Let’s say that I am a school-age child and can’t quite grasp a certain concept—say, multiplication—and to hide my embarrassment and distract everyone from my inability to multiply twelve times twelve, I pull the braids of the girl sitting in front of me. Is that a medical problem? Do I have a mental disorder? Or am I six months away from grasping a concept and in the meantime acting out?
For some reason (and we can name all the reasons) we have decided as a society that when I pull on Sally’s braids, I have a medical problem called a mental disorder and that I should be obliged to take so-called medication to treat my so-called mental disorder. That is where we are today.
It is fascinating that whether or not my behavior actually changes by virtue of the strong chemicals I am forced to ingest, you, my parent or teacher, will feel relieved that I am “being helped” by taking that “medication.” If asked, you will report that I am much improved. It doesn’t matter if the chemicals I am given are inert and part of a placebo effect experiment, you will still report that I am much improved. My taking something has eased your concerns, and you now see me differently, as a good boy on meds. A lovely marriage of the placebo effect and the halo effect! I am much the better boy by virtue of taking something that is in fact nothing.
The child psychiatrist Scott Shannon is director of the Wholeness Center in Fort Collins, Colorado, a collaborative care and integrative medicine wellness center. He is also the author of two excellent books in the area of the mental health of children, one for professionals called Mental Health for the Whole Child and one for parents called Parenting the Whole Child. In the former he explains:
“One of the most interesting facets of ADHD is the placebo effect. Children with ADHD typically express little placebo effect as they hold little expectation about the intended response. It appears, however, that there is a placebo effect in medicated kids’ parents. A meta-analysis confirms it. Parents and teachers express a placebo effect when children are given stimulants, because the adults hold a clear expectation for the medication’s effects (Waschbusch, Pelham, Waxmonsky, & Johnston, 2009). Parents and teachers evaluate a child more positively if they believe that the child has been medicated. They also tend to attribute positive changes to the medication even when no medications have been given (Waschbusch et al., 2009). This finding diminishes the reliability of parent and teacher reports in evaluating kids for ADHD—the core of the diagnostic process.”
We have come a long way over the millennia in our compassionate treatment of children. We no longer look at them as a workforce; we see them as having rights and deserving not to be abused; we believe that they have a right to be educated. Now, suddenly, in the course of just a handful of years, we have taken a huge step backward. As I write this, one in thirteen children are on so-called psychiatric medication. If you find yourself “in the system”—say in foster care—the number increases to one in four. And that number is increasing rapidly.
Because society looks to have swallowed hook, line, and sinker the pseudo-medical model that turns unwanted behaviors into mental illnesses just by saying so, we are on the brink of putting all of our children on powerful chemicals. Children are at risk; childhood itself is at risk. How did squirming in school or at church become a “symptom of a mental disorder” as opposed to an essential feature of childhood? How did sadness over the chaos around you, the constant yelling, or the break-up of your parents’ marriage become a “symptom of a mental disorder”? How did disagreeing with your parents become a “symptom of a mental disorder”? How did any of that happen?
Let’s say that you give birth to a child who comes into the world with a lot of energy. Should you maybe start medicating him at birth to make sure that you damp down all that energy so that he is fit for school and so that he can sit quietly in his chair when the drudgery of education begins? Say that you give birth to a child who comes into the world a little sensitive, a little sad, and a little anxious. Should you get her right on antidepressants and anti-anxiety medication and maybe some new anti-sensitivity medication so that she cries less, startles less, frets less, and is more like the child in the baby food ads, the one who is always so cute and smiling? Should we start all children on medication from birth?
Or should you maybe be a little reluctant to buy that your son’s energy, your daughter’s sensitivity, or your brood’s acting-out antics are “mental disorders”? Should you maybe put your foot down and say no to the abolition of childhood?
Many of the “mental disorders of childhood” can be reduced to the following demand: kid, don’t make so much trouble. Imagine that your child had the chance to talk to someone who actually wanted to listen, someone like the human experience specialist I’ve described previously or a good-hearted child psychotherapist who felt inclined to treat your child as a human being and not as a patient? Don’t you think that your child’s troubles might grow lighter if she had a chance to talk? Doesn’t that seem like a first option and not as some mere collateral help to powerful chemicals?
When I was in second or third grade I pulled on the braids of the girl sitting in front of me. No doubt I was bored . . . and probably I liked her. She turned around and stabbed me in the hand with her pencil, causing a nice ruckus. I had to see the school nurse and the principal and, I think, was sent home for the day, either as punishment or maybe as a precaution. The faint imprint of that quintessential elementary school moment lives on at the base of my palm to this day.
