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By Carter Hammett, Ever since 1840 when the American Census first included a question on idiocy/insanity, mental health professionals have been trying to put a label on things. Things are about to get a lot worse. With a scheduled 2013 launch, the fifth edition of that controversial psychiatrist’s bible, The Diagnostic and Statistical Manual (DSM-5) is currently reviewing all kinds of disorders you’ve never heard of, that are vying for inclusion. Conditions such as Internet Addiction, Apathy Syndrome and Parental Alienation Disorder are in direct competition with the better-known but not-yet-included Fetal Alcohol Syndrome and Seasonal Affective Disorder. Published by The American Psychiatric Association, the most recent version of the DSM clocks in at over 900 pages and includes almost 300 disorders, from mild mental retardation—itself a dated term—to depression, to a personal favourite, “cognitive disorder not otherwise specified”. Small wonder then that the tome has come under fire by critics who argue that some disorders listed are either cultural or imagined in nature. Homosexuality, once listed as a mental health disorder itself, was finally dropped in 1973. At a briefing in February, some psychiatrists winced at the possible inclusion of labels like, “Psychosis Risk Disorder, arguing that everyone was at risk of being labelled with something. Others charge that the DSM is too heavily influenced by avaricious pharmaceutical companies looking to make a profit from the latest diagnostic craze. Indeed, medication sales for drugs treating ADHD, autism and childhood bipolar disorder exploded after the definitions were expanded in the most recent DSM was published in 1994. In the United States alone, sales for ADHD medications topped $4.8 billion in sales in 2008. There have always been arguments against labelling children. “Labels are for jelly jars” chimes psychologist and writer Lynne Namka, who once wrote: “Labeling is definitive; once we say it, then it holds meaning. The danger of labels is that children tend to believe what is said about them and live up to that negative expectation. Negative labels keep children caught in negative behavior. Labeling what we do not know how to deal with is victimization.” Some, like psychologist Carol Dweck have conducted studies on gifted students and found that their motivation to take on challenging assignments actually decreases, when praised for their intelligence, thus pleading a case that labelling can also affect academic motivation. And while it is probably true that yesterday’s “quirky” child is today’s pathologized child, labels, especially those used constructively, can provide a useful framework for treating legitimate disorders. Furthermore, the appropriate label is necessary to obtain insurance and funding for treatment, and often, access to service providers. “Bureaucracy requires the label in order to fund services,” says Toronto psychologist and artist Michael Irving, who designed the well-received Child Abuse Monument. “Labels can help us understand what is going on as service providers and can help the child understand themselves and get more positive. Labelling needs to be helpful to the child and we need to see the positive and communicate it.” Ottawa psychologist Judy Goldstein concurs. “The label helps us (service providers) take the right direction and identify the proper intervention that will help. Everyone is an individual and not everyone needs the same intervention. It helps us look at the whole person and use the diagnosis as part of the puzzle to understand the person,” she says. But a diagnosis can be difficult to understand, especially if criteria differentiates from source to source, as sometimes happens with learning disabilities (LD), for example. “I prefer the terms ‘learning differences’ or ‘learning styles’ suggests another Ottawa psychologist, Brian MacDonald, co-founder of www.familyanatomy.com. “’Learning disabilities’ is the term recognized by schools and physicians, but I’m careful to define it for parents and kids because I think it’s a misleading term.” It helps when definitions complement each other. For example, The Learning Disabilities Association of Ontario’s definition of LD is frequently-cited throughout Canada, in part states that LDs are “ a variety of disorders that affect the acquisition, retention, understanding, organisation or use of verbal and/or non-verbal information. These disorders result from impairments in one or more psychological processes related to learning (a), in combination with otherwise average abilities essential for thinking and reasoning.” MacDonald is quick to point out that this is different from the DSM’s definition, which identifies problems with reading, math and written expression, “but the DSM looks at achievement vs. intelligence. “If you look at a child who spends three hours a night doing home work but his peers are taking only one hour to do the same volume of work and achieving at the same level, those kids wouldn’t meet the criteria to qualify for a label of learning disability,” he says. Sometimes labels are vague enough to fall into a completely different category of disability. For example, anxiety frequently mimics symptoms such as the restlessness, impulsiveness and inattentiveness often associated with Attention Deficit Hyperactivity Disorder. Two diagnoses that frequently and erroneously cross back and forth are those for non verbal learning disabilities, and Asperger’s Syndrome, a “higher-functioning” form of autism. These disabilities often involve excellent verbal skills, but may also include problems with mathematics, visual spatial processing