среда, 4 июня 2008 г.

About my daughter

My daughter, 10, has always had a very strong will and she can be very argumentative. I am concerned that she is not finding it easy to cope with not getting her way and that with puberty looming this might become more problematic.

So I took her to see a psychiatrist who diagnosed oppositional defiance disorder (ODD), which we then looked up on the internet. Most of the criteria seem to apply, but it sounds like a new term to describe children who are rebellious and stubborn, and to give parents a label for children who pose more than the usual parenting problems. The doctor also said that she indicated autistic traits, while not having classic autistic syndrome. My child became very upset with him, and said that she was no different from her friends, who also argue with their parents. When we left she told me that she was normal and it was the doctor who wasn't normal. I reassured her that we were only concerned to help her to find ways of accepting things that don't go according to her wishes. The doctor said that while he realised that medication would not be our first choice he felt it would be helpful to her. He talked about other options, namely CBT, play therapy and group therapy. All this upset my daughter, but I reminded her that her sister had had art therapy to help her through a difficult period and how helpful it had been. I cannot deny that my daughter's behaviour does give me cause for concern, and there are times I have been frustrated with it. But part of me thinks I am making a mountain out of a molehill. I don't want a diagnosis to become a self-fulfilling prophecy.


ODD is usually diagnosed in childhood or adolescence. The diagnostic criteria for ODD in a young person are the following, but need to occur more often than is typically observed in individuals of comparable age and development: losing temper; arguing with adults; actively defying or refusing to comply with adult requests; deliberately annoying people; blaming others for their mistakes or misbehaviour; easily annoyed by others; angry and resentful; spiteful or vindictive. Four or more of these problems must be present with a "clinically significant impairment in social, academic or occupational functioning".

For many, having "symptoms", or behaviour, similar to ODD, is a transient state during puberty and adolescence. So, should we rush our children to a psychiatric clinic in case there are any other psychiatric diagnoses? Certainly some would also be described as having "autistic traits" -being withdrawn, finding difficulty in being close to others, wanting to be alone and so on.

Because psychiatry is underpinned by a medical model, psychiatrists use diagnostic criteria when dealing with mental ill health in the same way that a GP would for someone who is physically ill -thus leading to the notion of prescribing medication within the medical "diagnose-treat-cure" model. However, with mental health there is huge evidence that such a model can be limited and limiting: at times, neither adequately describes a person's difficulties nor treats them successfully. A psychiatric diagnosis of a condition can be dehumanising -your child now has ODD plus autistic traits, which tells us nothing about her, how she is experiencing her world and how you, as her family, experience and react to her.

These are the most essential considerations for successful assessment and treatment. In this case, a diagnosis places responsibility for the difficulties with the person experiencing them, with no idea of sharing understanding and responsibility for the problems. I agree with your disquiet at the diagnosis and your daughter's rejection of how she is hearing herself being described.

Your daughter is 10 and already could have a psychiatric evaluation. This makes me angry. It reminds me of parents who wave the latest newspaper article in my (and colleagues') faces telling us, for example, that their child has ADHD and could it please be diagnosed. When it is suggested that the child may be responding to family atmosphere, the parents behave erratically, some moving on until they get the diagnosis they want. It negates their need to take responsibility for their child's difficulties. And when I say "take responsibility" I do not mean "be blamed for". I mean enter into an honest dialogue that looks at the problems.

I am not criticising psychiatrists -many of my most valued colleagues practice within the profession. But we live in a world that is sanitised in a way that places the value of a label over the more ragged process of understanding the individual. A diagnostic label may provide a psychiatric shorthand for your child's difficulties, and may also allow a neater (though not necessarily more successful) treatment, but I agree with your concerns about it becoming a self-fulfilling prophecy

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