Audio transcript: Diagnosing children with mental health difficulties: Benefits, risks and complexities
Return to CFCA webinar – 2 August 2018
Audio transcript (edited)
Good afternoon everyone, and welcome to today's webinar, ‘Diagnosing children with mental health difficulties: Benefits, risks and complexities.’ My name is Kathryn Goldsworthy and I'm a Senior Research Officer here at the Australian Institute of Family Studies. Today's webinar presentation will explore some of the complexities involved when psychiatric labels are applied to children.
This webinar complements a recently published CFCA paper, "Diagnosis in child mental health; exploring the benefits, risks and alternatives," authored by AIFS researcher, Dr Rhys Price-Robertson. It aims to encourage practitioners in the child and family welfare sector to examine their own understanding of diagnostic systems and critically reflect on the role that diagnosis plays in their work with children and families. This paper is available on the CFCA website.
Before I introduce our speaker, I would like to acknowledge the traditional custodians of the lands on which we are meeting. In Melbourne, the traditional custodians are the Wurundjeri people of the Kulin nation. I pay my respects to their elders, past and present, and to the elders from other communities who may be participating today.
Firstly, some housekeeping details. One of the core functions of the CFCA information exchange is to share knowledge. So, I'd like to invite everyone to submit questions via the chat box at any time during this webinar. We will respond to your questions at the end of the presentation. Please note any unanswered questions may be published, along with your first name, on the CFCA website for a response from the presenters after the webinar. Please let us know if you don't want your question or first name to be published on our website. We'd also like you to continue the conversation we begin here today. To facilitate this, we've set up a forum on our website where you can discuss the ideas and issues raised. Submit additional questions for our presenter and access related resources. We will send you the link to the forum at the end of today's presentation. As you leave the webinar, a short survey will open in a new window. We would appreciate your feedback.
Please remember that this webinar is being recorded and the audio transcript and slides will be made available on our website and YouTube channel soon. It's now my great pleasure to introduce today's speaker Dr Peter Parry. Peter is a child and adolescent psychiatrist in Brisbane. He has worked in both clinical and managerial roles in in-patient and community child and mental health services in South Australia, the UK and now Queensland. He is a senior lecturer with Children's Health Queensland, University of Queensland and visiting senior lecturer with the Department of Psychiatry, Flinders University. Please join me in giving Peter a very warm virtual welcome.
Thank you, Kat. So just by way of disclosure, I have no relevant pharmaceutical industry financial interests but I am a member of this watchdog group of health professionals. I'm grateful to Rhys Price-Robertson for asking me to present this webinar. Rhys has recently published a paper which you mentioned, Kat, "Diagnosis in child mental health: Exploring the benefits, risks and alternatives." Rhys found that I had some similar publications and I would certainly concur with the key messages in his paper and shall expand on them in this talk. What Rhys highlights is that diagnoses can be very helpful and it's important that we make them in cases where warranted.
He also notes that the third addition of the diagnostic and statistical manual of mental disorders at the American Psychiatric Association was a key document in creating a common language in definitions of disorders, but both it and subsequent editions like the current DSM-V or the International Classification of Diseases 10th Edition of the World Health Organisation focus on symptoms rather than causes and contexts. As his next message shows, this leads to a range of problems. Pathologising normality, lack of context, being culturally insensitive and having problems with the validity of the actual disorders themselves. There is evidence of unhelpful influence of the pharmaceutical industry, which I will show.
The industry can, of course, also be very helpful in producing valuable medicines and I agree with Rhys' statement that current diagnostic systems are best seen not as scientific certainties but rather as cultural tools used to understand different varieties of psychological distress and impairment. Anyway, Rhys asked me to give my own views rather than parrot his. So we'll move on. This talk will take an historical and philosophical overview of the subject. Rather than delve into particular diagnoses in depth. There's plenty of slides which will all be available online and many contain references for further reading, so I'd just ask that you, you know, listen and get the overview.
I shall start with a paper of my own in the Medical Journal of Australia's Christmas edition in 2009, "Cough disorder; an allegory on the DSM-IV," where I made the point that the manual is more a reliable descriptive nomenclature than a valid classification of diseases. The Christmas issue did give me some poetic licence, so I wrote an allegory of a common scenario in my daily clinical practice and here's the story.
