Katerina Theodoraki, Child & Adolescent Psychiatrist, Family Therapist, Centre for the Development of Children, Adolescents and the Family, Heraklion, Crete
Abstract
In the present paper, I will express an opinion through both my roles, both as a child psychiatrist and a systemic psychotherapist. The reasoning that I will develop has emerged from my incertitude when I am requested to make an assessment and diagnosis and was enriched by the questioning of the usage of classification systems by two members of the DSM revision task force, Allen Frances and Bessel Van der Kolk, at different periods.
Very frequently, over recent years, we receive requests from parents to perform a child psychiatric “assessment”, as they put it, so that psychotherapy for their children may be compensated by their insurance provider, or their children may receive specialist help at school or even attend special classes. Herein, a question arises for us child psychiatrists/systemic therapists who work stepwise, investigating in collaboration with the family, the child’s symptoms. Quite often, the diagnostic and therapeutic processes are intertwined in an inseparable manner, as the investigation moves alongside the therapeutic interventions, whose results guide us, many times, in arriving at certain diagnostic conclusions, after the fact. Thus, if we rush to come to conclusions in order to make a hasty diagnosis, we risk treating the child in a non-comprehensive manner and assigning a label to them, which could potentially lead to dismissing other therapeutic paths, an act that will ultimately lead to bad practice. This paper investigates and comments on these issues.
I will begin with Hippocrates’ words. According to Hippocrates, it is more important to know the person who suffers than the illness that he suffers from. Hippocrates also said: “First do no harm”. “Be modest and know your limits”.
As systemic psychotherapists, we receive requests for therapy, questions from parents, couples, families, requests for counselling, requests regarding difficult relationships etc., and we attempt to comprehend with the persons involved what it is that dysfunctions in order to help them in a collaborative manner. Very often, however, in recent years, we have children referred to us for “assessment”, as they put it, mostly from psychologists that the parents have contacted, who need the child psychiatrist’s assistance, or are requesting a diagnosis so that the child may be eligible for psychotherapy etc. Child psychiatrists/systemic psychotherapists are put in a difficult position, especially as they are against any kind of labelling that would narrow their own field of vision, and that of the family. Thus, they try to see the family in a collaborative, holistic manner, make a comprehensive evaluation of the child’s mental state, as well as that of the family and its relationships with the wider environment, also taking into account the child’s school performance. We know that very often the child expresses the dysfunction of the entire family.
The evaluation also includes the instances where things are going well, the circumstances under which this happens, and of course, the positive role that the existence of the symptom might be playing. We must always seek what is fundamentally normal in people, and not only what seems to be ailing. All these things cannot fit in the narrow box of a label, which will, among other things, also block our way of thinking. On the other hand, why should the parents not be financially compensated if they are eligible? These are critical dilemmas.
If the mental condition is not clear, it is preferable to postpone the definitive diagnosis, as uncertainty is much better than false certainty, according to Allen Frances. The best approach to ADHD, for instance, is a step-by-step diagnosis. A big part of the increased ADHD percentages is due to positive diagnoses that should never have been made. This leads to abuse of stimulants, with whatever this entails, as Allen Frances states in his book “Saving Normal”. We know that, very often, a child’s behavior reflects a family dysfunction, an inadequacy of the school environment etc. Therefore, we must exhaust all educational and psychotherapeutic interventions before we reach a diagnosis. Of course, our dilemma has to do with the insurance coverage. How will the parents be compensated by their insurance provider? Yet, it is easy to give the child a vaguer diagnosis that will not follow it for the rest of its life, even if ADHD is ultimately verified. In children’s diagnoses we must always take under consideration developmental factors that often bring about rapid changes.
Manuals have definitely helped us these past years, in finding a common ground of communication as professionals. However, many authors, including Bessel Van der Kolk in his book “The body keeps the score”, have addressed the need to be cautious towards manuals, and to only trust what we can learn through our experience and our patients. It is necessary that we comprehend the goals, achievements and motives of our patients, as every person is unique and we need to know them holistically. Many times, we fail to pay attention to when things are going well, under what circumstances the problems are reduced or disappear, and we are only concerned with illness. It is stated in the DSM III preface that this specific system cannot be utilized as an insurance or forensic tool. Yet, this was not adhered to. The classification systems that define a dividing line between normality and mental disease acquired an enormous social importance, and regulate many issues in people’s lives, beyond diagnosis and therapy. According to Allen Frances (p. 27), these include judicial, insurance and professional issues. But were these systems designed for this, or at least was this huge effect taken under consideration when they were being composed? Historically the DSM has shifted from the psychodynamic and psychosocial model to the biomedical one. DSM 5 abolished the multiaxial system and introduced the dimensional model in disorder assessment. This led to the medicalization of psychiatric disorders, and the relegation of the role of the social and the relational context.
The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems, which is not realistic and does not help assuming responsibility for one’s self (Van Der Kolk, 2014). From the model of the schizophenogenic mother that incriminated entire generations, we move to the other extreme: parents that often desperately seek a diagnosis that will remove the blame for their child’s problem from them and will place it on its “brain-disease”, that will be there forever and affect the child for the rest of its life. Despite huge advancements having been made in neurosciences, these have not passed on to clinical psychiatry. The expectation that every mental disorder will be explained by a gene, neurotransmitter, or neural circuit proved to be naïve and deceptive, and we still do not possess laboratory tests for this in psychiatry (Frances, 2013). This means, according to Frances, that our diagnoses are based on subjective judgements, which are inherently susceptible to error. One could, of course, say that from the point of view of therapy this is an advantage, as it urges us to, in a way, view a person holistically rather than mechanistically.
