due to luck.
"Whether and to what degree we choose to pathologize personality is always going to be both important and controversial."
Warner's claim is that this is not a matter of pathologizing personality. Any child with a diagnosis of bipolar disorder, OCD, suicidal depression, etc. is very ill, and if you met those children, you would not dispute it.
We are not talking about the difference between quirky children and average children. We are talking about the difference between destroying every breakable item in the house and a simple temper tantrum, the difference between having nightly rituals and being too anxious to leave the house, the difference between feeling sad and hanging yourself in your bedroom closet.
I have often wondered if anorexia, cutting and other self destructive behaviors occur because society generally ignores children who are mentally ill, comforting themselves with the belief that children with no visible sign of their illness are quirky or poorly parented. What if these efforts to destroy their bodies are the only way for mentally ill children to get people to understand how seriously ill they are?
"people rush to medicate when there is nothing really wrong with their kids"
Warner spent more than 5 years doing the research for this book, and changing her beliefs dramatically in the process. One of the reasons that she changed her mind is that of the hundreds of parents she interviewed and dozens of mental health professionals she spoke to (including those who publicly claim, in books and on websites that normal children are being "drugged") she couldn't find a single instance of medicating normal children. When pressed, no mental health professional could recall a single instance, either.
Of course it could happen, but the reality is that situations like yours are far, far more common. Parents do not recognize childhood mental illness and refuse to seek treatment for it even when they recognize it, or cannot afford to pay for it even if they desperately wish to access help for their children.
Some children and young people are labled "bad" or "depressed" when they are simply mirroring what is going on with their parents or siblings. Others are clearly suffering (and their parents are suffering along with them) because of the way their brain chemistry is functioning. It might have been inherited.
Others are given appropriate care by mental health professionals, only to be sabotaged by their parents' myths and fears. I have seen children with ADHD begin to thrive and excel in school after being put on an appropriate medication for their disorder, only to take a nose-dive emotionally and academically when their parents decided they didn't believe in giving drugs anymore. Some children shut down or act out because they are being bullied, abused, neglected or a combination of the above. The key is to listen to the children and adults to find out: Who is suffering in this household -- could it be everyone? Why is that? When did it start? What do the child's parents think is going on? What does the child or teen think is going on? Does the child or teen have fears about talking honestly? Does the child fear labels about depression or anxiety? Is it okay to be depressed, sad, grieving, scared, frustrated, anxious and otherwise imperfect in that family? Or do adults in his/her world hide their most vulnerable feelings behind expressions of anger? Our culture has many, many defects and our bodies are imperfect. We won't figure it out unless we listen.
All I know is that an SSRI liberated our OCD child from a prison of anxiety and allowed him to live life much more fully.
Walk a few steps in our shoes to experience what it means to "medicate a child" and I think all the judgmental high dudgeon would dissolve pretty quickly.
Not a big fan of Judith Warner (NYT) but I'm glad she allowed her findings to change her mind and not the other way around.
I find that the book has extra credibility when I know that the author started out with a premise that differs from her findings.
"I can tell you that the key is listening. Listen, listen, listen. Isn't that what healthcare providers are trained to do?"
So simple and so incredibly powerful.
"Some children and young people are labled "bad" or "depressed" when they are simply mirroring what is going on with their parents or siblings. Others are clearly suffering (and their parents are suffering along with them) because of the way their brain chemistry is functioning."
Warner makes a critical observation in her book: Children of color and poor children with serious mental illness are labeled as "bad" while white and affluent children with serious mental illness are much more likely to get a diagnosis. We refuse to see mental illness in children in general, but it is much worse for some groups than for others.
I am not extremely knowledgeable about mental issues, even children diagonsed with ADHD, and adults that might also be plauged with the symptoms and not be aware that the symptoms are standing between them and living a normal life. It is difficult with different perceptions that parents may have regarding the use of medication to help with certain issues. Note I tread very carefully there, as a result of also wondering if discipline is lacking, depending on certain situations that are not always black and white. Discipline has a lot to do with kids acting out, or behaving in ways that makes dealing with a child much less a joy, and more of a kid with behavior issues rather than medical.
That discipline question always comes up.
As part of my son's diagnosis of ADHD, the specialist team (psychiatrist, psychologist, and educational specialist) spent hours (yes hours) not only with our son but with us privately, asking about every intimate detail of our family life.