So reading from the paper: "It was time for the annual post-prandial Christmas dinner nap. A niece was coughing on inhaled lemonade. Dreams are often allegorical. It had been a busy year and I started to dream. A mother came into my consulting room with her son. 'He's got cough disorder,' she declared. She'd read the symptoms on the internet. A short repetitive noise coming from the throat associated with the expulsion of air from the lungs. This was indeed true. The website had quoted the DSM-IV. That is, the fourth edition of the Diagnostic and Statistical Manual of Human Noises published by the American Phoniatric Association. 'He's clearly got cough disorder and he needs Supressalin Cough Suppressant.,' the lad's mother said. Supressalin had been advertised via a link on the, 'Help for parents of kids with cough disorder,' website.
"The young chap himself broke into a succession of hacking coughs as if to emphasise the problem, at which point his mother widened her eyes and slowly and firmly nodded to emphasise the obviousness of the diagnosis. One that, presumably, was now even more clearly in need of the advertised pharmico-therapy. I sighed. That is, I exhaled in concert with slight laryngeal constriction, following a deep diaphragmatic inhalation making a soft, rather low-pitched noise and this occurred in a situation of frustration, tension, tiredness or boredom. I noticed my noise, recognised I was in a situation of frustration and recalled research showing I'd just stimulated my vagus nerve to maintain autonomic nervous system equilibrium. I coughed, but it was the, 'Ahem,' subtype.
"The short, sharp double noise emanating mainly from the larynx without significant pulmonary expulsion. This is not normally considered a pathological cough, although I noted the lad's mother raised an eyebrow. I knew my ahem cough was the prelude to my well-worn noise educative spiel to parents of coughing kids. 'Well, yes, he does cough. I totally agree with you there,' I said, to get Mum onside and noticed a slight easing of her defensiveness. 'But, you see, cough disorder doesn't tell us very much. It's not really a diagnosis, but a description of behaviour,' she was starting to resume the wary, defensive posture.
"The boy uttered a quick succession of coughs. I started to look grave and said how concerning his coughing was, and that it was very important we thoroughly investigated it. She said the parents' help website had indicated that Suppressalin was exactly what was needed, but I noticed she was now less certain. I made a, 'Hmmm,' sound in a particular way to indicate understanding and empathy but also that I knew more. I was, after all, the doctor. I sensed she seemed willing to listen to the spiel. 'Cough disorder is simply a description, a starting point,' I said. 'We have to find out why your young man here is coughing. Cough disorder can have many causes and for some children several causes can combine.'
"I went on to describe inhaled objects, drinks down the wrong way, asthma, croup, bronchitis, pneumonia, pharyngitis, post-nasal discharge and rarer, more serious causes such as throat and lung cancer, pneumothorax, bronchiectasis, silicosis and congestive cardiac failure. It could be a reaction to dust or cold, dry air. There is always an environmental context and it could even be something as mild as a frequent, habitual ahem cough to try and gain attention. I had the lad's mother's attention now and the lad himself had also stopped coughing and was listening.
"I said that his cough may not need Suppressalin, although I acknowledged for some kids Suppressalin is very beneficial and they may need it for many years. We went on to look collaboratively for what was causing the cough. Even Dad came to the next consultation. I also had an informative telephone discussion with the child's teacher who told me how the boy generally stopped coughing by morning recess." And we'll come back to finishing the story at the end of this webinar. Of course,…. just wait for this slide.
Of course, you can't just get at bedtime story into the MJA. The bulk of my paper was a historical overview of the DSM and psychiatric nosology, a term which means the classification of disease and illness in general. Broadly speaking – and it's another slide that's about to come. Here we are. Broadly speaking in the history of psychiatric nosology there have been two perspectives. One called the Kraepelinian after Emil Kraepelin, a Munich based psychiatrist around the turn of the 20th century. He used a medical model to distinguish manic depression from dementia praecox which was later called schizophrenia.
DSM-III used this same symptom checklist style model and has been termed the triumph of the neo-Kraepelinians. On the other-hand Adolph Meyer practised in the USA in the early 20th century and promoted the psychobiological model which was a forerunner of the biopsychosocial model. It emphasised uniqueness of individuals and that their symptoms had to be understood in their live context. Meyer influenced the first two editions of the DSM. Where many disorders were reactive states to stress past or present. Meyer's – it's taking a long time to move. Having a slide movement problem here. Whoops we've gone – yep. Meyer's – no we've gone now too far. Yep. Meyer's sensible model, however, was – here we are. Meyer's sensible model, however, was eclipsed, at least in the USA in the mid-20th century by psychoanalysis.
Which, at its extreme, attributed absolutely everything to psychodynamic factors relating to early childhood experiences. This paper in the lancet by Andrew Skull, a sociologist and historian of psychiatry notes just how dominant psychoanalysis was in US academia by the 1960s. It led to blaming autism and schizophrenia on the refrigerator mother, or schizophrenogenic mother or father.
