So today the first ever guidelines from NICE in relation to ‘Conduct Disorder’ are released See (http://www.nice.org.uk/nicemedia/live/14116/63308/63308.pdf). Also today I’ve had the chance to read some interesting insights into IAPT from @drmurphypsy on his blog and a subsequent conversation and the gist is this: IAPT is increasing the medicalisation of children. This sounds abhorrent but it is being construed as a medical intervention and that, to me is very concerning. It is focused on diagnoses, one of them, is conduct disorder.
I have a myriad of concerns about the use of the use of the term disorder generally which are summed up by my colleagues Peter Kinderman, Richard Bentall, Joanna Moncrieff and John Read title of their excellent piece ‘ It’s time to drop the language of disorder’.( http://www.madinamerica.com/2012/09/a-call-to-drop-the-language-of-disorder/) but in relation to children and in particular ‘Conduct Disorder’ this needs further exploration.
I do wish to make one point abundantly clear: I am in no way against parents or carers receiving support to assist them in supporting their children. Parenting is the hardest job in the world and we all need help from time to time. What I am fundamentally against is the concept that the child has to be diagnosed with a ‘mental health disorder or condition’ before the family can receive help and placing the problem within the child.
In fact I’m fundamentally against the diagnosing of children with ‘disorders’ in general (yes even Autistic Spectrum Disorder, I have no issue with Autistic Spectrum but why call it a disorder?)
It does seem that the language used, even by those who developed the guidelines can be confused at times.
To illustrate my point, I am copying text from the NICE website which refers to the new guidelines.
“Conduct disorders are a serious, but frequently unrecognised, mental health condition characterised by repeated and persistent misbehaviour that may include stealing, fighting, vandalism and harming people or animals.”
Indeed it is serious, but is it a condition? Do all problems with well being have to be a condition/disorder/disease/illness? If so which is it?
“In the first national guideline in this area, NICE recommends group parent training programmes be offered to help support parents and carers of children and young people aged between 3 and 11 years who have been identified as being at high risk of developing oppositional defiant disorder or conduct disorder, or have oppositional defiant disorder or conduct disorder or are in contact with the criminal justice system because of antisocial behaviour.”
“Group social and cognitive problem-solving programmes should be offered to children and young people aged between 9 and 14 years who are at high risk of developing oppositional defiant disorder or conduct disorder, or have oppositional defiant disorder or conduct disorder, or are in contact with the criminal justice system because of antisocial behaviour.”
Right so it’s a disorder now, along with Oppositional Defiant Disorder, (I know, I know) but hang on, so they think that people in contact with the criminal justice system should be offered this help, that’s, good. But who is going to do this? CAMHS are being cut and asked to see more and more kids, who on earth is going to also see all the kids in contact with CJS? Does that mean that criminal behaviour is a mental health disorder? Doesn’t this have rather large implications for the CJS amongst many others?
“If left untreated, many children will go on to have serious mental health problems as adults. The cost of not treating these children early on is huge not just to the NHS but also to society.”
I agree and intervention is so clearly needed and the outcome of lack of early intervention can be significant.
So what is the aetiology of this serious mental health/criminal/behavioural disorder/condition/problem?
“Professor Stephen Pilling, Director, National Collaborating Centre for Mental Health and facilitator of the Guideline Development Group, said: “The new guideline highlights the importance of supporting the child’s parents or guardians in the treatment of the condition – recommending training programmes tailored specifically for them – as aspects of parenting have been repeatedly found to have a long-term association with antisocial behaviour.”
No argument there, aside from the condition bit, but I can see that may be a little pedantic on my part.
“Many parents do an excellent job in caring for a child with a conduct disorder, but it can be incredibly challenging. Parent training programmes provide them with strategies for dealing with difficult children and how to better handle them going forward.”
Hang on, it’s a disorder again now. Where did that come from?
“Professor Gillian Leng, Deputy Chief Executive, NICE, said: “The new NICE guideline includes a number of recommendations to support healthcare professionals to accurately diagnose and treat conduct disorders. It aims to significantly improve the lives of young people with a conduct disorder, which is a serious but frequently unrecognised mental health problem.”
So you need to diagnose and then treat. And there it is. The medical model in all its glory. This is a beautiful illustration of why the medical model is not appropriate for mental distress. The diagnose and treat model is not fit for purpose and is damaging (this is for another post, in fact posts).
To be clear, this is not about doctors and nurses in mental health services, it’s about the dominance of the model and like it or not, it is dominant.
