ASSOCIATION FOR THE ADVANCEMENT OF PHILOSOPHY AND PSYCHIATRY
21ST ANNUAL MEETING
SAN FRANCISCO, CALIFORNIA
MAY 16 AND 17, 2009
The Fairmont Hotel, 950 Mason Street, San Francisco, California, 94108
Conference is free and no registration is necessary.
THEME: PHILOSOPHICAL ISSUES IN CHILD AND ADOLESCENT PSYCHIATRY
Co-directors: Christian Perring, Ph.D. and Lloyd Wells, Ph.D., M.D.
Note that there may be changes to the scheduled times of talks.
Each presentation will be 20 minutes long, followed by 10 minutes of discussion. Time limits will be strictly enforced.
Saturday, May 16, 2009
8 AM: Opening Remarks: Christian Perring
NOSOLOGY (Moderator: Christian Perring)
8:15 Child and Adolescent Mental Disorders: Conceptual and Diagnostic Issues – Fayez El-Gabalawi
8:45 Moral and Non-moral Values in DSM – IV Conduct Disorder – John Sadler
9:15 BREAK
9:45: NOSOLOGY (Moderator: John Sadler)
9:45 Conduct and Oppositional-Defiant Disorders: Pathologizing the Normal – Sara Worley
10:15 Bad Behavior: Pathologizing Difficult Children – Allison Mitchell
10:45 The Concept of Disease and our Responsibility for Children – Leen De Vreese
11:15: Rethinking Attention-Deficit Hyperactivity Disorder – Michelle Maiese
11:45 LUNCH
1:30 PM INVITED PANEL: Child Bipolar Disorder:
Nassir Ghaemi, Chair
Solay Unal, M.D.
Bhanukrapresh Kolla, M.D.
Nassir Ghaemi, M.D.
Anna Yurchenko, M.D.
3:00 PM: Break
3:15 PM IDENTITY ISSUES AND ETHICS (Moderator: Nancy Potter)
3:15 Erikson’s Concept of Adolescent Identity: a Philosophical Perspective – Majid Amini
3:45 Adolescence, Immoral Individualism, and the Biomedical Model – Elizabeth Throop
4:15 Discussion
4.30 ADJOURN
Sunday, May 17, 2009
8:45 AM: MISCELLANEOUS ISSUES (Moderator: James Phillips)
8:45 Ethical Issues in Child Psychiatry: Kindling, the looping effect, and bipolar disorder – Peter Zachar
9:15 I Am the Boss of You – Peter Brown
9:45 Kraepelin’s Perspective on Schizophrenia as a Model for Psychiatric Diagnosis – Benjamin Spinner
10:15 AM: Break
10:45 AM: PERSPECTIVES (Moderator: Peter Zachar)
10:45 Perspectives in Child and Adolescent Psychiatry: a Pragmatist Approach – Jorid Moen
11:15 Healthcare Inequalities, Transgenerational Trauma, and Children -- Christy Rentmeester
11:45 The Mind Outside – Some Reflections on Child Psychiatry, Family Therapy, and the Cartesian Inner Mind – Stuart Kaplan
12:15: LUNCH
1:30 P.M.: REASONING AND EPISTEMOLOGY (Moderator: Jennifer Hansen)
1:30 Developing a Case-Based Program Addressing Errors in Reasoning in Child and Adolescent Psychiatry – Marin Gillis and Melissa Piasecki
2:00 The Epistemology and Ethics of Psychiatric Neural Imaging in Children and Adolescents – Robyn Bluhm
2:30 p.m.: BREAK
2:50 P.M.: RESEARCH ISSUES (Moderator: Lloyd Wells)
2:50 Antidepressant-Induced Suicide: a Hypothesis for Paradoxical Clinical Responses – Douglas Heinrichs
3:20: The Right of Children to Equal Participation in Research – Adrienne Van Nieuwenhuizen
3:50 Legal and Ethical Issues Arising from the Epistemic Status of Mental Diagnosis in Children – Samantha Godwin
4:20 Closing Remarks: Lloyd A. Wells
4:30 End.
Participants and Abstracts
Majid Amini, Ph.D., Associate Professor of Philosophy, Department of History & Philosophy, Virginia State University mamini@vsu.edu
Erikson’s Concept of Adolescent Identity: A Philosophical Perspective
There is an abundance of research literature on the psychology of adolescent identity in various contexts ranging from juvenile delinquency to acculturation of immigrant adolescents. Yet, despite the widespread usage of the phrase “adolescent identity”, there is a dearth of conceptual clarification of the notion. The concept came into prominence through the pioneering efforts of Erik Erikson. His works, especially Childhood and Society and “The Problem of Ego Identity”, are, in one commentator’s appraisal, some of the “most important contributions of Erikson on identity formation and adolescence”. (Browning, p. xiii) Indeed, Erikson’s innovative theoretical framework for identity formation during adolescence has been elevated to the honorific status of the Ego Identity Status Paradigm. (Adams, p. 3) In the foreword to the first edition of Childhood and Society, Erikson describes his reflections on these issues and the subsequent formulation of an explanatory structure for them as “a conceptual itinerary.” (1963, p. 17, original emphasis) Correspondingly, the purpose of this paper is to trace Erikson’s conceptual itinerary in the course of his ruminations over the notion of adolescent identity through the prism of a conceptual critique. Inevitably there will not be any empirical discussion of Erikson’s ideas, whether sympathetically through the investigations of, for example, James Marcia (1966, 1976 & 1980) or critically through the studies of, for instance, David Hershenson (1967), Cote & Levine (1988), and Waterman (1988). On the basis of this conceptual perspective, the paper is consequently divided into the following three sections: (1) Concept of Adolescence/Adolescent; (2) Concept of Identity; and, finally, (3) Erikson’s Concept of Adolescent Identity. In the first section, it will be argued that Erikson’s delineation of adolescence suffers from two serious problems that may prompt one to cast a shadow of disbelief on the very notion of adolescence. First, adolescence is delimited relationally by Erikson in terms of a transitional phase between childhood and adulthood instead of having a sui generis definition and status. Secondly, Erikson’s functional rather than definitional characterization of adolescence in terms of identity formation runs the risk of creating a vicious circle if one subsequently attempts to explain the notion of identity itself in terms of what is supposed to be achieved during adolescence. In the opening remark of the prologue to Youth: Identity and Crisis, Erikson suggests that to ‘review the concept of identity means to sketch its history.’ (p. 15) However, in the second section, it will be argued that in his historical review of the notion of identity Erikson is doubly sidetracked. First, he focuses on the concept of “identity crisis” instead of identity itself. And, secondly, he confines his attention to the three decades subsequent to the World War II instead of the prolonged and chequered track record of identity in history thereby neglecting some of the important conceptual lessons from the historical discussions on the concept of identity. Finally, in the third section, it will be argued that Erikson’s account of adolescent identity is, à la John Locke’s theory of personal identity, a psychological reductionist theory and, as such, suffers from the same set of classical problems that Lockean accounts of personal identity suffer. Namely, (i) on such accounts there is no genuine continuation of the sameness of self over time, and (ii) psychological reductions of identity are guilty of explanatory circularity.
References
Adams, G. R. (1992). Introduction and Overview. In G. R. Adams et al. (Eds.), Adolescent identity formation (pp. 1-8). Newbury Park: Sage Publications.
Browning, D. L. (2008). Preface. In D.L. Browning (Ed.). Adolescent identities: A collection of readings (pp. xi-xiv). New York and London: The Analytic Press.
Cote, J.E., & Levine, C. (1988). A critical examination of the ego identity status paradigm. Developmental Review, 8, 147-184.
