Tag Archives: parenting

ADHD:  The Hoax Unravels

At the risk of stating the obvious, ADHD is not an illness.  Rather, it is an unreliable and disempowering label for a loose collection of arbitrarily chosen and vaguely defined behaviors.  ADHD has been avidly promoted as an illness by pharma-psychiatry for the purpose of selling stimulant drugs.  In which endeavor, they have been phenomenally successful, but, as in other areas of psychiatry, the hoax is unraveling.

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In 2001, the American Academy of Pediatrics published Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder Here’s a quote:

RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).

The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances.”

Clearly, this recommendation is pushing the drugs (evidence good), and is downplaying the usefulness of behavioral interventions (evidence fair).  The reference to behavioral interventions “…as an adjunct…” doesn’t inspire a great deal of confidence in their use as the primary intervention.  And, indeed, this is how “treatment” of “ADHD” has developed in the intervening years:  pills for all, and occasional behavioral programs, many of which were geared towards accepting one’s “illness” and promoting “medication compliance”.

And all of this in a context in which ADHD was being fraudulently promoted by psychiatry, and by its pharma partners, as a neurochemical imbalance which was corrected by stimulant drugs.  Here’s what the eminent Harvard psychiatrist Timothy Wilens, MD, wrote on the matter in the article Paying Attention to ADHD in Family Circle magazine on November 20, 2011:

“ADHD often runs in families.  Parents of ADHD youth often have ADHD themselves.  The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations.”

“Contrary to what most parents think, medication is one of the most important treatments for ADHD and is essential for long-term success of these kids.” (p 65)

The above quotes were clearly aimed at mothers, were designed to break down parental resistance to drug-taking, and are typical of what psychiatry generally has been saying on this subject for decades.

Dr. Wilens is an Associate Professor of Psychiatry at Harvard, and works as a psychiatrist at Massachusetts General Hospital.  In 2014 he was named Chief of Staff in Child and Adolescent Psychiatry.  So promoting the chemical imbalance hoax has certainly not harmed his career.

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In recent years, psychiatrists have been experiencing increased scrutiny and criticism from the media, the general public, and some legislators, for the “pill for every problem” approach.  In this context, the American Academy of Pediatrics, in 2011, published an updated set of guidelines for ADHD under the title ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents  In this revised document, their recommendations for treatment are divided into three parts:  preschool children (4-5); elementary school children (6-11); and adolescents (12-18).  Here is a quote from each section:

Action statement 5a: For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.

Action statement 5b: For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence -based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).

Action statement 5c: For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.

Note in particular that for preschool children, the recommended “first line treatment” is behavior therapy administered by the parent and/or teacher, and the pills are recommended only if the behavioral interventions are not effective, and the problem is moderate-to-severe.  This is a sea-shift from the earlier guidelines.

Note also that for older children, pills and/or behavioral therapy are recommended, “preferably both”.  Here again, behavioral interventions are being emphasized a good deal more than was the case in 2001.

Later in the guidelines document, the authors clarify what they mean by behavior therapy:

“Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior. The training involves techniques to more effectively provide rewards when their child demonstrates the desired behavior (eg, positive reinforcement), learn what behaviors can be reduced or eliminated by using planned ignoring as an active strategy (or using praising and ignoring in combination), or provide appropriate consequences or punishments when their child fails to meet the goals (eg, punishment). There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectations for each task as they are mastered to shape behaviors.  Although behavior therapy shares a set of principles, individual programs introduce different techniques and strategies to achieve the same ends.” [Emphasis added]

Note that what’s being recommended here is that the parents be trained in the ordinary, time-honored principles of effective parenting.

And remember, this was in 2011 – five years ago, but the shift in the pediatric guidelines has not resulted in a significant shift in practice.

In response to this inertia, on May 3, 2016, the Centers for Disease Control and Prevention (CDC) issued a press release titled More Young Children with ADHD Could Benefit from Behavior Therapy.

Obviously the CDC considers ADHD to be a disease, but if you can bear with the medicalization wording, here are some interesting quotes:

“The American Academy of Pediatrics recommends that before prescribing medicine to a young child, healthcare providers refer parents to training in behavior therapy. However, according to the Vital Signs report, about 75% of young children being treated for ADHD received medicine, and only about half received any form of psychological services, which might have included behavior therapy.” [Emphasis added]

Note that what’s being stressed here is the need to refer parents to behavioral training.

“Parents of young children with ADHD may need support, and behavior therapy is an important first step.  It has been shown to be as effective as medicine, but without the risk of side effects. We are still learning about the potential unintended effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to first refer parents of children under 6 years of age with ADHD for training in behavior therapy before prescribing medicine.” [Emphasis added]

“CDC is calling on doctors, nurses, and allied health professionals who treat young children with ADHD to support parents by explaining the benefits of behavior therapy and referring parents for training in behavior therapy.” [Emphasis added]

In addition to the press release, the CDC also provided a press telebriefing in which reporters were able to put questions to senior CDC officials.  One of the questions was from Ariana Cha with the Washington Post.  Her question was:

“Hi.  I had a quick follow-up question about the — about insurance.  And when you say that these should be covered, are you also talking about kind of the gold standard, which is A.B.A. [Applied Behavior Analysis]  Therapy, which is incredibly expensive and usually used for autism but also to address a lot of the same behaviors that you see in ADHD?”

Two CDC officials responded.  First was Anne Schuchat, MD, Principal Deputy Director for CDC:

“No, you know, the treatments are quite different.  And I’d like Dr. Georgina Peacock to comment on that because we don’t believe the same interventions for autism should be used for children with ADHD.”

And then Georgina Peacock, MD, MPH, FAAP, Director, Division of Human Development and Disability:

“So we are talking about behavioral therapy, but this particular behavioral therapy is parent training.  So parents learn skills that help promote positive behaviors in their children.  There’s also a strengthening of the relationship between the parent and the child.  And some of the other things, some of the examples of things that happen, is parents learn about limit setting.  They learn about applying appropriate consequences for inappropriate behaviors and learn about how to improve communication between the parent and the families.  That’s the type of behavioral therapy that we are talking about and the American Academy of Pediatrics recommends for families.” [Emphasis added]

It is clear from these responses that the CDC is not conceptualizing these recommendations as the provision of some kind of specialized treatment to the children, but rather as training the parents in the basic principles and practices of effective parenting.

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In other words, as we “mental illness deniers” have been saying for years, the problem does not reside in the child in the form of some hypothesized brain dysfunction.  Rather, the problem is the direct result of ineffective discipline, training, and correction on the part of caregivers.  And the truly ironic thing is that older people, with no particular training in psychology, psychiatry, social work, counseling, etc., have been saying this for decades, shaking their heads in sadness and disbelief as they watch their children and grandchildren accept pharma-psychiatry’s hoax, and feed the serotonin-disruptive drugs to their children in ever-increasing numbers.  Grandparents – nature’s own trainers in parenting skills – have been effectively silenced by pharma-psychiatry’s spurious, self-serving insistence that these kinds of misbehaviors constitute a brain illness which needs the attention of medically-trained experts.  These unsubstantiated assertions undermine parental confidence, open “uncooperative” parents to accusations of child neglect, and create an environment in which the levels of mastery and self discipline that were the norm for children fifty years ago, are rapidly becoming the exception.

Even CHADD, not noted for challenging the ideology of their pharma benefactors, makes some concessions in this direction.  Here’s a quote from their About ADHD document:

“Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.”

This, incidentally, is a truly delightful example of typical psychiatric mental gymnastics.  Let’s take a closer look.

“Problems in parenting or parenting styles may make ADHD better or worse…”

Now, as is well known, ADHD is defined by the presence of six or more habitual behaviors from either or both of two checklists of nine items each.  So if it is being conceded that “problems in parenting” can make ADHD worse, this can only be in terms of a deterioration on one or more of the criterion items.  But since all the criterion items are continuous variables, this inevitably entails a recognition that problems in parenting can push a child past whatever threshold of severity or frequency is required to constitute a “hit”.  Which in turn entails the fact that problems in parenting can produce the six or more hits required to make the “diagnosis”.  In other words, problems in parenting, by CHADD’s own admission, can cause ADHD.  Obviously the drafters of the document realized that they had opened this door, and immediately tried to slam it shut by countering even their own logic with their customary mantra-like assertion:  “ADHD is clearly a brain-based disorder”, the proof of which will be forthcoming any decade now!

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And incidentally, the American Academy of Pediatrics guidelines includes a section on the adverse effects of stimulant drugs.  Here’s a quote:

“An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations and other psychotic symptoms.”

