Tuesday, April 7, 2015

Book Review: A Disease Called Childhood by Marilyn Wedge

The theme of this blog, as well as of my last book, How Dysfunctional Families Spur Mental Disorders, is that family systems issues have been disappearing from psychiatry in favor of a disease model for everything because of a combination of greedy pharmaceutical and managed care insurance companies, naïve and corrupt experts, twisted science, and desperate parents who want to believe that their children have a brain disease in order to avoid an overwhelming sense of guilt.

I gave a positive review to Marilyn Wedge's previous book, Pills are Not for Preschoolers, which took pediatricians and child psychiatrists to task for medicating children with dubious diagnoses without even evaluating their home situation to see if the children are acting out in relationship to family dysfunction, family discord, overall environmental chaos, or poor and inconsistent discipline.

In her new book, the author specifically tackles the diagnosis of ADHD, a frequent topic of this blog. She goes over a lot of the history and twisted "science," caused by the confluence of the above factors, that has led to a drastic increase in this diagnosis, along with the concomitant increase in the use of the methamphetamine clone Adderall and other stimulants.

In doing so, she covers much of the same ground as my book and this blog, discussing the influence of Big Pharma, corrupt academics who have their papers ghostwritten by drug company hacks, poor study designs, inadequate evaluation of a child's home situation by practitioners, and the appeal of a "brain disease" label for their child's misbehavior to parents - so they don't have to look at their own behavior as the reason for their acting-out children.

So you think I would be happy to recommend this book as well. Unfortunately, I cannot, for two reasons. First, she comes dangerously close to tarring all pharmacotherapy and all psychiatric diagnoses, especially as they are described in the DSM, with the same brush. Second, she does not apply the same criticisms she applies to research on ADHD and stimulants to research on such side issues as food additives or violence on television.

While I indeed agree and have argued in this blog that some diagnoses in the DSM are completely bogus, diagnoses such as schizophrenia, true bipolar disorder, autism, and melancholic depression are real brain diseases that are well described in the DSM. Many misdiagnoses in practice are not caused by the use of invalid diagnostic criteria, but are due instead to the criteria not being applied correctly - if they are applied at all.

Contrary to popular belief, the DSM is not just a symptom checklist. The book clearly states that, in order to meet diagnostic criteria, symptoms have to have certain specific qualities and must occur in certain environmental contexts. Furthermore, the DSM describes in detail associated features that support the diagnosis, the prevalence of the disorder, the development and course of the disorder, risk and prognostic factors, culture-related diagnostic issues, disorders that tend to co-occur with a given diagnosis, and other similar disorders that need to be ruled out (the differential diagnosis).

A correct diagnosis has to be consistent with all of these factors as well as having the required number of symptoms. As the author herself notes on page 30, many practitioners these days base their diagnoses "...on no more than a twenty minute evaluation using a checklist of symptoms." That sort of "evaluation" precludes accuracy.

She holds the DSM to task for not basing its diagnoses on causes but merely on descriptions of disorders. That is true. However, this ignores the fact that the vast majority of psychiatric conditions have no specific causes, but only risk factors. No matter what biological, psychological, or socio-cultural risk factor you look at for a given diagnosis, some patients will have a lot of it but no disorder, while others will have very little of it but will have the disorder.

She also ignores the fact that the brain is so complicated that we don't even know where nerve tracts begin and end. So just because we do not know the precise cause of something like schizophrenia, that does not prove that it is not a brain disease. That's like saying we didn't know that the bubonic plague was a disease until after germs were discovered.

The author does not specifically say that adult schizophrenia is more of a cultural construction than a real disease - as is, we agree, actually the case with the vast majority of cases diagnosed with ADHD - although she does say that this is a distinct possibility with child schizophrenia. Nonetheless, she does use words like "madness" and "insanity" and describes them as being culturally defined, which might be seen as implying that this idea does, in fact, apply to schizophrenia.

Schizophrenia, despite the cherry picked and fact-challenged theories of author Robert Whitaker, has been described in pretty much the same way in almost all cultures from all over the world - and for hundreds of years. It is clearly and unequivocally not merely a cultural construction.

The author even tries to make the case that psychosis might possibly be a cultural construction rather than disease by bringing up the issue of drapetomania, something that has lately become a favorite of anti-psychiatry zealots. This was a proposed mental illness that was applied to American slaves prior to the US Civil War when they tried to escape captivity. 

Three seconds of deliberation would lead anyone with half a brain to conclude that this "diagnosis" was made solely for the benefit of racist slaveholders so they could rationalize treating Blacks as subhuman, and had nothing to do with any legitimate psychiatric diagnostic issues whatsoever. 

Making even the implication that drapetomania is somehow analogous to schizophrenia is the worst kind of straw man argument. Maybe I'll go find a straw man and beat him up - perhaps the Scarecrow from the Wizard of Oz, who was obviously a real person.

This is a serious issue because the public thinking that chronic, severe and persistent mental illnesses are just manifestations of culture gone awry is the reason there are a whole lot of people living on skid row in cardboard boxes and languishing in jails because they committed nuisance crimes upon the instruction of the voices in their heads.

In some passages in her book, the author subtly goes back and forth between adult disorders and childhood disorders in the DSM, which are often very different breeds of cat. It is extremely rare, for instance, that a teenager will actually meet the full DSM criteria for major depressive disorder when those criteria are correctly applied. It is no surprise, then, that they don't have a whole lot of response to antidepressant drugs.