Erikson, E. H. (1963). Childhood and society (Second Edition). New York: Norton.
Erikson, E. H. (1968). Youth: Identity and crisis. New York: Norton.
Erikson, E. H. (2008). The Problem of Ego Identity. Reprinted in D.L. Browning (Ed.), Adolescent identities: A collection of readings (pp. 223-240). New York and London: The Analytic Press.
Hershenson, D. B. (1967). Sense of identity, occupational fit, and enculturation in adolescence. Journal of Counseling Psychology, 14, 319-324.
Locke, J. (1982). An Essay Concerning Human Understanding. Oxford: Clarendon Press.
Marcia, J. (1966). Development and validation of ego identity status. Journal of Personality and Social Psychology, 3, 551-558.
Marcia, J. (1976). Identity six years after: A follow-up study. Journal of Youth and Adolescence, 5, 145-160.
Marcia, J. (1980). Identity in adolescence. In J. Adelson (Ed.), Handbook of adolescent psychology (pp. 159-187). New York: John Wiley.
Waterman, A.S. (1988). Identity status theory and Erikson’s theory: Communalities and differences. Developmental Review, 8, 185-208.
Bluhm, Robyn, Ph.D., Assistant Professor, Co-Director of the Institute for Ethics and Public Affairs, Department of Philosophy and Religious Studies, Old Dominion University RBluhm@odu.edu
The Epistemology and Ethics of Psychiatric Neuroimaging in Children and Adolescents
Despite a proliferation of studies examining the neurophysiological correlates of psychiatric disorders in adults, relatively little neuroimaging research has been conducted in pediatric patients. Downie and Marshall (2007) note that neuroimaging has provided insight into neurological disorders in children, including epilepsy and cerebral palsy, and that many investigators believe that similar advances in our understanding of behavioral and cognitive disorders are possible. Thus, there is good reason to think that the field of child and adolescent psychiatry may benefit from neuroimaging research. Yet this area of medicine is confronted with a number of ethical and epistemological issues that make the interpretation of study results more difficult than in similar research in adults (which is itself far from straightforward). Both Downie and Marshall (2007) and Hinton (2002) recognize that the relative lack of data on “normal” brain function in children, the lack of knowledge of how neural and cognitive functions develop throughout childhood and adolescence, and limited evidence for the validity of many diagnostic modalities in child psychiatry all present challenges to pediatric neuropsychiatry.
In this paper, I examine these issues more closely, drawing on two examples of research in developmental neuroimaging to clarify the epistemological challenges facing researchers who hope to increase our understanding of childhood psychiatric disorders. These examples are: (1) the study of the development of so-called “intrinsic” connectivity networks (particularly the default network), which are sets of brain areas that show correlated spontaneous oscillations when we are resting quietly in the scanner (as opposed to performing cognitive tasks) and (2) the investigation of the development of cognitive flexibility (the ability to adapt to changing task demands) throughout childhood and early adolescence. I will describe the current state of pediatric neuroimaging research in each of these examples and draw out the epistemological lessons that each case presents for psychiatric research. The first of these examples is interesting because it shows that, even in cases where we can remain agnostic about the function of a neurophysiological process (specifically, here, connectivity among a number of brain regions when an individual is at rest), we cannot readily interpret “aberrant” brain activity that may be observed in children diagnosed with a psychiatric disorder unless we have a great deal of information about normal development. The second example shows that linking neural activity with a behavior (in this case, with performance on a cognitive task, but the problems are the same if we look at such indicators of psychiatric conditions as emotional experience and behavioral problems) is only possible if we have a well-developed theory of the behavior itself. I will also briefly consider the additional issues that arise when the research is to be conducted on a condition such as depression, in which both the diagnostic criteria and the neural activity thought to be relevant to the condition may be importantly different than in adults. Although it is common to use cognitive tasks to investigate alterations in neural activity in adults with a psychiatric disorder, little can be inferred from these studies in interpreting the results of similar work in children and adolescents.
Finally, having examined the epistemological challenges faced by psychiatric neuroimaging research in a pediatric population, I will then return to a consideration of the ethical implications of these problems. I will focus in particular on what kinds of solutions to these problems will be required in order for neuroimaging research to play a significant role in our understanding of childhood psychiatric disorders. A clear understanding of what we can infer from the results of neuroimaging studies is required – both epistemologically and ethically, before we can consider these studies to provide even potentially useful information for diagnosis, prognosis or treatment.
References:
Downie, J and Marshall, J. Pediatric neuroimaging ethics. Camb Q Healthcare 2007;16:147-160.
Hinton VJ. Ethics of neuroimaging in pediatric development. Brain Cogn 2002;50:455-468.
Peter Brown MD FRCPC, Signal Mountain, TN PBrown@UNUM.COM
I am SO the Boss of You: Father-Son Narratives and the Development of Self Regulation
"The Moon is empty tonight." (Zachary, age 18 months)
"I know: Don't tell Mom." (Zachary, age 23 months)
"Stop in the name of the Lord!" (Benedict, age 5 years)
"I know: Don't tell Mom." (Benedict, age 10 years):
Psychodynamic models have traditionally focused on the central role of personal narrative, typically dating back to childhood, in the pathogenesis, diagnosis and eventual treatment of psychiatric disorders. Emerging multidisciplinary research gives us a more detailed picture of the way in which personal narratives develop and the connection of those narratives with self regulatory behavior.
Narrative is conceptualized as a dynamic and interactive process that promotes joint attentional regulation. This presentation will focus on the evidence for the neurodevelopment of ‘collaborative competency’:1) shared attentional processes, and 2)the capacity to flexibly change point of view in personal narrative. Current research will be presented within the context of, and illustrated by, two, brief, case illustrations.
A recent model of the development of self regulatory capacity points to the key role played by maturing attentional processes (Posner and Rothbart 2007, Berger at al, 2007).Similarly, joint attentional processes are theorized as central to cognitive and linguistic development in childhood (Tomasello, 1999). The ability to develop effective mental representations depends on a "ratchet effect" based on the development of two separable but complementary cognitive processes: i) control of attentional resources; and ii) the capacity to identify with others. These processes form the basis of the interpersonal attunement that underlies storytelling. They also permit and promote the development of various competencies: linguistic, cognitive and executive function. In turn, the elaboration of coherent personal narrative intertwines with the development and expression of personal values (Sadler, 2002).
A brief review of the literature will focus on the evidence of impaired attentional processes underlying deficits in self regulation and the results of clinical trials that examine the effects of different treatment modalities in improving attentional function and self regulatory capacity in children. The emerging model emphasizes the continuous interaction between social and biological processes and has significant implications for psychiatric diagnosis and treatment planning in children. In particular, the vexed, and vexing, question of the high comorbidity rates associated with the DSM nosology will be considered.
Leen De Vreese, PhD. Centre for Logic and Philosophy of Science, Ghent University, Belgium Leen.DeVreese@UGent.be
The concept of disease and our responsibility for children.
Given that our understanding of what a “disease” is, in important ways influences our way of behaving towards what we conceive of as “diseased people”, philosophers have an important role to play in the analysis of the conceptualization of the notion “disease” and the establishing of a justified image of the meaning of the label “disease”. This might also affect our children, both those that are prone to be labelled “diseased” as also those that might not, but will nonetheless base their stance towards “diseased” children on their image of the notion “disease” and might carry this over to their adulthood.
