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Marilyn Wedge has provided an excellent resource for clinicians and parents. Her book, Suffer the Children, is a tour de force argument against the current trend in American education and psychiatry which assumes that children with behavioral difficulties will likely require medication. Throughout her argument against this trend, she provides positive support for the alternative treatment that she is recommending--strategic child-focused family therapy. This support comes by way of numerous case studies drawn from her years of clinical practice; perhaps the greatest virtue of the book is the large number of case studies that she provides for the reader.
In this review, we will highlight some of the book's features that recommend it to clinicians and concerned parents. In chapter 1, Wedge describes the current situation in child psychiatry and discusses some of the trends in family systems therapy since the 1970s. She questions the trend in child psychiatry to label emotional or social disorders as "brain diseases." She argues that medicating in many situations might appear to be a "quick fix," but often medicating a child causes unforeseen side-effects or other negative consequences.
Furthermore, Wedge argues that many so-called "disorders" with which children are diagnosed are most likely related children's family environments: "[…] instead of giving them a label or a diagnosis, I view children's symptoms--unhappiness, jumpiness, moodiness, suicidal thoughts--not as signs of a 'psychiatric disorder' but as evidence of something wrong in the family, something that I can remedy with the right interventions" (p. 2). The right intervention for Wedge is not merely to substitute talk therapy for medication; it involves working with a child's entire family and incorporating a child's teachers, friends, and others. It is a more holistic approach.
In chapter 2, Wedge illustrates how her recommended alternative framework, strategic child-focused family therapy, approaches issues in a dramatically different way. To do so, she works through a few case studies from her own practice. Among these cases is the example of a seven year old child named Paolo. Paolo was having difficulty paying attention in class and was also disruptive (p. 32). Paolo's teacher had recommended that he be evaluated for ADHD. After meeting with Paolo, Wedge determined that he did not display any signs of ADHD; however, since he had moved to the US at age 4 from the Philippines, she thought that he might be having difficulty comprehending English. After Paolo had been in an after-school program for reading comprehension and after he had been seeing his school's reading specialist, he still had difficulty in class. His teacher then suggested that he be reevaluated, this time for autism.
When Wedge observed no signs of autism, she began to be pressured to give some sort of diagnosis to Paolo: "The school counselor was pressing me for a diagnosis of ADHD, ODD (oppositional defiant disorder), or even autism" (p. 34). Wedge remained unconvinced that Paolo had any of these disorders, and so she sent him to a pediatrician. In the end it turned out that his eyesight needed to be corrected, and a pair of glasses took care of the issue. The worry with this situation was the assumption on the part of the teacher and the school counselor that there must be something wrong with Paolo that could be corrected with medication. Wedge argues that strategic child-focused family therapy provides an alternative starting point: "Working within the frame of strategic child-focused family therapy, I approached Paolo's problems without the preconception that he had a mental illness" (p. 36). Given the stigma that can surround the diagnosis of a disorder, as well as the myriad side-effects that can result from believing that one has a disorder, it seems that avoiding having such a preconception is well worth it.
At some points it is difficult to determine Wedge's general viewpoint on prescribing medication to children for behavioral difficulties. Sometimes it seems like Wedge is not completely against the use of medication for the treatment of children. Chapter 7 focuses on two cases where children were administered medication and improved somewhat. One of the cases she discusses is the case of Matt; Matt was having difficulty performing in school. His parents were resistant to having medication prescribed for their son, so Wedge began to treat his family. The parents responded somewhat well to therapy, but Matt did not improve. Finally, his parents decided to have Matt treated by a psychiatrist for ADHD with medication and discontinued family therapy; soon his performance improved in school. Unfortunately, Matt had other difficulties that arose after he began taking medication, such as weight loss and difficulty sleeping. So Wedge contends that medication in Matt's case was a mere "band-aid" which helped only his performance in school but which did not treat other problems that resulted from dysfunctions at the family level, since his family stopped participating in therapy (p. 175).
Chapter 9 is a wide-ranging chapter, dealing with issues ranging from current debates in psychiatry over classification in the forthcoming publication of the Diagnostic and Statistical Manual (DSM) by the American Psychiatric Association to issues in the history of psychiatry such as the so-called "moral treatment" of 19th century French physician Philippe Pinel. Wedge is keen to criticize the current way in which the disorders in the DSM are classified, according to what she calls "classification by [the] consensus" of DSM panelists (p. 205). She contrasts this method of classification with one that would classify according to biological causes. However, it's not clear that this is entirely fair to the DSM panelists. After all, it is not mere consensus of a group of panelists that determines whether a disorder will be included or not; instead, for a given disorder there is a cluster of symptoms which are determined, and then the diagnostic criteria for that disorder are tested to determine their validity and predictive power. While Wedge is certainly correct to draw her reader's attention to the fact that the vast majority of so-called "mental" disorders are not classified according to some biological cause(s), she has not done justice to the process of classification that the DSM panelists actually undergo (and are currently undergoing as the DSM 5 is being finalized).
Wedge's book has much more of worth for practicing clinicians and for parents than we have discussed. Her argument encourages an overall caution in medicating children for behavioral difficulties. The force of her argument suggests that psychiatrists and family care physicians should be much more hesitant to prescribe medication than many currently are.
© 2012 by Shannon M. Bernard-Adams and Marcus P. Adams
Shannon M. Bernard-Adams, M.A. is a community mental health therapist in Pittsburgh, PA. Marcus P. Adams is a Ph.D. candidate in the department of History & Philosophy of Science at the University of Pittsburgh.