Eric Maisel
Source: Eric Maisel

Welcome to Childhood Made Crazy, an interview series that takes a critical look at the current “mental disorders of childhood” model. This series is comprised of interviews with practitioners, parents, and other children’s advocates as well as pieces that investigate fundamental questions in the mental health field. Visit the following page to learn more about the series, to see which interviews are coming, and to learn about the topics under discussion:

http://ericmaisel.com/interview-series/

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Sami Timimi is a consultant Child and Adolescent Psychiatrist who is Director of Medical Education at Lincolnshire Partnership Foundation, NHS Trust, and Visiting Professor of Child Psychiatry and Mental Health Improvement on the faculty of Health and Social Sciences at Lincoln University. He is the author of Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture, A Straight Talking Introduction to Children’s Mental Health, and The Myth of Autism: Medicalising Men’s and Boys’ Social and Emotional Competence.

EM: How would you suggest a parent think about being told that his or her child meets the criteria for a mental disorder or a mental illness diagnosis?

ST: It is essential to understand that in psychiatry there is no such thing as ‘diagnosis.’ Diagnosis in medicine refers to the process of understanding how a person’s symptoms relate to an underlying disease processes. Diagnosis is a technical process in which a medical practitioner identifies a possible cause or causes of a patient’s complaints. Making the correct diagnosis in medicine is essential for choosing the correct treatment.

In psychiatry we have a number of systems for classification of people’s complaints, but we do not have diagnoses. The classifications we use are descriptive (they describe the patient’s problems) but not diagnostic (they tell us nothing about the possible causes of those problems) and therefore do not aid decision making for treatment and may lead to worse outcomes if the classifications are used as if they are diagnostic.

Consider the following comparison. If, for example, I were to ask the question “what is Attention Deficit Hyperactivity Disorder (ADHD)?” then in our current state of knowledge it isn’t possible for me to answer that question by reference to any particular known biological abnormality. Instead I will have to provide a description, in other words ADHD is the presence of hyperactivity, impulsivity, and poor attention (plus a few extra qualifiers such as age of onset).

Contrast this with asking the question “what is diabetes?” if I were to answer this question in the same manner that I answered the question about ADHD, by just describing symptoms such as needing to urinate frequently, thirst and fatigue, I could be in deep trouble as a medical practitioner as there are plenty of other conditions that may initially present with a similar picture and indeed diabetes itself may not present with these symptoms in a recognizable way.

To answer the question “what is diabetes?” I have to refer to the biological cause of abnormalities in sugar metabolism. My task is then to carry out biological tests (such as analyzing the blood and/or urine for levels of glucose) that provide me with empirical data that is independent of my subjective opinion to help support (or not) my hypothesis about possible causes of the patient’s behavior. In this situation my diagnosis explains the behaviors/symptoms that are described, and is vital for choosing the correct treatment.

In psychiatry what is referred to as ‘diagnosis’ will only describe but cannot explain. This can be further illustrated by considering what happens if we try to use a psychiatric diagnosis to explain. If, for example, I were ask why a particular child can’t concentrate, is hyperactive and shows impulsivity and I were to answer that it is because they have ADHD, then a legitimate question to ask is “how do you know it is because they have ADHD?” The only answer I can give is that I know it’s ADHD because the child is presenting with hyperactivity, impulsivity and poor attention. Thus we end up with a circular argument where the behaviors are caused by the behaviors. It’s a bit like saying my headache is caused by a pain in the head.

Not only is it essential to understand that there is no such thing as diagnosis in psychiatry, but it’s also important to understand the problem of ‘reliability’ in psychiatric classification. ‘Reliability’ refers to the likelihood that different doctors seeing the same person with the same description of their problems will reach the same conclusion about their diagnosis/classification.

Reliability when it comes to psychiatric ‘diagnoses’ is very poor. This means that what classification you get often has more to do with who you see, what country you are in, who has trained them and so on, than what the actual problems being reported are. As a result there are wide variations within countries and between countries in the numbers being ‘diagnosed’ with labels like ADHD, Autism, and Depression. Furthermore, a ‘diagnosis’ once given in psychiatry is often not taken away, but rather, if problems persist new ones are added, thus it is not uncommon for those who attend mental health services long term to ‘collect’ several ‘diagnoses.’

In brief, then, in psychiatry we have a system for classification and not diagnoses. The classifications can be helpful (for example to validate suffering or to access resources) but they cannot be used to explain behaviors and experiences and therefore cannot help with finding the approach or treatment that will prove most helpful. As psychiatric classifications have poor reliability, the diagnoses you receive has more to do with the doctor you see than the problem you have and if your problems continue you become vulnerable to receiving more ‘diagnoses’ with all the consequences this may bring.

EM: How would you suggest a parent think about being told that his or her child ought to go on one or more psychiatric medications for his or her diagnosed mental disorder or mental illness?

ST: As explained above a psychiatric diagnosis will tell you more about the beliefs of the doctor diagnosing than the nature of the problems you or your child are experiencing. From my perspective both as a parent and as a professional with a thorough knowledge of the outcome literature on the use of psychiatric medication in under-18s, I would never agree to a child of mine going on any psychiatric medication apart from in extreme circumstances (for example experiencing voices telling him/her to kill themselves) and then only for a limited period of time until other interventions can help.