In my talk, I will defend a pluralistic view on the concept of “disease”. According to this view, physical and mental diseases cannot be clearly separated but should be situated on a same continuum of kinds of diseases, although both classes of disease might tend towards the opposite extremities of this continuum. Such a continuum approach opposes the mainstream in the current philosophical debate on the concept of “disease”. In this debate, the search for a single, monolithic definition of “disease” still stands on the foreground. Further, the concept of a “mental disease” is often interpreted as being categorically different from the notion of a “physical disease”. And lastly, the social constructivist approach to the concept of “disease” is in this debate often seen as one totally opposing the biological basis approach. This state of affairs is astonishing given the diversity of diseases and the different degrees of influence of sociocultural beliefs on disease conceptualization. In as far as philosophers aim at a descriptive view on what the notion of “disease” covers, they would better consider an account in the line of psychologist Nick Haslam’s account of mental disorders (Haslam 2002). He recognizes different kinds of mental disease causes as defining different kinds of mental diseases (“kinds of kinds”) in which sociocultural ideas can further play a role to different degrees. The continuum approach that I will propose is based on this view of Haslam, but broadened to the concept “disease” in general in order to include physical diseases. I will argue that such an account stands much closer to medical practice, including psychiatry. And, what is equally important, such an account also furthers a more nuanced and more appropriate view on what it means to be “diseased”. Such a view is currently lacking, at least in philosophy of medicine and psychiatry, but probably as well among the lay public and maybe even among clinicians, as recent research suggests.
In the second part of my talk, I will go deeper into some of the problems that might result from an over-simplified view on the notion of “disease”, in order to clarify the need for a more nuanced view. I will briefly highlight problems such as medicalization and essentialistic thinking in health matters, the stigmatization of “diseased” people, ethical problems of e.g. genetic screening, and the building on too high expectations for scientific evidence. I will use ADHD in children as a central example to make these problems concrete, and to show how taking a more nuanced stance to what is and what is not a “disease” can make us look at, for example, ADHD in a more appropriate perspective. Such a perspective will not amount to denying ADHD as a “real disease”, nor to overemphasize its possible biological basis, but will enable one to appreciate ADHD as a disease of a certain kind within a range of different kinds of diseases.
In a last part of my talk, I will reflect on the importance of all this in regard of our responsibility for children. I will argue that children might profit from a more nuanced view on “diseases” at present - as subjects of our actions - and in the future - as actors themselves. To conclude, the image of the concept of “disease” which is currently prominent, at least in philosophy of medicine and psychiatry, is not noncommittal and might underlie problems that also affect our children in different ways.
Reference
Haslam, Nick (2002), “Kinds of Kinds: a conceptual taxonomy of pscyhiatric categories,” Philosophy, psychiatry & psychology, vol. 9, nr. 3, pp. 203-217.
Fayez El-Gabalawi, MD, Clinical Assistant Professor of Psychiatry, Thomas Jefferson University ElGabalF@einstein.edu
Over the last twenty years, since my residency in child psychiatry, I have experienced the significant transformation of the field from the psychoanalytic orientation to the biological and medical orientation.
The increasing number of children (including preschoolers) and teenagers who are receiving psychotropic medications without clear evidence of efficacy or lack of risk has caused a considerable alarm. The recent dramatic rise of youngsters diagnosed with mental disorders, especially Bipolar and Attention Deficit Disorders, has raised legitimate questions regarding the validity and specificity of the psychiatric diagnosis in child psychiatry. I argue that child psychiatry is facing a crisis of self-definition and credibility in its theoretical formulations and clinical practices. It needs to develop its own conceptual framework of psychopathology that guides diagnosis and research and derives effective and safe treatment.
My argument has four parts. First I draw on my clinical experience as a child psychiatrist when significant changes have occurred in the diagnostic and treatment practices as a result of new societal and parental expectations of children, escalating school pressure, and family’s search for concrete explanation and remedy. Practitioners, with few guidelines, and under increasing pressure from third payer parties and admitting hospitals to provide diagnoses and justify treatment, began to extrapolate from adult psychopathology/psychopharmacology, and resort increasingly to the biological/medical model which coincided with the rise of the medication subculture. The second part of the argument is that historical and economic forces have shaped the concept of childhood and adolescence throughout ages (Philppe Aries), continuously modifying societal expectations and demands of youngsters. The philosophical debate about the relationship between the child and society advocated by Rousseau (nature) vs. Locke (nurture) continued to resonate in our recent times. The industrial revolution and the increasing life span (e.g., required large scale schooling system) prolonged the period of adolescence, demanded more equality for women, and delayed age of marriage, resulted in changes in parent-child relationship. The drop in age of onset of puberty (physiological/hormonal) over the last 150 years by about three and half years, may have some effect on the behavior and emotional adjustment.
The third part of the argument is that DSM classification has inherent difficulty particularly in regard to child/adolescent mental disorders. Research data showed that the reliability and validity of child/adolescent diagnoses are low when extrapolated from adult psychopathology.
The current essentialist approach implies that disorders exist as natural entities whose true nature can be discovered, it imposes a categorical nosological construct on the diagnostic process: Each child is diagnosed as either having the disorder or not having it, despite the dimensional descriptive criteria for some disorders. In the fourth part I argue that child psychiatry should have a diagnostic scheme of mental disorders that employs a developmental model of psychopathology, can generate empirical data to develop reliable and valid definitions of child/adolescent disorders, and reflect the different manifestations of psychopathology characteristic of this age group. Treatment should be sensitive to the child developmental needs and family issues. Medication can be beneficial if efficacy is clear, long term negative effects on the developing child are better understood, and only if it is a component of a comprehensive treatment approach.
Marin Gillis, LPh, PhD, Director of Medical Humanities and Ethics, University of Nevada School of Medicine mgillis@medicine.nevada.edu
Melissa Piasecki, MD, Professor of Psychiatry, University of Nevada School of Medicine
Developing a Case-Based Program Addressing Errors in Reasoning in Child and Adolescent Psychiatry
The Institute of Medicine reports that medical error accounts for up to 98,000 preventable deaths a year. (IOM 2000) Other studies show that 15 % of medical diagnoses clinicians make are wrong (Schiff, et al. 2005). Experts who study medical mistakes claim that the majority of errors are due to flaws in physician thinking, not technical mistakes (Bartlett 1998). That is, error is not due to ignorance of facts, or the practice of evidence –based medicine, it is rather a function of faulty reasoning and/or cognitive bias (Groopman 2006; Croskerry 2003). Nowhere is attention to the process of making correct diagnoses more critical than in Child and Adolescent Psychiatry where recent controversies regarding the over-diagnosis of certain diseases, namely ADHD, Bi-Polar Disorder and ASD, profoundly affect public trust in the practice of Child and Adolescent Psychiatry.
We know that critical reasoning skills can be taught. There is substantial evidence that some education interventions are better than others at improving cognitive reasoning skills; in particular those that providing learning skills about critical thinking (Nathanson, et al. 2004). Since diagnostic error generally is a function of faulty reasoning and cognitive bias, and because questions of diagnosis mark one of the controversies in child psychiatry, we think it is critical to reinforce critical reasoning skills in child and adolescent psychiatry, whether it be in the lecture hall or the clinic. We have developed a case-based education project for medical students and residents using examples of clinical reasoning from child and adolescent psychiatry. Our project introduces the concept of metacognition and specifically addresses cognitive bias and fallacious reasoning in medical decision making in Child and Adolescent Psychiatry. We think that learning to think well, to identify and reinforce valid reasoning skills, requires students to develop competency to detect problems in reasoning.