In 2009, Mosholder et al conducted a study on the incidence of these kinds of events and found:

“A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In approximately 90% of the cases, there was no reported history of a similar psychiatric condition.”

Eleven cases in 743 person-years (i.e. one in 68 person-years) sounds like a small effect.  But in any given year, about 3.5 million American children take a stimulant drug for ADHD.  And if we assume that each of these children takes the pills for an average of six months (almost certainly an under-estimate), this amounts to approximately 25,700 drug-induced psychosis/mania incidents each year in the US alone.  To the best of my knowledge, no large-scale, systematic study of the outcome of these incidents has been undertaken.

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SUMMARY

The 2011 pediatric guidelines, reinforced as they were by the CDC’s recent press release and telebriefing, represent a formidable broadside against psychiatry’s promotion of ADHD as a brain illness residing within the child.  If this “illness” can be “cured” by improved discipline/correction on the parents’ part, isn’t it eminently reasonable to conclude that ineffective discipline was the precipitating cause of the problem in the first place?  We can be sure that pharma-psychiatry are already working on counter-measures to neutralize the impact of these documents, and we should not expect the bastions of bio-bio-bio psychiatry to crumble overnight. But as Andrew Lloyd Webber and Tim Rice put it so lyrically back in 1968:

“But if my analysis of the position is right,
At the end of the tunnel there’s a glimmer of light”
(Joseph and the Amazing Technicolor Dreamcoat)

On all sides the hoax is unraveling, and psychiatry has  no response other than the repetition of the same unsubstantiated assertions, laced generously with PR, obfuscation, and the assignment of blame to others for their own errors and deceptions.

 

Drugging Toddlers for Inattention, Impulsivity, and Hyperactivity

On May 16, the New York Times ran an article titled Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worriesby Alan Schwarz.  Here is the opening sentence:

“More than 10,000 American toddlers 2 or 3 years old are being medicated for attention deficit hyperactivity disorder outside established pediatric guidelines, according to data presented on Friday by an official at the Centers for Disease Control and Prevention.”

The CDC official is Susanna Visser, MS, DrPh, Acting Associate Director of Science for the Division of Human Development and Disability, and she was speaking at the annual Rosalyn Carter Georgia Mental Health Forum.  I have not been able to find the text of Ms. Visser’s speech.  (It will probably be published later.)  Meanwhile, there is a good deal of information in Alan Schwarz’s article.  Here are some more quotes:

“The report, which found that toddlers covered by Medicaid are particularly prone to be put on medication such as Ritalin and Adderall, is among the first efforts to gauge the diagnosis of A.D.H.D. in children below age 4. Doctors at the Georgia Mental Health Forum at the Carter Center in Atlanta, where the data was presented, as well as several outside experts strongly criticized the use of medication in so many children that young.”

“The American Academy of Pediatrics standard practice guidelines for A.D.H.D. do not even address the diagnosis in children 3 and younger — let alone the use of such stimulant medications, because their safety and effectiveness have barely been explored in that age group. ‘It’s absolutely shocking, and it shouldn’t be happening,’ said Anita Zervigon-Hakes, a children’s mental health consultant to the Carter Center. ‘People are just feeling around in the dark. We obviously don’t have our act together for little children.'”

“Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, Calif., said in a telephone interview: ‘People prescribing to 2-year-olds are just winging it. It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.'”

“Dr. Visser said that effective nonpharmacological treatments, such as teaching parents and day care workers to provide more structured environments for such children, were often ignored. ‘Families of toddlers with behavioral problems are coming to the doctor’s office for help, and the help they’re getting too often is a prescription for a Class II controlled substance, which has not been established as safe for that young of a child,’ Dr. Visser said. ‘It puts these children and their developing minds at risk, and their health is at risk.'”

But there was also some support for the practice, albeit cautiously worded:

“Keith Conners, a psychologist and professor emeritus at Duke University who since the 1960s has been one of A.D.H.D.’s most prominent figures, said that he had occasionally recommended it when nothing else would calm a toddler who was a harm to himself or others.”

“Dr. Doris Greenberg, a behavioral pediatrician in Savannah, Ga., who attended Dr. Visser’s presentation, said that methylphenidate can be a last resort for situations that have become so stressful that the family could be destroyed. She cautioned, however, that there should not be 10,000 such cases in the United States a year.”

The article finishes with quotes from Nancy Rappaport, MD:

“Dr. Nancy Rappaport, a child psychiatrist and director of school-based programs at Cambridge Health Alliance outside Boston who specializes in underprivileged youth, said that some home environments can lead to behavior often mistaken for A.D.H.D., particularly in the youngest children.”

“‘In acting out and being hard to control, they’re signaling the chaos in their environment,’ Dr. Rappaport said. ‘Of course only some homes are like this — but if you have a family with domestic violence, drug or alcohol abuse, or a parent neglecting a 2-year-old, the kid might look impulsive or aggressive. And the parent might just want a quick fix, and the easiest thing to do is medicate. It’s a travesty.'”

ADHD IN THE DSM

ADHD is listed in the DSM and is widely promoted by psychiatry as a brain illness which causes children and adults to be excessively inattentive, hyperactive, and/or impulsive.

DSM-III-R specified that the onset of this “illness” had to be prior to age seven, but set no lower age limit.  In fact, in this edition of the APA’s manual, the assignment of this “diagnosis” to preschool children is clearly endorsed.

“In preschool children, the most prominent features are generally signs of gross motor overactivity, such as excessive running or climbing.  The child is often described as being on the go and ‘always having his motor running.’  Inattention and impulsiveness are likely to be shown by frequent shifting from one activity to another.” [Emphasis added] (p 50)

and

“In approximately half of the cases, onset of the disorder is before age four.” [Emphases added] (p 51)

DSM-IV-TR states:

“It is difficult to establish this diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children and may include features that are similar to symptoms of Attention-Deficit/Hyperactivity Disorder.  Furthermore, symptoms of inattention in toddlers or preschool children are often not readily observed because young children typically experience few demands for sustained attention.  However, even the attention of toddlers can be held in a variety of situations (e.g., the average 2- or 3-year-old child can typically sit with an adult looking through picture books).  Young children with Attention-Deficit/Hyperactivity Disorder move excessively and typically are difficult to contain.  Inquiring about a wide variety of behaviors in a young child may be helpful in ensuring that a full clinical picture has been obtained.  Substantial impairment has been demonstrated in preschool-age children with Attention-Deficit/Hyperactivity Disorder.” (p 89)

DSM-5 is briefer but just as clear:

“In preschool, the main manifestation is hyperactivity.” (p 62)

So, as far as the APA is concerned, children of preschool age can, and do, “get” ADHD.

But what is ADHD?  Here again, the APA’s position, in their fact sheet titled “ADHD,” (2014) is  brief and clear:

“Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. ADHD is a brain condition that is often first identified in school-aged children when it causes disruption in the classroom or problems with schoolwork.” [Emphasis added]

Note, incidentally, the assertion of causality.  ADHD is a brain condition that causes classroom disruption and problems with school work.  In reality, the causal connection is spurious, and is just one more example of psychiatric “logic.”  To illustrate this, imagine a conversation between a parent and a psychiatrist:

Parent:  Why is my child so disruptive in class?  Why won’t he concentrate on his schoolwork?
Psychiatrist:  Because he has ADHD.  ADHD causes these problems.
Parent:  But how do you know he has ADHD?
Psychiatrist:  Because he is so disruptive in class and doesn’t concentrate on his school work.

Psychiatry defines ADHD by the presence of an assortment of vaguely-defined behaviors and then adduces this construct as the cause of these behaviors.  In other words, a child has ADHD because he is disruptive; and he is disruptive because he has ADHD!  This particular piece of psychiatric sophistry has been identified and highlighted, at one time or another, by virtually everyone on this side of the “mental illness” debate.  But I have never seen an attempt at rebuttal from any proponent of psychiatric orthodoxy.