They were looking for all the red flags that cause behavior problems in children. Lack of structure. Divorce. Death. Moves. Changing schools. We have none of those. We are in every way as apple-pie a family as you could hope to see. Married parents, involved, loving grandparents, stable home, no moves, no divorce, no trauma. Consistent discipline. Reading at home. TV off. Consistent meals, bedtime, household routines. Consequences, time-outs, behavior management. All the things that are supposed to make a "disciplined" child. Except that they don't.
Yes, kids with ADHD are unruly. It's so easy to point to the parents and say "discipline your kids!" But parents who have neurotypical children have no idea what they're saying. It's like the parent with the "easy" baby who sleeps through the night and gurgles and coos all day, pointing at the baby who screams nonstop and saying "discipline that child! What's wrong with those parents?"
There are plenty of discipline problems around, virtually everywhere you look (I could tell you stories that would curl your hair) BUT that is something entirely different than ADHD. ADHD, OCD, depression, bipolar illness; these are all the result of neuro-chemical problems. They are no more amenable to discipline than diabetic coma is amenable to discipline. It's like yelling at a kid in a diabetic coma to quit being lazy and wake up. Not only does it make no sense, but it is cruel to boot.
Children with discipline problems are capable of regulating their emotions and actions, but choose not to do so, because the rewards are too enticing or the penalties are minimal. Children with ADHD or mental illness are incapable of regulating their emotions and actions and need significant help in doing so. Often that help involves returning their neuro-chemistry to the "normal" that the rest of us are lucky enough to enjoy without effort.
Yeah - except the ones who went to prison because of their erratic and violent behaviour, or became alcoholics or drug addicts while trying to medicate themselves. Or the ones who simply committed suicide.
How many children do you have?
How much time have you spent around children (other than ranting about babies crying on airplanes)?
Do you have any experience with children with mental illnesses?
I'm not claiming that psychiatry is perfect, nor is Warner. Indeed her chapter on the conflicts of interest of psychiatrists is gut churning. The key point is that childhood mental illness is real.
"That is, if I hadn't called them first to express concern over their child's unhappiness, inability to focus, social difficulties, and declining performance."
There are numerous stories in the book like that. Parents often start or stop medication without alerting the teaching (why I don't know), but the teacher always notices very quickly.
"One of the things that Warner wrote that particularly resonated with me is that people whose children don't have ADHD, Asperger's depression etc. consciously or unconsciously take credit for it! They credit their "superior parenting" when all it's entirely due to luck."
Interesting that you should do so since in another comment post you hearken back to cutters and anorexics trying to get attention for the deeper issues they may face psychologically that they are "calling attention " to this way. You really can't have it both ways, you know–– logically. Either you give some credit to good parenting and environment or you flip it all off as being entirely due to genetics and then the parents of cutters and such should just titrate their blood--forget attention!
I speak as a parent who has managed to get praised by psychologists as being a very good mother. I really don't want more "authorities" trying to take away the benefit of being so!
I don't know a single parent who knowingly mistreats their child to psychiatric medications. I do know of one who would rather medicate than do any type of therapy and I watched their parenting skills. They supplied no types of boundaries for this child before school and I never witnessed a single consequence for behavior held. By the time he went to school, he was setup to think the world should revolve around him and suffered behavior problems. Now he is on ADHD medication and he was one of the most laid back children I knew in terms of temperament but was defiant.
I will get the book and read it. To comment on the overall picture based on this post would be hard as their are some things I agree with (not to be prejudice) and things I don't (that because their is mental illness in a child it doesn't always require medication, either, which seems to be an assumption in your post).
Thought provoking.
"but I want to say that I think the mental health care industry on the whole rests on some dubious assumptions about what is normal."
Where is your evidence that normal children are being given the diagnoses of bipolar illness, severe depression, OCD or even ADHD? Everyone seems to "know" that this is happening, but no one seems to be able to provide any real life examples.
The stigma against mental illness (and against medical interventions) is deadly. Rated.
When we started our son on ADHD medication, the pediatrician suggested we not tell the teacher because that way we would get a more objective opinion on his behavior. I thought that was a bit irresponsible, especially since our school was sharing a nurse at the time with another school and I wanted somebody in the building to know my kid was taking a controlled substance!