For this presentation, we will describe semi-fictional cases based in Child and Adolescent Psychiatry using the classic cognitive biases recently highlighted by Groopman and Croskerry. The three cases will illustrate the biases of: anchoring error, the tendency to anchor a diagnosis on the first bit of data offered (for example, an abnormal lab); availability error, the tendency to judge the likelihood of a phenomenon by how quickly relevant examples come to mind; and attribution error, which is like stereotyping. In so doing we will also show correlative and distinctive logical errors or fallacies involved in making these errors. In our model, we first introduce students to clinical cases which illustrate specific faulty reasoning and cognitive errors in order to identify specific errors and fallacies. The initial cases provide illustrations of cognitive errors as serve to develop students’ foundation skills is critical thinking as described by Lawrence and colleagues (2008). The illustrative cases are followed by additional clinical cases which students must analyze thinking through a rubric we are developing, a “Think Check.” Again using the framework described by Lawrence, the second set of cases represents higher level skills of analysis and application on concepts.
Medical education must expand beyond factual knowledge, interpersonal skills and application of pattern recognition in order to address medical errors and controversies. A systematic and case based approach to teaching cognitive reasoning skills is our approach to addressing this need in the area of Child and Adolescent Psychiatry.
References:
Bartlett E (1998) Physicians' cognitive errors and their liability consequences. Journal of Health Care Risk Management 18:62-9.
Croskerry P (2002) Achieving quality in clinical decisionmaking: cognitive strategies and detection of bias. Academic Emergency Medicine 9: 1184–204
Croskerry P (2003) The importance of cognitive errors in diagnosis and strategies to prevent them. Academic Medicine 78: 1–6
Gigerenzer G, Selten R (2001) Bounded Rationality: The Adaptive Toolbox. Cambridge, MA: MIT Press.
Groopman J (2007) How Doctors Think. Boston: Houghton Mifflin Company.
Kohn LT, Corrigan JM, Donaldson MS. Eds. (2000) To Err is Human: Building a Safer Healthcare System. Wahsington, DC: National Academic Press.
Lawrence NK, Serdikoff SL, Zinn TE, Baker SC. (2008) Have we demystified critical thinking? In Dunn D , Halonen H, Smith RA. Eds. Teaching Critical Thinking in Psychology: A Handbook of Best Practices. London/New York: Blackwell.
Nathanson C, Paulhus DL, Williams, KM (2004)The challenge to cumulative learning: Do introductory courses actually benefit advanced students? Teaching of Psychology 31: 5-9.
Schiff GD, Kim S, Abrams R, Et al. (2005) Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project . In Advances in Patient Safety: From Research to Implementation Volume Two: Concepts and Methodology. Henriksen K, James BB, Leewin DI. Eds. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality.
Tversky A, Kahneman D (1974) Judgment under uncertainty: heuristics and biases. Science. 185: 1124–31
Samantha Godwin, J.D. candidate at Georgetown University Law Center, sg429@law.georgetown.edu
Legal and ethical issues arising from the epistemic status of mental diagnosis in children
The appeal to scientific authority as the basis for diagnosis poses potential ethical and social dilemmas for child and adolescent psychiatry. The legal status of medical professionals depends on their scientific expertise in organic illness, and while there is every reason to believe that our minds, as they have a physicality in the brain, may suffer from illnesses like any organ, there are unique epistemic problems in investigating those illnesses scientifically.
Neuroscience at best makes correlations between observable brain activity and experienced mental activity. These correlations tend to be merely statistically significant and not one to one, and their causal relationship is difficult to evaluate. Physically induced changes in the brain may affect subjective mental experience, but subjective mental experience may also affect physically observable changes in the brain. Likewise, abnormal behavior and ideation taken to be symptomatic of mental disorder are observable, but their underlying causes are not, so etiological explanations are speculative. Similarly, these abnormal behaviors and ideation may be relieved through drug treatment, but the precise mechanism by which this relief is induced is also unobservable. Analytic flaws exist in nearly any attempt to draw inferences about the preexisting, abnormal mental state from the induction of a more typical mental state. This presents a dilemma: we can have empirical reasons for believing an abnormality is present without any means of empirically verifying theories to explain that abnormality.
The difficulty in empirically testing theories of taxonomy and etiology of abnormal behavior make the epistemological status of discreet mental disorders with specific diagnostic criteria dubious. The fact that one can construct a plausible narrative ascribing specific real world behaviors as symptomatic of a conceptually coherent mental disorder is not itself sufficient to establish that the narrative corresponds to any materially existent discreet condition. Moreover, when applying analytic scrutiny to the diagnostic criteria themselves, many diagnoses can be exposed as necessarily invented fictions in that their taxonomies are categorically incoherent; prime examples in children include ADHD, ODD, Anorexia and Bipolar disorder. To observe and describe abnormal behavior or ideation in a patient does not amount to the ability to recognize and describe symptoms of any materially existent disorder except in the sense that they're symptomatic of fictional narratives concerning those symptoms. This of course is circular and epistemologically incoherent.
If the diagnoses of mental disorder entail potentially fictional accounts of real symptoms, there are major scientific, ethical and legal dilemmas, not just for psychiatrists and philosophers of science but society at large. The most blatant dilemmas are in the justification of imprisonment by committal without the due process afforded in criminal cases, prescription drugs and insurance coverage, and other instances where the presumed scientific and medical basis for diagnoses justifies special status in law. Special social concerns arise with children and adolescents in that the choice of narrative in describing similar behavior potentially depends on age: adults diet, adolescents have ED-NOS, adults are assertive, children are oppositional defiant, adults commit crimes, children have conduct disorders. Problems of epistemology in the diagnosis of adults may be mostly theoretical, but in the treatment of minors the power dynamics involved make the choice of specific diagnoses one with greater social ramifications.
Doug Heinrichs, MD, Ellicott City, Maryland. heinrichs@medscape.com
ANTIDEPRESSANT INDUCED SUICIDE: A HYPOTHESIS FOR PARADOXICAL CLINICAL RESPONSES IN PSYCHIATRY
Antidepressant induced suicidality (AIS), most prominent in youth, is a source of deep concern given growing use of these medications. As evidence accumulated, denial and defensiveness in the psychiatric community was replaced by the search for an explanation for what seemed a shocking aberration. Many hypotheses have emerged. One sort looks to misdiagnosed subgroups, usually bipolar individuals, expected to worsen with antidepressants. Another sort asserts a non-specific energizing action alleged to mobilize suicidal impulses already present in the depressed individual who was too anergic and abulic to implement them before medication. While such explanations may account for some cases, they cannot fully explain AIS. Even with careful retrospective consideration, all instances do not show a misdiagnosis that makes AIS understandable or pretreatment evidence of quiescent suicidal urges. Especially inexplicable is AIS in patients with non-affective disorders and even in normal controls, usually screened for psychopathology.
The alternative approach to be explored here is to view AIS as a particularly tragic instance of a much more pervasive phenomenon of paradoxical responses (PR) to drug use. These are in fact quite common but seldom viewed as instances of the same category of event. Any experienced clinician has seen cases of PR to medications: increased anxiety on anxiolytics, manic exacerbations on mood stabilizers, insomnia on hypnotics, sedation and hyperphagia on stimulants. Further cases apply to responses that are viewed as “side effects.” Thus the same medications may produce insomnia and hypersomnia, agitation and sedation, weight gain and loss, hypersexuality and hyposexuality, diarrhea and constipation, etc. While each instance may be uncommon enough to be dismissed as an inexplicable oddity, the general phenomenon of PR is common.