But back to the question: what is ADHD?  There is a document titled ADHD: Parents Medication Guide published jointly by the APA and the American Academy of Child and Adolescent Psychiatry in July 2013.  Here’s a quote:

“Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by difficulty paying attention, excessive activity, and impulsivity (acting before you think). ADHD is usually identified when children are in grade school but can be diagnosed at any time from preschool to adulthood.” [Emphases added]

This document also stresses that:

“Early identification of ADHD is advisable…”

and lists the dire consequences if “ADHD is left untreated”:

  • “Increased risk for school failure and dropout in both high school and college
  • Behavior and discipline problems
  • Social difficulties and family strife
  • Accidental injury
  • Alcohol and drug abuse
  • Depression, anxiety and other mental health disorders
  • Employment problems
  • Driving accidents
  • Unplanned pregnancy and sexually transmitted diseases
  • Delinquency, criminality, and arrest”

The NIMH document Attention Deficit Hyperactivity Disorder (2012) states:

“Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and adulthood.” [Emphasis added]

So it’s pretty clear that organized psychiatry, as represented by the APA, AACAP, and NIMH, endorses the notion that preschool children can “get” ADHD, and that ADHD is a brain illness.  It is also widely promoted that ADHD should not be left “untreated.”

RESEARCH

In 2006, Greenhill L. et al. published Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD, in the Journal of the American Academy of Child and Adolescent Psychiatry.  Here’s their conclusion:

“MPH-IR [methylphenidate-instant release], delivered in 2.5-, 5-, and 7.5-mg doses t.i.d., produced significant reductions on ADHD symptom scales in preschoolers compared to placebo, although effect sizes (0.4-0.8) were smaller than those cited for school-age children on the same medication.”

The paper lists 17 authors.  The lead author is Laurence Greenhill, MD.  Dr. Greenhill is a very eminent psychiatrist.  At present he is a professor of Psychiatry and Pediatric Psychopharmacology at Columbia University.  He is also Director of the Research Unit of Pediatric Psychopharmacology at the New York State Psychiatric Institute.  Dr. Greenhill has served as principal investigator on several NIMH studies, and on 14 pharma-funded studies.  He has also served as President of the American Academy of Child and Adolescent Psychiatry (2009-2011).

His 2008 conflict of interest statement which is on file with the AACAP, states that during the period when he was president-elect, he was spending 50% of his work time “…dedicated to the private practice treatment of toddlers, adolescents, and adults mostly with ADHD.” [Emphasis added]

Incidentally, according to the disclosure section at the end of the 2006 article, 11 of the 17 authors had ties to pharma.  (In addition, a twelfth author disclosed links in a 2009 paper that will be discussed below.)

This study was funded by the NIMH, and on October 16, 2006, NIMH issued a press release in which they described the study as:

“The first long-term, large-scale study designed to determine the safety and effectiveness of treating preschoolers who have attention deficit/hyperactivity disorder (ADHD) with methylphenidate (Ritalin) has found that overall, low doses of this medication are effective and safe.  However, the study found that children this age are more sensitive than older children to the medication’s side effects and therefore should be closely monitored.” [Emphasis added]

Thomas Insel, MD, Director of NIMH, provided a quote for the press release:

“‘The Preschool ADHD Treatment Study, or PATS, provides us with the best information to date about treating very young children diagnosed with ADHD,’ said NIMH Director Thomas R. Insel, MD. “‘The results show that preschoolers may benefit from low doses of medication when it is closely monitored, but the positive effects are less evident and side-effects are somewhat greater than previous reports in older children.'”

The press release concluded with a quote from Laurence Greenhill, MD, the lead author:

“‘The study shows that preschoolers with severe ADHD symptoms can benefit from the medication, but doctors should weigh that benefit against the potential for these very young children to be more sensitive than older children to the medication’s side effects, and monitor use closely,’ concluded Dr. Greenhill.”

MORE RESEARCH

There’s another piece of research by Abikoff, et al. published in the journal Advances in Preschool Psychopharmacology in 2009.  It’s titled Methylphenidate Effects on Functional Outcomes in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS)  Here’s the conclusion:

“Preschoolers with ADHD treated with MPH [methylphenidate] for 4 weeks improve in some aspects of functioning.  Additional improvements might require longer treatment, higher doses, and/or intensive behavioral treatment in combination with medication.” 

This paper lists as authors most of those who are also shown in the Greenhill et al. study cited above.

So, according to the best psychiatric authorities, the condition known as ADHD

  • Is a brain illness;
  • Can and does occur in children of preschool age;
  • Causes severe problems if left untreated;
  • Can be safely and effectively treated with stimulant drugs (with the caveat that children of preschool age should be closely monitored for adverse effects).

Against this well-orchestrated and heavily promoted background, it is easy to see how the drug-prescribing is drifting into the lower age range.  In fact, if one buys the psychiatry line, wouldn’t it be tantamount to criminal to deprive these preschoolers of “treatment” for their “brain illness”?  Wouldn’t it be unconscionable to expose them to the risks outlined earlier?  Surely the risk of taking a few pills – that have been proven safe and effective anyway – is justified when weighed against the dangers of “untreated ADHD.”

Besides, in their booklet on Mental Health Medication (2008), the NIMH state unambiguously:  “Stimulant medications are safe when given under a doctor’s supervision.”  I kid you not.

DISCUSSION

The critical issue here is that the loose cluster of vaguely defined behaviors that psychiatry calls ADHD is not an illness.  Rather, it is, in the vast majority of cases, a reflection of inadequate discipline and training on the part of the parents.

In former times, parents accepted, as an intrinsic part of their role, training their children: to sit still when required; to pay attention to authority figures; to be obedient; to complete chores; to stay focused when needed; to be quiet when needed; to wait his/her turn; not to interrupt when others were speaking; to respect other children’s property; etc…

But today, psychiatry tells us that children who have not acquired these habits are ill.  This is emphatically not something that psychiatry has discovered in the normal scientific manner.  Rather, it is something that psychiatry has decided.  Psychiatry has decided that all significant problems of thinking, feeling, and/or behaving are mental illnesses.  So, children who have not been trained in the skills listed above are ill – by definition.

And because they are “ill,” they must take “medicine.”

Despite the protestations and the expressions of outrage, the expansion of the ADHD “diagnosis,” and consequent drugging, into the preschool population is an inevitable consequence of psychiatry’s spurious medicalization of every conceivable human problem, and their eagerness to prescribe drugs to “treat” these problems.

Protesting that the drugs have not been approved for children under the age of four misses the point, for two reasons.  Firstly, because the approval process is intrinsically flawed, and secondly because drugs are not an appropriate response to these problems, for preschoolers or for older children.

Debates as to whether the preschoolers in question “really” have ADHD are meaningless.  ADHD is defined by the presence of certain vaguely-defined behaviors.  If a two-year-old is engaging in these behaviors, then he “has” ADHD.  This is the travesty that the APA has created.  There is no test or reality against which the child’s presentation can be compared to confirm or refute the “diagnosis.”  All that’s needed is the subjective opinion of a mental health professional that the child displays the misbehaviors in question to a degree that is “inconsistent with [his/her] developmental level and that negatively impacts on social and academic…activities.” (DSM-5, p 59).

And there is no lower age limit for this “diagnosis.”  Well, that’s not absolutely true.  The “symptoms” must have been present for at least six months, so I suppose 6 months is effectively the lower limit!  So the babies are still safe – at least until DSM 5.1!

Psychiatry’s primary agenda for the past fifty years has been the expansion of its “diagnostic” net, and the prescribing of more and more pills to more and more people.  Psychiatry promises joy, happiness, and a trouble-free life from a pill bottle, and tragically our society and our political leadership have bought it.  Today, no group is safe from psychiatry’s depredations.  Their net embraces people of all ages, all walks of life, and all circumstances.  There is truly no human problem that cannot be “diagnosed” as a “mental illness,” and for which psychiatry doesn’t have a pill.

Ten thousand American toddlers taking stimulants for ADHD is just business as usual.  By all means, let us speak out against this psychiatric assault on our toddlers, but let’s not lose sight of the greater tragedy – that this kind of approach has become the norm.  Feeding children psychoactive drugs as a substitute for instilling age-appropriate habits of discipline, self-control, and interpersonal respect is a tragedy beyond description.  If street-dealers were promoting their products to toddlers and their parents in this way, there would be outrage – and rightly so.  But psychiatrists, dressed in nice suits, and with their image polished by an international PR firm, are accepted.

As a society, as a culture, we have truly lost our way.

Social Services and Psychiatry

The controversy surrounding Justina Pelletier and her family has expanded its scope in recent months, and has now become a general public scrutiny of Massachusetts’s Department of Children and Families.

On April 29, State Governor Deval Patrick gave a press conference in which he announced the resignation of DCF Commissioner Olga Roche.

