Sunday, September 28, 2008

It is a sick sick child who disobeys authority: APA

In 1980 the American Psychiatric Association added an interesting diagnosis to the DSM IV. Let's set aside their tendency to create diagnostic criteria for every imaginable human condition with fetishistic thoroughness. I'll assume you're aware that they do this, even if they're no longer classifying all homosexuals as victims of disease. I want to talk about a specific instance that has become a bit more high-profile recently.

The APA found a way to medicalize juvenile rebellion: Oppositional Defiant Disorder. No really. Never mind that Margaret Mead concluded that teen rebellion is largely a phenomenon of American culture. We won't worry about that. Here's what we'll worry about: the medicalization of deviance.

Now, this is nothing new. When a woman was unhappy in a life without any real agency, she was called a hysteric, her discontent being the result of her own sickness rather than oppressive conditions. They used to say that slaves who ran away from their masters must surely be mentally ill, for what slave in his or her right mind would do such an inconvenient and noncompliant thing?

It turns out that if your child has frequent temper tantrums, argues "excessively" with adults, and exhibits "active defiance and refusal to comply with adult requests and rules," he or she might be mentally ill. In the second grade classroom where I volunteered in high school, they called these kids "emotionally handicapped," and at least a couple were kept so tranquilized by medication that they slept through the day's lessons on a beanbag in the corner. The worst I observed in any of them (when sober) was one boy telling the other children what he'd read about extraterrestrials. Clearly this child is a threat to himself and everyone else around him. Someone call the APA.

Keep in mind that ODD isn't the same thing as conduct disorder. That's a separate disorder in which a child is actually acting out instead of simply making a nuisance of themselves verbally.

The official symptoms of ODD include "often actively defies or refuses to comply with adult requests or rules" and "often argues with adults." While ODD-diagnosed young people are obnoxious with adults they don't respect, these kids can be a delight with adults they do respect; yet many of them are medicated with psychotropic drugs. (Levine at AlterNet)

Because of the history of medicalizing deviance (exemplified by the historical diagnoses of female hysteria and drapetomania), this makes me nervous. It turns dissatisfaction with one's lot--and according noncompliance to those who perpetuate it--into a sickness, thereby delegitimizing it. Aside from the fact that it's annoying as hell, why would doctors encourage the delegitimization of noncompliant behavior? Levine offers an interesting suggestion.

While there are several reasons for behavioral disruptiveness and emotional difficulties, rebellion against an oppressive environment is one common reason that is routinely not even considered by many mental health professionals. Why? It is my experience that many mental health professionals are unaware of how extremely obedient they are to authorities. Acceptance into medical school and graduate school and achieving a Ph.D. or M.D. means jumping through many meaningless hoops, all of which require much behavioral, attentional and emotional compliance to authorities -- even disrespected ones. When compliant M.D.s and Ph.D.s begin seeing noncompliant patients, many of these doctors become anxious, sometimes even ashamed of their own excessive compliance, and this anxiety and shame can be fuel for diseasing normal human reactions.

If you need any further evidence that psychiatrists expect children to be as compliant as they are, check this out.
The skill of compliance—defined as the capacity to defer or delay one’s own goals in response to the imposed goals or standards of an authority figure—can be considered one of many developmental expressions of a young child’s evolving capacities in the domains of adaptation, internalization, self-regulation, and affective modulation. (Source here.)

Granted, I understand that kids need to learn that what they want is not always necessarily the best first priority, but the way this is worded suggests to me that Levine may be onto something. The "skill of compliance," of subordinating your will to the will of another, is so important that if you can't do it right... they may have to drug you.

If you need a further indication that compliant children are more valuable than noncompliant ones, chew on this.
One of the most pervasive ad campaigns draws on the rhetoric of homeland security to label youth defiance “The War at Home,” urging a corrections mentality on the family: “The focus of treatment should be on compliance and coping skills, not on self-esteem or personality. ODD is not a self-esteem issue; it’s a problem solving issue.” (Source.)

Norm Diamond suggests that delegitimizing noncompliance this way actually hampers the ability of diagnosed children to develop proper critical thinking skills. Critical thinking requires a willingness to question, to argue. If a child is judged to be excessively noncompliant by the authority figures who have an interest in seeing them comply (parents, teachers, psychiatrists treating them), the child may be too tranquilized by medication to actually turn their noncompliance into a vital cognitive skill. As a result, they won't develop that skill. He goes further (but not much further) and suggests that excessive compliance is much more alarming, and created a parody diagnosis of "Compliance Aquiescant Disorder," characterized by blaming of oneself or other individuals for social problems, staying restrained when outrage is warranted, and failure to argue back.

The fact that psychiatrists have medicalized ODD and not CAD says a lot about what they perceived to be "problem" behavior in children. That really takes away a lot of their credibility for me in diagnosing children with ODD. Another problem is that children with ODD are often going to present with comorbid mental illnesses like ADHD, mood disorders, anxiety disorders, or language impairments. For example, if a kid has ADHD and ODD, you can treat the ADHD and it'll generally help both.

Imagine that. You treat the mental disability that actually has a biochemical component, and the disorder characterized by resentment, frustration, and anger gets better! Who'd have imagined it, right? I guess this was news to these guys. "Clearly, characterization and treatment of oppositional defiant disorder on the basis of comorbid presentations is an area worthy of significant research attention. The high prevalence of oppositional defiant disorder within other clinical populations also deserves additional attention." You mean people being treated for mental illness can become resentful and rebellious? No way.

It seems to me that if by treating an actual illness you can simultaneously make ODD go away that ODD may not really make too much sense as a unique diagnosis.