When I suggested that might be a concern, my doctor looked surprised, like no one had ever mentioned it before. Anyway, maybe other doctors are giving the same advice. I think it would be unfair to the teachers, and I have always warned them when we're changing meds or dosages.
[and yes, we also did everything else before trying drugs - it took 18 months after his diagnosis, and we did weekly OT, special behavior plans, etc., before it became clear that something more was needed.]
Nice review. The book looks interesting.
i've been an artist since i could first pic up a crayon. i've also suffered from depression since that time. then there were the periods when i never wanted to go to sleep again but just stay up forever and never miss anything yada yada yada.
i grew up to 'what's wrong with you?' 'why can't you ever just be happy?' 'god! one minute you're up then you're down. WHAT'S WRONG WITH YOU?'
luckily i was also smart as a whip and as soon as i figured the world and i were marching to not only different drummers but totally out of sync drummers i learned coping skills. i faked a lot. i pulled inwards. i developed a 'healthy me' and 'the real me'. this while in grade school.
i was finally dx'd bi-polar depressive at the age of 36. it took a couple years to get the right mix of meds but i would not be here today if something hadn't been done.
i certainly wouldn't have been able to help my daughter battle leukemia from age 14-19. i would have killed myself shortly after she died. i wouldn't have been able to see that the problems my son had was only partly due to his sister being so ill for so long.
i still carry a lot of the baggage of growing up knowing something was wrong but trying so hard to be what i couldn't be. yet i don't regret it because it made me strong enough to not care about being stigmatized.
i have felt my whole life as if i were standing at the edge of an abyss with the world trying to push me in. maybe. but i can stand there and tell the world to fuck off as i accept the label of mentally ill as i had to accept cait's dx of leukemia.
i have empathy, compassion and the ability to walk in others' shoes. it helps my art and it helps me be the person i want and and capable of being. without the bi-polar? who know. i might have been a wanker. ;-)
Wow. I am bowled over by your powerful post.
The people who think childhood mental illness is a creation of contemporary society have never met a child with mental illness. Anyone who has lived it, as a parent, but especially as a child knows that it is painfully, tragically real.
Thank you so much for sharing your experience.
Sparking, thanks for bringing up this issue. Though the parents make the ultimate decision of whether to medicate the child, that decision is strongly guided by the child's doctor. I make no judgment of parents who act in good faith with their children's best interest at heart.
I am much more critical of clinicians who take a short-term view of a child's treatment, and of a healthcare system that will pay for a child to take a medication with known long-term risks and unknown benefits (I am talking of atypical antipsychotics), and may not pay for long-term therapy to help that child learn to deal with extreme moods or rages or whatnot.
Good psychiatrists are well-versed in therapeutic options other than medication; they use medications judiciously and monitor patients carefully. They spend time with their patients; they get to know the patient as a person, rather than a diagnostic code. In my experience as an adult, those kinds of psychiatrists are the minority; i have been trying to figure out why. I hope that the training for child psychiatry is more rigorous, or that all the shrinks who don't like people are dealing with adults instead of kids; i'd take that as a silver lining to my own experience.
The number of children diagnosed with bipolar disorder is climbing alarmingly quickly. PBS's Frontline did a nice story on children's mental illness and psychiatric prescription drug use in children which can be found here: http://www.pbs.org/wgbh/pages/frontline/shows/medicating/watch/. It presents a balanced picture, I think.
In other words, they believe the conventional wisdom, and real children be damned. They don't seem to remember that the conventional wisdom is often wrong.
I am old enough to vividly remember the conventional wisdom during my youth was that girls couldn't play sports, must take "home economics" in school, should be careful not to get "too educated" so that no one would marry them, and, certainly, should never go to a professional school like medical school or law school. I assure you that everyone "knew" it just as firmly as everyone "knows" that children are overdiagnosed and drugged with medication they don't need. In addition, such "knowledge" was generally couched in terms of "protecting" women. Not actual, individual women, Women with a capital "W."
How was it that everyone "knew" such ridiculous things. They "knew" it because they were projecting their cultural anxieties on to everyone else. Those who "knew" how women should behave feared the threatening possibilities of gender equality. Similarly, adults who have literally NO experience with mentally ill children are projecting their cultural anxieties (self righteously, no less) about technology, society and business onto children who have no way to protect themselves.
