The DSM-IV is currently being revised, and has come under increasing scrutiny in the decades since its introduction. One of the central concerns is the way mental disorders are now perched on the stoops of normalcy. There isn’t much mental room for people to wiggle in without raising the eyebrows of some in the medical community who are, as Jon Ronson suggests in his latest article “Bipolar Kids: Victims of the ‘madness industry’?”, too quick to diagnose.
One of the central questions raised by the article is whether or not some parents are accepting the diagnoses of overzealous health professionals too quickly. Of course, there is the parallel question of whether or not some health professionals are overzealous in diagnosing children with mental disorders. Ronson suggests that the answer to both of these questions is ‘yes’.
One of the difficulties in evaluating these arguments is wrapping your head around the concept of “normalcy”, a problematic notion if ever there was one. Ronson discusses some of the difficulties with it. Drawing the lines around a particular kind of behaviour is difficult enough in adults, but even more so in children, who are prone to all sorts of erratic and unpleasant acts even on their best days.
As a parent of young children I can think of many situations where I thought for sure my children were drifting into some seriously abnormal behaviour.
If I’d been in a state of mind to record the details I’m sure there were days where I spent the bulk of my waking hours watching my kids kick, scream, and hit–could they be bipolar? Other days (most days if I’m being completely honest) I wonder whether my kids have hearing problems because they seem completely oblivious to my voice. When they do hear me, they usually ignore me–does that mean they have problems with concentration? I’ve seen them pet the cat, lovingly, right before pulling its tail, and marvel at the sight of a delicate spider only to stomp on it ruthlessly seconds later–empathy issues? My kids have problems deviating from their routine, if they don’t get a book before bed they will raise a mutiny–OCD?
Parenting comes with a litany of these doubts, concerns and questions. In the absence of good comparative information, it can be quite difficult to know how to characterize your own child’s behaviour. My wife and I have constant conversations about our children, and what their actions mean in terms of their development, and whether or not it is ‘normal’.
Of course there are legitimate cases of mental illness in children. I would never suggest otherwise. Mental health is one of the most underfunded areas in our healthcare system. Sufferers of mental illness are some of the most stigmatized, and misunderstood members of society. It’s important to pay more attention to mental health, so we can better understand the diseases and disorders and develop more effective ways of diagnosing and treating mental illness. Ronson’s article, and my comments here, deal specifically with a subset of diagnosed children who ought not to have been diagnosed. It would be wrong to suggest that I don’t believe in childhood mental illness, or that I am trying to minimize the importance of mental illness in children, or that I am flippant with respect to mental health in general. I take these issues very seriously, and criticize them accordingly.
Ronson’s article does come off as overly critical of parents. It is unfair to suggest, as I think he does, that parents are much too quick to accept the diagnoses of healthcare professionals. They might be too quick, but they are in a position of acting in the best interest of their children who they believe could be abnormal. In cases where the children are being misdiagnosed, it is the healthcare profession that is confirming suspicions that those parents have. Parents who have a suspicion confirmed then find themselves in a position of having to accept or reject an expert’s opinion. It’s not so easy to reject an expert’s opinion.
We are supposed to be able to trust doctors and psychologists. Parents who are having difficulties coping with their children are certainly in need of resources to help them cope. Experts have the power of institutions behind them, and Ronson’s point is that the institutions are suggesting that a pill is the most appropriate coping strategy. Parents also have to make that decision against the backdrop of a publishing industry of churning out advice books for parents, much of which is based on the same medical literature the healthcare professionals base their decisions on. Rejecting a doctor’s diagnosis is made very difficult because of all of this. It is difficult to pick out systematic problems in the healthcare industry even for individuals whose job it is, like Jon Ronson. For a stressed-out parent it is no easier. For this reason the criticisms Ronson levels against the DSM, and the healthcare industry appear quite justifiable in comparison to his criticism of parents, which seems unbalanced.
These issues suggest that parent’s could use better strategies for coping with difficult children. Part of that resource could be an honest discussion in society, and in the health care industry, about what we should take to be normal. (there’s a very interesting blog dedicated to research related to this, and other relates, issues.) Researchers are doing a great job at categorizing the many different sub-species of psychology that are found in this world, but we seem to be struggling when it comes to deciding which of those sub-species is acceptable. In extreme cases we will be more justified in seeking ways of modifying people’s psychology through medical intervention. But if Ronson is right in arguing that the pharmaceutical industry sees every new sub-species as a potential market, and if the medical community has a difficult time rejecting the views of the pharmaceutical industry (Sergio Sismondo has done fantastic work into the influence that pharmaceutical companies have on the medical publishing industry in articles like this, and this), then there would appear to be a bias towards categorizing new sub-species as abnormal by default. That is misleading and problematic.
A focused discussion of normalcy could have surprising results. Here’s an anecdote. In my experience, when I talk to other parents to find out how their kids behave, there are always two layers to the discussion. At first, there is the veneer of hyper-normalcy–everyone wants their children to be as normal as possible. Kimmy loves school; Peter doesn’t really like bath time.
But when I dig deeper I always reach another place (my unscientific sampling and complete lack of statistical analysis will put this number at 100%, and I am completely confident in it), a place where parents admit to feeling like they’re losing their minds because their children test their limits in ways that were previously inconceivable to them. Kimmy loves school but is obsessed with looking at herself in the mirror before she leaves the house in the morning–I’ve run out of tactics for getting to stop fiddling with her clothes and hair, and last week I had to take a day off of work because she refused to go to school. Peter doesn’t like bath time and we’ve had to resort to one of us closing the bathroom door and holding it shut while the other [parent] chases him, kicking and screaming bloody murder, with a wet cloth just to try to wipe the dirt of of his body, this takes about an hour on a good night, sometimes we go two weeks without bathing him because we just can’t deal with it. It’s hard to get parents to talk about the most frustrating things their kids do. I suspect that some parents avoid having those conversations with anyone but their family doctor. Hearing these stories from other parents makes me feel much better about my own situation, because my kids are the similar. (Note to publishers: If there’s a book out there about all the horribly frustrating things that kids do, and the many ways that they can drive parents to the brink, my wife certainly never received it as a baby shower gift; that book would have been tremendously rewarding, and comforting to a new parent.)
Would a discussion about normalcy lead to massive changes in the DSM? Perhaps not. But it could help temper the urge to find a medical explanation for problems that could be dealt with in other ways. The border between normal and abnormal might legitimately shift. And that could help legitimately reduce the number of children that are misdiagnosed with mental illnesses.
Parents of children who have been misdiagnosed are currently coping with trying to make their kids normal by means of medications their child doesn’t need. But the problem lies with the misdiagnosis. It would be too easy to blame just parents, or just the healthcare industry. Misdiagnoses are a problem in all areas of healthcare, a complicated one to be sure, and also a dangerous one. It has been suggested that socioeconomics plays a role in mental health misdiagnoses, and misdiagnosing a mental illness can have life-threatening effects.
Ronson‘s article raises important issues and is well worth reading. The prospect of there being many misdiagnosed children out there is troubling. In those cases, it shouldn’t take a diagnosis to raise a child.
Update: June 8, 2011 – Added reference to What Sorts of People