Rethinking Mental Health Diagnoses in Children with Dr. Sami Timimi

Foreign.

Welcome to the Where Parents Talk podcast. We help grow better parents through science, evidence and the lived experience of other parents.

Learn how to better navigate the mental and physical health of your tween teen or young adult through proven expert advice. Here's your host, Lianne Castelino.

Welcome to Where Parents Talk. My name is Lianne Castelino. Our guest today is a consultant child adolescent psychiatrist.

Dr. Sami Tamimi is also a psychotherapist with the National Health Service in the UK and an author. His latest book is called Searching for A New Approach to Understanding Mental Health, distress and neurodiversity.

Dr. Tamimi joins us today from Lincoln in the UK. He's also a father and a grandfather. Thank you so much for taking the time.

Thank you so much for inviting me.

What concerns you most, Dr. Tamimi, as you look out at the current landscape as it relates to how we are diagnosing mental health, particularly when we're talking about young people?

Well, there are many things that are concerning, but it starts with some fundamentals that we're talking about things, and we're calling them psychiatric diagnoses, which in medical terms and in strictly classification terms, they are not diagnosis. And there are a lot of consequences that happen when you treat something as if it's a diagnosis.

So as if you've got an explanation for your experiences or your behaviors or your child's experiences or behaviors, which in fact are not an explanation, but a description, and a particularly bad one at that.

So, for example, if you go to the doctor and you've got a cough and you don't expect the doctor to go through a checklist of symptoms like a questionnaire, and at the end of it say that you've got a recurrent cough disorder and they'd add the word disorder at the end, you'd expect them to listen to your chest, perhaps order some other investigations like a chest X ray or take a sputum sample or whatever, because there could be a whole lot of different reasons and causes for that cough. And so a diagnosis is something that will point towards the possible reasons for that cough and that will influence the treatment.

And so in that case, the diagnosis is something beyond the imagination of the person making the diagnosis because it points to some sort of physical process going on in the body of the person who has the cough. But when it comes to mental health, we talk about things as if we're dealing with something very similar.

So we imagine that if you get a diagnosis, for example, of attention deficit hyperactivity disorder, that this is explaining the reason for why your child might be struggling with their attention. So we treat ADHD as if it is a diagnosis.

So we assume that the reason that the person is struggling with their attention or their impulsivity is because they have adhd. However, you have to follow that up with asking the question, how do you know it's ADHD that's causing that?

The only answer you can give is, I know it's ADHD because they have poor attention. So this is a circular argument. What we have is a description of certain types of behaviors and we're using that description as if it causes itself.

So it's a bit like saying, the pain in my head is caused by a headache. And there are many consequences potentially to confusing a description with a diagnosis. For a start, it assumes there's something wrong.

We use the word disorder at the end.

So assumes that your functioning or your behavior or your experiences has something that we might consider to be out of the ordinary abnormal and furthermore something that you shouldn't have. And what we do in medical terms with things that we call symptoms is we try to get rid of them or try to reduce them.

So also then shapes how you want to intervene, whether that's through medication. And there's been a huge increase in the use of psychiatric medication, particularly amongst young people.

And the evidence for that is in the long term these are associated not only with many side effects, but also that they don't appear to lead to long term improvements. That's what the long term studies show. So there.

So you've got this situation where people are being exposed to more psychiatric medication that is of dubious value, that causes a lot of side effects. But there's something even deeper.

So this idea, and I think it's fundamental, this idea that one of the constants in life is that we change, we change throughout our life, but particularly children. So that's the one thing I can predict with absolute certainty for any of the patients that I see, is that you're going to change.

I don't know in what way you're going to change. You don't know yet in what way you're going to change.

Your body is going to change, your interest is you're going to change potentially your friendship groups, what you want to do in the future, your relationships, your music interests, the. The way you think, the way you experience your emotions.

And the problem with putting these types of psychiatric labels, these mental health labels, is it risks fixing an idea that there's something within you. Especially now that we talk about ADHD and autism and things like that as kind of lifelong conditions.

The idea that there's something fixed that doesn't work, that shouldn't be there, and that we're persuading more and more young people and parents to imagine that this is going on in their children.

We're persuading more and more people to think in a way that's not developmental, in a way that doesn't keep sacrosanct, the possibility and the openness for change. And it kind of then focuses your attention into the things that are considered to be problematic. And your attention will keep being drawn to that.

And you'll notice less and less the things that might be not so problematic. And you'll notice less and less the changes that are taking place or could take place, because you'll now be interpreting them in a certain way.

That was a long answer, but it gives you a tip of the iceberg. I think this is a huge problem we've created.

Certainly the way you lay it out and with your background and experience over a number of decades, and with the growing number of people being diagnosed with a variety of mental health issues, it certainly points to becoming or being a huge issue, especially when you also consider the current global epidemic of youth mental health challenges that we find ourselves living through. Your book Searching for Normal has been described as, quote, an antidote to the cult of over diagnosis.

How do you think that we got to this place, Dr. Tamimi, in terms of over diagnosis becoming so widespread as you described?

So I think that quote is wrong because I think I am challenging the cult of diagnosis. Not over diagnosis. The problem isn't over diagnosis. It isn't under diagnosis. It's the cult of diagnosis.

As I've just explained, one of the issues is that we are confusing a descriptive category with a diagnostic one. One of the things that is clear about our diagnostic categories is that in psychiatry is that they are subjective.

They are not based on, you know, I gave the example earlier of listening to somebody's chest. There are no signs that we can listen to. The other example I gave is taking an X ray. There's no X rays, there's no blood test.

You can't see a thought under the microscope. So we're talking about a different arena of knowledge. We're Talking about experiential knowledge.

And one of the things that you can say about this arena of knowledge is that we are meaning making creatures.

So the framework we use to make sense to understand certain behaviors and certain experiences shapes how we then respond to those experiences and those behavior. This is very powerful stuff. I mean, sociologists have known about the power of labeling for, for decades.

You know, when you internalize an idea about how, what the meaning of your experiences are, it shapes those experiences even further.

So in the cult of diagnosis that we have, we have been putting all sorts of experiences, from anxiety, low mood and all types of behaviors into a framework of them being considered as symptoms.

And as I said earlier, once you consider them as symptoms, your idea is that this is something that you need to get rid of or you need to somehow suppress. The problem is growing up is full of struggles. It's always been full of struggles.

I sometimes say to some of the families that I meet with, I really hope reincarnation isn't a real thing because I would hate to go through my adolescence again. It's tough. And the world has got a lot tougher. Expectations have got a lot tougher.

There's all sorts of reasons why people might feel pessimistic about the future. We're a very performance focused culture these days. You know, growing up is tough.

That doesn't mean when you struggle that there's something inherently wrong, broken, disordered, dysfunctional, dysregulated within you.

But when you put it into that framework, you're setting people up to struggle against a part of themselves, so against a part of themselves that they feel shouldn't be there, or that they feel is something to do with something being wrong with them.

The problem with that is you've created a meaning making framework which turns experience experiences which are meaningful, which are connected to the whole struggles of growing up, of peer relationships, of changes in the family, of what's going on with your parents, etc, etc, you've changed things that are potentially meaningful into meaningless torture stuff that you need to somehow suppress, get rid of.

And if you then go down the route of a diagnosis, and particularly if you go down then the route of medication, and particularly if medication makes you feel better for a period of time, you've actually set yourself up into a potential lifelong struggle against a part of yourself that a different framework might have helped you understand in a different way.

Not as something that you need to struggle against, but as a part of yourself that might have meanings for you, but at the very least a part of yourself that Actually, you will deepen your resilience. You will deepen your sense of the world.

You will deepen your experiences by learning how to live alongside that part of yourself instead of struggling against it. In terms of accepting and being able to. To learn how to live with.

And I, and, and I don't mean that in terms of this is something that we should do for all suffering, but we be. We.

We're in a dangerous precipice when we start to put all suffering into a category of something that isn't meaningful, of something that we need to have a technical way of getting rid of. So good therapy is about helping a person grow, not helping a person stay stuck with a sense that this part of themselves is broken.

So if we are, as you suggest, medicalizing normal childhood behaviors, then what would you say to a parent in terms of how they are to differentiate in their child? Something that is just truly struggling versus just a kid being a kid?

That's a impossible question to answer in any formulaic way because each situation is different, each child is different, each family is different. Some kids have learning difficulties and need a lot of extra support, whether that's educational.

Some kids have physical difficulties that need extra support. Some kids are more sensitive than others. Some kids are more intense than others. My.

One of the things that I feel is important at this moment in time is the pendulum has swung so far towards viewing kids in this way as something very fragile, as a disorder waiting to happen. So that we've got more and more children being diagnosed, more and more children being treated particularly with psychiatric medication.

So it was used very, very rarely. So I think the danger now is that we're viewing more and more behaviors and experiences as potential disorders and conditions waiting to happen.

And this is going alongside another very dangerous trend, which is this idea of early intervention, that we need to catch things early, because if we don't catch things early, it's going to develop into a deeper problem. Again, this is an idea drawn from physical medicine.

Of course you want early intervention in cancer, you must get early intervention as quickly as you can in heart disease to try.

You know, so there's lots of areas of medicine where you want early intervention in mental health, because as I've explained, we're not Dealing with diagnosis.

Early intervention creates long term patients by the process, I've said, because it becomes an entry point into patienthood and into viewing behaviors and experiences through that particular lens, which becomes harder and harder to come out of.

So my experience is if you start down this route of imagining your child's problems being related to a diagnosis and they get a diagnosis, you might start with a diagnosis of anxiety or ADHD. Look at the child 3, 4, 5, 10 years down the line and they've collected more diagnoses, they've collected more medications, more interventions.

One of the areas that I've been involved in as a consultant is as a consultant in the team and by the way, I have recently retired so very recently. So this is born of decades of experience.

Until very recently as the consultant in the team, I've been seeing those who are considered at the severest end and quite often those are young people and children who've had several interventions, sometimes medication, often several therapy interventions.

The problem is when you've absorbed the idea that there's something inherently wrong in you and that has followed with, you know, diagnoses and particular treatments and if you don't feel better, or if you feel better and then gradually problems come back again, your going to find yourself down a route where it's being reinforced the idea that there's something even worse wrong with you than you first thought. And this is when you start collecting labels.

And I, and it's been shocking to me that I've seen young people who are presenting have been diagnosed with anxiety, ptsd, autism, ADHD and coming looking for a bipolar diagnosis because none of these were actually enough of an explanation because they've been inducted into that way of, of thinking. And it's not the parents fault, it's not the young person's fault. This is what we're advertising to people.

So my long answer, short is my advice to parents is be very careful about falling down this route.

So even with this, and by the way with these cases that are at that severe, I've seen some cases of the severest kind where people are really not functioning, have clocked out of life and I've seen them recover. So I know the human, human, humans have an incredible capacity to find more hopeful meanings and to get through even the difficulties situation.

So I've seen people recover after years and years of being in these sorts of situations. So that's one thing I would say, whatever, however severe the problems are, do not give up hope. People get through these things.

Remember that alongside what I one of My little phrases, if you like, is stories of suffering are also stories of survival. And we can. We need to hear the suffering. We need to validate it. We need to make sure we don't minimize it.

People need to feel heard, but we can also nurture that side of you that has survived and keeps surviving and keeps finding a way through. There's a part of me that feels compelled these days to say to parents, don't try so hard.

I think when we've set up this system that is so suspicious of the possibility that somebody is experiencing a serious mental health problem, they need an expert, they need this, that they need various interventions. It impels parents to often, I mean, by the way, all parents feel guilty. Most all good parents feel guilty most of the time.

So this is something I say to parents.

It often drives us as parents to try harder than we should because sometimes by trying too hard, we actually undermine the patience needed to let children.

So there's a great paper written by a child psychiatry colleague of mine called John Uridini, the title of his paper, which caused a lot of controversy when it was published in Australia a few years back. The title of his paper was Let the Children Cry. And in his paper he was arguing correctly.

I think that our role as parents, as carers, as people involved in trying to guide children as they grow up is not to stop them from suffering, because you can't do that. You have to be able to allow them to experience that.

Our role is to be there, to pick them up, to be patient with them, to allow them the time and not to panic. So that is my little addendum to why I often say to parents, don't try too hard. The one thing I can never solve for any parent is guilt.

All parents, good parents who love their children, will feel guilty most of the time. They'll wonder, should they have done this? Should they have done that?

The problem with that is it can lead you to being more interventive in trying to stop suffering rather than trying to help children survive it, work through it, and they will.

So against this backdrop that you've just described for us, when we talk about diagnoses and how that is taking place, you know, in the world at large, when we look at what's going on with society, social media, the Internet, parenting today, high expectations, toxic achievement, there's a long list of things that could contribute to what you are talking about. So how do we go about stemming the tide of what is the focus of searching for normal?

You're absolutely right that there are These multiple drivers. And this is why I've labeled it a mental health industrial complex.

It turns out that there's a lot of money to be made in medicalizing a whole raft of our experiences. And so, so there's a, there's a whole industry, it's kind of turbocharged by social media because it spreads ideas around.

And it's also been turbocharged by what I see as a failure of politics, particularly a failure of politics on the left. And I'm a traditional left person in that the left wing politics kind of fell into the culture wars.

And so mental health industrial complex has sort of merged with identity politics now. So people are now internalizing their diagnoses and they're turning them into part of their identity.

And, and that goes along the whole arena where identity politics has become quite a, quite a big thing. And it's an, unfortunately, in a way, you're setting yourself up into this hyper individualized way of thinking about the world.

And I personally think that distracts from the bigger structural issues, which are partly a crisis of our economy. A lot of people are struggling. You know, they have material challenges to get through in their life, but also there's a crisis of legitimacy.

So people don't trust that politicians are able to solve some of these problems because at the moment I don't think they are. So we get austerity after austerity after austerity and we get this push on performance and performance cultures.

So we've got all of these things in our broader society that are pushing us in these directions. The thing is, whenever there is a particular movement that is bad for our society, bad for people, there's usually also resistance.

And this is where, you know, I'm hoping some, in, in some spaces it might be possible to push back against this public narrative that's developed around mental health because I think it's, it's harmful. I think it's harmful for children, it's harmful for families.

And I can see that there is other ways of delivering mental health services that is a lot more hopeful, that helps people recover. I mean, that's why I came into child and adolescent psychiatry.

I wanted to be part of a profession that helps people get on with their life, not inducts them into becoming long term patients, but hopefully reduces the possibility that they'll become long term patients.

So things like what you're doing, in the end, I guess it's up to each of us to do what we can, but also to be aware that there is a limitation in terms of what we can each do in terms of the global picture, in terms of how society, economy, our politics is functioning. But there are things we can do in our own lives, with our own children, with our own schools, with our own local communities.

I know of people, I know of various projects across the country in the UK who are trying to do something different. Some of them are school based, some of them are clinic based.

And the thing about all of these different projects is that these are people who sort of come together because I think you're going to be a lot more effective if you can come together as groups and they're trying out something different.

Some of them are getting funding because clinics are so full now, waiting lists are so full that funders are looking for people who have alternatives to offer. Some are doing it privately, some are doing it, but it's kind of do whatever you can and with your own kids, just be patient with them.

And I know it's hard, but resist the invitations for them to be become pathologized. I know a parent, very recently, just from my personal life, whose school wanted to.

Whose school thought that her daughter was likely to have autism and wanted her to go to get an assessment because this daughter was having trouble attending school and this mother fought against it, stood her ground, worked with the pastoral teaching staff in that school, and over the course of a couple of months, it was hell. It was hell. And they were having trouble at home.

She wouldn't want to go to school, she refused to do this, refused to do that, but she got through it. And that young person I know now is happily settled. She's in school, she didn't need an autism assessment and they got through it.

People can get through these. Don't give in to the. It's very hard, you know, that's the messages that you get all around you. You should go for an assessment. You should.

As a professional, of course, I've. I've had the advantage of being able to support parents who didn't, who wanted to resist this.

I know it's harder for parents who don't have professionals around who might help them, but I know plenty of stories of people who do.

Dr. Tamimi, we're almost out of time, but I do want to ask you clearly, you know, writing this book, Searching for Normal, brings together your experience, your lived experience, your professional experience, what you're seeing going on and have seen going on for a long time. What is the single message, if there was one, that you want parents who read this book to take away from it?

I think it's what I've been talking about. Mental health services are not always good for your mental health.

Beware, please resist and don't fall down the psychiatric diagnosis rabbit hole for parents.

Who then will turn to Dr. Google as an option because that is the easiest next step to take, fraught with all kinds of potential issues there as well. So what could you suggest could be a reasonable first next step to take? If you believe your child may have require professional medical help?

Find somebody who works in a relational way or a systemic way. Ask them specifically do you make psychiatric diagnosis? Do you believe in psychiatric diagnosis? Avoid the ones who do.

Lots to think about on a massive topic that we've only just skimmed the surface of.

Indeed.

Dr. Dr. Sami Tamimi, psychotherapist with the National Health Service in the uk, author of Searching for Normal. Really appreciate your time and your perspective today. Thank you so much.

Thank you so much.

To learn more about the today's podcast guest and topic, as well as other parenting themes, visit whereparents talk.com.