Jerome Kagan on The Meaning of Psychological Abnormality

Jerome Kagan, a highly prominent developmental psychologist, weighs in the Dana Foundation's Cerebrum on the roots of the skyrocketing rates of diagnosis of childhood bipolar disorder, autism, and ADHD. "[it] is important ... to ask," he writes

whether this troubling [increase] reflects a true rise in mental illness or is the result of changes in the definition of childhood psychiatric disorders. The latter explanation is likely because the concept of psychopathology is ambiguous, and physicians have considerable latitude when they classify a child as mentally ill. Because a diagnosis of ADHD, bipolar disorder, or autism allows parents to obtain special educational and therapeutic resources that would not be forthcoming if the child is called mentally retarded, incorrigible, or uninterested in academic progress, doctors are motivated to please the distraught parents who want to help their child.

As Kagan notes, a disorder is often declared mainly because the child is disorderly, rather than really sick. If the parents think the child needs help, the doctor usually goes along - and the solution is far more often pharmacological than family-based. This comes into play most seriously in the accelerating diagnosis of bipolar disorder in children in the U.S.

Equally serious, if not more so, is the dramatic rise (more than 40 percent in the past decade) in diagnoses of bipolar disorder in young children, based on parental complaints of chronic levels of extreme disobedience, impulsive bursts of aggression, and an inability to control emotion. These symptoms can in part be the product of permissive socialization practices by parents who are reluctant to induce anxiety or guilt in children placed in surrogate care because both parents are working. Most children classified as bipolar do not display the cycles of manic excitement and depression that define this disease in adults. Thus it is a diagnostic error to call children who cannot regulate their moods “bipolar” simply because they seem to have a single feature in common with the adult disorder: uncontrolled behavior. I do not believe that psychiatrists have detected a new childhood disorder; they have used a new term for a serious rise in poor regulation of emotion that is probably a result of experiential rather than genetic factors.

The setting aside of family issues in favor of focusing on genetic "causes" and pharmacological solutions gets overlooked in most of the writing -- both academic and mainstream media -- about pediatric bipolar disorder. Why don't doctors more often focus on the family and home environment? A slew of reasons -- little time, the desire for a quick fix, the awkwardness of bringing up the issue of family dysfunction and the difficulty of treating it or of getting the family to sign on to a solution that requires them to change behavior rather than just medicate the child.

At a panel about pediatric BPD at the first Neuroethics Society conference earlier this month, Hastings Center bioethicist Josephine Johnston suggested a major reason family issues aren't brought up is the "schizophrenogenic phantom" -- the memory that in the 1970s, schizophrenia, which usually shows itself in late adolescence, was blamed on harsh or cool upbringing by the patient's mother: the "blame the mom" etiology. Was quite a backlash against this when heavy genetic components were found underlying schizophrenia -- a backlash, Johnston suggested, that now keeps the touchy subject of family dysfunction off the table when parents bring deeply troubled or disruptive to doctors seeking help.

Kagan doesn't touch on this, but he covers much else. It's well worth reading the entire article -- and worth a peek at Vaughn's commentary on this piece at Mind Hacks, which gets the hat tip on this one.

The Dana Foundation - The Meaning of Psychological Abnormality: