Labelling Children as Abnormal and Issues with Treatment in the Case of ‘America’s Medicated Kids’
The Diagnostic and Statistical Manual IV (DSM-IV) details mental illnesses and provides codes and criteria on which diagnoses can be made (American Psychiatric Association, Task Force on DSM-IV, 1994). Abnormality is never defined with DSM-IV but it crops up many times in the assessment of individuals. There is a need to define normality in order to be able to know when abnormality exists and this is what Gross refers to as the implicit assumption that is it possible and meaningful to draw the line between normal and abnormal (Gross, 1996 p.786) Normal is average; it is the accepted behaviour and actions of a given society. Giftedness is also considered abnormal as any deviation from ideal mental health can be considered abnormality (Gross, 1996 p.562-3)
The theory of mind is a label for the conceptual system and represents the mental states that we each have, and impute upon others (Perner & Lang, 2000 p. 150).
Within this executive function are the processes that control behaviour, and it is these that are believed to underlay the abnormalities that children can be labeled with. However there is a developmental progression for executive function and it could be argued that children do not, by definition, have this progression to a sufficient degree to be able to define normal and abnormal.
Definitions of mental illness focus on the pathological aspects – e.g. a diagnosis of a ‘psychopathology’ (Gross, 1996 p.789). Therefore if a child is labelled as mentally ill or abnormal then they have received a clinical diagnosis with an associated stigma. The DSM-IV includes a specific section for disorders diagnosed within childhood, with behavioural and emotional disorders forming the bulk of these, yet states that there is no clear distinction between childhood and adult disorders in some of the cases (DSM-IV, 1994 p.37)
In Louis Theroux’s recent documentary ‘America’s Medicated Kids’, there were a number of children who had multiple medications. Obsessive compulsive disorder, anxiety and attention deficit disorder were all being treated in some children. It is true that there are documented associations between such disorders (Peterson, Pine, Cohen, & Brook, 2001 p.686), but when viewing the program it did appear as if the medication was an excuse; the cosmetic psychopharmacology that critics suggest is swamping America. Medication is cited as being beneficial in restoring faith in the medical profession (Prentice, 1996 p.257), perhaps as the issuing of a prescription indicates [falsely?] that the physician understands what is wrong in order to be able to issue that prescription.
Attention deficit disorder was a prominent issue raised in the documentary. It is a clinically diagnosable disorder characterised by a triad of symptoms involving persistent age-inappropriate problems of hyperactivity, inattention and impulsivity (Sahakian & Mehta, 2001 p.77). It is the most common psychiatric disorder of childhood affecting up to 1 in 20 children. Stigmas are known to become self-fulfilling prophecies (Jussim, Palumbo, Chatman, Madon, & Smith, 2000), so if adults and other consistently treat someone in a particular way, then they will act that way as any deviation from the expected behaviour is not noted. This is particularly the case when considering that value judgments for the basis of mental health, and these are defined by the individuals who construct them (Gross, 1996). I would say children who are labelled abnormal will come to believe that all of their actions are abnormal; labelling excuses actions as the individual has been told they cannot act normally, so doesn’t.
In Louis Theroux’s documentary, the wisdom of a 6 year old boy on anti-depressants was queried but the parent was adamant that there was a substantial improvement in behaviour as a result. A US Task force report on the use of medication in childhood highlighted that many psychoactive drugs are used for considerably broader age ranges than those deemed effective (Barkley et al., 1990 p.1). Psychopathological disorders of childhood are not identical with those of adulthood so cannot be approached in the same way (Barkley et al., 1990 p.5), however, childhood mental illness often predisposes the individual to develop adult mental illnesses such as substance abuse, poor social engagement and antisocial personality disorder (Sahakian & Mehta, 2001 p.78).
In the program it was highlighted the medications are tested for safety and efficacy on adults, and a 6 year old has a massively different physiology than an adult, so the medication could have long term effects about which they may be unaware. The labeling as abnormal could mean that any side effect arising from the medication could be viewed as a facet of the initial disorder. This is a known issue with antipsychotic drugs such as chlorpromazine, which can cause motor disturbances and uncontrollable movements (Kandel, Schwartz, & Jessell, 1995 p.482). Some children would be blamed as fidgety and unable to keep still when the medication could be the cause. Likewise there are critical periods within the brains development that require critical sensory experiences for the development to progress appropriately (Kandel, Schwartz, & Jessell, p.483). If the child is medicated away from being able to experience sensory inputs then their development could be impaired, through no fault of their own.
A viable alternative to medication is the use of psychological therapies, but the only way in which these can be effective is for the patient to have insight into the problem (Prentice, 1996 p.259). One child within the program was provided with an emotion thermometer to use; to indicate the degree to which their emotions were running high, in an effort to be able to control them after recognizing that a problem existed. Whilst the child was also medicated, it is this kind of intervention that can provide a long-term solution to causes of the behavioural issues, rather than merely treating the symptoms.
American Psychiatric Association. Task Force on DSM-IV. (1994). DSM-IV: Diagnostic and statistical manual of mental disorders.
Barkley, R. A., Conners, K., Barclay, A., Gadow, K., Gittelman, R., Sprague, R., et al. (1990). Task force report: The appropriate role of clinical child psychologists in the prescribing of psychoactive medication for children. Journal of Clinical Child Psychology, 19(Suppl.), 1-38.
Gross, R. (1996). Psychology, the science of mind and behaviour (3rd ed.). London: Hodder & Stoughton.
Jussim, L., Palumbo, P., Chatman, C., Madon, S., & Smith, A. (2000). Stigma and self-fulfilling prophecies. In T. F. Heatherton, R. E. Kleck, M. R. Hebl & J. G. Hull (Eds.), The social psychology of stigma (pp. 374-418) The Guilford Press.
Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (1995). Essentials of neural science and behavior. Norwlk: McGraw-Hill/Appleton & Lange.
Perner, J., & Lang, R. (2000). Theory of mind and executive function: Is there a developmental relationship. In S. Baron-Cohen, H. Tager-Flusberg & D. J. Cohen (Eds.), Understanding other minds: Perspectives from developmental cognitive neuroscience (2nd ed., pp. 150-181). New York, NY: Oxford University Press.
Peterson, B. S., Pine, D. S., Cohen, P., & Brook, J. S. (2001). Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. Journal of the American Academy of Child & Adolescent Psychiatry, 40(6), 685-695.
Prentice, P. (1996). Therapeutic approaches. In M. Cardwell, L. Clark & C. Meldrum (Eds.), Psychology for A level (1st ed., pp. 256-279). London: Collins Educational.
Sahakian, B. J., & Mehta, M. (2001). Attention deficit disorder. In P. Winn (Ed.), Dictionary of biological psychology (pp. 77-79). London: Routledge.