Obviously very defamatory and blaming concepts that added much harm and guilt to families of sufferers of these conditions. The author went on to note a sea change occurred during the 1980s following the DSM-III such that by the 1990s not only the psychiatrists but also people in general were attributing mental illness, not to psychodynamic interpersonal factors, but to faulty brain biochemistry. This, he concluded, was a bio-babble. As unscientific as the psychobabble that it replaced, but it facilitated the marketing of psychotropic drugs. Leon Eisenberg was the most prominent US child psychiatrist of the 20th Century.
His career spanned this pendulum swing from what he termed an era of brainless psychiatry in the 60s to 80s. At the time he was a strong proponent for recognising and treating ADHD which he believed was generally missed. To mindless psychiatry where he bemoaned the over-diagnosing and over-medicating American children. Here in Australia Professor Phillip Boyce when he was the president of the Royal Australian New Zealand College of Psychiatrists, in his presidential address noted the same pendulum swing and said that our profession had been, to quote, "Dumbed down." He attributed this to an almost religiously fundamentalist interpretation of the DSM manual. The lack of time to see and properly assess patients due to increased service and bureaucratic demands.
The marketing power of the pharmaceutical industry including influence on research and medical education coupled with consumerist demands for quick pill fixes and a misunderstanding of evidence-based medicine that neglected clinical wisdom and psychodynamic and family dynamic factors. The Lancet paper placed a lot of the blame on the DSM calling it, "An anti-intellectual system. A checklist approach to diagnosis and treatment." So, at this point a bit of background as to why the DSM-III adopted a symptom checklist approach.
In the 1970s psychoanalytic theory was engaged in overreach as has been indicated and also some prominent psychoanalysts were literally caught in scandals with their pants down with their patients. The parent blaming was extremely hurtful. Psychoanalytic theory in the USA also over-diagnosed schizophrenia so that you had double the risk of being diagnosed in the US than you did in Europe. There was additionally a perceived need to make psychiatry seen as a medical speciality, particularly under the philosophical attacks on it by the anti-psychiatry movement as being an agent of social control, using subjective diagnoses to enforce conformity.
An interesting personal historical twist is that the head of the DSM-III task force, Professor Robert Spitzer had it in for psychoanalysis. Some say this was because his mother suffered chronic depression and never seemed to get better despite years of psychoanalytic therapy. Spitzer, in interviews, said things like, "We eliminated the term neurosis, which meant inner psychic conflicts, because it had psychoanalytic meaning." Therefore, there was this agenda within American psychiatry – at least within biologically oriented psychiatrists to expunge psychoanalysis from psychiatry. In fact, the token psychoanalyst in the DSM-III task force actually ended up resigning in protest saying the whole project was, from his point of view, highly prejudiced and skewed to phenomenological and descriptive, in other words, symptom checklist point of view and quite anti-psychodynamic. Not just anti- the excesses of some schools of psychoanalysis but anti- the idea of psychodynamics and that mental symptoms can have intrinsic meaning in contexts of past and present stressors.
Spitzer et al managed to get the DSM-III accepted by the APA's board by cleverly promoting the manual as a-theoretical with respect to causation of psychiatric syndromes and symptoms. None of which could be very biologically oriented or very psychoanalytically oriented. They emphasised in the introduction that it was designed for research to create a common language and cautioned against using it clinically and medico-legally. However, by the time of the fourth edition published in the early 1990s under Alan Francis' chairmanship the introduction bluntly stated to users, "Don't use it in a cookbook fashion."
In other words, the DSM fundamentalism that Boyce had referred to was all too evident. People ticked symptoms, got a diagnosis and voi la thought they had all the answers. The Lancet paper noted that this DSM fundamentalism that neglected context posited the disorder as arising somehow de novo in the individual and then, with marketing based medical research and education, psychiatric nosology was easily hijacked to presume everything was a chemical imbalance in need of a chemical fix. To match, as he said, the requirements of the psychiatric marketplace.
Now, I actually know about this, as Glen Spielmans, a psychology professor from Minnesota and I went through over 400 internal pharmaceutical industry documents that were released from court cases, in which companies were fined billions of dollars for off label marketing concealment of data. As an example of what is known as, "Disease mongering," which is making many more people believe they have an illness than real numbers of sufferers and doctors believe that they need to diagnose more widely. These documents from Eli Lilly about Zyprexa, also known as olanzapine, are interesting. Because in 1994 the company planned to market Zyprexa simply as an anti-psychotic for use in schizophrenia. A small market where it, in fact, is a very useful medication. However, the company had a looming financial problem with a patent on its blockbuster antidepressant Prozac also known as fluoxetine expiring in August 2001.