I think there’s a very real risk of confusing some issues here.  The sad fact is that, despite the enormous strides we have made as a society, there are still a great many children who are abused and neglected.  Every state in the US has a social services department, one of whose statutory responsibilities is to investigate reports of abuse and/or neglect.  The case workers who conduct the investigations are required to follow set procedures.  Often they find that the allegation is unfounded, and the investigation is terminated.  When they do find probable cause, they are required by law to present their findings to a judge, who scrutinizes the evidence in accordance with the normal judicial procedures.  The social services department, the parents, and the child are usually represented by attorneys.

A wide range of options is available to the court, from outright termination of parental rights to outright dismissal of the case. Both of these extremes are rare.  The usual outcome is some kind of remediation program, whereby the parents are encouraged and coached in childcare matters.  Sometimes the children are placed in foster homes pending resolution of issues in the home.   If the home issues aren’t resolved, the foster care placement can be lengthy.

The system isn’t perfect.  Mistakes get made, and sometimes the mistakes are serious. I have no way of knowing if the Massachusetts Department of Children and Families was more error-prone than social service departments in other states. Obviously the commissioner Olga Roche has to take responsibility.  But whether she was personally derelict in her duties or was just the designated fall-gal, I don’t know.

But this I do know: the spotlight has been taken off psychiatry.

The central issue in Justina’s case was, and is, the “diagnosis” of somatic symptom disorder and the allegation of medical child abuse.  And there’s a danger of losing sight of that when a departmental commissioner gets tossed to the wolves and the state governor says

“DCF has one of the toughest assignments imaginable. Every single day they’re called upon to intervene and make difficult decisions…And most of the time, DCF gets it right.”  (Quoted from a Metro article by Morgan Rousseau).

Most of the time, DCF does get it right.  Most of the time they’re dealing with allegations of blatant abuse and neglect; children being raised in unsanitary and unsafe conditions; children being sexually abused and even prostituted; etc… Social services case workers investigate these complaints on behalf of society.  They are bound by strict procedures, and when they go to court they are subject to cross-examination, and their findings are subject to official and legal scrutiny.

The issues are never simple, but the critical questions are usually clear and understandable.  If a child has a broken bone, X-ray reports are introduced into evidence, and the radiologist is subject to cross-examination.  If there are allegations of an unsafe home environment, photographs are produced.  If there are live electric wires protruding from wall sockets, everybody in the courtroom can see the pictures, and everybody knows the potential danger if there are toddlers in the home.  And so on.

But all of this changes in a case of “somatic symptom disorder” and alleged medical child abuse.  In these cases the issues, the “realities,” consist entirely of psychiatric opinion.  When a psychiatrist states on the witness stand that the child “has somatic symptom disorder,” the impression is conveyed that this is a real illness with the same kind of verifiable reality as asthma or diabetes or kidney failure.  So there’s a very strong tendency for the lawyers, and even the judge, to afford the same kind of respect to a psychiatrist’s statement as they would to a report from a radiologist or other genuine medical specialist.

What’s not routinely recognized is that the psychiatric “diagnosis” is nothing more than the psychiatrist’s opinion.  In the case of Justina, the “diagnosis” was somatic symptom disorder, which simply means that Justina in the opinion of a psychiatrist, was inordinately preoccupied with her medical condition.

I have worked with a great many sick people over the years, and have struggled with chronic medical problems myself, and frankly, I can’t even imagine how one could assess whether a person’s concerns in these areas were excessive or inordinate.  And this is especially the case in that, since DMS-5, the “diagnosis” of somatic symptom disorder can be assigned even in cases where the person actually has a real illness!

And the allegation of medical child abuse simply means that, again in the opinion of a psychiatrist, Justina’s parents had been foisting on her the notion that she was sick, and had pressured various surgeons and other specialists  to subject their child to extreme and invasive medical procedures.

Here we have no photographs of exposed electric wires; no reports of young children being left home alone; no evidence of malnutrition or emaciation; no medical evidence of young children having been sexually abused; no X-ray reports of broken bones; etc… Only the opinions and the invented “diagnoses” of psychiatrists!

When Governor Patrick stated that DCF usually get things right, he made no distinction between the kinds of abuse/neglect that social services departments traditionally investigate and the inherently vague psychiatric “abuse” of which Justina’s parents stand accused.

It was perhaps inevitable that media coverage of Justina’s case would expand into a general criticism of DCF and the commissioner.  Criticism of that sort is healthy, and is one of the cornerstones of democracy.  But what’s noteworthy at present is that we’re seeing very little coverage of psychiatry or of the role that the psychiatric “diagnosis” played in this matter.  This is critical, because without the “diagnosis” of somatic symptom disorder and the subsequent allegation of medical child abuse, none of what’s happened to Justina and her parents could even have gotten off the ground.

Psychiatry captured Justina with one of their spurious labels, confident, presumably, that the parents would cave and play along.  But the parents rebelled, and the psychiatric sham was exposed for what it is.  Psychiatry, as usual, had no rational defense, so instead they side-stepped the issues, and the spotlight has moved elsewhere.

And let’s not forget that psychiatry’s leaders are being schooled by Porter Novelli, a major PR firm, in how to interact with the media.

Justina Pelletier: The Debate Continues

On April 1, 2014, Slate published an online article titled Mitochondrial Disease or Medical Child Abuse?  The author is Brian Palmer.  Slate is a daily, general interest web magazine, founded in 1996, that provides “analysis and commentary about politics, news, business, technology and culture,” and is a subsidiary of the Washington Post.  Brian Palmer is Slate’s “chief explainer.”

As the title suggests, the article tries to explore the central question in Justina’s case:  does she have mitochondrial disease or is she a victim of medical child abuse?  The author does a good job of defining the various terms, unraveling the issues, and presenting both sides of the argument, though on balance he comes down in favor of Boston Children’s Hospital.  Here are some quotes:

“It’s easy to get angry about this scenario—and there are some troubling things about the way the conflict has been managed—but the doctors at Boston Children’s deserve a defense.”

“…the science is complicated. Mitochondrial disease (Justina Pelletier’s original diagnosis) and medical child abuse (the Boston Children’s diagnosis) can look extremely similar. Both can be deadly if not treated properly.”

“‘Mito,’ however, is incredibly difficult to diagnose definitively.”

“Just as Justina Pelletier exhibited some symptoms consistent with mitochondrial disease, her case also has some of the hallmarks of medical child abuse. One of her chief complaints was digestive trouble, the most common symptom among medically abused children. She had gone through extreme surgical procedures, including the placement of a permanent port in her belly to flush her digestive tract. Her parents had engaged in physician shopping, and experts at Boston Children’s felt that Justina’s emotional state improved when her mother left the room.”

“The doctors at Boston Children’s had few options if they really believed in their diagnosis. Just as the treatment for strep throat is antibiotics, the treatment for medical child abuse is separating a child from her parents. Sending Justina Pelletier home would have represented the height of irresponsibility if their diagnosis was correct. One in 10 children who suffers medical abuse eventually dies at the hands of his or her parent.”

Obviously all of these issues have been debated at great length, not only in the courtrooms, but also in the mainstream media and in the blogosphere.  It is likely that these debates will continue, and will be wide-ranging.

But in this post I would like to focus on just one issue.  If the “extreme surgical procedures” that Justina had undergone were an integral part of the alleged “medical child abuse,” why is the surgeon who performed these procedures not being censured or charged?  Are we to believe that this surgeon performed these extreme procedures without valid cause or justification?  Is it plausible that he/she performed these procedures more in response to parental pressure than genuine medical need?

If, as is claimed, Justina was the victim of “medical child abuse,” isn’t it reasonable to consider the surgeon one of the primary perpetrators?  And if not, why not?  In other forms of child abuse, aiders and abettors are routinely taken to task.  Why is medical child abuse different?

It has been widely reported that an abnormal “congenital band” of cartilage, 20 inches long, was removed from Justina’s abdomen in 2010.  This indeed would constitute an “extreme surgical procedure,” but the critical question is:  was it justified?  Is there a pathologist’s report that casts doubt on the need for the surgery?  If not, then what is the relevance of the assertion that she had gone through “extreme surgical procedures.”  It is possible that a surgeon might excise tissue needlessly either to boost his income or even from over-enthusiasm.  But there exists, in the form of the pathology lab, a time-tested safeguard against this sort of excess.

The validity of the concept of medical child abuse in this case hinges, at least to some extent, on a history of surgical procedures which, apparently, in the opinion of psychiatrists were unnecessary and potentially injurious.  But, on the other side of the scale, we have a surgeon excising real tissue and subjecting this tissue, and incidentally his/her own medical judgment, to critical objective scrutiny.  A surgeon who routinely excises benign tissue, or who performs other unnecessary surgeries, will quickly incur some challenges from the hospital’s Q.A. committee, the medical licensing authorities, and ultimately from malpractice trial lawyers.

