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.

Yet Another Ruse by Pharma to Muddle Conflict-of-Interest Rules

On January 7, Medscape  reported, "The American Psychiatric Association (APA) has fired back a strong response to a recent article in theWashington Post questioning the possibility of pharmaceutical industry influence on decisions regarding the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)." 

David Kupfer, MD, chair of the DSM-5 Task Force, said in a news release, "While speculation is bound to occur, we think it is important to stay focused on the fact that APA has gone to great lengths to ensure that DSM-5 and APA's clinical practice guidelines are free from bias."

In his news release, in which he defended the policies regarding conflict of interest in the members of the different groups that were working on the DSM -5, published in the Psychiatric Times, he stated“… all individuals agreed that, starting in 2007 and continuing for the duration of each individual member’s work on DSM-5, that individual’s total annual income derived from industry sources (excluding unrestricted research grants) [italics mine] would not exceed $10,000 in any calendar year, and he or she would not hold stock or shares of a pharmaceutical or device company valued at more than $50,000."

So nothing to worry about?  No conflict of interest here?

Unfortunately, that part I highlighted in the above quote is big enough to drive the proverbial truck through. As the article in the Washington Post of 12/26/12, pointed out, “Members [of the various task forces creating the new DSM] could also receive unlimited amounts of money from pharmaceutical companies to conduct research.”

If the drug companies are supporting the research of an "expert," how is that not financial influence?  Most of these experts are academics; if they do not get funding, they often cannot keep their jobs! Depending on Pharma for your income is hazardous to your objectivity.

This very sly loophole in disclosure and conflict-of-interest rules has also been exploited by some Pharma-funded researchers who label themselves as “unpaid consultants” in the “disclosures” attached to journal articles.

As was pointed out by Alan Blum, a fellow member of Healthy Skepticism:

“I wanted to share my view that the term seems disingenuous and may not even make any sense. Is the reader supposed to believe that the author has served a multi-billion dollar company out of the goodness of his or her heart? Indeed, such a term seems even more offensive than "paid consultant" by possibly trying to take the reader for a fool.”

For example, “…the author of the Grand Rounds in JAMA [Journal of the American Medical Association] discloses that she receives funding "through research grants to her university" from Pfizer, for which, she also discloses, she "has served as an unpaid consultant."

In other words, what the “unpaid” part merely means is that she wasn’t paid directly for work done for the company. The money was funneled to her indirectly through research grants and other monies given to her employer, the university.

But back to the DSM workgroups. New definitions of psychiatric disorders can provide a financial windfall for a drug company, which suddenly has a whole new group of customers defined as having the disorders for which their drugs are indicated. So of course they do anything they can to influence these definitions in ways that feed their bottom line.

This strategy is part of a two-pronged attack that influences clinicians without the drug companies appearing to have had any involvement at all.  Covertly, they are pulling strings behind the scenes. 

The second part of the attack comes through the production of treatment guidelines, which are published by various professional organizations. (I touched on this in my post about PTSD treatment guidelines about guidelines that prohibit a class of drugs effective in panic disorder with no mention being made of the widespread co-occurrence of panic disorder in PTSD sufferers).

The involvement of big Pharma companies in the production of treatment guidelines, and the biases this produces, is well known.  The Washington Post article lists some of the problems this has created:

“But the associations and medical societies that develop these guidelines ... quite often  receive money from pharmaceutical companies, often through advertising at conferences and sometimes through outright grants for developing the guidelines. In recent years, those relationships have come under sharp criticism:

■ Guidelines written by the National Kidney Foundation and sponsored by the drugmaker Amgen effectively raised the recommended doses of the company’s drug. Those higher dosing targets are now considered unsafe. Eleven of the 16 members of the panel that approved the guidelines were found to have financial connections from the affected drug makers — they reported receiving consultant pay, speaker fees or research funds, according to a published paper by Daniel Coyne, a professor of medicine at Washington University.