So, in the last week of July the Zyprexa product team held a meeting, where they said the company was betting the farm on Zyprexa because sales of it would have to fill in the gap from lost Prozac sales. If Zyprexa was just used as an anti-psychotic in the schizophrenia market then sales would plateau at a low level, down the bottom here. But if used as a mood stabiliser for the bipolar disorder market then sales would increase dramatically. And here they say Zyprexa, to quote them, "Needs to be viewed as a true mood stabiliser." Working in all phases of manic depressive or bipolar illness, which would mean being like lithium for example, a medication that does just this.
The problem is that their own SWOT analysis noted they only had data for treating acute manic episodes. Which, by definition, are psychotic episodes. There was no data for the other phases. For treating depression or preventing mania or depression. They did note an opportunity was to change the bipolar treatment paradigm. "Bipolar," they said, "Is an opportunity equal to our top new clinical entities. Can we launch and grow it?" Launch and grow not Zyprexa as such but launch and grow bipolar disorder. One way of creating a market of more bipolar disorder sufferers is by helping US general practitioners diagnose more cases.
And I got into all this stuff, stumbling into looking at internal drug company documents, when I just wanted to be a clinical practicing child psychiatrist in Australia, because I was researching how was it that in the United States, two year old toddlers, in significant numbers, were being diagnosed with bipolar disorder. This is actually from an email that was published in the New York Times over these issues by a senior executive saying the company needed to expand marketing with Zyprexa in the child/adolescent population.
The paediatric bipolar epidemic in the United States led the head of the DSM-IV task force, Professor Emeritus Alan Francis to lambast the over-diagnosis of bipolar disorder in children in this article. Which he saw the epidemic fuelled by interactions between the pharmaceutical industry and some academics. However, he also noticed that over-diagnosis epidemics of ADHD and autistic spectrum disorders had already occurred which he attributed to his group making the criteria in DSM-IV too lax.
The paediatric bipolar controversy absolutely erupted in the US in 2007 in the media following the death of this little girl Rebecca Riley, aged four, who died from a combination of clonidine, quetiapine and valproate which she'd been taking since diagnosed with ADHD at aged 28 months and bipolar disorder shortly afterwards. And this boy Max made the cover of News Week for his diagnosis of bipolar disorder made when he was aged two. He'd had virtually the whole formulary of psychotropic medication given to him by age 10.
Part of the problem in the US is their health system, which despite costing double Australia's as a percentage of GDP provides minimal non-drug therapies for mental disorders. This leads to what is known as diagnostic up coding. You have to get a more serious diagnosis in order to get some kind of treatment, even if it is mainly medication and not talking therapies. In fact, the former president of the American Psychiatric Association called their managed care system, "Corpricare," because it cared for big corporate profits rather than people's health. So, we can see that DSM-III at least in the case of bipolar disorder but also with diagnoses like ADHD did not provide greater accuracy of diagnosis. Symptom severity and interpretation is subjective and external factors like the health system and marketing can heavily influence how the diagnoses get made in practice.
A relevant concept I'd like to introduce at this point is reification. Reification is the process where giving a concept, construct or process a name generally results in the assumption it has ontological existence as a genuine entity or thing. The introduction to DSM-IV offers cautions about absolute reification of psychiatric diagnoses. To quote, "There is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries." However, caveats like these in the DSM introduction are rarely read.
My Flinders University colleagues, Steve Allison and Tarun Bastiampillai and I published in the Lancet psychiatry journal on this very issue of reification of the paediatric bipolar hypothesis in the USA, noting the diagnostic up coding factors. And the slide's just a bit slow.
And it – the next slide should come. If I click again it'll end up skipping two slides. Here it is.
A decade ago we surveyed Australian and New Zealand child psychiatrists to find that only three and a half per cent of the group agreed with the United States practice of diagnosing bipolar at such rates in children. And part of the rational for DSM-III in the first place had been to stop international discrepancies in diagnoses rates, but look at these three conferences all held in the same year. There were over 40 presentations on paediatric bipolar at the American Academy of Child and Adolescent Psychiatry conference which I attended, and none at all at either the Australia and New Zealand conference or the European Child and Adolescent Psychiatry conference.
And eventually this international discrepancy was published in the American Academy Journal of Child and Adolescent Psychiatry showing almost a 100 to one discrepancy between the United States and England, with more kids under the age of six diagnosed in the US than by age 19 in England. In fact, there were actually no pre-teen children diagnosed at all in England.