By contrast, the psychiatrist’s opinion as to the necessity or appropriateness of the surgery is subjected to no objective check whatsoever.  And perhaps therein lies the answer to my earlier question.  If those psychiatrists who allege medical child abuse had to challenge the surgeons who aided and abetted the alleged abuse, it is likely that in  most cases, the surgeon’s judgment would prevail, and another nail would be put in psychiatry’s coffin.  It’s easier by far to lay the blame on the “persistent and deceptive” parents and to absolve the surgeons and other medical specialties by the blanket contention that they were duped.

Justina Pelletier and Boston Children’s Hospital

Justina Pelletier is the 15-year-old girl who is at the center of a dispute between her parents and the Psychiatry Department at Boston Children’s Hospital.

Justina, who lived with her parents in Connecticut, had been diagnosed with mitochondrial disease, a rare and debilitating illness, and had been receiving treatment for this from Mark Korson, MD, Chief of Metabolism Services at Tufts Medical Center in Boston.

In February of last year, Justina’s parents took her to Boston Children’s Hospital with flu-like symptoms.  Dr. Korson had recommended an admission to Boston Children’s so that Justina could be seen by Alex Flores, MD, a gastrointestinal specialist who had recently transferred from Tufts to BCH.

But instead, Justina’s care was taken over by the psychiatry department.  She was “diagnosed” with somatoform disorder (“it’s-all-in-your-head”), and BCH reported the parents to the state of Massachusetts for medical child abuse.  The complaint was taken by the Department of Children and Families (DCF), and within 24 hours Judge Joseph Johnston awarded custody of Justina to the Massachusetts DCF, and ruled that she had to stay at BCH.

The parents continued to press for Justina’s release from BCH, but were hampered in these efforts by a gag order that Judge Johnston had imposed.

In January of 2014, having spent almost a year in psychiatric care at BCH (nine months of which were in a locked ward), Justina was transferred to the Wayside Youth and Family Support Network in Framingham, Massachusetts.  She was still in the custody of the DCF, and still under the care of psychiatrists at Boston’s Children’s hospital.  In February of 2014, Justina’s father, Lou Pelletier, alarmed at the deterioration in his daughter’s medical condition, decided to break the gag order, and go public, despite the risk of imprisonment.  There was a huge outcry, and Massachusetts child protective services stated on February 28, 2014, that they are actively working to return Justina to Connecticut and the care of Tufts.

“The timetable for the shift of the teenager to her home state has not been set, and it is unclear just how much the Massachusetts Department of Children and Families is retreating from the girl’s case. But Loftus [DCF spokesperson] said child-protection officials from both states, the juvenile judge handling the case, and lawyers for the parents are actively working on identifying a new placement in Connecticut. He would not say what places are under consideration, but in cases like this, the child could be returned back to her home, or placed in a foster home or a residential treatment facility.

If she were to live at her family’s home in West Hartford, Conn., child-protection officials in that state, who would likely oversee the case, would likely demand that the girl receive services at home or that she attend a day program.”

Because of the gag order, which was in place since November 17, 2013, and the official secrecy that normally attends these matters, it’s difficult to establish all the facts.  But the gist of the conflict seems to be that the psychiatrists at BCH disputed the diagnosis of mitochondrial disease.  (In fact, there are indications that they may even have disputed whether such a disease even exists – an extraordinary accusation coming from psychiatry!)  They also, apparently, formed the belief that the parents were dysfunctionally invested in the notion that Justina was gravely ill, and were subjecting her to needless medicines and treatments.  During the eleven months she was at BCH, the psychiatrists placed very strict and stringent limits on how much contact the teenager could have with her family.  There’s a copy of a January 8, 2014, letter here from Kathleen Higgins, RN, a former BCH employee, to the DCF Commission.  The letter provides a great deal of insightful background.

The parents protested vigorously that Justina had been taken off the medicines for mitochondrial disease, and they stated that her physical condition had deteriorated markedly during her stay at BCH.

DISCUSSION

Somatoform disorder is a DSM-IV term.  It refers to a group of psychiatric “diagnoses,” the common feature of which is “…the presence of physical symptoms that suggest a general medical condition…and are not fully explained by a general medical condition…”  (DSM-IV, p 445).  In addition, “…there is no diagnosable general medical condition to fully account for the physical symptoms.” (ibid)  Like all psychiatric “diagnoses,” it has no explanatory value and is nothing more than a destructive and unreliably applied label.

So essentially what’s happened here is that Dr. Korson, a pediatrician who is board-certified in Clinical Biochemical Genetics, an associate professor at Tufts University School of Medicine, and a specialist in mitochondrial diseases, has been treating Justina for about three years for mitochondrial disease.  (According to the site MitoAction, “Dr. Korson is universally recognized as an expert in clinical practice for mitochondrial patients.”)  He sends her to BCH for a gastrointestinal consult with Dr. Flores.  And within 24 hours, the psychiatry department hijacks her, rejects the mitochondrial disease diagnosis, substitutes a “diagnosis” of its own, files a medical abuse report with DCF, and supports a DCF petition to have Justina made a ward of the state.  Prior to all this, Justina had no mental health history of any kind.

As soon as they realized what was happening, the parents sought to remove Justina from BCH – but when the teenager became a ward of the state, that door was closed, and the judge ordered that Justina be kept at BCH.

Justina’s case has focused a great deal of attention on these matters generally.  One of the points that has emerged fairly clearly is that BCH’s procedure for pursuing a commitment of this kind is a well-oiled machine.  The BCH physicians and staff on the one hand, and the DCF staff on the other, work closely to prepare their cases, and the courts are usually cooperative.  Psychiatric evidence is afforded a high measure of credibility and deference, and, as in this case, the child is routinely ordered to remain at BCH.

The problem with all of this is that BCH stands to make a great deal of money on every child that is court-ordered to remain in their care.  The conflict of interest is glaring.  It’s like a judge routinely sending convicted criminals to a private prison that he himself happens to own.  The difference is that any judge who engaged in activity of this sort would be looking at criminal charges and disbarment.  But in psychiatry, this sort of thing is common.

The matter is particularly compelling in that reports are emerging that BCH tends to pursue these kinds of court orders in cases where the family has “good insurance.”  Justina was kept at BCH for eleven months.  I have seen no reports as to the size of the bill, but I’m sure it wasn’t trivial.

BCH AND HARVARD

David R. DeMaso, MD, is the head of psychiatry at BCH.  He is also a professor at Harvard, and is a member of Harvard’s Psychiatry Department Executive Committee. He is evidently highly regarded at the University, and has his own Harvard Catalyst page.  There’s a tab on this page labeled “Similar People,” and one of the people listed as “similar” to Dr. DeMaso is our old friend Joseph Biederman, MD, the eminent inventor of pediatric bipolar disorder.  This is the bogus diagnosis that legitimized the prescribing of neuroleptic drugs to children as young as two years old for temper tantrums.  Even some psychiatrists spoke out against this spurious and destructive activity, but the practice continues.  The fact that Dr. DeMaso would allow Dr. Biederman’s name to remain on his Similar People tab seems noteworthy.  There is also a “connections”  page on Harvard Catalyst, listing three publications co-authored by Dr. DeMaso and Dr. Biederman.

Dr. Biederman is on record as promising Johnson & Johnson a positive result for their drug Risperdal if they would fund his study.  Why would any reputable physician allow someone like that to remain on his “Similar People” tab?

I did a PubMed search to see if there were other links between BCH psychiatrists and Joseph Biederman.  In addition to the DeMaso publications, I discovered papers co-authored by Joseph Biederman and at least two other members of the BCH Department of Psychiatry “Leadership Team:”  Joseph Gonzalez-Heydrich, MD (7 articles, as recent at 2012); and Deborah Waber, MD (3 articles, as recent at 2012).