Does that event sound like anything but childhood? If you are a parent, you have a new job in addition to all of your other pressing parental responsibilities: the job of standing up to the current hurricane of pressure to label your child with a medical-sounding “mental disorder of childhood.” That is one of your most serious jobs, as that pressure is mounting.
As a society, as practitioners, and as parents, we really must reconsider the very idea of “mental disorders of childhood.” We must make sure that we aren’t punishing and ruining our children just because they aren’t smiling, aren’t behaving, have fallen a bit behind, are having a hard time of it, or find themselves marching to a different drummer.
In real medicine, you use symptoms to help you discern a cause, which then helps you pick a treatment. You take fever, fatigue, swelling, and so on as indicators of, say, a particular virus, and then you attempt to deal with the virus. If you can’t discern the cause or if you can’t decide between two or more causes, you run more tests and, while you are trying to identify the cause, you do things you know are likely to help relieve the symptoms.
In the meantime, as you seriously look for the cause, you work to reduce the pain or bring down the fever. You are reducing the pain and bringing down the fever while you continue to investigate what is actually causing the fever and the pain. You do not focus all of your efforts on reducing the pain or on bringing down the fever. You continue your investigations. You are trying to figure out what is going on. Your job isn’t to merely treat symptoms.
One of our neighbors recently suffered from terrible stomach pains. For a long time, on the order of two months, no conclusive diagnosis could be reached among the four contenders vying as the cause of her affliction. Finally it was conclusively determined that it was cancer located in a certain stomach valve. Treatment began immediately. All along she was being given relief for her symptoms—relief for the pain, help with her inability to keep food down—while the cause was being determined. Treatment for the actual affliction could only commence once it was identified. That is how medicine works.
In the pseudo-medical specialty of “children’s mental health” something very different goes on. There you take the report of a child’s behavior—for example, that little Johnny pulled on the braids of the girl sitting in front of him—and for no reason that you can justify you call that a “symptom of a mental disorder.” You collect several of these “symptoms of mental disorders”—often four is enough—and you attach a provided label to that “symptom picture.”
The label might sound like “oppositional defiant disorder.” Once that name is announced, chemicals are provided. Zero interest is shown in what is causing the behavior; zero interest is shown in whether the behavior reflects something biological going on, something psychological going on, or something situational going on. This is not medicine, no matter how many white coats are in evidence.
A child who loses his temper, argues with his parents, defies his parents’ rules, and is spiteful and resentful is given, based on these four “symptoms,” the pseudo-medical sounding label of “oppositional defiant disorder” and is put on chemicals to make him more obedient. This is not medicine. This is behavior control instituted to make the lives of adults easier. Why not ask little Johnny why he is angry and resentful? Is that such a preposterous approach? Why not step back and see if his family is in chaos? Why not look at his life and not just his “symptoms”? Why presume that a child arguing with his parents is caused by some impossible-to-find medical condition? Isn’t it more likely—by a thousand-fold—that he is angry with them?
We don’t know why little Johnny is acting the way he is acting. But we do not believe it is cause-less, and we do not really believe that it is the result of a medical condition. We must test for genuine organic problems like brain damage or neurological damage that can cause explosive rage, but in the absence of such biological challenges, we are obliged to presume that little Johnny has everyday human reasons for his anger. Once you rule out brain damage and other possible biological causes of rage, your next step should not be to posit a made-up, invisible medical condition but rather to treat little Johnny like a human being with everyday human reasons for his anger and resentment.
One fact alone should prove the absurdity of considering these behaviors a pseudo-medical “mental disorder.” Imagine for a second that I said to you that my not being able to see any symptoms of your cancer was proof that you had cancer. Or imagine that I said to you that my not being able to see a break in your bone on an x-ray was proof that you had a broken bone. You would find those pretty odd assertions. What is fascinating is that mental health service providers are warned that they may not get to witness any of these “oppositional” behaviors because a child with this “disorder” is likely not to demonstrate any defiance except with his parents and teachers!
Unlike in real medicine, where the sore is visible both at home and in the examining room, with the behaviors associated with “oppositional defiant disorder” those behaviors are likely only observable when little Johnny is actually angry, namely at school and at home. It is absurd but true that an indicator that you have the mental disorder of “oppositional defiant disorder” is that you do not display any signs of it when you are talking to someone you don’t happen to hate. Seriously, shouldn’t the fact that little Johnny is only angry around his parents suggest that little Johnny is angry with his parents?