But let's stop picking on our American colleagues. We have a problem here in Australia with over-diagnosis of autistic spectrum disorders. Child psychiatrist colleague in Victoria, Soumya Basu and I published in our college journal about this and we called for a return to proper use of bio-psycho-social diagnostic formulations rather than relying too heavily on symptom checklist approaches. Diagnostic up coding factors in Australia have included special Medicare rebates for certain professions, welfare, parent carer payments through Centrelink for families with autistic children and schools with extra classroom assistance. And in fact, it's often the demands of the schools that are brought to paediatricians and child psychiatrists for giving an ASD diagnosis.
A couple of my Brisbane based paediatric colleagues, experts in developmental behavioural paediatrics have noted we have a problem of what they term discrimination by diagnosis. Because such up-coding reward factors favour some diagnoses like ASD but not other diagnoses and these equity issues need to be carefully considered and managed by the NDIS. Actually, there is an interesting backstory to why autistic spectrum disorders received favourable treatment. Former deputy prime minister, Tim Fischer's family had an autistic child and John Howard was well aware of this and the burden that it had placed on the Fischer family, so the second last act of Howard's government was to pass the funding for Autistic children package. It was a case of good intentions because for many families it was long overdue assistance, but there were unforeseen consequences in over-diagnosis and inadvertent discrimination against other disabilities.
And I'd strongly recommend this paper by my developmental behavioural paediatric colleagues for more about the art of a diagnostic formulation, which on its own would be a lecture or webinar in its own right. But essentially it means considering all bio-psycho-social factors past and present that may be contributing to the symptomology. Autistic spectrum disorders require careful experience evaluation and this can be improved with trained use of the ADOS – the Autism Diagnostic Observation Schedule, but even so that would still need to be embedded in a full bio-psycho-social formulation.
In the run up to the release of the current fifth edition of the DSM there were calls to consider attachment and relational processes. This editorial in the American Journal of Psychiatry from 2007 entitled, "Relational diagnosis; an essential component of bio-psycho-social assessment," reads, "We are hardwired to seek out attachment and relational processes will always be an essential part of the human experience. Although DSM strives to apply the bio-pscyho-social model, [actually the author is being overly kind by saying that in my view, but he goes on] there is a notable and strikingly absent consideration of the role of relational processes and disorders in the development, maintenance and manifestations of mental disorders."
Attachment theory is a bedrock theory of child development and therefore developmental psychopathology as well. The theory was promulgated by John Bowlby soon after the end of World War II in his work in orphanages across war-torn Europe and then in paediatric wards where he looked at human children, but he also derived much of his theory from the field of ethology, animal behaviour and this beautiful photo of a mother and baby shows a secure, loving attachment pattern.
This slide was graciously lent to me by Professor Jim McKenna, anthropologist from Notre Dame University Indiana. He was a keynote speaker at the inaugural Australasian parenting conference 20 years ago. McKenna stressed the importance of close mother/infant physical contact and co-sleeping for secure attachment and you can see the babies carried on mothers' backs here by these women in Africa as they go about their daily work as something that was common for infinite number of generations.
In fact, when I lectured on developmental psychology during a locum child psychiatry posting in my ancestral family home of Wales in the UK, I was reminded that in the West, the practice of infant holding African style, as, for example, wrapped with a shawl, was customary until the 20th century. Both indoors and outdoors. And over here you can there's a baby carried African – on the back, African style by this mother with her big Welsh black hat, traipsing along the muddy byways of probably 19th century Wales there.
As infants, us humans have an absolute need for mirroring body language and close human contact and this occurs from birth. This slide shows tongue protrusion, mouth opening and lip pursing mirroring. And all of this occurring within hours of birth. The same actually – it happens across other mammalian higher primate groups and we will see on the next slide with a little baby monkey. When the slide moves. But yeah, you know, we are very much um, designed and hardwired for attachment from the word go and the brain forms you know, through the relationship and the experience it has with the world. What little infants need is periods of what's termed alert inactivity. I press the slide mover again.
Peter, just use your mouse to click on that slide once and then use your arrow key again.
Okay, yep, we're moving again. We've moved two. Go back one.