PUBLIC OUTCRY

None of Justina’s story would have come to light had there not been an extensive and vigorous public outcry.  This in turn would not have happened if Justina’s father, Lou, had not breached the court’s gag order.  The fact that our courts can effectively prohibit a parent, on pain of imprisonment, from speaking out against his child’s enforced psychiatric treatment ought to be a huge concern.  Our legislative and legal systems have been hoodwinked by psychiatry for too long.  The right to free speech is our most fundamental political freedom.  The fact that a state court would so cavalierly suspend such a right to promote the agenda of BCH’s psychiatry department suggests a measure of partiality on the part of the court in an area where the child’s welfare ought to be the paramount consideration.  There had never been the slightest indication that Justina’s parents had been abusing or neglecting her.  In fact, they brought her to BCH on the advice of the child’s physician to get help for the flu-like symptoms.  By any conventional standards, they were being dutiful and attendant.  The gag order was clearly an attempt to prevent them from drawing adverse publicity to BCH’s psychiatry department.  Courts are supposed to be impartial.  Why would the court in this case have assumed that the psychiatry department’s motives were benign, that its “diagnoses” were valid and accurate, and that its practices were judicious and efficacious?  Why did the court not recognize the financial conflict of interest when it ordered that Justina be kept involuntarily in the locked psychiatric ward at BCH?

BCH’s psychiatrists kept Justina in a locked psychiatric ward for nine months.  Apparently it never occurred to them that they might have made an error, or that they had acted too hastily. Psychiatry seldom engages in anything even remotely akin to critical self-scrutiny.  They have resisted the parents’ protests at every step of the way, and have been backed throughout by the court.  It is only because of the public outrage that the facts are emerging.  Massachusetts’ Department of Public Health has called for a full investigation of the matter.  One can readily imagine the kinds of pressures that will be brought to bear to whitewash the entire affair.  Let us all, individually and collectively, do what we can to ensure that this does not happen.

The Problem of Blame

On January 27, I posted Maternal Attachment in Infancy and Adult Mental HealthIn this article I reviewed a longitudinal study by Fan et al.  The main finding of the study was:

“Infants who experience unsupportive maternal behavior at 8 months have an increased risk for developing psychological sequelae later in life.”

In my article, I pointed out that the correlation between the low maternal attachment ratings and subsequent “mental health” issues was not perfect, so clearly this was not the only factor involved in the adult children’s subsequent problems.  But I also made the point that what we do as parents affects how our children function in adulthood.

For me this is simply an obvious fact of life that tragically has been barred from discussion by the psychiatric mantra – that all significant problems of thinking, feeling, and/or behavior are genetic-linked brain illnesses, and that parents couldn’t have impacted the outcome one way or the other.

The post generated a few comments on the blame-the-parents issue, and, since this is a critical topic in the current psychiatric debate, I thought it might be helpful to discuss the matter further.

. . . . . . . . . . . . . . . .

Firstly, we can’t have our cake and eat it too.  If we reject the facile psychiatric brain illness theory, then we ought to be willing to discuss other notions, and follow the evidence wherever it leads us.  Most people have no difficulty accepting the notion that the experience of being bullied during childhood can promote the development of significant problems in adult life.  Why is it such a reach that cold, detached parenting during infancy might also have importance in this respect?

Secondly, in matters of human behavior, there are always multiple paths to the same place.  In other words, two people might be engaging in pretty much the same kinds of activity, but for very different reasons.

Thirdly, human behavior (including thinking and feeling) is always multi-determined.  In other words, not only are there different ways to get to the same place, but a given individual may have traversed several of these routes simultaneously to arrive at his present position.  Linear, simplistic explanations of human activity are almost always incomplete, and sometimes downright false.

Fourthly, looking for, and finding, reasons for human behavior is not at all the same thing as assigning blame.  I read of an incident recently in our local newspaper that nicely illustrates this difference.

A few months back we had a tragic traffic accident on one of our highways.  Earlier, there had been a fender-bender in which a vehicle had been disabled and was blocking a lane.  A police officer and a tow-truck driver were clearing things up, when another vehicle, the driver of which had clearly become distracted, plowed through at about 70 mph, killing the tow-truck driver and seriously injuring the policeman.  The driver was charged, of course, and the case is grinding its way through the legal system.

Recently the widow of the tow-truck driver asked the court if the matter could be expedited, because she and her family had forgiven the culprit, recognized that it was a tragic accident, understood how it had happened, and wanted to move on.

The point of the story is that blaming and asking why are two completely different activities.  The former is generally unhelpful; the latter is necessary if we are to learn from our mistakes.

Fifthly, in my experience, most parents are willing to accept a measure of credit when their children do well and a measure of responsibility when they don’t do so well.  I often hear parents of grown children say things like:  my son is kind of timid, and I think maybe it’s because I was too hard on him; or my daughter doesn’t have a lot of initiative, I think maybe we were too protective; or my son is a bit on the wild side, I don’t think I was strict enough, etc…

Most parents of grown children, including myself, can identify with these kinds of statements, and can see in hindsight things we might have done differently.  So why should the problems embraced by the term “mental health” be conceptualized differently?  These are not a special class of problem, despite psychiatry’s insistence to the contrary.

Psychiatry routinely condemns as parent-bashing any attempt to explore or discuss these problems in terms of family dynamics.  Anyone who doesn’t accept their orthodoxy must be a parent-basher.  This spurious nonsense has been developed and promoted to win parents over to the “take-your-pills-for-life” philosophy, but in fact it is nothing more than deceptive propaganda.  What they’re saying essentially is:  all significant problems are gene-linked brain illnesses, and anyone who suggests otherwise must be a parent-basher.  We need to recognize this self-serving nonsense for what it is.

So for all of these reasons, I think we need to keep an open mind.  I’m certainly not advocating a return to the “cherchez-la-femme” type of thinking that was popular in the 50’s, but we do ourselves no favors if we over-react to that kind of approach and deny the simple reality – clear and obvious to previous generations – that parents, mothers and fathers, have a significant impact on their children’s lives.  We are not the only influencing factor, but our impact is not trivial.  We can do a great deal of good, but we can also do a great deal of harm.

Psychiatry – in pursuit of its own self-serving agenda – has made this a taboo subject.  We need to break this taboo, and start discussing these matters, as well as other pertinent factors such as poverty, discrimination, injustice, bullying, etc., openly and honestly – not in a mode of blame and censure – but rather in a mode of exploration and understanding.  Some of the most effective therapy I’ve ever done was with parents and their grown children, where these kinds of issues were aired with openness and candor.

With regards to the Fan et al paper, I have no inside information, but in general terms the study seems to have been conducted in a thorough and careful manner.  Longitudinal studies of this kind are something of a gold standard in addressing these sorts of questions, and it would, in my view, be foolish to ignore the results.

It would also be foolish to overstate the results.  As I pointed out in my earlier article, in many cases where low maternal attachment was noted in infancy, there were no “mental health” problems in adult life; and in some cases where low maternal attachment was not noted there were “mental health” problems later.  The study does not give us a simple discriminator that we can apply blindly to all mother-infant interactions.  Rather, it leaves us with the suggestion that it might be a good thing to encourage mothers to interact positively and affectionately with their babies, especially in cases where this kind of interaction does not seem to be happening.  And who can argue with that?

It might be objected that this kind of material is self-evident, and that everybody knows that mothers should be affectionate and comforting to their babies.  It could be argued that conducting research on something this obvious is a waste of time and resources.  But we should remember that for two or three generations prior to the 1950’s, it was widely promoted and accepted in pediatric circles that parents should avoid “excessive” affection with their babies and young children.  In 1894, Luther Emmett Holt, MD, a leading American pediatrician, wrote The Care and Feeding of Children.  This book quickly became a bestseller, and remained influential well into the twentieth century.  Here are two quotes:

“Are there any valid objections to kissing infants?

There are many serious objections. Tuberculosis, diphtheria, and many other grave diseases may be communicated in this way. The kissing of infants upon the mouth by other children, by nurses, or by people generally, should under no circumstances be permitted. Infants should be kissed, if at all, upon the cheek or forehead, but the less even of this the better.” p 168

 “At what age may playing with babies be begun?

Babies under six months old should never be played with; and the less of it at any time the better for the infant.”  p 165

The psychologist John Watson (1878-1958) also advocated a businesslike approach to child-rearing.  In the book Psychological Care of the Infant and Child (1928), which he co-authored with his wife, Rosalie Raynor Watson, he stated:

“Let your behavior always be objective and kindly firm. Never hug and kiss them, never let them sit on your lap. If you must, kiss them once on the forehead when they say goodnight. Shake hands with them in the morning. Give them a pat on the head if they have made an extraordinary good job of a difficult task.” (Quoted in Bigelow and Morris, John B. Watson’s Advice on Child Rearing, Behavioral Development Bulletin, Vol. 1, Fall 2001).

 As with Dr. Holt, the Watsons’ child-rearing advice was generally well received.