Some better reflection comes at the end:
“Andrea Sutcliffe, Chief Executive, Social Care Institute for Excellence, added that collaborating with NICE enabled the social care perspective to be brought directly into the guideline.
“It is important not to concentrate solely on their clinical needs but also to consider their whole lives – as part of a family, school and local community.
“That is why it is crucial that everyone in health, social care and education work well together to provide the information and person-centred care necessary to improve the quality of life and life chances for children, young people, their families and carers.”
I was so pleased, the Social Care perspective brought in the SCIE. Nicely put, person centered care. Is labelling them with a disorder person centered? Which person are we talking about?
There isn’t room to do a literature review here sadly, but I would recommend a look at the NICE guidance itself, which states amongst other things:
“In addition to specific tests of Patterson’s reinforcement model there is ample evidence that conduct problems are associated with hostile, critical, punitive and coercive parenting.” P25.
So why then do we seek to place this problem within the child?
My admittedly crude illustration of this is that if someone punched me in the face would it be right to label me with ‘Punched in the Face Disorder?’ That sounds ridiculous, doesn’t it?
There are also references to gene/environment interactions which always give way to people stressing the genetic aspect, not the environmental, but that’s a post for another day. Just one comment, because something ‘runs in the family’ does not make it genetic.
Why is it a requirement of support that a child is diagnosed with a disorder? What century are we living in here? The very path of diagnosis is incredibly flawed, I have been concentrating my efforts on DSM5 recently (dsm5response.com) but the ICD10 is no better in fact it’s worse on this issue.
This is taken from the ICD criteria for Conduct Disorder (F91):
“Examples of the behaviours on which the diagnosis is based include the following: excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe temper tantrums; defiant provocative behaviour; and persistent severe disobedience. Any one of these categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.”
Anyone working with children with a degree of understanding of children would look at those behaviours (which if marked, is sufficient for diagnosis) and ask, what’s troubling this child? Surely.
It gets worse, much worse and the argument that ICD10 is not as bad as DSM5 goes out the window (flung by a conduct disordered child probably) because they have another diagnosable condition:
Conduct Disorder Confined to the Family Context (F91.0).
Yes, a disorder which is only present at home. As soon as the door opens to the outside world it vanishes. Magic. But what if the child was half way out? Would he be semi-disordered, or would only his feet be disordered? I just don’t know. Sorry for the defensive, poor humour, it’s masking my anger. Here’s the criteria, please sit down:
“Diagnosis requires that there be no significant conduct disturbance outside the family setting and that the child’s social relationships outside the family be within the normal range.
In most cases these family-specific conduct disorders will have arisen in the context of some form of marked disturbance in the child’s relationship with one or more members of the nuclear family. In some cases, for example, the disorder may have arisen in relation to conflict with a newly arrived step-parent. The nosological validity of this category remains uncertain, but it is possible that these highly situation-specific conduct disorders do not carry the generally poor prognosis associated with pervasive conduct disturbances.”
So mum gets a new boyfriend and the child gets a diagnosis of a mental health disorder? What on earth? The disorder may have arisen in relation to conflict? Like the sword in the lake?
They do at least acknowledge that it’s pretty crap, but then, why do it?
This has to stop. This systematic labelling of children as disordered when they are simply trying to get by in the world is inhumane and extremely unhelpful and potentially damaging.
People often say to me “stop nit picking, what does it matter what it’s called?” It does matter. When the school are asked why is Tom behaving like that, they’ll say ‘he has conduct disorder’. It places it in him, this happens throughout society, children are demonised and labelled with disorders and it does not help.
He will be told, ‘you have conduct disorder’ what does that mean to Tom?
What does it mean to the parents? I know that they’re offered parenting courses, which is good but why? The reason is “Your child has a disorder”. This is wrong.
They need our understanding, they don’t need us telling them they’re mad.
Yes, help children who display problematic behaviours and of course, offer help to parents, they need more, a lot more, but this should not require a diagnosis and a stigmatising label.
I joked on twitter earlier that it ought to be called Parenting Disorder and rightly I was brought to task. I was joking (not great I know) but the idea of blaming parents is unhelpful and we’re rightly against it so why do we allow children to take the blame?
As clinicians we must never stop being the 4 year old ourselves (as I constantly tell my trainees/assistants) and ask one simple question,
Why is this happening?
Dr Gordon J Milson
P.S. if you like me are against DSM5 please visit dsm5repsonse.com and sign the petition, if that goes through, things will get worse.