Okay, and you can see this mouth opening and tongue protrusion mirroring with just a tiny little newborn rhesus monkey. So this is how our brains grow. They grow in this environment of social and general sensory experience. And when such safety and loving mirroring attachment is prevented as in Harlow's infamous experiments where monkeys were taken away after birth and given a choice between two inanimate mothers who were kind of these mannequins. They would always choose the one that looked like a mother rather than the one that actually had the milk. So you can see the little monkey just leaning from the monkey it clings to, which isn't a monkey of course, to this one that has the milk bottle. And this emphasises that the primary drive is for attachment.
Such badly abused and neglected monkeys developed sever emotional and behavioural problems and autistic like traits as well as compulsive, deliberate self-harming behaviours and anti-social aggressiveness. And this is now well understood in us humans as well. There's a vast science on the effects of disrupted attachment and childhood trauma such as these books by Allan Schore and Louis Kotzolinger, titled for instance, "Affect dysregulation and disorders of the self." American child psychiatrist Bruce Perry, whose website childtrauma.org is definitely worth visiting, has done much to make this science well known. This neuroimaging reveals the stark failure of brain growth in a case of extreme neglect. And despite this extensive literature on attachment theory and developmental trauma, when I searched 1,113 published papers in the paediatric bipolar literature looking for reference to attachment and trauma factors such as the terms PTSD, emotional, verbal, physical and sexual abuse and neglect, I found very little at all. So, you can – this is an open source book chapter of my literature search.
So really it was the checklist symptom approach. And if we're going to have a symptom checklist approach to diagnostic labels it can go wildly astray as in the case of diagnosing toddlers with manic depression. Unless we have useful theories through which to interpret such symptoms as distractibility, moodiness, tantrums, disinhibited behaviour or anxiety and such useful theories include attachment theory, ethology, the neurophysiology of stress and how the brain grows under those conditions, evolutionary biology and psychology, family systems theory. That children's symptoms may be – you know, get – have a meaning in the way they're interpreting their place in the family and the family dynamics and the ability to also diagnose genetically based disorders which is still a developing field of research.
This slide shows in a more detailed way the so-called fight/flight response. You can see the rise and fall of the classical response to threat for a mammal. It involves sympathetic nervous system uproar as they term it here followed by parasympathetic shut down. Flagging and fainting at – perhaps. If one then survives then a parasympathetic recovery to a relaxed state would follow. And, in fact, in my clinical work I found that educating teens and older children and their parents in basic neurophysiology of the defensive, instinctual responses to threat or stress is very useful.
Tying the symptoms of the child, be they anxiety and avoidance as indicative of the flight/freeze reactions, or disruptive behaviour as indicating the fight reactions or the silly nervous excited play or obsequious, submitting, appeasing behaviour that a younger or a smaller mammal employs to disarm the scary aggression of an older, larger member of their species. The symptoms then to start to make more sense and have more meaning, depending on the context and the particular child and family's history and stressors. Because some of these things might be more driven by neurodevelopmental disorders that are genetic or related to other kind of more toxic stressors or birth trauma or something like that.
Nonetheless, even in cases like that it's also important to understand our responses to stress because this helps to explain the hijacking of the person by their amygdali which disable frontal lobe thinking, so you act on fight/flight/freeze and why trying to reason with a triggered child or a triggered adult for that matter mostly doesn't work and then I find that this leads on to a discussion of how the parasympathetic system or what I call the P for peaceful system as distinct from the sympathetic S for stress system can be triggered by deep, slow diaphragmatic breathes like sighs and yawns and laughing or other safety cues or soothing like a hug, a smile, rocking, stroking, loving eye contact, which all allows the child, and the parents for that matter to regain equilibrium and emotional control and the frontal lobe to switch back on.
So stuff that's now being incorporated into parent training things like one, two, three, you know, parenting. One, two, three, slow breathes, think about it and then say what you need to say. The problem is in more significant disordered relationships, where the attachment relationships is so disturbed that parents and children have actually become each traumatic triggers to the other's complex PTSD. So there's a lack of capacity to reset their relaxed, parasympathetic baseline states and this leads on to relationships that then become based on power and avoidance approach dilemmas. A kind of hostile dependency as psychoanalytic theory would have termed it.
And recently we had a colleague of mine from Adelaide, Dr Jacqui Amos come up and present work from her PhD thesis about exploring these complex PTSD parent/child dyads. The – looking at those dynamics that underpin a significant number of our severely disturbed children who we see who may receive a full range of the so-called alphabet diagnoses like ASD, ADHD, ODD, CD, SAD, RAD, GAD, or in the US, PBD. I'd recommend Jacqui's thesis. It's well worth reading and she presented a workshop here where she outlined the approach avoidance dilemma that these children and their parents' mothers have and methods of dyadic parent/child therapy to help repair this. And a lot of the symptoms will then start to settle down and the diagnoses – the labels which describe those symptom complexes may no longer be necessary or they may be just milder versions of those diagnostic labels. If a child is constantly in fear, flight, fight or freeze then the frontal lobes are off most of the time and as you may know it's a use it or lose it with regard to our neuro-plastic brains, so as this sad slide shows, frontal lobe atrophy can occur.