So the notion that parenting, even of very young babies, should be rather businesslike and unemotional had a lot of momentum in the first half of the twentieth century, and in fact it was largely in reaction to this kind of child-rearing ethos that Benjamin Spock, MD, wrote his famous book The Commonsense Book of Baby and Child Care in 1946.

It was presumably also in response to these kinds of ideas that the 1960’s researchers who initiated the longitudinal study currently under discussion had included a measure of maternal over-involvement which included displays of affection.  Not surprisingly, this measure was found to be not associated with the development of problems in adulthood.

Underlying the parent-bashing objection there is an unspoken assumption: that if a mother is not displaying strong emotional attachment to her baby, then she must be a “bad mother” – somehow defective – a disgrace to her gender.  But, in fact, there are all sorts of reasons why a mother might be emotionally detached.  Perhaps she’s an abused spouse.  Perhaps she’s never had role models and doesn’t really know what to do.  This is an increasing problem as families get smaller, and children aren’t involved in the care of younger siblings.  Perhaps the new mother lacks confidence and fears she might hurt the baby.  Perhaps she’s carrying some trans-generational vestige of the old Holt-Watson ideas.  Or perhaps she’s so worn-out and tired that she can’t generate much enthusiasm for anything beyond the bare necessities of childcare.  Whatever the reason, she needs help and coaching rather than censure.

But this kind of help won’t happen until we get to a point where we can discuss the link between parent-child interactions and subsequent development openly, and undefensively.  If this had been a study about sports, for instance, and had found that children of parents who encouraged their toddlers in sporting activities were more likely to pursue sports in later life, we would have no difficulty in joining the dots.  But the logic is essentially the same.  We critique psychiatrists for cherry picking their research results.  Let’s not fall into the same trap.  If there are methodological flaws in the Fan et al study, let’s critique them.  But we shouldn’t resist the paper just because we don’t like its conclusions.  We must not allow psychiatry’s threat, to brand us as parent-bashers, to scare us from stating the obvious.

 

Maternal Attachment in Infancy and Adult Mental Health

There’s an interesting article by Angela Fan et al, in Comprehensive Psychiatry, October 28, 2013.  It’s titled Association between maternal behavior in infancy and adult mental health: A 30-year prospective study.  The data for this investigation were gathered as part of a wider longitudinal study.

PROCEDURE

Participants in the study were 1,752 babies born between 1960 and 1965.  The babies received medical examinations at 4 and 8 months with their mothers present.  During the 8-month examination, the mothers’ interactions with the babies were observed and rated on the following dimensions:

(1) mother’s expression of affection;
(2) mother’s verbal evaluation of the child;
(3) mother’s physical handling of the child;
(4) mother’s management of the child during the testing;
(5) mother’s reaction to the child’s needs;
(6) mother’s reaction to the child’s test performance;
(7) mother’s focus of attention during the examination.

These ratings were analyzed statistically, and yielded the two following factors:

  • Low attachment, characterized by indifference, rough handling, and criticism of the baby.
  • Overly involved, characterized by excessive pride, caution, and affection. 

Between 1992 and 1994, when the children had reached the age of about 30 (actual range 27-33), they were contacted and interviewed.  They were asked to complete the General Health Questionnaire, and were also asked about their present mental/emotional health status.

The earlier and later data were combined to see if the maternal behavior in the 60’s correlated with the interview data from the adult children in the 90’s.

RESULTS

The primary finding was that:

“Mothers of subjects who reported poor adult mental health were significantly more likely to exhibit ‘Low Attachment’ behaviors at the 8-month exam than mothers of subjects with normal adult mental health (p = 0.040).”

There was no correlation between the maternal “over-involvement” in the 60’s and subsequent mental health of the adult child.

The components of the Low Maternal Attachment factor that were significantly associated with poorer subsequent mental health were:

  • Harsh and negative expression
  • Made no effort to facilitate the testing
  • Inconsiderate in handling the child 

The main findings are set out in the table below:

Low Maternal Attachment Measures Yes/No N %age Poor Mental Health Relative Risk P
Harsh and negative expression yes
no
128 1485 21.9%
15.4%
1.42 0.04
Made no effort to facilitate testing yes
no
146 1471 22.6%
15.4%
1.47 0.02
Inconsiderate in handlng the child yes
no
59 1556 25.4%
15.6%
1.63 0.04

 

As can be seen from the table, each low-attachment variable is associated with an increased percentage of poor mental health in adulthood (e.g. 21.9% vs 15.4% for the first variable – Harsh and negative expression).  The relative risk is the ratio between these two percentages:  21.9 ÷ 15.4 = 1.42, etc…

It is important to note that, as in most research of this kind, the correlation is not perfect.  For instance, although 1485 (92%) of the mothers were rated as not harsh and negative during the infant examination, nevertheless 15.4% of their children reported poor mental health in adulthood.  And conversely, of the 128 mothers who scored yes on this variable, only 21.9% of their children reported poor subsequent mental health.  The point being that low maternal attachment during infancy is only one of the factors that contribute to a person developing “mental health” problems in later life.

The authors concluded that:

“Infants who experience unsupportive maternal behavior at 8 months have an increased risk for developing psychological sequelae later in life.”

. . . . . . . . . . . . . . . . 

DISCUSSION

In recent decades it has become increasingly difficult to discuss the impact of parenting styles on subsequent behavioral/emotional problems in the adult child.  Any such attempt has been condemned by psychiatry – or at least some segments of psychiatry – as unwarranted blaming of the parent.  For psychiatry, problems of thinking, feeling, and/or behaving are illnesses caused by genetic and/or neurological factors, with little or no causal link to parenting behavior.

But the notion that what we do or don’t do to our children when they are young has a profound effect on how they function in adult life is obvious, and has been obvious throughout recorded history. 

Hopefully the publication of the Fan et al study might go some way to bringing this topic back into focus.

In the parenting arena, we all make mistakes.  Sometimes the mistakes are minor.  Other times they are more serious.  But we will do our species no service if we fail to learn from those mistakes, and if we fail to pass on the lessons learned to future generations.

The Living-With-Parents Blues

Despite the general rise in economic indicators over the past year or two, there are still many young adults who, for economic reasons, have had to move back in with their parents.  A proportion of these people become depressed.

Depression is the normal human reaction to loss, disappointment, or a general sense of unfulfillment.  Viewed in this light, it is not surprising that young people who have to move back in with their parents might be depressed.

In our culture, a good deal of emphasis is placed on becoming emancipated from one’s parents on completion of one’s education. Successful transitioning to adulthood is defined in terms of starting a job/career, setting up one’s own living arrangements, and finding a partner.

Most of the individuals who “return to the nest” are usually having difficulty in all three areas.  They either haven’t been able to get a job, or if they have a job, their salaries are insufficient to enable them to live solo.  With regards to finding a partner, living with parents can have a cramping effect, at least for some people.

In addition, moving back in can place a strain on the parent-child relationship.  If the parents are invested in keeping the adult child dependent, then the return to the nest provides them opportunities to indulge this perspective.  Usually, this is to the detriment of all concerned.

If the parents are invested in seeing their adult child go out and succeed on his/her own, then the return home can introduce a high level of friction.

Either of these scenarios can be depressing for the adult child.  If there is a strong tradition of dialogue and open discussion in the family, then these problems can be aired and resolved, but often this is not the case.

If the returned child becomes noticeably depressed, sooner or later the suggestion is made, by parents or others, that he/she consult a doctor.  The outcome of the visit is an antidepressant, and often the long term result is a downward spiral into disempowerment, reduced expectations, and recurrent bouts of depression.  Antidepressants are not a path to a brighter future.

The truly sad part of all this is that it doesn’t have to end this way.  Returning to the nest doesn’t have to be a depressing experience, either for parents or for the adult child.  What’s needed is communication, conflict resolution skills, and some support and coaching for the adult child in the art of job-hunting.  This is the kind of help that should be available at a mental health center, but usually isn’t.  Over the past two or three decades, the centers have degenerated into marketing outlets for psycho-pharmaceutical products.

One of the great evils of psychiatry is that they have poisoned our culture and our society.  They have spread the false and destructive message that if a person is depressed, he must have a brain illness, and he must take pills.  And so the individual who lives with his parents because he can’t find a job, and subsequently becomes depressed, is sacrificed on the altar of psychiatric turf and pharmaceutical profits.

The system is working perfectly; but it’s not working for the people who need help.

Parental Influences

If we’re happy to take some of the credit for our children’s successes, we should also accept a share of the responsibility when they don’t do so well.

In the late 70’s, I met an elderly gentleman in a social context.  I’ll call him James.  He was in his early 80’s.

