Slide outline: Diagnosing children with mental health difficulties: Benefits, risks and complexities

Return to CFCA webinar – 2 August 2018

1. Diagnosing Children with Mental Health Difficulties: Benefits, risks and complexities

Dr Peter Parry
Snr Lecturer, University of Queensland
Visiting Snr Lecturer, Flinders University
Children’s Health Queensland – Child & Youth Mental Health Service
Brisbane, Australia

2. Disclosure

No relevant pharmaceutical industry financial relationships to declare.

Member of “Healthy Scepticism”

“Improving health by reducing harm from misleading drug promotion.”

3. Australian Institute of Family Studies (AIFS)

  • Rhys Price-Robertson, AIFS
    • Requested me to present this webinar
    • Recently published his paper:
    • Key messages:
      • Diagnostic labels can be important and helpful
      • DSM-III (1980) created a common language for defining mental health disorders
      • DSM-5 or ICD-10 are used in Australia – “both focus on overt symptoms rather than underlying causes or surrounding social context.”
      • Critics argue: pathologize normality, decontextualize problems, lack validity, culturally insensitive
      • Evidence of overdiagnosImage shows screenshot of the opening paragraphs of the cough analogy as read by the of certain mental health conditions in children due to converging factors including influence of pharmaceutical industry
      • “This paper takes the view 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.”

4. Article in the Medical Journal of Australia

5. The problem with the DSM

Image shows screenshot of the opening paragraphs of the cough analogy as read by the presenter.

6. History of psychiatric nosology

  • Emil Kraepelin
    • 1856 – 1926
    • defined disorders by phenomenology and clinical course
    • disease model
    • dementia praecox (SZ) & manic-depressive psychosis
    • 1980 DSM-III = triumph of “neo-Kraepelinians”
  • Adolf Meyer
    • 1866 – 1950
    • “mental disorders emerge out of lives”
    • “psychobiology” = forerunner of biopsychosocial model
    • “case formulation” better than diagnostic label
    • DSM-I and DSM-II reflected Meyer’s influence – many “Reactive” states described.

7. “A Psychiatric Revolution” 

Andrew Scull -  
The Lancet, Volume 375, Issue 9722, Pages 1246 - 1247, 10 April 2010

  • …psychiatry, at least in its American guise, was dominated by psychoanalysis…Through the 1960s, its hold over the profession and the public imagination steadily grew.
  • departments of psychiatry at major medical schools were headed by psychoanalysts.
  • The “refrigerator mother” was blamed for the seeming epidemic of schizophrenia.

8. “A Psychiatric Revolution”

The Lancet Apr 2010

  • (The NIMH) proclaimed the 1990s “the decade of the brain”. A simplistic biological reductionism increasingly ruled the psychiatric roost.
  • Patients and their families learned to attribute mental illness to faulty brain biochemistry...
  • It was biobabble as deeply misleading and unscientific as the psychobabble it replaced, but as marketing copy it was priceless.

9. Leon Eisenberg
Chair American Psychiatric Association Section of Child Psychiatry (amongst innumerable posts and honours)

Brainless Psychiatry
Mindless Psychiatry

10. Restoring wisdom to the practice of psychiatry

Image shows screen shot of journal article titled ‘Restoring wisdom to the practice of psychiatry’ published in the Journal of Australasian Psychiatry, March 2006.

Factors "dumbing down" psychiatry

  • DSM ‘deification’ & fundamentalism
  • Increased service demands & managerialism
  • Influence of pharmaceutical industry & consumerism
  • Misunderstanding of evidence-based medicine

11. “A Psychiatric Revolution”
The Lancet Apr 2010

  • …counter-revolution (against psychoanalysis)… primary weapon was…an anti-intellectual system published in book form: a check-list approach to psychiatric diagnosis and treatment…
  • …the Diagnostic and Statistical Manual of Mental Disorders
  • proliferate pages and disorders, like the Yellow Pages on steroids.