Picture what a provider is doing here. He does not personally see any signs of little Johnny’s oppositional defiant disorder, and he takes not seeing them as further proof that little Johnny has an oppositional defiant disorder. He relies on reports of things that he has not observed for himself, things that are of course more logically signs of rebellion, protest, and anger than “symptoms of a mental disorder,” and from those reports he “diagnoses” a pseudo-medical condition called a “mental disorder” and moves on to dispensing chemicals. He has not seen the “disorder,” he has no tests for the “disorder,” and he is basing his “diagnosis” in part on the fact that he has seen nothing of the “disorder”!
This is akin to the absurd claim made that proof of the presence of an attention deficit disorder is the fact that you do not display it when something interests you. Might it not be the case that you like to pay attention to things that interest you, like sports and videos games, and don’t like to pay attention to things that don’t interest you, like math class and your parents’ dinner conversation? It is only through the looking glass that my interest in the things that interest me and that my failure to rage at someone who hasn’t angered me are signs of some pseudo-medical “mental disorder.”
There are many things we wish for little Johnny. We wish that he were having an easier time of it. We wish that he could stop his raging, for his own sake, since he is making everyone around him dislike him. We wish we knew what was causing his difficulties so that we could offer him help at the same level as his difficulties: if he is raging because school is too difficult for him, we would offer one sort of help; if he is raging because his parents are abusive alcoholics, we would offer another sort of help; if he is raging because he can’t abide his parents’ strict rules, we would offer another sort of help. We wish all of this for Johnny.
If a child has a medical condition, treat the medical condition. If a child is angry with his parents, do not call that a medical condition. Labeling an angry child with the pseudo-medical sounding “mental disorder” label of “oppositional defiant disorder” may serve adult needs for peace and order, just as prisons do. But it is not medicine and it is not right. Little Johnny is making it very difficult on the adults around him, who will naturally return the favor and make it very difficult on him. But that he is making life hard is not the same thing as being mentally ill.
We simply must stop saying that little Johnny is suffering from a mental disorder, that is, that he has a medical or pseudo-medical condition. It makes no sense on the face of it to believe that an angry child is angry because he has a disease. It makes much more sense to believe that he is angry because he is angry, just as you are angry when you are angry. Maybe little Johnny is a lot angrier than you are—but that he is angrier than you are doesn’t turn his anger into a disease. As a society, we may not be equipped to deal with all of our sad, anxious, and angry children—but the answer to that shortcoming must not be to call them all diseased.
The most common “mental disorder” to anoint a child with nowadays is “attention deficit hyperactivity disorder.” This is the “diagnosis” you get if you squirm. The diagnosis naturally comes in different flavors—you can be “predominantly impulsive,” “predominantly inattentive,” and so on—and these different flavors exist so as to make sure that every possible feature of childhood is captured by one label or another. The unstated goal is clear: to turn childhood into a mental disorder.
Of course this “diagnosing” and subsequent “treatment” of children with powerful, addictive chemicals that resemble our “war on crime” street drugs is at once bizarre and, if the powerful could be taken to task, felonious. Yet the average parent seems incapable of saying no to the idea that common, understandable features of childhood should be transformed into mental disorders.
Would anyone put up with calling playing golf too many times a week if that negatively affected your ability to do your job a mental disorder called “golf addiction disorder”? Would you put up with telling the husband you hate and who disgusts you that you don’t want to have sex with him a mental disorder called “sexual refusal disorder”? Would you put up with calling watching the same action movie ten times over a “violence attraction disorder”? Would you?
The funny thing is an awful lot of people would. Not only would people put up with such labels, they would likely embrace them and even crave them. It isn’t that I like to play golf a lot—I have a golf addiction disorder. It isn’t that I don’t want to sleep with my husband—I have a sexual refusal disorder. It isn’t that I’d rather watch Terminator 3 followed by Die Hard 2 than talk to my wife—I have a violence attraction disorder. I’m even a little afraid to name these “disorders” as a joke, as some readers will suddenly believe that these are disorders—just because I made up some names!
The mental health establishment has figured out that human beings in this culture at this point in human history will swallow such strings of words in a quick, deep, involuntary way, almost as if they have been waiting for them. Wish you had longer eyelashes? We have a chemical for your eyelash insufficiency disorder. Wish you had better taste in clothes? We have a chemical for your fashion blindness disorder. Wish you had a child who was zero trouble at all times? We have many disorders for you and many chemicals to take care of all that!