We got to talking, and found that we had a good deal in common – primarily a love for the land, the forests, gardening, and just generally being active.

One day he told me that his son had had a nervous breakdown.  He never specified what this meant, but it sounded serious.

James explained to me that his son had been very bright, and for that reason, he had pushed him hard to succeed.  But, James went on, his son was also sensitive.  James hadn’t realized this, and he acknowledged that he pushed his son “too hard,” and attributed the breakdown to this excessive pressure.

James and I chatted about these matters generally, and it was clear that he had discussed these issues extensively with his son, that they had reached an accommodation, and that at the time of our conversation, they had a good relationship.

What struck me particularly at the time was the honesty with which James was able to discuss these matters.  In my experience, this is fairly rare.

The point here is not to vilify parents.  Most of us do, or have done, our best.  But it seems unlikely that we got everything perfectly right.

When we challenge the illness assumption, psychiatry routinely accuses us of blaming the parents.  But if, in my parenting, I did things that impacted my children negatively, isn’t it better to face this and talk to my adult children about it, rather than stick to the fairy tale version of parental perfection.

Isn’t it actually a much more serious indictment of me as a person that I would be willing to accept – without the slightest evidence – the ego-salving assertion that my child has a broken brain, rather than accept that, although my parental intentions were good, my performance wasn’t always stellar?

Isn’t the truth the point from which we start to grow?

I was reminded of these matters recently on reading Neglectful Parenting Excused by Drug-Expert PsychiatristIt’s written by Cathi Carol and published on her website, The Science of Reality.

Here’s a quote:

“In reality, the parents who are the least aware of how their own behaviors toward their children – their neglect, anger, abuse, blame, condescension, control, resentment, attack, or undue punishment – affect them are the ones who are the most likely to blame their children for their subsequent behavioral problems, to take them to psychiatrists, and to listen to those psychiatrists when they recommend drugging their children into oblivion to control their reactions to their parents rather than taking responsibility for their own bad parenting, learning how to be better parents, and changing.

To have that ignorant, arrogant, dumb, self-defensive, or lazy it’s-not-our-fault parental attitude applauded and reinforced by psychiatrists is worse than no help to the family or to the child, it’s additional abuse heaped upon the child by even more authority figures negligent to their charter to heal, not to harm.”

Sometimes these mistakes, as Cathi says, arise from neglect, anger, abuse, etc.; other times they result from ignorance, bewilderment, distractions, or a failure to recognize the child’s uniqueness and individuality.  But all of these mistakes affect how our children develop, and how they cope with the difficulties and vicissitudes of adult life.  Parenting is not the only determinant of a child’s later functioning, but it is the major determinant.

To pretend otherwise – to accept instead psychiatry’s broken brain nonsense and to feed our children ever-increasing quantities of toxic chemicals – is a tragedy beyond words.

Cathi’s article is direct and straight-forward, and well worth a read.

More on Postpartum Depression

I recently wrote a post on postpartum depression which has generated a certain amount of negative comment.  For this reason, I thought it might be helpful to clarify some points.

DEFINITION AND EXPLANATIONS

The DSM makes no mention of postpartum depression as such.  The closest it comes is major depressive disorder with postpartum onset.  In other words, the APA conceptualizes postpartum depression as ordinary major depression (which can incidentally range in severity from mild to severe) which happens to occur in the postpartum period.  This is in marked contrast to the popular notion that postpartum depression is somehow a function of the postpartum woman’s hormones, and is fundamentally different from other forms of depression.

Despite two decades of very active research, there is no evidence that depression in the postpartum period is caused by a hormonal imbalance, no clearly specified mechanism of action, and no identifiable biological marker.  This is similar to the state of affairs in depression research generally, where several biological theories have been proposed, but none has stood the test of time.  There are some suggestions in the literature of correlations between physiological factors and depression in the postpartum period, but they are not always consistent and don’t establish a causal link.

In my view, the most reasonable way to conceptualize postpartum depression is that – similar to other depression – it is largely a function of adverse life events, coupled with feelings of isolation and hopelessness.  The postpartum period, as I mentioned in the earlier post, is fraught with adverse life events, especially if a mother is poor, young, and single.  This conceptualization of postpartum depression is consistent with the widely replicated finding that the risk factors most heavily associated with postpartum depression are:  low education, low income, being unmarried, and being unemployed.  Deepika Goyal et al (here) found that women with all four of these risk factors were eleven times more likely than women with none of these factors “to have clinically elevated depression scores, even after controlling for the level of prepartum depressive symptoms.”

TREATMENT

No hormone treatment for postpartum depression has been shown to be successful.  In the 1990’s there were some claims that hormone treatment had some efficacy in this area, but the claims have not stood the test of time.  The present Mayo Clinic guidelines for treatment of postpartum depression are not enthusiastic with regards to hormone therapy.

“Estrogen replacement may help counteract the rapid drop in estrogen that accompanies childbirth, which may ease the signs and symptoms of postpartum depression in some women. Research on the effectiveness of hormone therapy for postpartum depression is limited, however. As with antidepressants, weigh the potential risks and benefits of hormone therapy with your doctor.” [Emphasis added]

This is in marked contrast to genuinely biologically-induced depression.  It has been known for more than 100 years, for instance, that hypothyroidism, even at low levels, can lead to depression/psychosis in some people.  Treatment consists of thyroid replacement, and the depression/psychosis usually abates readily.

Antidepressant drugs are routinely given to women with postpartum depression, even though it has long been established that their average efficacy in the short-term is no better than placebo.

It is also well established that the use of antidepressants increases markedly the risk of recurrent episodes of depression in the long-term.

There is also a growing body of evidence which suggests that the use of some antidepressants increases the risk of suicide and serious aggression, including murders.

PREVALENCE

The point prevalence rate for depression in the postpartum period is not significantly different from similarly-aged women generally (Gaynes, BN, et al, Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes.)  In other words – and again, contrary to popular belief – the postpartum period is not marked by a significant increase in depressive episodes.  So even if there is some, as yet unconfirmed, hormone-induced depression, it clearly is not sufficiently prevalent to noticeably swell the ranks of postpartum women with depression.  In this context it is also worth noting that screening tests that are used for postpartum depression are the exact same tests used to screen for non-postpartum depression.  There is no special test for postpartum depression.  In this regard “postpartum depression” is a misleading term and would be more accurately called depression in the postpartum period.

SEVERITY

Much of the criticism directed at my earlier post charged me with minimizing the severity of postpartum depression.  In fact, I had made no mention of severity.  There is a widespread misconception that if one says that depression is not an illness, one is saying either that depression isn’t real, or that it isn’t severe.  That neither of these positions is true should hardly need saying, but let me clarify my position.

Depression is real.  Everybody gets depressed at some time or another.  Sometimes the depression is mild and can be shrugged off without difficulty.  Other times it is severe.   Occasionally – I believe very occasionally – it is primarily a function of a biological factor, but this should not be assumed without clear evidence.  The vast majority of depressionincluding depression in the postpartum period – is a function of adverse life events/circumstances.

THE CONCEPT OF DEPRESSION

An overriding consideration in this discussion, or indeed any discussion of depression, is the widespread assumption that depression is a unified, definable, and measurable phenomenon.  In reality, all of these assumptions are false.  There is a great deal of variation in the way that individuals experience, and respond to, depression.  There is no definition of depression that would meet scientific standards, and measuring instruments that purport to measure depression actually measure what people say about their depression, which isn’t necessarily the same thing. There are, for instance, all sorts of reasons that a person might say he’s “fine” when in fact he’s quite despondent.  And vice versa.

The point here is not that we shouldn’t discuss depression, but rather that when we do have discussions of this kind, there is great potential for confusion.

INDIVIDUAL PRESENTATIONS

At the risk of stating the obvious, everybody is different.  Different people react to situations and circumstances in different ways.  Some people do indeed become extremely despondent in the postpartum period and at other times.  How individual people conceptualize their problems and what they choose to do about them are clearly their own choices, and it is certainly no business of mine to challenge people in these regards.

The purpose of this website is to challenge what I believe are spurious and destructive tendencies in modern psychiatry, and my challenges are based on logical analysis, research findings, and common sense.  Some people agree with what I write.  Others do not.  We can agree to differ.

AN APOLOGY

In my original post I mentioned the websites Postpartum Depression and Postpartum Support International, and recommended that they be “viewed on an empty stomach.”  This was undignified and inappropriate, for which I apologize to the writers.  I have removed the sentence.  It is still my contention, however, that the sites be viewed with a critical eye.