■ An analysis last year of 17 guidelines used in cardiology indicated that 56 percent of members of work groups reported a conflict of interest, according to an investigation published in the Archives of Internal Medicine. A related study showed that about half of the treatment guidelines in cardiology were based on doctors’ opinions rather than more substantial evidence.

■ An international conference on early breast cancer that was issuing guidelines expressed a preference for a group of expensive proprietary drugs that appear to be no better than others in terms of patient survival. Twenty-four of 43 members on the panel, including both chairs, had financial ties to the makers of the proprietary drugs, according to a published account by Päivi Hietanen, the medical editor of the Finnish Medical Journal."

In the Washington Post article, APA chief executive James H. Scully Jr. was quoted as defending the APA’s conflict of interest policy for the DSM task forces.  He said that  said that if no financial ties were permitted, many knowledgeable psychiatrists would be excluded because so many university studies are funded by pharmaceutical companies.  He said The APA sought to have a balance:

“Our dilemma is: Do we not have the world’s experts, or do we have limits and disclosures [of their financial ties]... You could say absolutism should prevail, but then where are you going to get your experts?”

The Post article counters: It’s hardly impossible to find medical experts without financial ties to industry, however, according to research. A survey of academic researchers, for example, showed that 36 percent of full professors at medical schools report no financial connections to the industry in the previous year. The idea ‘that every expert in the field has industry relationships is not supported by the data,’ said Eric Campbell, a medical professor at Harvard University, who conducted the surveys. Instead, he said, such claims are rather ‘propagandist in nature.’”

No kidding.

Are Psychiatrists Who Criticize New Proposals for the Diagnostic Manual Dangerous?

Allen Frances, MD

Psychiatrist Allen Francis was chairman of the task force that developed the last edition of diagnostic Bible in Psychiatry, the DSM.  It was the fourth edition and came out in 1994.  As someone intimately involved in the process of formulating changes in the diagnostic nomenclature, he became concerned when he began to notice that the changes he helped create in the DSM were beginning to lead to the "upcoding" or expanding of psychiatric diagnoses to include normal but problematic variants of human behavior.  

With widespread changes in insurance plans that paid far more to psychiatrists for medicating many so-called "biological" disorders than for providing psychotherapy for what used to be called "neuroses" or "acting out," along with major pushes by pharmaceutical companies to expand the indications of their lucrative new drugs to larger and larger numbers of people, more and more people were being medicated with potentially toxic drugs for what are, for all intents and purposes, disorders of behavior and relationships.  This has been a major theme of this blog.

[For clarification, I should note that diagnoses in psychiatry are not based on the causes of disorders (etiology), but on descriptions of the typical behavior, emotional and cognitive attributes that are seen in various syndromes. A syndrome is a group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition. These characteristics tend to cluster together and can be distinguished from one another using epidemiology (the study of the risk factors, distribution, and control of disease in populations) and the presence of similar descriptions throughout history, as well as through the combined presence of a group of particular symptoms with the absence of other co-occurring symptoms and attributes.

The classification of psychiatric disorders is not based on causes because, in many if not most cases, we have not been able to track down an exact cause (due to our limited understanding of the brain and its relationship to behavior and mentation), and also because almost all psychiatric disorders have multiple biological, psychological, and socio-cultural risk factors.  In fact, "risk factors" rather than "causes" is probably the preferred term that should be used in psychiatry, because there are no necessary or sufficient antecedents to the development of the various disorders.

Nonetheless, all psychiatric diagnoses are not created equally.  Some - like schizophrenia - have been well described, and consistently so, for hundreds of years in multiple cultures.  The defining characteristics of many other conditions, like ADHD for example, are sort of voted on by committees of "experts," many of who have conflicts of interest because they get money from the pharmaceutical companies.  In those cases, the decisions about diagnoses are sort of like the ones made by the Council of Nicaea, during which various Christian Bishops literally voted on which of the many Gospels were the word of God, and which were not].

