In real medicine, you use symptoms to help you discern a cause, which then helps you pick a treatment. For example, you take fever, fatigue, swelling, and so on as indicators of, say, a particular virus; you run tests to see if it is that virus; and, if it is, you then attempt to deal with that virus.
If you can’t discern the cause or if you can’t decide between two or more causes, you run more tests and, while you are trying to identify the cause, you do things that you know or that you suspect are likely to help relieve the symptoms. Symptom relief is a genuinely useful enterprise and you certainly engage in it in medicine; but it is not everything that you are attempting to do, not by a long shot.
In the meantime, as you seriously look for the cause, you work to reduce the pain or bring down the fever. You are reducing the pain and bringing down the fever while you continue to investigate what is actually causing the fever and the pain. You do not focus all of your efforts on reducing the pain or on bringing down the fever. You continue your investigations. You are trying to figure out what is going on. Your job isn’t merely to treat symptoms.
One of our neighbors recently suffered from terrible stomach pains. For a long time, on the order of two months, no conclusive diagnosis could be reached among the four contenders vying as the cause of her affliction. Finally it was conclusively determined that it was cancer located in a certain stomach valve. Treatment began immediately. All along she was being given relief for her symptoms—relief for the pain, help with her inability to keep food down—while the cause was being determined.
Treatment for the actual affliction could only commence once it was identified. That is how medicine works.
In the pseudo-medical specialty of “children’s mental health” something very different goes on. There you take the report of a child’s behavior—for example, that little Johnny pulled on the braids of the girl sitting in front of him—and for no reason that you can really justify you call that a “symptom of a mental disorder.” You collect several of these “symptoms of mental disorders”—often three or four are enough—and you attach a provided label to that “symptom picture.”
The label might sound like “oppositional defiant disorder.” Once that name is announced, chemicals are prescribed. Little interest is shown in what is causing the behavior; little interest is shown in whether the behavior reflects something biological going on, something psychological going on, or something situational going on. This is not medicine, no matter how many white coats happen to be in the room.
A child who loses his temper, argues with his parents, defies his parents’ rules, and is spiteful and resentful is given, based on these three or four “symptoms,” the pseudo-medical sounding label of “oppositional defiant disorder” and put on chemicals whose job is to make him more obedient. This is not medicine but rather behavior control instituted to make the lives of adults easier.
Why not ask little Johnny why he is angry and resentful? Is that such a preposterous approach? Why not step back and see if his family is in chaos? Why not look at his life and not just his “symptoms”? Why presume that a child arguing with his parents is caused by some impossible-to-find medical condition? Isn’t it more likely—by a thousand-fold—that he is angry with them?
We don’t know why little Johnny is acting the way he is acting. But we do not believe it is cause-less and we do not really believe that it is the result of a medical condition. Certainly we ought to test for genuine organic problems like brain damage or neurological damage that can cause explosive rage. But in the absence of such biological challenges we are obliged to presume that little Johnny has everyday human reasons for his anger. Once you rule out brain damage and other possible biological causes of his rage, your next step should not be to posit a made-up, invisible medical condition but rather to treat little Johnny like a human being with everyday human reasons for his anger and resentment.
One fact alone should prove the absurdity of considering these behaviors a pseudo-medical “mental disorder.” Imagine for a second that I said to you that my not being able to see any symptoms of your cancer was proof that you had cancer. Or imagine that I said to you that my not being able to see a break in your bone on an x-ray was proof that you had a broken bone. You would find those assertions pretty darn odd. Isn’t it fascinating that mental health service providers are warned that they may not get to witness any “oppositional” behaviors because a child with this “disorder” is likely not to demonstrate any defiance except with his parents and teachers? How strange! Does any medical condition operate that way?
Unlike in real medicine, where the sore is visible both at home and in the examining room, with the behaviors associated with “oppositional defiant disorder” those behaviors are likely only observable when little Johnny is actually angry, namely at school and at home. It is absurd but true that an indicator that you have the mental disorder of “oppositional defiant disorder” is that you do not display any signs of it when you are talking to someone with whom you don’t happen to angry. Seriously, shouldn’t the fact that little Johnny is only angry around his parents suggest that little Johnny is angry with his parents?
Picture what a mental health provider is doing here. He does not personally see any signs of little Johnny’s oppositional defiant disorder and he takes not seeing them as further proof that little Johnny has an oppositional defiant disorder. He relies on reports of things that he has not observed for himself, things that are of course more logically signs of rebellion, protest, and anger than “symptoms of a mental disorder,” and from those reports he “diagnoses” a pseudo-medical condition called a “mental disorder” and moves on to dispensing chemicals. He has not seen the “disorder,” he has no tests for the “disorder,” and he is basing his “diagnosis” in part on the fact that he has seen nothing of the “disorder”!
This is akin to the absurd claim made that proof of the presence of an attention deficit disorder is the fact that you do not display it when something interests you. Might it not be the case that you like to pay attention to things that interest you, like sports and videos games, and don’t like to pay attention to things that don’t interest you, like math class and your parents’ dinner conversation? It is only through the looking glass that my interest in the things that interest me and that my failure to rage at someone who hasn’t angered me are signs of some pseudo-medical “mental disorder.”
There are many things that we might wish for little Johnny. We wish that he were having an easier time of it. We wish that he could stop his raging, for his own sake, since he is making everyone around him dislike him. We wish we knew what was causing his difficulties so that we could offer him help at the same level as his difficulties. If he is raging because school is too difficult for him, we would offer one sort of help, if he is raging because his parents are abusive alcoholics, we would offer another sort of help, if he is raging because he can’t abide his parents’ strict rules, we would offer another sort of help. We wish all this for Johnny.
If a child has a medical condition, treat the medical condition. If a child is angry with his parents, do not call that a medical condition. Labeling an angry child with the pseudo-medical sounding “mental disorder” label of “oppositional defiant disorder” may serve adult needs for peace and order, just as prisons do. But it is not medicine and it is not right. Little Johnny is making it very difficult on the adults around him, who will naturally return the favor by making it hard on him. But that he is making life hard is not the same thing as him being mentally ill.
We simply must stop saying that he is suffering from a mental disorder, that is, that he has a medical or pseudo-medical condition. It makes no sense on the face of it to believe that an angry child is angry because he has a disease. It makes much more sense to believe that he is angry because he is angry, just as you are angry when you are angry. Maybe little Johnny is a lot angrier than you are—but that he is angrier than you are doesn’t turn his anger into a disease.
As a society, as practitioners, and as parents we may not be equipped to deal all that effectively with our sad, anxious, and angry children. But the answer to that shortcoming must not be to call them all diseased.
Download this resource: Is Defiance a Medical Condition?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.