So in understanding attachment, family dynamics, evolutionary principals of neurophysiology and the deleterious effects of child trauma are vital to making a valid diagnostic formulation of children's mental health difficulties. DSM and ICD do give some credence to attachment disorganisation and trauma in the diagnosis of reactive attachment disorder and disinhibited social engagement disorder and the V codes of DSM and the Z codes of ICD-10 cover psychosocial stressors and relational traumas, but it's a pity, in my opinion, that developmental trauma disorder is not accepted into the DSM manual as it expands and goes beyond both RAD and DSED both of which rather narrowly defined problems in younger children. Developmental Trauma Disorder covered complex trauma extending into adolescence as a precursor or a vulnerability factor for personality disorder. And certainly some of the cases I've seen diagnosed with ADHD or ASD over the years I would have thought DTD would have been a better diagnosis.
The V codes of DSM have been more clearly defined in DSM-V but they still appear to be seldom used in research or clinical practice and in the US have little chance of getting insurance funding for any therapy. This book, and I saw the authors present at an American Psychiatric Association conference workshop, gives another philosophical point we need to consider. That is, that the same symptoms can have totally different meanings depending on individual and context. They noted four perspectives to consider with all the psychopathology that you see. The disease, the dimension, the behaviour and the life story perspectives. And these four perspectives relate to, but intersect from different angles with the DSM format.
Some disorders are quite clear cut covered by a disease perspective such as perhaps schizophrenia or the brain damaging effects of foetal alcohol or a psychosis induced by autoimmune, anti-neural or antibodies that can be cured by immunological therapy. Others like computer gaming addiction are very much behaviourally induced as may be oppositional defiant disorder, but many, like problems with ADHD symptoms or depression can have input from stressors and factors in any of these four domains and the treatment depends not on the syndrome or diagnosis but on understanding and managing the actual causative factors.
So it is a case of synthesising complex information. Realising that children and teens are developing over time. That the brain is different at different ages and concepts that are relevant include that multiple causes can lead to equi-final endpoints or a particular stressor leading different individuals to differing disorders because their inheritance and various vulnerabilities and protective factors. That would be like a multi-final endpoint from an equi-causative factor. Is it complex? Yes, sure is.
And another philosophical consideration that's worth considering here is the idea of informational reductionism versus holistic clinical wisdom. There has to be processing of data into information and ultimately into understanding that is put into a much broader wise context. And clinical experience helps. Too much of modern mental health practice is time poor and taking shortcuts and research is focussed heavily on quantitative data while at the same time minimising or diminishing the importance of detailed case histories which filled journals a couple of generations ago.
It is, as Einstein said, not everything that counts can be counted and not everything that can be counted counts. Just to quickly note two alternatives or companions to the DSM also with three letter acronyms. The DMM, Dynamic Maturational Model, which arose out of attachment theory, and the PDM, the Psychodynamic Diagnostic Manual. The psychoanalysts finally managed to get their contentious groups together to face the common enemy of descriptive neo-Kraepelinian psychiatry and publish a diagnostic manual. Unfortunately they lack the marketing power that the American Psychiatric Association had, and so the PDM remains relatively unknown. But, as they say here, the PDM, you know, goes into more depth.
Robert Spitzer, who, as you'll recall, expunged contexts and psychodynamic meaning from the DSM-III said sorry in a forward to a book titled, "The loss of sadness; how psychiatry turned normal sorrow into depressive disorder." Which, having read the book, I must say they do still acknowledge that there is clinical depression, but there is a bit of an
over-diagnosis issue with more reactive states of depression. Anyway, Spitzer noted that this book forced him to rethink his own position such that he regretted that the DSM diagnostic criteria ignored the context in which symptoms developed. And things actually got a bit contentious in the lead up to the publication of the DSM-V.
The British Psychological Society's journal engaged in conduct – a sort of fire-setting behaviour with a copy of the DSM-IV. To quote from this issue, "In an attempt to emulate general medicine, psychiatry has attempted to distinguish between different psychiatric diseases, each assumed to have its own specific pathology, but the story is not that simple." It's by Joanna Moncrieff, a British psychiatrist, actually. And the American Psychological Association – that's the psychologists, not the American Psychiatric Association – joined with their British counterparts in a campaign to bring context and human relational dynamics into the diagnostic system in an open letter they wrote to the American Psychiatric Association. They noted that taxonomic systems such as the DSM are based on identifying problems as located within individuals. This misses the relational context of problems and the undeniable social causation of many such problems.