Warner speaks directly to you in the excerpts that I quoted:
"People who share the views I used to espouse don't see themselves as prejudiced. They believe they are raising their voices in protest of a world that's gone mad, and, in particular, providing necessary push back against a pharmaceutical industry that's grown way too powerful, with the collusion of our government and far too many research scientists and clinical practitioners.
... [I]f you let your feelings about industry and society cloud your vision of parents and children, you run the risk of not seeing them at all."
Warner thought she "knew" that childhood mental illness was over-diagnosed and that psychiatric medications were over-prescribed for children, yet in 6 years and hundreds of interviews she could find ANY children who had been over-diagnosed or over-treated.
None, and neither can you. You just "know" it because you read it and it appealed to you, truth (and real children) be damned.
Although you said that this author rejects the notion of pathologizing personality, I still think there's a line somewhere that has to be drawn. I'm thinking, for example, of the boy with autism who takes a stand against the Autism Speaks language that encourages "stamping out" the disorder. He is offended that autism is seen as something that needs to be stamped out; rather he sees it as simply a different way of being.
I don't mean to suggest that I agree with him. I'm just open to the wildly liberating idea of it. On balance, I think I have come to this conclusion: some of what the DSM calls disorders could be seen as extremes on the personality continuum, and the extent to which those traits interfere with normal functioning (as defined by whatever context you live in) is precisely the extent to which treatment should be sought.
I guess all I'm saying is that I don't know nearly as much as I thought I did 20 years ago and then again 10 years ago. I keep getting these periods of ignorance that are driving me crazy :)! It's so much more comfortable to "know," isn't it?
My son was “diagnosed” with ADD at 7 years old. Some of his teachers were visibly disappointed that we did not put him on Ritalin, when so many of the other students with similar diagnoses were being medicated. He struggled in school, and some of his teachers seemed to have very little tolerance for his behavior. Although he brought home failing grades at times, through a combination of one on one tutoring and staunch discipline, we insured that he stayed on track and passed on to the next grade each year.
My son graduated high school on time and attended 2 years of community college (his choice). He is gainfully employed and awaiting entry into the US Marines.
My son is gifted musically (can play by ear). He has an excellent vocabulary, but poor social skills. He tends to get nervous in social settings, which robs him of his ability to express himself clearly. Although he continues to improve socially, he is much more comfortable interacting via computer or text messaging, where he has more of an opportunity to collect his thoughts.
This past year we convinced our son to see a mental health professional, after he became depressed over breaking up with his girlfriend. We encouraged him to be open and honest about all of his hopes, dreams, fears and challenges. After several sessions, he seemed to have a more positive outlook on life. He has even become more dependable around the house. We never asked if his doctor suggested medication, but I’m certain he would have told us if that were the case. You see, my son is a health nut. He is reluctant to take as mush as an aspirin when he has a headache.
After reading up on the symptoms of ADD, I realized I’ve had this “condition” to some degree throughout my entire life. Although my academic grades were outstanding, I spent many weeks on punishment as a child, due to unsatisfactory conduct in school.
In spite of my affliction, I managed to have a decent life (stable job, loving wife and children).
Years ago, when my wife and I were considering potential treatment options for my son, I read about an experimental treatment that did not involve the use of drugs. A doctor in Tennessee was hooking ADD patients up to electrodes and getting them to turn a red light to green by focusing on a stationary object. In short, he was helping them to improve their ability to concentrate. At the time, the treatment was very expensive, and our family would have had to relocate to Tennessee. This non-medicinal treatment seemed rather promising. I wonder whatever became of it.
The brain is a very complicated organ. Science and the medical community are still has much to learn about its inner workings. I struggle with the term “normal”, since we are all so unique in many ways. I feel the public education system fails many of our children with their rigidity and their “one size fits all” solutions. We did not give our son drugs, because we questioned whether he truly needed them to function as a human being in society. As a young adult we encouraged him to seek out a mental health professional when an opportunity presented itself, so that he could make his own informed decisions about his continued mental well being.
I can tell you first hand that many of the teachers we encountered put pressure on us to medicate our child. In my opinion, the primary goal was not the welfare of our child; but to maintain order in the classroom. I will not speculate as to the primary motivation of the doctors we consulted; but I think it’s fair to say their motives may not have been 100% altruistic. There are corrupt, unethical, selfish and self-centered individuals in every profession. The public school system and medical community are hardly exceptions.