This paper offers the hypothesis that PR is an expectable attribute of complex biological systems, as such systems evolve mechanisms (such as “simulated annealing”) to avoid being stuck in sub-optimal local stable states and thereby having the chance to find more globally optimal ones. This discussion draws heavily on the work of the theoretical biologist Stuart Kaufman (1993, 1995, 2000), who has modeled such mechanisms across a wide array of complex, evolving systems (including autocatalytic metabolic networks, genomes, neural networks, ecosystems and economic networks) in search of general laws operating in such systems. He postulates the emergence of mechanisms (such as “patching procedures”) that may temporarily move the system to a less desirable condition to increase the likelihood that the system will ultimately find an even more optimal state. Intrinsic uncertainty emerges both because the ultimate stabile state is not always best and because the transitory destabilizing state may be itself dangerous to the system’s survival. It will be argued that antidepressants, in order to “move” the patient from the relatively stable if undesirable depressed state must first “destabilize” the system to free it to move to another, more desirable stable state. As one of many possible PR, AIS would then be an occasional product of such destabilization.
This approach mandates clinical caution and vigilance in applying interventions in all patients, as some PR are expectable in a non-trivial portion of all patients. It will also be shown that this model of PR would predict several other known features of antidepressant response, such as the higher rate of AIS in younger patients, the preponderance of AIS very early in the course of treatment, and the reduced frequency of positive response to antidepressants in more chronic depression.
Stuart L. Kaplan, MD, Clinical Professor of Psychiatry, Penn State College of Medicine. kaplan.stuart@att.net
The Mind Outside: Some Reflections on Child
Psychiatry, Family Therapy and the Cartesian Inner Mind
"It is not the consciousness of men that determines their existence, but
on the contrary, their social existence that determines their
consciousness" Marx, Contribution to the Critique of Political Economy,
quoted by Robert Archambeau, "A Guildhall Summons: Poetry, Politics, and
Leanings-Left," Poetry, November, 2008, 193(2):169-176.
In accord with the quotation above I suggest in this paper that a theory of mind must include the outside world.
Ryle (1949) notes in his well known critique of Descartes that Descartes viewed the mind as residing inside the individual. This focus on the mind inside the individual has preoccupied contemporary philosophy for several decades. Issues related to sensation, cognition, intention and action have led to an array of subtle, well-reasoned treatises. More recently, the philosophical search for mind within the person has been complemented by the extraordinary success of the neurosciences. This success has contributed to philosophical discussions about the mind but also has enhanced the philosophical focus on mind as inside the individual. At times it has led to a "material Cartesianism" Searle (2007).
In this tradition, DSM-IV explicitly defines mental illness as existing within an individual. Family conflicts and conflicts with the larger culture are specifically excluded from the designation of mental illness. The development of psychopharmacology and managed care's partially successful efforts to restrict child psychiatrists' treatments to solely prescribing medication re-enforced practitioners' focus on the individual.
Classical psychoanalytic theory offered little help in bridging the chasm between the child and his or her larger world. After the resolution of the oedipal complex at around age five, the personality was immune from external influence, unless psychoanalysis was employed. It was the psychoanalyst Erik Erikson, however, in his widely circulated Childhood and Society who beautifully described the pervasive influence of culture on development throughout the human lifespan and illustrated the culture's influence on the development of the child through culture- specific child rearing practices.
In the late 1960's and early 1970's family therapy gave promise of becoming an important modality for the treatment of children in child psychiatry. To oversimplify, there were two extremes in the approach to family therapy at that time. At one extreme was a psychoanalytic approach in which families met together with an analytically oriented therapist who provided psychoanalytic interpretations with some modifications to the family members during the family group treatment. At the other extreme was a deliberate attempt to minimize individualized approaches and to avoid any insight on the part of family members. Of paramount importance was the interaction between people rather than what happened within them. Individuals were believed to be largely non-existent; they were capitalistic abstractions. All of these modalities seemed to offer the promise of improved approaches to treating children. For child psychiatry, this effort has largely been abandoned.
A brief case vignette of school refusal is presented in which the contemporary methods of "in the mind" interventions including cognitive therapy and psychopharmacology quickly led to a dramatic deterioration in the child. An "outside the mind" family intervention quickly returned the child to school and immediately relieved the painful distress of the child and family.
Michelle Maiese, Ph.D., Assistant Professor of Philosophy, Emmanuel College, Boston, MA m_maiese@comcast.net
Rethinking Attention Deficit Hyperactivity Disorder
‘Attention deficit hyperactivity disorder’ (ADHD) is typically ascribed to children or teens who suffer from a breakdown of organizational skills, inattentiveness, and/or impulsiveness. In this paper, I wish to rethink two of the assumptions that shape current understandings of ADHD. The first is that the disorder can be traced to a neurological dysfunction and is brain-based and genetic; and the second is that ADHD should be understood as a behavioral disorder resulting from impaired executive functioning.
First, many philosophers have begun to move beyond the notion that the mind is simply the brain and emphasize the degree to which the mind and human psychology is fully embodied and embedded in a particular environment. Evan Thompson (2007), for example, has argued that human cognition is not simply an internal psychological process, but also a sociocultural activity. An individual’s developmental process does not unfold according to some genetic blueprint. Instead, experience-dependent activity affects the way that the brain constructs itself during development, so that culture and family life affects the way major parts of the brain become wired up during childhood. In this paper, I outline and briefly defend this picture of the human mind and then consider what implications this outlook has for the treatment of ADHD. In particular, I argue that any trend to move towards a more individualistic, primarily brain-based understanding of ADHD should be rejected. Insofar as this disorder cannot be fully treated unless relevant family problems or social pressures are addressed, it is a mistake to over-emphasize the role of medication.
Second, while affective disturbances typically are viewed as symptoms of the disorder rather than its underlying cause, I will recommend that we understand the source of the disorder as a disruption in an individual’s affective framing processes. Affective framing is the mechanism whereby we interpret persons, objects, facts, states of affairs, and situations in terms of embodied desiderative feelings. Just as a cognitive frame is a cognitive shortcut that people rely on in order to carve out and categorize features of their surroundings, an affective frame operates as a feeling-driven shortcut whose interpretive focus is targeted and contoured by an individual’s embodied desires and cares. Such framing typically occurs prior to conceptual information processing, and yields a pre-reflective, finegrained emotive mapping of that world, so that we can immediately target and focus our attention. As they navigate their way through the world, obviously they do not sequentially process all of the cognitive and practical information that is potentially available to them, but instead almost always home in on certain very specific things rather than others. This sudden, non-inferential way of discriminating and filtering information allows us to reduce the overwhelming clutter of information to something first-personally manageable.
What happens when affective framing processes are disrupted? Lack of attentional focusing at the affective, pre-reflective level is likely to result in inattention, lack of concentration, and an inability to stay focused on one particular activity. This lack of focus also may lead the individual to shift constantly from one activity to the next, making it difficult to organize tasks. Energy that is not focused on a particular task, but instead spreads out in many different directions, is likely to be interpreted as hyperactivity and may surface as an inability to sit still. A breakdown in affective framing is also likely to arouse feelings of frustration and social isolation insofar as the child finds it difficult to navigate through social interactions. One way to better understand ADHD, then, is as a behavioral disorder resulting from a breakdown in affective framing processes.