Imagine little Bobby who squirms at school, squirms at church, squirms at home, squirms in his good clothes, squirms when given chores, squirms when told to sit down and chat with his aunt Rose, squirms . . . a lot. What if you lived on a huge farm, it was always perpetual summer with no mandatory schooling requirements, and you didn’t need to see little Bobby from morning until night? What would little Bobby be then? Would he be “ADHD”? Or would he be happy?
Wouldn’t little Bobby zip in and out, make himself a sandwich, put a band-aide on his skinned knee, take a shower once a week or once a month, change his clothes after he fell in the pond, complain once a day about being bored, and be completely a boy? No one would be having any problems, neither you nor little Bobby. Where did the “ADHD” go? Where did the “mental disorder” go? Well, try to sit him down at the dinner table or in a pew at church and there it would appear. Imagine a disease only appearing at the dinner table, at school, or in church. What sort of disease is that?
The “problem” would, of course, return the second you tried to impose unnatural constraints on little Bobby’s energy. Try to have him sit still during a sermon in church—now you have a problem. Try to have him sit still at the rule-burdened dinner table—“eat your peas first, sit up straight, stop fidgeting”—and you have a problem. Try to have him not climb on something that looks promising to climb. Then you would have a problem. Have you ever seen a child NOT climb on things that were there to be climbed on? Asserting your stubborn desire to climb on everything you encounter may well get you into hot water, but it should not get you a mental disorder label.
If you gave little Bobby the freedom he craves, would it surprise you if he popped in at three in the afternoon from his adventures to give you a hug out of gratitude for being allowed to be? Might he not even fail to fidget for significant amounts of time because he had spent his energy nicely being a boy? Would it really surprise you if he became the son you wanted him to be because you let him live?
Of course, I am painting a pretty and unrealistic picture. What if little Bobby’s friends drank beer, used cocaine, and robbed your neighbors’ homes? You would of course have to parent. You can’t really let little Bobby run free—that picture of a huge farm and endless summer is a metaphor. In reality, you must parent. But there is a difference between parenting and letting little Bobby be labeled with a nonexistent “mental disorder.”
Should a child learn to be orderly in school? Yes, for the sake of civil society. But that is a very different question than whether a child should receive a mental disorder diagnosis for not being orderly in school. There the answer is no. The issue of “being orderly in school” is not a medical one.
Doesn’t a child have the right not only to a childhood but also to his or her individuality? Shouldn’t a child have permission to say, “I don’t want to be like you”? Shouldn’t a child have permission to say, “I don’t want to live like you”? Shouldn’t a child have permission to say, “I don’t want to think like you”? Shouldn’t a child have permission to say, “I don’t believe in you?” But of course, no child has such permission. That would be intolerable to adults. Parents would take that as criticism, as insubordination, as betrayal, and not as a right of childhood.
Such a child would be scolded, punished, belittled, and even hated. And, nowadays, almost certainly labeled and tranquilized. A child who fidgets is likely to get following messages. “You are such a burden to us because you fidget so much.” “You are such a disappointment to us because you fidget so much.” “You will never amount to anything in life if you keep fidgeting that much.” “We can’t love you if you fidget that much.” In addition to those messages, which increase his unhappiness, he will nowadays get a label and a chemical.
Behaviors are not symptoms of a medical disorder unless they are symptoms of a medical disorder. Some honest person must fairly and appropriately distinguish between a behavior like restlessness that in virtually all children is not a symptom of a medical disorder, and signs and symptoms that are indicators of a medical disorder. That appropriate and fair appraisal is absent today. Someone with clout should shine a bright light on our current thirst for turning all squirming into mental disorders.
Rather than presume that your child has a medical condition or a pseudo-medical condition called a “mental disorder” when sad, anxious, or angry, presume something else instead. Presume that you do not know what is going on and that you need to ask some important questions of yourself, your child, the people in your circle, and, if they enter the picture, mental health service providers. Decide that you will think before you agree to allow your child to be labeled and “medicated.”
Here are some questions to ask. This is not an exhaustive list. I hope that you’ll dream up more questions yourself. Better to ask too many questions than too few!