12. Pre- DSM-III

  • Psychoanalysis impairing diagnostic clarity. (Klerman, 1981)
  • Different rates schizophrenia USA v Europe.
  • Over-reach of psychoanalysis:
    • Schizophrenogenic mothers.
    • Refrigerator mothers cause autism.
    • Physical disorders as specific unconscious conflicts.
    • Freudian analysts rigid psychosexual theories.
  • Reaction to the “anti-psychiatry” movement
    • Need to emphasise that mental disorders are real.

13. DSM-III (1980)

  • Spitzer (head DSM-III task force)
    •  “eliminate neurosis because… psychoanalytic meaning”
    • his mother had poor outcome from psychoanalysis
  • Fink (token psychoanalyst on task force)
    • “DSM-III process was…highly prejudiced…skewed to a phenomenological and descriptive point of view and quite anti-psychodynamic.”

Quoted in “Shyness: how normal behavior became a sickness” Lane, 2007.

14. DSM itself has modest (in practice overlooked) claims:

  • “generally atheoretical stance” (with respect to aetiology)
    • is designed for research, caution needed clinically and not appropriate for forensic/insurance purposes
      • introduction to DSM-III.
  • “not to be used in a cookbook fashion”
    • introduction to DSM-IV.

“15. A Psychiatric Revolution”
The Lancet Apr 2010

  • …drug money has come to dominate psychiatry. It underwrites psychiatric journals and psychiatric conferences (where the omnipresence of pharmaceutical loot startles the naive outsider)…
  • …many of those whose careers it fosters become shills for their paymasters...
  • The very categories within which we think…are manipulated and transformed to match the requirements of the psychiatric marketplace…

16. From Evidence-based Medicine to Marketing-based Medicine

Image shows screen shot of journal article titled ‘From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents’ published in Bioethical Inquiry, 2009.

17. ZY100035541 Olanzapine Lifeplan

Image shows front cover of report titled, ‘Olanzapine: LifePlan’, with the words ‘Confidential: July 1994’ written below.

  • The “Safer Clozapine”
  • Market is Schizophrenia.
  • No mention of bipolar or dementia.

18. ZY201548768 Betting the Farm

  • Prozac patent due to expire August 2001.

19. Straight Talk - What's at Stake

Image shows screen shot of document except titled “Straight Talk – What’s at stake”.

20. ZY200270343 Zyprexa Product Team summary 1997

Global Zyprexa Bipolar Forecast

Image shows diagram that compares the projected sales value of three marketing strategies for the drug Zyphrexa between Quarter 3 of 1998 to end of 2000.

21. Bipolar Vision of Product Evolution

Image shows screenshot of document excerpt that says “To be a leader in the bipolar market, Zyphrexa will need to viewed as true mood stabilizer.”

22. ZY200270343 Zyprexa Product Team summary 1997

Image shows a Zyphrexa Product Team SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis.

23. Summary

Image shows a Zyphrexa Product Team document excerpt with one of the dot points highlighted that reads “Bipolar is an opportunity equal to our top NCE’s (new clinical entities). Can we launch and grow it properly…”

24. Zyprexa PCP Vision

Image shows a Zyphrexa Product Team document excerpt that identifies that one way of creating a market of more bipolar disorder sufferers is by helping US GPs diagnose more cases.

25. Email (2003) from Eli-Lilly Executive Vice-President for corporate development (later company CEO) reported in New York Times Mar 2008

  • “The fact we are now talking to child psychs and peds and others about Strattera means that we must seize the opportunity to expand our work with Zyprexa in this same child-adolescent population”

26. “Psychiatric Diagnosis Gone Wild: The 'Epidemic' Of Childhood Bipolar Disorder”

  • Emeritus Prof Allen Frances – in Psychiatric Times 2010
  • As Chair of the DSM-IV Task Force I bear partial responsibility for two other false "epidemics"--of attention-deficit and autistic disorders.
  • “Thought leading” researchers encouraged child psychiatrists to ignore the standard bipolar criteria…Then enter the pharmaceutical industry – not very good at discovering new drugs, but extremely adept at finding new markets for existing ones.