Allison Mitchell, MA, teaching special needs students in Florida's public school system, alli.mitchell@fulbrightweb.org
Bad Behaviour: Pathologizing Difficult Children
Philosophers and psychiatrists, parents and teachers alike would probably agree that most children and adolescents behave in ways that seem odd, troubling, or excessive at some point in their development. Yet our culture is quick to attach a label to every child whose behaviour seems in any way surprising or out of the ordinary. In recent times we have witnessed an explosion in the number of children and adolescents receiving psychiatric diagnoses for being intense, moody, or offbeat. In fact mental health diagnoses have become the primary explanation for children who are perceived to be ‘abnormal’ or who are, for a variety of other possible reasons, difficult to raise, deal with, or educate. Our culture has developed a worrisome habit of attaching the label ‘pathological’ to any and all behaviours we find strange or hard to manage in our children and adolescents. Current government surveys suggest that at least six million American children have difficulties (such as emotional reactions, poor concentration, or the inability to get along with peers) which are serious enough to meet the criteria for a mental disorder. What should we make of this very strange and quite saddening state of affairs? If we begin with the thought that diagnosis has to do centrally with the identification of disease, we may challenge whether or not the problems we notice in difficult children or adolescents derive from or contribute to a genuine psychiatric condition. Are the specific and various traits underlying a child’s challenging behaviour constitutive of mental ‘disease’, in any substantive and meaningful sense of the term? Can particular behaviours be added up to ‘equal’, so to speak, a general mental illness? What happens when we equate difficulty or difference with disorder? These are the basic questions I will explore in my philosophical consideration of the diagnostic categories most commonly associated with young people. My particular project will involve challenging the conceptual legitimacy of ‘conduct disorder’ and ‘oppositional defiant disorder’, two diagnostic categories that are relatively new and notoriously controversial. In the spirit of interdisciplinary and ‘hands on’ research, I will use my background and training in Anglo-American analytic philosophy to make sense of my recent experiences as a teacher of ‘special needs’ students (many of whom were labelled ‘oppositional defiant’ or ‘conduct disordered). Over the course of my discussion, I hope to raise some very serious (and unavoidable) doubts about the appropriateness and desirability of applying certain psychiatric labels to children and adolescents.
Jorid Moen, M.D., M.A.; Faculty of Humanities, University of Oslo, Norway jorimo@online.no
Perspectives in Child and Adolescent Psychiatry; a Pragmatist Approach
The call for abstracts for this AAPP meeting says that
It is generally acknowledged that family dynamics can play a major role in the development of a child’s emotional problems, and many in the field have argued that the family should be the central unit of treatment. Yet the trend in psychiatry is to move towards a more individualistic or atomistic understanding of mental disorder, and this places child and adolescent psychiatry [CAP] potentially in tension with the rest of the field.
Although this characterization of today’s psychiatry may be correct, it doesn’t imply that this trend represents the “true” way of approaching mental disorders. Neither does it imply that family treatment necessarily should be the main focus in CAP. I will question the relevance of asking on a general basis which perspective is considered to be the “best”.
An outstanding model for understanding mental disorders today, is that of gene-environment bilateral interaction. There is no consensus, however, how this model should be interpreted. Although the model also has been used to legitimize the authority of natural science - undermining the importance of other perspectives - in my view this model could be a tool for a dynamic and complex understanding of human development, disorder and treatment. The field of CAP could lead the way towards a pluralistic interpretation of the model rather than worrying about how to fit into a certain trend.
One possible interpretation and implementation of the gene-environmental model is that of philosophical pragmatism, emphasizing pluralism and normativity. This is a point of view that takes human practice to be the foundation of all knowledge, and which claims that what we say about reality depends on the perspective into which we throw it. In line with this it is not current to ask what the mental really is, which clears the ground for questioning both the hierarchical world view that legitimates the authority of natural science and the dualistic understanding of the mental. Such a view does not imply that science should not be taken seriously, but rather that every perspective – the natural sciences included – should be understood on a contextual basis.
We may regard the different perspectives (theories, understandings) of psychiatry as different vocabularies (ways of talking about the world). From the pragmatist viewpoint, vocabularies are looked upon as tools, so the primary question will not be: “Which of the perspectives represent the truth?”, but rather: “In which ways are the perspectives useful, and by virtue of what are they useful?”. Such questions can be meaningfully answered only when our purposes are specified, i.e. the point of any vocabulary can be explicated only relative to the specific goals, needs and interests of its users. With regard both to the atomistic and the family dynamic perspectives, we have to ask: “What is at stake for the users of this vocabulary?”, “Which, and who’s, needs, interests and purposes does the vocabulary express?”.
In a practical context like the clinical, facts tend to be differently interpreted by different listeners and actors - being it the patient, the relatives, the psychiatrist, the teacher, etc. - according to their different interests and values. The definition of evidence based medicine underlines the complexity of the situation: “[EBM] requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances”. In other words, more and different vocabularies (perspectives) are, and should be, at play at the same time – and more and different vocabularies (perspectives) may be legitimately relevant at the same time.
Adrienne van Nieuwenhuizen, Research Coordinator, Inpatient Psychiatric Unit, Massachusetts General Hospital. adriennevan@gmail.com
The Right of Children to Equal Participation in Research
Clinicians in the field of pediatric psychiatry are struggling to determine exactly how their patients differ clinically from adult psychiatric patients. Although it seems clear that there are at least some differences, their implication for research protocols appears less obvious. With regards to the inclusion of children in research, I argue that a more libertarian conception of children’s rights should be applied, as described by Cohen (1980). Currently, particularly conservative standards of safety are applied to research involving children. Unfortunately, these same protective measures were once applied to other research subject populations, with deleterious consequences for the clinical care they received. For example, heart attack symptoms in women went undiagnosed because a protective conception of women’s rights meant that women were excluded from research on heart attacks, and it was incorrectly assumed that women experienced the same symptoms as men. Recently, limited data on antidepressants and suicide in young patients led to a decrease in antidepressant prescriptions for this population, and clinicians began prescribing antipsychotics with potentially serious side effects instead. In the meantime, rates of pediatric suicide have only increased. Precisely because of the uncertainty about how children’s psychiatric disorders differ from adults’, there is a duty to balance protective measures with the need for more research on this population.
Cohen points out three major problems with a protectionist approach to children, two of which are particularly relevant to the issue of including them in research. The first problem is that this approach is based on the belief that the child’s parent can understand their child’s needs well enough to act in their best interest. Second, even if a parent were able to fully understand what it is like to be a child with a mental illness, there remains the problem that the parent’s interests may conflict with the child’s. Parents are under intense pressure from social norms when it comes to exposing children to research. If a child is unfortunate enough to experience an extremely rare side effect of an investigational treatment, the parent will likely be subject to severe criticism for exposing their child to that risk. If, instead, the parent provides the child with standard clinical care, or no psychiatric care, they are at less risk of receiving criticism. These social pressures make it very difficult for the parent to make a fair assessment of what is best for their child.
The American Academy of Pediatrics (AAP) Committee on Bioethics has acknowledged that consent by proxy is not optimal. I argue that incorporating borrowed capacity, as advocated by a libertarian conception of children’s rights, addresses the problems discussed above. Borrowed capacity would entail outside counseling for children with mental disorders and their parents, so they could be made fully aware of the advantages and disadvantages to participating in clinical trials. While many parents and children may initially equate research participation with sub-optimal care, a greater awareness of the quality and speed of access to care in clinical trials may help them make a more informed decision about participation. More research on pediatric mental disorders is likely to reveal that a per-kilogram adjustment of standard adult treatments is inadequate, as current findings seem to indicate that the presentation and etiology of psychiatric illnesses differ significantly in children and adults. For this reason, it is critical to overcome the traditional protectionist approach to children, in order to increase their participation in psychiatric research and develop effective treatments for this population.
Christy A Rentmeester, Ph.D., Assistant Professor,Center for Health Policy and Ethics, Creighton University School of Medicine ChristyRentmeester@creighton.edu
Healthcare Inequalities, Transgenerational Trauma, and Children
What do healthcare professionals need to know about patients to care well for them? This question is especially interesting, important, and complex when considering clinical and policy-level responses to individuals suffering transgenerational trauma. This concept characterizes experiences and responses among individuals and communities for whom legacies of oppression importantly influence one’s own and one’s children’s health. It deserves careful theoretical and practical attention, particularly regarding children and adolescents of color with symptoms of anxiety, depression, and other mental illness.
Racial inequalities persist in the United States’s healthcare system, and children and adolescents with mental illnesses are particularly vulnerable. Though inequalities have been hot topics in recent public health and bioethics literature, the impact of legacies of oppression on mental health care for children and adolescents of color has been neglected. My work draws upon a few cases that call clinicians, bioethicists, and policy makers to cultivate richer understandings about two things: (1) When and how deeply entrenched historical, political, cultural, and social patterns of oppression influence experiences of mental illness for children and adolescents, and (2) How ancestral legacies of oppression “passed on” through generations persist in modern healthcare and persist as sources of suffering among children and their families and communities.
Specifically, I draw upon postcolonial and feminist theory to illuminate how ancestral histories of suffering and ongoing psychological processes of immigration, assimilation, and oppression among people of color can offer insight to clinicians, bioethicists, and policy-makers about consequences for children and adolescents with mental illness in an acute-care-driven (not public health driven) healthcare system that privileges whiteness. This conceptual work on transgenerational trauma generates a vocabulary for clarifying how legacies of oppression are clinically and ethically relevant, illuminates avenues for subsequent empirical clinical and health policy research about trends in underservice to mentally ill children and adolescents, and motivates scholarly and educational innovation in what it means to take healthcare inequalities seriously.
Additionally, I consider how cultural competency training in health professions education neglects clinical work with children and adolescents. Cultural competency training has been one educational response to healthcare inequalities, but it’s not clear that it actually works or that it makes a difference for children and adolescents. I illuminate gaps in the cultural competency literature by focusing less on developing clinicians’ knowledge of cultures and more on what they need to know about patients, particularly children and adolescents of color. Specifically, I focus on developing clinicians’ knowledge about conceptual relationships between legacies of oppression and healthcare inequalities. This pedagogical work focuses upon cultivating new assessment criteria by which educators can critically analyze the merits and drawbacks, successes and failures, and outcomes of their curricular efforts to produce clinicians well-prepared to respond with care to underserved, vulnerable children and adolescents.
John Z. Sadler, M.D., Daniel W. Foster Professor of Medical Ethics, Professor of Psychiatry & Clinical Sciences, Distinguished Teaching Professor, Chief, Division of Ethics and Health Policy, Department of Clinical Sciences, Chief, Division of Ethics, Department of Psychiatry, UT Southwestern, Dallas, TX John.Sadler@UTSouthwestern.edu
Moral and Nonmoral values in DSM-IV Conduct Disorder
Moral philosophers such as Frankena have divided values into two general categories: moral values, concerned with right/wrong and virtue/vice, and nonmoral values, which include a broad set of values, including pragmatic ones (such as “efficiency,” or “capacity”), epistemic ones (“clarity”, “comprehensiveness”) and aesthetic ones (such as “elegance” or “beauty”). In medical contexts, nonmoral values are associated typically with illness, injury, or disease judgments: incapacities, pain, suffering, disability, and the like. When we examine mental disorders, however, moral values involving wrongful conduct are often concretized into diagnostic criteria, lending a morally-wrongful quality to the disorder. For this paper, I illustrate how the moral/nonmoral value distinction is helpful in understanding the particular kinds of evaluations, or value-judgments, built into disorder concepts. The exemplar case is DSM-IV-TR Conduct Disorder, whose diagnostic criteria will be shown to be exhaustively moral in character. The “wrongfulness-laden” character of Conduct Disorder criteria leads to important questions about the nature of mental illness and psychiatric practice. Wrongfulness-laden diagnostic criteria, I argue, contribute to public perceptions of psychiatry as an agent of social control, with psychiatrists functioning as police as much as doctors. Moreover, wrongfulness-laden disorders are confusing to lay perceptions of mental illness. While psychiatry would like the public to believe that mental disorders are diseases like any other, formulating disorders in heavily moral-value laden terms confuses the public with mixed messages about wrongfulness vs. disease, effectively undercutting efforts to reduce the stigma of mental illness as well as posing challenges to designing effective services for such individuals.
The most important question about this problem is what to do about it. I will sketch a several-point approach to this issue. First, bona fide mental disorders should be able to be defined such that essential features of the disorder involve nonmoral evaluations. Second, disorders which are currently largely or entirely nonmoral in descriptive character should be empirically studied so as to bolster the nonmoral-value character of the disorder. Third, wrongfulness-laden disorders should be investigated to determine whether the disorder involves a moral incapacity (a disability in the moral sphere or “faculty”) or is simply a matter of wrongful moral choice. Fourth, category failure in facing the above challenges suggest the disorder should be removed from the DSM. Under these challenges, whether a category such as Conduct Disorder could be sustained as a legitimate mental disorder remains to be seen.
Benjamin Spinner, MD, Fellow in Child & Adolescent Psychiatry, New York-Presbyterian Hospital of Columbia & Cornell Universities bes9045@nyp.org
Kraepelin’s Perspective on Schizophrenia as a Model for Psychiatric Diagnosis in Children and in Adults
Contemporary psychiatric nosology finds its roots in the work of the German psychiatrist Emil Kraepelin, who attempted to describe and to classify psychiatric disease. An important focus of Kraepelin’s work was the description and classification of schizophrenia, which he called dementia praecox, applying the term of Benedict Morel. The term itself reveals a two-fold description: the dementia refers to a dysfunction within the cognitive domain; the praecox refers to the early onset of the disease. According to this definition, schizophrenia requires a longitudinal perspective. This paper, using Kraepelin’s approach to schizophrenia in which the notions of will and volition are central, in addition to symptom clusters, argues that a common psychiatric diagnostic scheme for both children and adults is beneficial. If a binary distinction is made between childhood and adulthood—and consequently between childhood illness and adult illness--the notion of longitudinal diagnosis is fragmented. This requires that longitudinal diagnosis function not as serial cross-sections of observed symptoms, but as developmentally valid applications of the concept of a particular illness. An epidemiological approach to schizophrenia in children and in adults would carry an emphasis on the reliability of the diagnosis, but would not in itself comment on the validity of the diagnosis. A conceptual approach to schizophrenia, with a Kraepelinian emphasis on will and volition and a Kraepelinian approach to a longitudinal course, would require the appropriate developmental perspective and would create not a distinction but a continuum between childhood schizophrenia and adult schizophrenia. In doing so, this approach would provide a model for a common psychiatric diagnostic scheme with appropriate attention to development as an integral factor of diagnosis.
Elizabeth Throop, Ph.D, MSW, Chair, Anthropology, Sociology, and Social Work
Associate Professor of Anthropology, Eastern Kentucky University Elizabeth.Throop@EKU.EDU
Adolescence, Immoral Individualism, and the Biomedical Model: The View from Psychological Anthropology
In the last ten years, there has been a spate of profoundly disturbing behavior performed by violent adolescents coming from the ranks of non-historically oppressed populations. That behavior has been explained almost solely through the lens of psychiatric nosology (unlike the explanations provided for young men of African-American or Latino descent). Any explorations of America’s violent culture, for instance, as contributing to the actions of teenagers (or younger children, for that matter) are seen as unacceptable attempts to help children “evade responsibility” for their actions; as well, by being able to label disturbing behavior as psychiatrically based, we seem to believe we can spot “warning signs” in other adolescents. If someone tried to say that the parents of the Columbine murderers—who seemingly knew, and certainly should have known, that their boys had weapons, explosives, and the like—failed in their child-rearing efforts, psychologists rushed in to tell the world that the parents had suffered enough.