and social perception. “Both of these disabilities have social problems for very different reasons,” says Judy Goldstein. “There is some overlap, but kids with Asperger’s may get caught in something and repeat it over and over, but a non verbal wouldn’t do that. A student with non verbal learning disabilities might have problems in school with spatial perception, but no such problems with Asperger’s. You have to look at strengths, weaknesses and symptoms,” she says. There are some who argue that both disabilities are one in the same, but there is no conclusive proof of this; another situation where labels given responsibly by a qualified psychologist can clearly help. All the psychologists interviewed also agreed that a psychodiagnostic assessment, while helpful, isn’t nearly enough. There have to be solutions and recommendations for accommodations so strategies can be implemented to suitably monitor and manage the disability accordingly. “It’s important that parents and students have an awareness of the specific nature of the problem, not just some overall view of the problem, like, say ‘anxiety’.” says MacDonald. “But what does it mean specifically for that person? That gives a starting point to find strategies that will be helpful.” He cites an example of an Ottawa teacher who noticed several students were having problems remembering concepts on a particular subject. “The teacher worked with the class to brainstorm the areas they were having difficulty in remembering and then had them write each item down on 4X6 index cards. These were put into a portable format and personalized so the students could use the information on a day to day basis and for tests, which is much more like the real world.” The teacher took an identified—or labelled—problem, in this case, memory, and found positive results when the class collectively took ownership of their situation and wound up with a positive outcome. And it’s the positivity that’s critical for finding a successful solution when dealing with negative behaviours, says Michael Irving. “If a child is bull-headed, you might want to say he has tenacity,” he says. “In using a label, realize that we’re using that label to serve the client and it does help for the agency and administrative end of things.” He argues that when inappropriate behaviours present themselves, it’s important to look beneath the surface to determine positive underlying causes. “A child with a brain injury may become angry or irritable and may be trying to protect themselves from too much thinking and processing, so the irritability may be self protection. You have to ask what is the intent behind the behaviour? “Realize that there’s an external response in a problem behaviour and there’s likely a positive root as some form of self protection. So, we have to say, “it’s really great that you’re trying to protect yourself, but now we have to ask, what is a more successful way of taking care of yourself? What’s going on inside so you don’t have to arrive at the place where bad stuff is going on?” When placed in a positive context, a label in fact, can be tremendously empowering thing for people becoming labelled. It can provide a kind of blue print for treatment, offer an understanding and ownership of a particular challenge. Likewise, it can form the basis for a “healing partnership” between client and support team as the labelled person can formulate strategies for later success. “We have to switch to labels that help understand the positive forces behind problematic behaviours,” says Irving. “At that point we have to shift the label to the positive to serve the child, and not the teacher or the system.” Carter Hammett is a Toronto social worker and journalist. He currently works for JVS Toronto, where he assists job seekers with LD/ADHD find and maintain meaningful work. He is also the author of several publications, including Benchmarking: A Guide to Hiring and Managing Persons with Learning Disabilities (2005), and the editor of Communique Magazine, published by The Learning Disabilities Association of Ontario.  He can be reached at iwrite@wordgarden.ca
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  1. Larynxa August 28, 2011 at 3:42 pm

    Unfortunately, there are no regulations that require all medical personnel everywhere to accept everything in each new edition of the DSM. In fact, many places in the Bible Belt still insist on using the pre-1973 edition, because they refuse to accept that homosexuality is not a mental illness. As a result, there are still many minors there whose parents commit them to mental institutions purely for displaying homosexual tendencies.

  2. BrianMacDonald September 29, 2011 at 9:10 pm

    The DSM-IV-TR doesn’t capture the current understanding of learning disabilities (or adult ADHD, according to many researchers and therapists). I’m hopeful that the DSM-V will improve the areas where the current version is lacking!

  3. Rick October 30, 2011 at 11:39 am

    That’s a great point, Larynxa.
    I’m reminded of a statistic I heard at an event I was hosting for the Canadian Mental Health charities:
    “90% of what we know about the human brain has been discovered since 1995!”
    Why is this? It has to do with new brain scanning techniques on people while they are alive, like MRIs and stuff, and also with breakthroughs in how they can stain brain tissues when they’re studying them through microscopes. (As in no longer alive.)
    Here’s my concern. The DSM-V comes out in a few years. The name is changed to Executive Function Disorder. And we now have to figure out how to build a website called TotallyExecutiveFuctionDisorder.com!

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