27. Controversy in American public media

Photo shows face of Rebecca Riley.

  • Death of Rebecca Riley, 13th Dec 2006, age 4.
  • Diagnosed ADHD age 28 months + PBD shortly after.
  • Clonidine, Quetiapine, Valproate.
  • Parents gave decongestants + extra clonidine.
  • Coroner: chronic organ damage from meds.

28. Newsweek 26 May 2008

Image shows front cover of Newsweek magazine featuring the image of Max.

  • “Max”
  • “One family’s struggle to raise a troubled son.”
  • 38 psychotropics from age 2 to age 10.

29. ‘Diagnosis upcoding’ for insurance reasons
From USA TODAY 1st May 2006:

  • "With some companies, the only thing they reimburse for is prescribing. There's little or no therapy,"
    • Ronald Brown, editor Journal of Pediatric Psychology and dean at Temple University.

30. “Corpricare

  • managed care should be called corpricare – caring for the profits of corporations not the legitimate psychiatric needs of employees and their families”

Prof Harold Eist, president APA in 1990s

31. 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: “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries” (p. xii).

32. Reification cont..

“Reification of the paediatric bipolar hypothesis in the USA.”

Parry, Allison, Bastiampillai
The Lancet Psychiatry, January 2015

  • Diagnostic upcoding factors drove premature declaration of a new diagnostic category for children

33. ANZ Faculty C&A Psychiatry survey on PBD 2007
Parry, Furber, Allison (2009) Child and Adolescent Mental Health 14:140-147

Image shows bar graph titled ‘Diagnosis of PBD in USA’ with degrees of diagnoses along the X axis and number of respondents along the Y axis.

In your opinion, PBD in the USA at present is overall…

34. Number PBD presentations at child & adolescent psychiatry conferences 2009

  • AACAP – Hawaii, USA = 40 (+ 6 SMD + 6 trad bipolar)
  • RANZCP FCAP – Queenstown, New Zealand = 0
  • ESCAP – Budapest, Hungary = 0

35. Journal of the American Academy of Child and Adolescent Psychiatry June 2014
US 100.9/100,000 pop. v England 1.4/100,000 pop.
More < age 6 in US than < age 19 in England
Nil prepubertal cases in England

Image shows screenshot of journal article titled ‘A comparison of American and English Hospital Discharge Rates for Pediatric Bipolar Disorder, 2000 to 2010’ published in the Journal of the American Academy of Child and Adolescent Psychiatry, June 2014.

36. ASD epidemic in Australia

Image shows screenshot of journal article titled ‘The autism spectrum disorder ‘epidemic’: Need for biopsychosocial formulation’ published in the Australian and New Zealand Journal of Psychiatry, 2013.

  • Special Medicare rebates for paediatricians, psychologists, speech pathologists.
  • Welfare parent/carer payments.
  • Schools extra classroom assistance.

37. Public services for children with special needs: Discrimination by diagnosis?

Image shows screenshot of journal article titled ‘Public services for children with special needs: Discrimination by diagnosis?’ published in the Journal of Paediatrics and Child Health.

38. Tim Fischer, Deputy PM, Australia 1996-1999

Image shows Tim Fischer shaking hands with the Pope.

  • Later Ambassador to the Vatican
  • PM John Howard 2007:
  • “motivation for the (new funding for autistic children) package” from the Fischer family
  • Very good intentions
  • Severe ASD is a huge strain on families!

39. Diagnosis in developmental-behavioural paediatrics: The art of diagnostic formulation

Image shows screenshot of journal article titled ‘Diagnosis in developmental-behavioural paediatrics: The art of diagnostic formulation’ published in the Journal of Paediatrics and Child Health.

40. DSM neglects the relational/subjective

Image shows screen shot of an editorial titled ‘Issues for DSM-V: Relational Diagnosis: An Essential Component of Biopsychosocial Assessment’.

41. Mother infant holding

Image shows an adult gorilla with its arm around an infant gorilla.

42. The !Kung San Bushman

Image shows three women with babies wrapped to their backs while they work in a field.

Infants are integrated into daily life, with continuous contact and breast feeding

Slide courtesy Prof J McKenna

43. Mother infant holding: The Welsh Shawl


Image show a woman holding an infant with a shawl wrapped around both of them.


Tradition of long holding and carrying of infants was in West too.

44. Infant mirroring behaviour

Image shows two rows of three images. The top row shows three different photos of an adult male making different facial expressions and the bottom row shows three different photos of an infant making the same facial expressions as the adult.

45. Infant rhesus monkey mirroring behaviour

Image shows images of a rhesus monkey mirroring the same facial expressions of a human adult. One group of images showing the rhesus monkey opening its mouth in response to the human adult, the other group of images showing the rhesus monkey sticking its tongue out to mirror the same expression as the human adult.

46. Ethology – the effects of severe neglect

Image shows a monkey in Harlow's infamous experiments - choosing between chose an inanimate 'mother' mannequins that looked like a mother and one that had the milk. 
  • Harlow’s monkeys
  • Cling to the toweling ‘mother’ not the wire ‘mother with milk’
  • Attachment (love) the primary drive for infants

47. The neuroscience of attachment and trauma

Image shows the covers of three books titled ‘Affect dysregulation and disorders of the self’ and ‘Affect dysregulation and the repair of the self’ by Allan Schore and ‘The Neuroscience of Human Relationships: Attachment and the Developing Social Brain’ by Louis Cozolino.

48. Importance of early intervention and child protection

Image shows scans of the brains of two different 3 year old children. One titled ‘normal’ and next to it one titled ‘extreme neglect’ that is about 30% smaller and has different patterns than the ‘normal’ brain.

From Prof Bruce Perry’s website:

49. Paediatric Bipolar Disorder – Are Attachment and Trauma Factors Considered

Image shows screenshot of book chapter titled ‘Paediatric Bipolar Disorder – Are Attachment and Trauma Factors Considered?’ published in ‘Bipolar disorder: A Portrait of a Complex Mood Disorder’, 2012.

50. If labelling symptoms can go so astray…

  • Need grounding in established theories:

Attachment Theory
Neurophysiology of Stress
Evolutionary Biology/Psychology
Family Systems Theory
Genetic knowledge – where well replicated

51. Schauer & Elbert (2010) Dissociation Following Traumatic Stress: Etiology and Treatment
Journal of Psychology 21: 109-127

Image shows complex diagram and line graph with ‘Increasing dissociation during cascade progression’ along the X axis and ‘Defense reaction’ along the Y axis.

52. Defensive Responses to Threat 

A model I use for parents and teens to put symptoms in evolutionary biological context

Sympathetic (stress/survival) activation = “Amygdala Hijack” (frontal lobes turned down/off)

  • Avoidance
  • Attentive Immobility
  • Appease (if less threatened in social relationship)
    • ‘silly, giddy and goofy’, nervous excitement, histrionic behaviour
  • Flight
  • Fight
  • Tonic Immobility (Freeze ‘Fright’)

Parasympathetic (peaceful, rest, digest and grow) nervous system recovery after threat gone

  • Recuperation
  • Proximity seeking – according to attachment security/insecurity pattern
    • Secure, Avoidant, Ambivalent-Reactive, Disorganised attachment patterns
  • In insecure patterns – no reset to relaxed parasympathetic baseline
    • Agonic relationships based on power and avoidance-approach dilemma
    • “Hostile dependency”

53. Amos, J.  PhD Thesis, Uni of South Aust.

  • “When wounds from infancy collide: The mother child relationship as trauma, trigger, and treatment.”
    • The nature of complex trauma in dyadic relationships.
    • Approach-avoidance dilemmas and patterns.
    • Exposure and response-prevention in dyadic parent-child therapy.

54. Frontal lobes switch off – maybe permanently

Image shows two brain scans side by side: one shows temporal lobes switched on and the other with the temporal lobes switched off.