I don't think this is an either/or proposition. There are some truly ill people in the world who benefit enormously from treatment including and perhaps especially pharmaceuticals. And we are diagnosing much differently today than ever before, and the diagnoses are often wrong. It takes about 20 years to diagnose bipolar disorder on average. We have a massive shortfall of care for the mentally ill in general and for children in particular, and child psychiatrists are stretched so far that they cannot possibly provide adequate care.
I have nothing but the highest respect and regard for parents who raise children with such disabilities, and I applaud therapists and doctors who are committed to helping others. I have had good and bad mental health treatment myself.
So let's stop the us/them bullshit now, please.
"Warner points out that real children and real parents are suffering terribly" Yes they are.
Real children are also suffering the ignorance of real parents and our mental health system is overloaded trying to deal with the consequences bad experiences have on our mental health.
It is a sad, destructive realm of our reality.
Parents need to educate themselves, make their own observations and ask pertinent questions so that they can make informed decisions about their child’s welfare. There are children (and adults) who are in need of medication and can greatly benefit from it; but similar to the school system, dosing our children should not be a “one size fits all” solution.
While I have difficulty imagining the value in partially effective treatments for illnesses such as schizophrenia, or even for very severe autism spectrum disorder, many children -- including those with milder cases of ASD, or kids who really do merit diagnoses of ADD, for example -- might benefit from partial treatment. After all, our differences can be advantages, as my own life trajectory has proven. Such partial treatment should therefore be a focus for pharmacological research. Moreover, in such cases, the children themselves should have partial autonomy as regards treatment decisions. Any understanding of ethics which allows parents, doctors, or educators to force neurotypicality upon the atypical -- which sees the atypical child not as an unusual person who needs help to achieve integration into the world, but as a defective person -- is, in my opinion, problematic. I speak as one who, because I needed explicit social skills training, was forced against my will to take amphetamines with unpleasant side effects.
I'm glad that Judith Warner wrote this book, and despite what I've written here, I think that widespread civil rights activism by the neuro-atypical should probably wait until we've managed to ensure that all kids who need psychiatric care get it. But please, please, remember that mental illness is at least in part a social construct. Read your Foucault, people.
But Foucault was wrong about that, and about so many other things. That's one the issues that Warner addresses in the book.
Ah, I'd be difficult to sell on the idea that Foucault was flat out wrong. He was a provocateur, though, which I think has led his devoted followers to head in some, um, unproductive intellectual directions. (I speak as a qauntitative sociologist; I've had lots of frustrating conversations with people who almost seem to think that the laws of physics are social constructs).
With regard to the definition of mental illness: back in the day, when I was studying abnormal psychology with the intent to become a clinician (um, not a good career option for somebody who can't read facial expressions accurately, as it turns out; hence my changed career plans), I saw plenty of evidence that the Ph.D.-level clinicians who were educating me and training me were themselves influenced by Foucault. I learned that mental illness is defined not simply as violation of cognitive, behavioral, or emotional norms as defined by the wider society, but violation of such norms which also either endangers the violator or those around her, or which causes her what she herself identifies as serious distress. Hence the definition contains a clause which is clearly meant to ensure that social construction is not the sole arbiter of mental illness; this prevents us from committing people who violate gender norms to mental hospitals, for instance. This clause seems to me to be both a reasonable precaution and a direct incorporation of Foucault's ideas. While I don't doubt that the same reasoning has been used by parents or by patients themselves to reject needed treatment, I'll be surprised if Warner can prove to my satisfaction that Foucault was entirely wrong-headed. Though I'm impressed that she included such a contention in a pop science book.
I'm looking forward to reading Warner's book, though I'm likely part of the choir to which the author is preaching. If I had a dime for all the times that I've heard people make the very claims she's refuting, usually in reference to children who were clearly mentally ill, I could buy a whole lot of something (new bras with which to give myself breast cancer, perhaps).
You know, I got so excited that you directly responded to my comment that in my fangirl excitement, I almost answered with a big essay about how much I adore your blog and forgot entirely to object to your objection :). Evidence-based medicine rocks!
I'm glad you enjoy the blog.