Dr. Francis has become a leading critic of the plan to come out with a newer edition of the diagnostic manual, to be called the DSM-5 (I guess roman numerals have become passe).  He worries that upcoding will get even worse with many of the new proposals, and medications even more widely mis-prescribed.  And not just by psychiatrists.  80% of anti-depressants, for example, are prescribed by primary care  physicians, and most stimulants by pediatricians.  


And just wait and see what happens if psychologists ever get prescribing privileges, which they desperately seek!  Psychotherapy as we know it may disappear completely.

I also think that, since for most psychiatric conditions we do not know a whole lot more about the causes of the various psychiatric conditions than we did when the DSM-IV was published, coming out with a new diagnostic manual is premature to say the least. Also, since the current research base uses current definitions, changing all of the definitions can be very destructive to building on our scientific knowledge in the future.  


Some of the suggested changes seem to center around the idea of "spectrum" disorders, in which various disorders are grouped together because some of the symptoms sort of look alike.

Just recently, the American Psychiatric Association (APA) recruited a new public relations spokesman, formerly of the US Defense Department, who was quoted as saying that "Francis is a 'dangerous' man trying to undermine an earnest academic endeavor."  It sounds like, rather than address the well-thought-out criticisms of Dr. Francis, the APA has elected to circle the wagons defensively and engage in ad hominem attacks. 

In response, Dr. Francis posted a rebuttal in a psychiatric newspaper.  Allow me to quote his very cogent response:  

"The piece in Time Magazine manages to raise again the silly APA suggestion that my objections to DSM-5 are motivated by a feared loss of royalties. Let’s set the record straight—hopefully for the last time. The royalties on my DSM IV handbook are about $10,000 a year—not at all commensurate with all the time I have spent trying to protect DSM-5 from making all its repeated mistakes.

"My motivation for taking on this unpleasant task is simple—to prevent DSM-5 from promoting a general diagnostic inflation that will result in the mislabeling of millions of people as mentally disordered. Tagging  someone with an inaccurate mental disorder diagnosis often results in unnecessary treatment with medications that can have very harmful side effects. I entered the DSM-5 controversy only because I had learned painful lessons working on the previous three DSM’s, seeing how they can be misused with serious unintended consequences. It felt irresponsible to stay on the sidelines and not point out the obvious and substantial risks posed by the DSM-5 proposals.

"I don’t consider myself a dangerous man except insofar as I am raising questions that seem dangerous to DSM-5 because there are no convincing answers. My often repeated challenge to APA—provide us with some straightforward answers to these twelve simple questions:

1.   Why insist on allowing the diagnosis of Major Depressive Disorder after only two weeks of symptoms that are completely compatible with normal grief?

2.   Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just 15 years?

3.   Why include a psychosis risk diagnosis which has been rejected as premature by most leading researchers in the field because it risks exacerbating what is already the shameful off-label overuse of antipsychotic drugs in children?

4.   Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks encouraging the inappropriate antipsychotic drug prescription for kids with temper tantrums?

5.   Why sneak in Hebephilia under the banner of Pedophilia when this will create a nightmare in forensic psychiatry?

6.   Why lower the threshold for Generalized Anxiety Disorder and introduce Mixed Anxiety Depression when both of these changes will confound mental disorder with the anxieties and sadnesses of everyday life?

7.   Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

8.   Why label as a mental disorder the experience of indulging in one binge eating episode a week for three months?

9.   Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

10. Why not delay publication of DSM-5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage?

11. Why should we accept ambiguously worded DSM-5 diagnoses whose reliability barely exceeds chance?

12. And most fundamental: Why not allow for an independent scientific review of all the controversial DSM-5 changes identified above—proposed by 47 mental health organizations as the only way to guarantee a credible DSM-5? What is there to hide and what harm is done by additional careful review?

"If I am a dangerous man, it is because I am exposing DSM-5’s carelessness and thus putting at risk APA’s substantial publishing profits. During the past 3 years, I have made numerous attempts, private and public, to warn the APA leadership of the troubles that lie ahead and to implore them to regain control of what was clearly a runaway DSM-5 process.