55. Underused and Rejected Diagnoses

  • Reactive Attachment Disorder
    • Of infancy and early childhood
  • Disinhibited Social Engagement Disorder
    • Relates to severe attachment trauma
  • Developmental Trauma Disorder
    • Proposed by Van der Kolk et al
    • Rejected by DSM committees
  • Parent-child relational problem
    • DSM ‘V’ codes
    • ICD-10 F code diagnosis “Other Problems Related to Severe Stress” and contextual issues listed in Z, R & X codes

56. V codes in DSM-5

Image shows screen shot of table of contents titled ‘V codes in DSM-5’ with a sub-heading titled ‘Diagnostic Criteria for Relational Problems’.

57. Alternatives/improvements to DSM

Image shows book cover titled ‘The Perspectives of Psychiatry: Second Edition’ authored by Paul R. McHugh, M.D. and Phillip R. Slavney, M.D.

  • “The 4 perspectives”
  • John Hopkins University
  1. Disease
  2. Dimension
  3. Behaviour
  4. Life story

58. Four Perspectives Relate But Not Equivalent to DSM/ICD Syndromal Symptom Model

Some examples:

  • Disease (including abnormal neurological function):
    • ADHD; Developmental delays; Foetal Alcohol Spectrum Disorder; Trisomy 21; Antineuronal antibodies; Bipolar disorder; Schizophrenia; Autism; Anorexia Nervosa
  • Dimension:
    • ADHD; Developmental delays; CD; Mood lability; Anxiety disorders
    • Externalising v Internalising Disorders
  • Behaviour:
  • ADHD; ODD; CD; Mood lability; Eating disorders, Addictions (e.g. computer game addiction)
  • Life Story:
    • ADHD; ODD; CD; Mood lability; Eating disorders; Anxiety disorders; Complex trauma; Reactive Attachment Disorder etc including avoidant ASD like traits; Language and learning delays

59. Four Perspectives Still Not Enough: Transactional-Developmental Perspectives

  • Have to synthesize the data from all domains
  • Children and adolescents are growing and changing
  • Concept of Equifinality or Multicausality
    • Different stressors and contexts in different children’s development may end up looking the same symptomatically – a syndromal diagnosis like ‘ADHD’, ‘ODD’/’CD’, milder ‘ASD’, ‘Depression’, & in USA ’PBD’ – may need differing forms of treatment addressing the underlying causative pathways.
  • Also Multifinality from a single causative stressor
    • Inborn temperament may lead similarly abused siblings down either internalizing or externalizing disorder pathways.

60. Informational Reductionism

data ≠ information

information ≠ knowledge

knowledge ≠ understanding

understanding ≠ wisdom

Clifford Stoll

  • Reliability ≠ Validity !!
  • Rating scales/questionnaires trumping clinical experience, in-depth case reports and tradition?
    • In research
    • In journals
    • In clinical practice
  • Where are time consuming but invaluable child-centred playroom assessments?

61. Albert Einstein
– plaque he hung over his door at Princeton

“Not everything that counts can be counted, and not everything that can be counted, counts.”

62. The DMM

Image shows a diagram titled ‘A Dynamic-Maturation Model of Attachement’ by Patricia M. Crittenden.

63. The PDM

Image shows front cover of book titled ‘Psychodynamic Diagnostic Manual (PDM)’.

  • A collaborative effort of the
    • American Psychoanalytic Association
    • International Psychoanalytical Association
    • Division of Psychoanalysis (39) of the American Psychological Association
    • American Academy of Psychoanalysis and Dynamic Psychiatry
    • National Membership Committee on Psychoanalysis in Clinical Social Work
  • The PDM is a diagnostic framework that describes both the deeper and surface levels of an individual's personality, emotional and social functioning, and symptom patterns.
  • The PDM opens the door to improvements in diagnosis and treatment of mental health disorders.

64. Spitzer’s mea culpa

Image shows front cover of booked titled ‘The Loss of Sadness: How psychiatry turned normal sorrow into depressive disorder’.