In the United States children from low income families are four times as likely to receive antipsychotic medication, as compared to children with private insurance (Van Der Kolk, 2014), even for behavioural problems that are due to environmental factors. Non-pharmaceutical treatment studies rarely receive funding. By focusing on brain-disease we dismiss the holistic approach and view humans mechanistically (Van Der Kolk, 2014), while overlooking the restoration of relationships, and relationships with the community that are vital for mental health and for the regulation of our own physiology.
Children with a history of abuse are very often diagnosed with ADHD, They are subjected to treatments with stimulants that do not seem to be very helpful in these kinds of situations, and frequently these diagnoses conceal the underlying trauma (Van Der Kolk, 2014).
Labelling children with a disorder may have long-lasting effects on them and their families, and profoundly affect the way they view themselves. Furthermore, focusing on the diagnosis often makes us overlook the functional skills that the children have developed (Van Der Kolk, 2014). Many times, the symptoms are short-term beneficial solutions to a deeper problem that is not easily observable (Van Der Kolk, 2014).
Moreover, there are cases that are not covered by existing diagnoses, like child abuse that is much more frequent than we believed, as the Adverse Childhood Experiences (ACE) study revealed in the United States (Van Der Kolk, 2014).
Recent studies have shown that a biological result is not simply connected to a specific gene, but more genes are usually involved. What is even more important is that the function of genes is not irreversibly predetermined. This has to do with the very important role of epigenetics, through the mechanism of methylation which passes from one generation to the next (meaning that life events trigger the production of biological messages that alter the gene’s behaviour but not its structure and these patterns are passed on to the offspring) (Van Der Kolk, 2014).
Eighty-two percent of the traumatised children seen in the National Child Traumatic Stress Network in the United States do not meet the diagnostic criteria for PTSD. They often exhibit suspiciousness, aggression or lack of responsivity to the environment, and are saddled by several different, non-comprehensive and meaningless diagnoses over the years (Van Der Kolk, 2014). This leads to incredible confusion, and further hinders therapeutic practice.
Today we are experiencing new pseudo-epidemics in children; autism (X20), ADHD (X3), childhood bipolar disorder (X40) in the past 15 years (Frances, 2013). As the limits to what is pathological continuously widen and normality is medicalised, we lose touch with our strong self-healing capacities (Frances, 2013). Furthermore, we know that the developmental process itself alters the child’s image. Frequently, changes in everyday life or the environment have positive results on symptomatology.
Both the DCM and ICD must remain simple, but psychiatry should not. Diagnosis is but a small part of evaluation that serves to explain the function of the person on the individual, family, and social levels. However, as Allen Frances writes (2013), diagnosis and diagnostic inflation dominated. As the author characteristically mentions, diagnosis needed to rest in order to let research catch up, as it does not make any sense to rearrange diagnoses that are not based in research findings.
In short, we are experiencing a contradiction. On the one hand, we talk about diversity and accepting it, and at the same time, the world is being homogenised, and we show progressively less tolerance towards individual differences, treating eccentricity as a disease. If children, for instance, deviate from the predicted course, they will receive a label, a diagnosis. This diagnosis follows them and defines them for their entire lives. Ultimately, diagnoses are oversimplifications of complex problems.
Taking a pill is a passive action. In contrast, psychotherapy places responsibility on the patient, offering him new capabilities to cope with life, and also functions preventively for future problems.
The stigma, very often, has long-term effects. Labelling can lead to self-fulfilling prophecies and identification with the diagnosis (Frances, 2013).
On the other hand we must recognise that in autism, for instance, for people that are really autistic, a diagnosis leads to: 1) better support with therapeutic and training programmes, 2) lessening of the stigma, and 3) a more convenient and easy way of communicating through the internet, as well as social support and companionship. In contrast, the children that were falsely diagnosed as autistic pay the price of being stigmatised, of having less expectations for themselves, and of potentially not receiving the treatment that they actually needed (Frances, 20123).
In conclusion, we should accept that the issue of diagnosis in children and adolescents deserves greater attention, and is not simply a “snapshot”, but a long-lasting process during which diagnosis and treatment evolve alongside one another and oftentimes bidirectional.
References
Frances, A. (2013). Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. William Morrow & Co.
Van Der Kolk, B., A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
Merten EC, Cwik JC, Margraf J, Schneider S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries_). Child and Adolescence Psychiatry and Mental Health_, 11:5. doi: 10.1186/s13034-016-0140-5. PMID: 28105068; PMCID: PMC5240230.
Μούτσου Ε., & Γεωργάκα Ε. (2020), Developments and conflicts regarding the classification of mental disorders inDSM-5: A review of the scientific dialogue and critique. Psychology: The Journal of the Hellenic Psychological Society. 21(2), 130–148. https://doi.org/10.12681/psy\_hps.23272.