The research is quite clear in my opinion – there is very little evidence that any form of psychiatric medication used long term leads to lasting positive outcomes and much evidence that they can result in considerable harms. There is some evidence that used judiciously short term (a few days, weeks, or months) it can be beneficial. There is no credible evidence that any of the diagnoses we use are the result of biological abnormalities like a ‘chemical imbalance’ – none have been found and therefore there are no biological tests to find such abnormalities before psychiatric mediations are given (unlike the case with most other medications).

However, as a psychiatrist dealing with struggling and worried families and young people I am also aware that many people are understandably keen to try pharmacological approaches when they feel (whether this is objectively true or not) that they have tried all that they can or perhaps having heard of others for whom they believe it was successful. To them I have the following advice:

Firstly, normalize your view of suffering. Western culture, perhaps as a result of advances in healthcare, pain management, temperature regulation of our buildings and so on, has much greater intolerance toward mental suffering than many other cultures. We now view growing up as a process loaded with risk and are more likely than ever to feel that it needs experts, like myself, to ‘know’ what kids need to grow up mentally healthy.

In the past few decades our trust in who had the best knowledge on how to help kids grow up, changed from being our own parents, grandparents and communities to professionals. As a result, the trials and tribulations of growing up have been increasingly ‘medicalized’ and turned into ‘disorders’ that are sometimes ‘treated’ with medications that have been given names like ‘anti-depressant’ to give the marketing illusion that they have specific properties that treat a disease.

Growing up is not a pain free process and I encourage everyone involved in looking after kids to focus less on their vulnerabilities and more on celebrating and recognizing their strengths, talents, skills (whatever these may be) and resisting the idea that there is something mentally ‘defective’ or ‘disordered’ about their child that sets them apart from the rest of us.

Secondly, if we wish to go down the route of trying a psychiatric medication, then I suggest the best way to view them is as enhanced placebos that function primarily as ‘enablers.’ The placebo response for psychiatric medications is higher than for any other class of medications and is the main basis for any effectiveness. In order to exploit this, I suggest setting some simple targets to work on prior to starting medication. Think about what changes you would like to see should the medication work and set an achievable goal to aim for after starting medication based on this.

For example, if you have withdrawn from your friends as a result of how you feel, you may wish to set the goal of contacting one friend during the week after you first start the medication. For stimulants it might be a little different as it’s often adults (parents and teachers typically) who are more keen on getting change than the young person themselves. Stimulants tend to narrow your field of focus and make you more absorbed in whatever task you are doing. If this improves a child’s behavior from the adult’s perspective, then use this as an opportunity to praise them and provide them with a different experience of how the adults around them respond to them.

As long as you can keep a positive attitude going it is likely eventually to result in that child having a shift in their identity and attitude (though not necessarily in the exuberance of their behavior). A useful metaphor here is that the medication will work in a similar way to plaster of Paris for a broken arm. The plaster of Paris has no direct healing effect on the broken bone, but rather it creates a context in which the healing takes place – it thus acts as an ‘enabler.’ Once its ‘enabling’ job is done it is no longer necessary.

Therefore, I believe that whenever psychiatric medication is used with anyone under-18, it should be accompanied by a clear plan for withdrawal of medication, typically after about 6 months if successful changes have taken place, but within a few weeks if there has been no positive change. If withdrawing medication after 6 months or longer, it should be done as a carefully phased decrease over 2 to 3 months or longer, as all psychiatric medications may result in withdrawal symptoms on stopping.  

EM: What if a parent currently has a child who is receiving pharmacological treatment for a mental disorder? How should he or she monitor the treatment regimen and/or communicate with mental health professionals involved?

ST: Keep in mind the above advice. Remember that in psychiatry there is no such thing as diagnosis and that the evidence for long-term benefit of taking psychiatric medication is missing. However, that doesn’t mean you should stop any psychiatric medication that they have been on long term and in fact it is very dangerous to do so abruptly.

If you do decide you would like to wean your child off psychiatric medication that they have been on long term, then I advise to do this slowly with step wise reductions and allowing things to stabilize before reducing again. Typically this would mean reducing the dose once a month in small steps. For example, if someone is taking the stimulant Ritalin with a total 40mg per day for several years, as you can get these into 5mg dosages, reduce the total dosage by 5mg every month until totally weaned off (i.e. go to 35mg a day for one month, then 30mg a day for one month etc.).

It will thus take about 8 months or longer to wean off. If you experience a setback or want to stay at a particular dose for longer than a month, then this is, in my opinion, better than going too fast and having to go back to the original dose. Hopefully your physician will support you in this, but remember, many physicians have been trained to believe that they are treating a chemical imbalance and that the child should remain on medications, so you may have to politely disagree with this. Unless your child is on a mandatory treatment order legally, then exercise your rights to decide what is right for your child and I believe most physicians will respect this and hopefully provide the relevant prescription.

My second recommendation is to focus less on symptoms and more on functioning and what your child wants to change in their life. Good outcomes in mental health care relies on collaborative practice – including the ideas, beliefs, dreams, ambitions, etc. of the patient. Focus less on behaviors that may worry and/or irritate you as a parent or teacher and more on what changes and/or new skills your child would like to develop. Focus less on the medicalized idea of managing ‘symptoms’ as if your child is receiving treatment for an illness (she/he is not) and more on what helps them make the changes and/or develops the skills they would like to achieve.

Whilst medication short or longer term may be a part of that, remember medication doesn’t make decisions, it’s people who do that, so that any positive change achieved should always be praised as being the achievement of the person who’s done this.

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To learn more about this series of interviews please visit http://ericmaisel.com/interview-series/

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