  • Relentless in its logic, Horwitz and Wakefield’s book forces one to confront basic issues that cut to the heart of psychiatry. It has forced me to rethink my own position…
  • The very success of the DSM and its descriptive criteria… has allowed psychiatry to ignore basic conceptual issues… especially the question of how to distinguish disorder from normal suffering.”
  • “DSM diagnostic criteria… ignored any reference to the context in which they developed.”

Robert Spitzer (former chair DSM-III)

Foreword to book:

“The Loss of Sadness: How psychiatry turned normal sorrow into depressive disorder”

65. Backlash against biomedical reductionism

Image shows front cover of The Psychologist magazine, published in May 2007. The feature image of the magazine show a copy of the DSM on fire.

  • The Psychologist May 2007
  • –Magazine of British Psychological Society.
  • –“In an attempt to emulate general medicine psychiatry has attempted to distinguish between different psychiatric diseases, each assumed…own specific pathology. …the story is not that simple.”

J. Moncrieff,   psychiatrist

66. Other APA’s open letter & petition re DSM-5

In sum, we have serious reservations about the proposed content of the future DSM-5, as we believe that the new proposals pose the risk of exacerbating longstanding problems with the current system. Many of our reservations, including some of the problems described above, have already been articulated in the formal response to DSM-5 issued by the British Psychological Society (BPS, 2011) and in the email communication of the American Counseling Association (ACA) to Allen Frances (Frances, 2011b).

In light of the above-listed reservations concerning DSM-5’s proposed changes, we hereby voice agreement with BPS that:

  • “…clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.”
  • “The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation.  The criteria are not value-free, but rather reflect current normative social expectations.”
  • “… [taxonomic] systems such as this 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.”

67. Some further reading/watching

  • Laura Batstra et al & Allen Frances (2012). Childhood emotional and behavioural problems: reducing overdiagnosis without risking undertreatment. Developmental Medicine & Child Neurology 54: 492-494
  • Batstra & Frances (2012). Diagnostic inflation: Causes and a suggested cure. Journal of Nervous & Mental Disease 200: 474-479
  • Dignam, Parry & Berk (2010). Detached from attachment: neurobiology and phenomenology have a human face. Acta Neuropsychiatrica 22: 202-206
  • Bracken et al. (2012). Psychiatry beyond the current paradigm. British Journal of Psychiatry  201: 430-434
  • Sara McLean (2018). Developmental differences in children who have experienced adversity: Emerging evidence and implications for practice. AIFS

68. Biopsychosocial Case Formulation

Image shows a data table titled ‘Figure A.11.1 Integrating the data as a diagnostic formulation: the diagnostic matrix’.

Nurcombe B. Diagnosis and treatment planning in child and adolescent mental health problems. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2014.

69. It is as important to know the man who has the disease as it is to know the disease the man has.

Image shows a close up photo of a marble statue of a man with a beard with a thoughtful expression.

Slide courtesy Prof Barry Nurcombe

70. The “Four Session Assessment”

Traditional training in child psychiatry (lost in rush to ‘time efficiency’ in recent years)

  1. See whole (if possible) family together
    Genogram to chat around – build rapport, establish confidentiality and goals, observe interactions
  2. See parents on their own
    Gain intergenerational family history and detailed developmental history
  3. Playtherapy room assessment with younger child/ interview with adolescent
    (ideally two sessions of this with younger children)
  4. Feedback to family of the diagnostic formulation

Meanwhile gather information from other stakeholders such as past and current providers and especially the school

71. A previous title for a similar talk to today’s.
Psychiatric Diagnosis:
Answers, Educated Guesses or
Good Questions?

Perhaps should also have added:  “or Blinkered Short Cuts to Disaster.”

In truth, diagnostic labels can be any of the above – depends on the individual client and the historical and contemporary context of their life and relationships – and the skill and time spent of the diagnostician.

72. “What is behind the symptom”

Karl Menninger, 1963

73. Return to our allegorical dream of cough disorder

Image shows excerpt of document titled ‘Return to our allegorical dream of cough disorder’ with the opening paragraphs of the story told by the presenter.

74. Continue the conversation


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