Really, the best thing about medicalizing deviance from the point of view of the population with authority (men in the case of hysteria, whites in the case of drapetomania, and adults in the case of ODD) is that it isn't your fault. You haven't done anything wrong, and there's nothing wrong with society. The only changes that need to be made are within the twisted and maladapted mind of the disenfranchised "noncompliant" person.

Medicalizing the noncompliance of children does the same thing. It takes a child who is reacting in an understandable way to their environment and labels their mistrust of authority figures a disease. Studies show that children with ODD are more likely to have difficult home lives. According to this study, children with dysfunctional home lives are more likely to be the ones presenting with ODD. As the study states in its abstract, "families of oppositional defiant disorder youth with or without conduct disorder were characterized by significantly poorer cohesion and significantly higher conflict." It doesn't give any causation here. You could just as easily argue that they create hostile home environments as you could argue that the home environment makes them that way.

I am swayed toward the first argument because of the way I've read ODD is evidently managed.

Parents can help their child with ODD in the following ways:
  • Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation.

  • Take a time‑out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if he decides to take a time‑out to prevent overreacting.
  • Pick your battles. Since the child with ODD has trouble avoiding power struggles, prioritize the things you want your child to do. (American Academy of Child & Adolescent Psychiatry)

Look at these treatments. What doctors are telling parents is essentially, "It's not your fault your child has never learned to deal with conflict. They're just sick. Nonetheless, all the solutions we know to give you are changes you need to make in your behavior."

Here's my perspective on it. If a child comes from a home environment in which parents are, for example, handling conflicts in ways that make them worse instead of better, how are they supposed to know how to act when conflict occurs outside the home? The changes that parents are recommended to make suggest to me what kind of a home environment these kids are coming from.

Look in particular at the section about picking battles. It basically comes down to, "if you start a power struggle, the kid won't back down. So try not to turn everything into a dominance play." If I came from a home environment in which every suggestion was an enforcement of dominance, in which parents make conflicts worse instead of better by having emotional outbursts, I would probably develop a healthy distrust for the legitimacy of authority as well.

Oh, wait, that's right.

I did.

Here's the personal anecdote section. I realize that the plural of "anecdote" is not "data," but there's something to be said for an insider perspective.

In retrospect, I was not a terribly defiant child. I was just told that I was by a parent who turned every conflict into a battle for dominance that we both knew I must lose. I learned the art of invisibility early on. Creep through the house silently to avoid attention if you can't afford to be noticed just then. Always come when you're called; drop everything, no matter how important. If you make a mess in a public area of the house, clean it up like you were never there, because if you can be detected you have created an inconvenience for the adult who must put things to rights. There is no respectful way to point out when a parent just plain is not making sense.

And y'know what? I humiliated teachers I didn't respect by mercilessly tearing apart every inconsistency and perceived flaw in everything they did, and I did it in front of everyone. Every single person who treated me like an idiot child got the full brunt of my open disgust that they were in a position of authority. Things were different in science classes, or social studies. Here were teachers who knew important things, things I liked. In these classes I took detailed color-coded notes, relished every project, and in general was the most attentive student around. Sometimes I was a dreaded troublemaker, and sometimes I was teacher's pet.

If a teacher gave me the slightest notice as a bright little girl who wanted something interesting to do, I'd probably have gone to war to defend their honor. My ability to control myself was not magically improved in classes I enjoyed, which means that my self-control or "compliance skill" was not the problem. The problem was that I didn't obey people I didn't respect.

I would have been diagnosed with ODD. I spent so much time submitting to an authority I perceived to be unjust that I absolutely would not let any other one like it have sway over me.

Tell me why we want children to learn to submit to perceived injustice again? In what was once alleged to be the land of the free and home of the brave, we are drugging children who are too free and brave for the comfort of authority figures who are accustomed to commanding the respect of subordinate humans instead of earning it. Why are we taking their side?

I'll end with a question posed by Levine on AlterNet (and I'll ask you to forgive his excessive blaming of "Big Pharma," because otherwise his argument is sound).
In every generation there will be authoritarians. There will also be the "bohemian bourgeois" who may enjoy anti-authoritarian books, music, and movies but don't act on them. And there will be genuine anti-authoritarians, who are so pained by exploitive hierarchies that they take action. Only occasionally in American history do these genuine anti-authoritarians actually take effective direct action that inspires others to successfully revolt, but every once in a while a Tom Paine comes along. So authoritarians take no chances, and the state-corporate partnership criminalizes anti-authoritarianism, pathologizes it, markets drugs to "cure" it and financially intimidates those who might buck the system.

It would certainly be a dream of Big Pharma and those who favor an authoritarian society if every would-be Tom Paine -- or Crazy Horse, Tecumseh, Emma Goldman or Malcolm X -- were diagnosed as a youngster with mental illness and quieted with a lifelong regimen of chill pills. The question is: Has this dream become reality?


Anonymous said...

You're full of $h*t to say what you have about ODD. Have you any personal experience in dealing with a child that has that? And as far as saying to take a look at the homes of children that have been diagnosed, perhaps maybe you should further your own "research" and delve deeper into this before spouting off your diatribe. For someone who claims to be as highly educated as you say you are, you're definitely not showing it. Research, btw, consists of more than just reading many pieces of literature and forming your own opinion. That is a hypothesis, and nowhere close to being a full research project.

Live a week in the shoes of a parent who's child has ODD, and I guarantee you'll be saying differently. Until then, shut your pie hole and keep your ignorance to yourself.

Cobalt said...

I hope you don't talk to your kid the way you're talking to me, another adult (or even do worse, with even less control, because a child isn't your equal).

If you're this emotional and confrontational when a disagreement or conflict comes up, is it any wonder you can't get a kid to listen to you?