Here's what Warner has to say about Foucault and Derrida. She starts by recounting her belief, as a graduate student, that they were right ... about everything. And then:
"'Theory' was like a religion for me - until, one day, it wasn't. That is to say, until I went to graduate school and somehow ... sort of outgrew it... I decided I wanted to dwell and work in the world of reality. I grew up.
Or so I thought.
... [F]inding my current thoughts [that childhood mental illness did not exist] echoed so exactly in the antipsychiatry thinkers of the 1960's, I wondered if I'd really grown up, intellectually, at all.
Was I really doing my own thinking?
Was I really engaging with reality?
Did I really want to be operating on this level?"
I don't get people that think like this. I only have anectdotal experience to bring to the table but here goes...
Quirky and authentic-great for a theoretical child, but for a real one it means NEVER getting invited to birthday parties or sitting next to someone in lunch. It means not being able to sit through class and to absorb maybe half of the material, all the while annoying everyone else in class. It means that you have a 140 IQ and maybe get "c's" in class because you just can't get your stuff together, or put together a project. It's people getting creeped out because you can't look them in the eye or have a weird tic. It's people getting offended because you can't read social cues or tend to correct others or pontificate. It means getting yelled at by your parents because you are sloppy, clumsy, or out on Mars somewhere. It means harming yourself or becoming institutionalized because you have emotions you cannot handle. It means getting kicked out of the military because you slashed the seargent's tires. It means getting fired because you can't relate with your coworkers. It means abusing illicit drugs or alcohol to quiet your brain.
This "hypothetical child" is a mixture of several people I know-all of whom were eventually properly diagnosed (usually with Asperger's and/or ADD/depression/Schitzoaffective) and treated-yes-with medication and other means. They are still "quirky and authentic" but they can at least function. The world doesn't accomodate quirky-medication allows differently wired people to find work, get married, have kids, and do all the things most people take for granted.
Also, while I do know people on the wrong meds, with the wrong diagnosis-I don't know any people personally that are feeling great and seeking antidepressants or antipsychotics.
For the person who is concerned about antipsychotic use in 5 year olds-they are often used for tics/anxiety/self injury and not for psychosis. Off label use is very common for many drugs.
I'd be the first to suggest that social theory is not a good basis for assumptions about reality; I am after all an empiricist, and working with theorists, I've seen a lot of faulty ideas generated with no reference to reality. However, the social construction of mental illness is not one of those faulty ideas.
The problem with rejecting social construction entirely, and especially with rejecting it as an arbiter of mental illness, is that it's as much an empirically established fact as a a theoretical perspective. Strong evidence exists that our definition of mental illness is normative in the Foucaultian sense. For an introduction to this body of empirics, see "On Being Sane in Insane Places". That study is only the tip of the iceberg, however; while it is ethnographic and therefore inherently limited in application, there exists plenty of more soundly designed empirical research which has examined and supported the authors' conclusions.
I'm glad Warner has learned the lesson that adherence to social theorists' writings as some sort of scripture is intellectually immature. (I'd say it's intellectually dysfunctional, even). However, it sounds as though her reaction to that realization has been to assume that the theory she once treated as gospel is in fact complete bunk. That sort of reaction does not display intellectual maturity; it displays a fundamental misunderstanding of the relationship between theory and empirics. As any social scientist would have explained to her had she discussed her realization with them, we have theory to guide our research agenda, and often our empirical work produces results which disconfirm (or at least, dramatically fail to support) our theory. In such cases, we reject the theory. Sometimes, however -- as in this case -- the results of our empirical work support the theory. When that happens, we seek first to reproduce the research, because of course if the results are not replicable then there's a very good chance the original research was flawed. But when (as in this case) the results are replicated, we take that theory as accurate and we conduct further research to establish the limits of the theory's applicability. And on, and on, and on.
My impression is that Warner's book is based on interviews and perhaps other sorts of ethnography? Qualitative work, I mean. Not quantitative, and certainly not experimental. Unless she's done a pretty thorough review of the wider literature on mental illness and social construction and applied those findings in the analysis of her results, I'm not inclined to take her dismissal of Foucault very seriously. Evidence should rule in social science as in medicine, and certainly in the intersection of the two disciplines.
"They are still "quirky and authentic" but they can at least function."
Even more important, they are happier. What those who "know" children don't need medication don't seem to understand is that it's not about making children conform to some arbitrary standard; mental health treatment is about treating misery.