"This has had no real effect other than delaying publication of DSM-5 for a year and the appointment of an oversight committee that turned out to be toothless. I am reduced now to just one means of protecting patients, families, and the larger society from the recklessness of the DSM-5 proposals—repeatedly pointing out their risks in as many forums as possible."

Well said, my good man.  It seem to me that the APA is at risk of being dangerous, not Dr. Francis.

Parental Alienation Disorder

In my May 20th post, Babies and Bathwater, I remarked how I am constantly amazed by how people can take obviously extreme positions and then argue vehemently for them. I came across another example of this in a column and a series of letters to the editor in Clinical Psychiatric News about something called Parental Alienation Syndrome or even Parental Alienation Disorder (PAD). The original column was by Dr. Paul J. Fink, M.D.

A group called Fathers & Families has been organizing a letter-writing campaign urging the APA to list PAD as a disorder in the DSM (https://nationalparentsorganization.org). They define PAD as "a disorder that arises primarily in the context of divorce/separation and/or child-custody disputes. Its primary manifestation is the child’s campaign of denigration against a parent, a campaign that has no justification. It results from the combination of a programming (brainwashing) of a parent’s indoctrinations and the child’s own contributions to the vilification of the targeted parent. Parental Alienation is also sometimes referred to as 'Parental Alienation Disorder' or 'Parental Alienation Syndrome.'”

In other words, this group wants the APA to recognize that sometimes, in a nasty divorce, one parent (usually the custodial parent) turns the child against the other parent so that the second parent can not have a normal relationship with his or her child. The group recognizes that PAD may be more of what is referred to as "relational disorder" in the DSM rather than a true psychiatric illness. However, they believe that including it in the DSM will "...increase PA’s recognition and legitimacy in the eyes of family court judges, mediators, custody evaluators, family law attorneys, and the legal and mental health community in general. Adding PAS would also "spur insurance coverage, stimulate more systematic research, lend credence to a charge of parental alienation in court, and raise the odds that children would get timely treatment.”

Since the custodial parent is even now still more frequently the mother after a divorce, Fathers & Families was organized originally to advocate for the rights of fathers, and to protest the way fathers are often portrayed negatively in the media.

In nasty divorces, one tactic that is sometimes employed - and quite effectively - to keep the father out of the child's life is to falsely accuse the father of having sexually or physically abused the child. Children under adult influence can in fact easily be manipulated into making accusations that are not true. (For reasons I discuss in my book, in the infrequent incidents when adults make false accusations of having been abused as children, that is an entirely different story. I know this remark might generate some flack from the False Memory Syndrome Foundation types, but I will not get involved in a debate about it on this post).

Such false accusations are clearly reprehensible. However, a big problem is created. How do we know that the accusations are indeed false? Perhaps the reason the mother wishes to keep the child away from the father in the first place is that he is actually abusive. The abusive father might then turn around and falsely accuse the mother of making up allegations of abuse in order to cause PAD.

Dr. Fink deservedly got into some hot water for saying in a column advocating the position that PAD is junk science that those advocating inclusion of PAD in the DSM "don't like to be interfered with when they are sexually abusing their children." I am amazed that the editor of the newpaper allowed that in. Dr. Fink apologized in response to the critical letters to the editor that followed the publication of his column.

His statement is clearly one of those extreme positions I decry, although hopefully he was sincere when he retracted it. How can anyone think that parents never turn their children against an ex, or that any father who thinks this is happening is a pedophile?

Thankfully, the Fathers & Families group does not, at least at first glance, seem to go to the opposite extreme. They say on their website, "as we’ve often noted, simply because false claims of Parental Alienation can and are made doesn’t mean that Parental Alienation doesn’t exist or isn’t a problem."

Clearly, all claims of abuse and PAD (or just parental alienation if you object to its being included in the DSM), should be investigated on their own merit with out a pre-determination of who is telling the truth and who is lying. In nasty divorces, all bets are off.