The Columbine tragedy has been sadly repeated in more recent history at Virginia Tech and Northern Illinois University, but will be considered here since it is clear that our concept of adolescence has extended past the teenage years. The notion of adolescence as a period of apprenticeship now seems to carry on through to about thirty years old.
The typical psychological description of teenagers invokes hormones, identity, conflicts, and emotional states. Teenagers, according to the child development experts, are beings largely at the mercy of biological processes. It is, for these experts, “natural” for adolescents to be moody, lustful, rebellious, and risk-taking, given their raging hormones. They are of course incorrect.
The peculiarly indulgent view of adolescence is an American artifact. Many teenagers across the world are involved in adult activities—marriage, child-rearing, earning a living, fighting wars. The American—and, less so, western European—version of adolescence is one that emerges from privilege. We have been able to extend childhood to ridiculous lengths, forgiving infantile behavior far beyond biological childhood. Raging hormones do not create American adolescence. American culture does.
Nowhere is culture mentioned in any of this, except as a rejected throwaway line. It cannot be denied that American culture is a highly violent one; when coupled with the overweening sense, promoted by the cultural dominance of psychotherapeutic values, of a person’s emotional self-importance, Columbine, Virginia Tech, and NIU begin to look like a microcosm of American hyperindividualism., one in which one’s interiority, presumably driven by biogenetic structures, is almost inalterable. At the same time, though, this construction of a biologically constructed self, of the adolescent self, is one for which the person must take responsibility. You may be wired funny, but it’s your fault (particularly if you are a member of an historically oppressed group) and you must acknowledge your biological deficiencies and accept the consequences of your inborn tendencies while trying to change. It’s an impossible task, and when coupled by the belief that adolescence is a special period, imbued with rights but no responsibilities, we get some very odd readings about teenagers.
Through an examination of what are clearly culture-bound syndromes-ADD/ADHD, oppositional defiant disorder, and borderline personality disorder-a challenge to the dominant paradigm will be had. Arguing against the overwhelming amount of "evidence" situating poor behavior and suffering solely within the individual, this paper blends psychological anthropology and family systems theory to produce a
unique take on understanding the behavior of American adolescence, through a cultural lens.
Sara Worley, Ph.D., Associate professor, Director of Graduate Studies, Department of Philosophy, Bowling Green State University sworley@bgsu.edu
Conduct and Oppositional Defiant Disorders: Pathologizing the Normal
In this paper, I argue that conduct problems of childhood which currently fall under the DSM rubrics of conduct disorder and oppositional defiant disorder should, at least in some of their instantiations, be regarded as involving (merely) problematic patterns of behavior rather than mental disorders. I argue that we need to make a distinction between genuine disorders and mere problems of living, where problems of living are patterns of behavior which may be maladaptive, or lead to distress for the individual, but are not genuine disorders. A useful analogy can be constructed by thinking about problems which arise in the context of education. We distinguish between kids who simply haven’t learned something because of bad environment or bad schools or perhaps even bad study habits and cases where someone’s failure to learn something genuinely results from a kind of disability or learning disorder. In both kinds of case the failure to learn may well result in problems in a child’s future and may need to be remedied, but nonetheless mere failure to learn because of adverse circumstances is neither itself a disorder nor evidence of a disorder. Just as failure to learn is not itself a disorder (although it may be explained by one) I suggest that behavior which can be entirely explained in terms of an individual’s learning history should also not be regarded as a disorder. At least some instantiations of conduct problems in children do seem entirely explicable in terms of the learning history of the child, i.e., in terms of poor parenting, poor environment, and reinforcement of maladaptive behaviors. These cases, I argue, should not be regarded as manifesting disorder. As long as a child would have been able to learn to control his behavior in a socially acceptable ways had he grown up in a different environment, we should not regard his current behavior as an instance of mental disorder.
In the course of the argument, I also respond to an important objection to the view that being explicable entirely in terms of learning history precludes something from being a disorder. That is that some genuine cases of disorder seem to arise as a result of certain sorts of (traumatic) experience. Post-traumatic stress disorder is a case in point. So we don’t want to say that any pattern of behavior which is explicable in terms of experience is therefore precluded from being a disorder. The difference, I suggest, is that in post-traumatic stress disorder and other stress-induced disorders, the experience results in certain changes in brain function which are genuinely dysfunctional. Insofar as there is no reason to believe that such changes are involved (all) cases of conduct or oppositional defiant disorder, there is no reason to regard (all) such cases as involving genuine disorder. (In the course of this argument, I rely on the claim that genuine dysfunction can be understood in terms of loss of capacity, although full defense of that claim is beyond the scope of this paper.)
Finally, I also argue that some subtypes or variants of conduct problems may ge genuine cases of disorder. Conduct disorder sometimes develops into anti-social personality disorder, and there is some reason to believe that there are biological abnormalities (e.g., in the “violence inhabitation mechanism” ) which underlie some cases of this malady. So it is not unreasonable to assume that the same abnormalities underlie the earlier manifestations of this behavior in conduct disorder. But, importantly, there is no reason to think that this is true for all cases of conduct disorder.
Peter Zachar, PhD, Psychology Department, Auburn University Montgomery pzachar@aum.edu
Ethical issues in child psychiatry: Kindling, the looping effect and bipolar disorder
Kindling is a hypothesized biological process used to explain the observation that each episode of a mood disorder raises the probability that another episode will occur in the future. In its various forms this model has proven to be an effective, morally-based marketing strategy for the use of psychiatric medications in general, and for the medical treatment of childhood bipolar disorder in particular. The claim is that treatment has to occur early and continue on past recovery in order to reduce the risks of future episodes. In the realm of social policy, such future-oriented claims are analogous to moral justifications for childhood vaccination and pre-K education.
Another important concept having ethical implications for childhood disorders is Ian Hacking’s discussion of the looping effect in classifying kinds of people. The looping effect refers to how people are aware of the classifications which are applied to them, and more importantly, how they are affected by this knowledge. Hacking’s examples include ADHD, anorexia, autism and child abuse. To some extent ‘awareness’ refers to the individuals’ responses to the label itself, but also to how they and their conspecifics change as a result of the institutional and social practices that are implemented following the introduction of the classification. The subsequent changes can feedback to alter the phenomenon that is being classified. An alteration of the phenomenon leads to the classification itself being modified, and so on. The looping effect can be used to understand the evolution of the ADHD diagnosis and it is quite likely currently influencing the evolution of childhood bipolar disorder.
In contrast to kindling, the moral arguments potentially associated with looping are more varied. Social constructionists are concerned that science has a way of making its classifications seem natural and inevitable. The ethical implications of such a ‘naturalization’ effect with respect to bipolar disorder depend on one’s view of the disorder. Those who view psychiatry as continually expanding its reach by medicalizing normal distress are more likely to view the diagnosis and treatment of bipolar disorder as morally suspect. Those who accept kindling can acknowledge a looping effect, but it is likely to be seen as having limited ethical implications for treatment. The ethical implications are the most ambiguous for those who adopt a spectrum-based approach in which bipolar phenomena occur in varying degrees of severity. Deciding what to do in such cases is an ongoing ethical problem that requires practical reasoning in the purest sense of the term. Similar problems exist with respect to other dimensional disorders of childhood such as autism and ADHD.
In many respects, the problem of childhood bipolar disorder helps make clear how our ethical intuitions will vary depending on how diagnostic categories are structured. It also exemplifies how such ethical intuitions should not only be studied as outputs, but should also be considered as important input variables when making decisions about how to develop an adequate psychiatric nosology. This is especially true if the spectrum in question represents a heterogeneous collection of conditions rather than a continuum of severity along a single dimension.