We're really running short of time, but here is some further reading and also another recent AIFS webinar that covers similar territory that I would strongly recommend to you. Now, Professor Emeritus Barry Nurcombe was the Uni of Queensland child psychiatry professor for many years. This chapter on diagnosis and treatment planning in child and adolescent mental health problems is in the International Association for Child and Adolescent Psychiatry and Allied Professions e-textbook and it's freely available online and very much worth reading for practical advice around today's topic. Whereas I have focussed more on a historical and theoretical background.
For those who don't know, the bio-psycho-social-diagnostic formulation grid then this is it. More or less as I was taught it in my first year of psychiatry training. The DSM symptom complexes mostly fall within the middle column of what's termed as pattern. But you can see there are plenty of pre-disposing, precipitating and perpetuating factors to consider as well as the potential or protective factors to make a holistic understanding of what's going on for the child in their own life and in their own world. And in a similar talk to mine here, Professor Nurcombe noted that Hypocrates in ancient Greece was giving the same sagely advice at the dawn of medicine. It is as important to know the man who has the disease as it is to know the disease the man has.
I was trained in child and adolescent psychiatry in the mid-1990s. At that time, the four-session assessment was still standard. Sadly, it seems to have fallen by the wayside in the quest for managerial efficiency of pushing cases through the system. What it involved was that you would see the whole family if possible. The whole – as many of them as you could get together together and you'd do a family tree, a genogram which you'd chat around and build rapport establishing, you know, the confidentiality, limits and goals and observing interactions of the family and then starting in to taking a history, a story of the presenting problems that they've brought their child or adolescent here for. Then you'd have another session.
Now if it was actually an adolescent, you'd probably see the adolescent before you'd see the parents, because adolescents hate parents being able to speak to therapists before they can, but when we – I was trained in this we were doing it with younger children and you'd probably see the parents and gain an intergenerational family history and a detailed developmental history, you know, going through the pregnancy and the birth and the milestones and what was going on in the context of the family as the child was growing, et cetera.
So you've got a lot of information already, and then you'd want to see the young person or the child on their own. So we would do two sessions in a play therapy room with the younger child. One would be unstructured play which is a good way to observe how children act, you know, and their levels of hyperactivity, their degree of focus, the way they respond to being in a strange environment, and then a more structured – where you get them to do particular drawings et cetera. Or you'd have an interview with an adolescent and get their story and often use, you know, drawings or emotional coloured bar charts and rating scales so – because sometimes adolescents and younger children find it much easier to convey information that way. And you'd meanwhile gather information from other stakeholders, particularly the school and particularly any psychometric assessments that might have been done by school guidance officers or other psychologists or treating practitioners in the past.
In the end, we had to bring this – using the grid that I've just shown you into a diagnostic formulation, then put that into a language that was understandable for that family and feed it back to the family and we had to kind of do this as a group watching each other through one way mirrors, presenting our cases in front of the group of other trainees with an experienced child and adolescent psychiatrist therapist. I have to say that that level of assessment seems to have fallen by the wayside, sad to say.
In fact, I give a variation of this talk to psychiatry trainees in their teaching and this is a previous title for a talk very similar to todays, "Psychiatric diagnosis; answers, educated guesses or good questions," but I'm thinking about it and perhaps I should also have added, "Or blinkered shortcuts to disaster," in truth though, diagnostic labels can be any of the above. It depends on the individual client and the historical and contemporary contexts of their life and relationships and their skill and time spent with the diagnostician. Or more simply stated by a famous US psychiatrist, "What is behind the symptom?"
So we'll get back to our story about the coughing boy. The dream ended happily. The lad and his parents came to understand that cough disorder was not a diagnosis but a description and his real problem, mild asthma, required a different medication and then no medication at all, when his parents stopped smoking in his presence. We had tried Suppressalin at one point but it gave only short term relief. The parents and I even had a more philosophical discussion about how the third edition of the DSM of human noises focussed on defining human noises descriptively at a time when some doctors talked about cough when they really went sneeze, burp or hiccup and how that was a good development back in 1980.
But we also discussed how as an a-theoretical descriptive system it generally gives no information about underlying causes and how important the search for real causes is. Something the family now appreciates. So yep, that's the end of the formal slide part of this and open to questions now.
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