The author presents the case of a patient she calls "Jeanette" and says she "undoubtedly would fit" the criteria for clinical depression, and who of course had not responded to antidepressants. Well, maybe she fits the criteria, but it sounds like the author does not know. Did she or didn't she? I would bet not.

Then there are the side issues of the effects of diet and TV/video game violence, in which the author's standards for good research go out the window. For example, she mentions uncritically one researcher at the Mayo clinic who "speculates" about the reasons why gluten intolerance may have increased in the last few decades. Even mentioning this without any disclaimers makes a mockery of her legitimate criticisms of ADHD "research."

Focusing on these side issues diverts attention away from the main issue - family behavior - every bit as much as pretending that all behavior problems are evidence of a brain disease. Doing so takes parents of the hook, which according to the rest of the book, is highly counterproductive.

With studies about food dyes causing attention problems, according to most observers, at best they provide limited and somewhat questionable evidence that some synthetic colors and sodium benzoate may have a small effect on activity and attention in some children. And when that happens, it might be because of other medical reactions to specific foods. When someone feels sick, they don't pay attention so well. So maybe it's a metaphorical tummy ache and not the food dyes per se which are causing problems.

The real reason some kids may seem to improve dramatically with dietary changes is that the parents have finally begun to set limits on their children about what they can and cannot eat, instead of letting them pig out on anything they want to. Again, eating a lot of junk food can make you feel poorly, and that would have nothing to do with particular foods being a proximal "cause" of ADHD-like behavior. The author herself correctly points out that lack of structure and discipline can lead children to become "infant kings" who throw tantrums when they don't get their way.

As further evidence of this point, a recent study found that 15 percent of parents in one sample said that their two-year-olds are coffee drinkers! Again, coffee is probably not good for toddlers, but it is the lack of discipline and attention by the parents that is the much bigger problem.

As to television and video games, the issue is similar. Many parents these days are allowing their kids to stay up all hours of the night looking at screens. The combination of sleep deprivation and lack of discipline is more than enough to account for the behavior problems consistent with what passes as ADHD these days. The content of the programming is only relevant in one way: the level of stimulation. 

The author points out that one study pointed out that children watching Spongebob Squarepants on television did worse immediately afterwards on attention and memory testing than if they watched PBS. Well, that is very most likely a temporary effect of the cartoon being much more exciting than the other show. That doesn't mean than watching Spongebob is inherently bad for kids. 

In fact, as I described in a previous post, much of the research on violence on television measures thoughts and impulses immediately following the show, and there is not a shred of evidence that kids who watch these shows become psychopaths just from watching them. I mean, while I was reading A Tale of Two Cities I thought more about the French Revolution afterwards. That did not cause me to then rush out and get a degree in history with a concentration on France in the 19th century.

I do have to give the author of this book kudos, however, for taking her life in her hands by recommending that children be allowed to walk to school.


  1. So just because we do not know the precise cause of something like schizophrenia, that does not prove that it is not a brain disease. That's like saying we didn't know that the bubonic plague was a disease until after germs were discovered.

    How are you defining disease here? Do you make a distinction between illness and disease? I ask, because--depending on how you use the word--it's not so far off to say that we didn't know that Bubonic Plague was a disease until we had the germ theory.

    Saying something is a brain disease or biological doesn't tell me anything much, because, as far as I'm concerned everything having to do with living beings is, by definition, biological. Biological, pace Dawkins, does not mean merely genetic. Until we can prove that our mental life is determined by the bacteria in our guts, then that leaves us with our brains.

    Schizophrenia and bipolar disorder and autism are no joke, but without a known etiology, it seems to me that it might be more useful to call them illnesses or (in the cases of autism) developmental disabilities.

    1. Hi Anonymous,

      Thanks for your comment. People have been going around and around with defining "disease" forever (is alcholism a disease, or is it merely self-destructive behaviror?), and one can get lost semantic trivia. And of course all behavior is "biological," including me writing this sentence.

      The way I'm using it (and of course it's hard to prove one way or the other so I'm sure someone could easily get me in some sort of a semantic trap), a psychiatric "disease" is a problem with the basic wiring of the brain, while a "psychological" or "functional" problem falls within the range of a normal brain's neuroplastic adaptation to ones social (particularly interpersonal and family) environment.

      Since we don't really understand the wiring of the brain, we have to rely on indirect evidence to tell what is probably one from what is probably the other. The key issue is pervasiveness.

      When someone is in a psych hospital, for instance, you can see how someone is behaving when they don't think anyone is looking. Someone in a acute schizophrenic break, for example, looks pretty much the same no matter what they are doing and whether someone is watching or not. That is definitely NOT the case with, say, borderline personality disorder, whose behavior differs widely over the day depending on who they are with and who they think is their audience.

      Someone in a true melancholic depression isolates themselves and looks like the world is coming to an end 24/7 no matter who is around. A patient with a more functional depression may look that way at first, but when they aren't aware of being observed, can be seen out socializing on the ward, laughing and joking. True brain pathology (as opposed to physiology) does not just appear and the suddenly evaporate from moment to moment like that.

  2. Right, I agree with much of what you just said.* Still, I wonder whether the word "illness" might not be more meaningful.

    I don't care very much for the phrase "semantic trivia." I happen to think that semantics is an incredibly important are of study.