Let’s say that your child is exhibiting some sort of problem. First of all, is it a problem? Is it a problem that your child waits two months longer to speak than did Jane across the street? Why is that a problem as opposed to a natural difference? Is it a problem that he enthusiastically signs up for violin lessons and then wants to stop them after two weeks? Why is that a problem as opposed to a change of heart? Is it a problem that he doesn’t want to sit at the dinner table where you and your mate are always fighting? Why is that a problem as opposed to good common sense? You can call any of these a problem—a developmental delay, a lack of discipline, a refusal to obey—but where is the love, charity, or logic in that?
2. Who has the problem?
If you belittle your child and he grows sad and withdrawn, your child certainly has a problem. But don’t you as well? Isn’t your habit of belittling him a genuine problem? If you are highly anxious and your child becomes highly anxious, your child certainly has a problem. But don’t you have a problem as well? Isn’t your anxious nature infectious? If you are rigid and dogmatic and your child rebels against your house rules, your child certainly has a problem. But don’t you as well? Doesn’t rigidity virtually demand rebellion? You can blame your child for his behaviors and take no responsibility for yours, but how righteous is that? The word “parent” doesn’t make you right and the word “child” doesn’t make him wrong.
3. What does your child say?
Have you asked your child what’s going on? Asking is very different from accusing or interrogating. Have you had a quiet, compassionate, heart-to-heart conversation with your child in which you express your worry, announce your love, listen to your child’s concerns, and collaborate with her on creating some strategies and tactics that might help her deal with the problems she’s experiencing? Are you in the habit of checking in with your child to understand what she is thinking and feeling?
4. What do other people say?
Have you checked in with the people in your circle: your mate, your other children, your parents, and anyone else who knows your child well? What are their thoughts on what’s going on? They may have nothing useful or productive to offer or they may have some very important insights into what’s going on. Ask the people who know your child what they think.
5. Do you love your child?
Human beings do not automatically love other human beings. Do you love your child? Do you soften in his presence and want to hug him or do you harden in his presence and want to scold him? Do you look at him with love or do you look at him to see if his fingernails are clean and if his homework is done? How reasonable is it for your child not to grow sad or angry if he feels that what he gets from you is not love but criticism and revulsion? This is one of those “looking in the mirror” questions that must be answered.
6. Are you quick to accept labels for yourself?
Do you regularly believe that you “have” something—clinical depression, say, or ADD? If you too easily agree that you have a “mental disorder” that requires “medication,” it is reasonable to suppose that you’ll find it easy to go along with the labeling of your child. If you say things to yourself like, “Oh, I have ADD and Bobby does too,” “Depression runs in our family,” or “We can’t get Sally’s anxiety meds right, but I’ve had the same problem myself,” please ask yourself the question, “Isn’t it time I really understood what a ‘mental disorder’ is and if I actually have any?”
7. Has my child had a full medical workup recently?
What if her school difficulties have to do with poor eyesight or poor hearing? What if her lethargy, her pain complaints, or her sleeplessness are symptoms of an actual medical condition? Make sure that you rule out genuine organic and biological causes for the “symptoms” that your child is displaying. This can prove a complicated, frustrating experience. The root causes of human behaviors are not so easily traced back to medical conditions even when such conditions exist. As complicated and frustrating as the experience may prove, a medical workup should be part of your plan.
8. What sort of help are you looking for?
You may well decide that you alone can’t do enough to help your child reduce her experience of distress. But where should you turn for help? It amounts to a very different decision to take her to a child psychologist whose specialty is talk and who uses techniques like play therapy and to a psychiatrist whose specialty is “diagnosing mental disorders” and whose technical interventions are chemicals. There are many types of helpers, from school counselor to family therapist to residential treatment specialist to psychiatrist, who come at problems from different angles. Educate yourself as to what these different service providers are actually likely to provide.
9. What is the rationale for labeling my child with a mental disorder and prescribing chemicals?
If a mental health professional would like to give your child a mental health label, inquire as to his or her rationale for doing so. Ask questions like, “By ‘mental disorder’ do you mean ‘medical issue’? If you do not mean ‘medical issue,’ why do you want to prescribe medicine to my child? If you do mean ‘medical issue,’ I would like you to prove it to me at least a little. And I would prefer that you do not offer up as proof that book, the DSM, which I am very aware is not a genuine manual but only a catalogue of labels and which I know does not offer up a whisper about causes or treatments.”
Children are a vulnerable population. Their parents are their first line of protection. Taking your child’s side sometimes means actively disputing conventional ideas about “what is right” and “what is best.” The first step in defending your child’s right to be herself and to have a childhood is educating yourself about the issues I’ve been discussing. You may agree with me or you may disagree with me; I put it in your hands to become the expert you need to be.