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Book Review: 'Back to Normal' by Enrico Gnaulati, Ph.D.

Drawing on first-rate research and scholarship, Dr. Gnaulati makes a very strong case for going "back to normal," and taking care of our more challenging children in the ways that are most likely to help them, and the least likely to traumatize them.
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An Armenian mother who had just learned from a psychiatrist that her son "had ADHD" asked me if I would help her understand the diagnosis. I showed her the behavioral criteria in the Diagnostic Statistical Manual of Mental Disorders under the category Attention Deficit Hyperactivity Disorder. She turned to me in shock, "My God, it's a description of children."

Two centuries ago, we had very few classifications of mental health diagnoses. It is indisputable that our recent work in classifying mental disorders has helped us make great strides in research and treatment. However, it must be kept in mind that these classifications are based on observations of behaviors thought to lie outside a norm that is at best a provisional cultural construct, and in the case of children, a very, very fluid and subjective construct indeed.

Our uncertainty as to what constitutes normal childish behavior, coupled with a variety of pressures from our schools, social service agencies, phramaceudical companies and insurance companies, has produced an alarming increase in normal children being diagnosed with severe psychological diseases. Dr. Enrico Gnaulati has written the book of the hour, an extraordinarily well-researched explication of our rush to pathologize normal behavior in children and an impassioned plea to reflect very carefully before placing our youngsters under diagnostic categories that hinder their growth and leave them believing they suffer from "brain diseases."

"Context is everything in understanding children's behavior," Dr. Gnaulati reminds us. And yet context is often the first thing dispensed with in the diagnostic encounter. Poorly trained in psychotherapy (the modality most likely to reveal systemic issues underlying a child's behavior), psychiatrists and pediatricians tend to rely on checklists of behavior supplied by parents and teachers in order to make initial diagnoses and prescribe a first battery of drugs. After this initial assessment, more often than not, psychiatrists and pediatricians rely on a monthly "15-minute med check." This is the current acceptable standard of care. Given the nature of our gatekeeping, it is little wonder that the forces that press for pathology have had their way.

The NIMH has reported over the last decade a staggering 40 percent increase in bipolar diagnoses. According to Time magazine, 11 percent of children have ADHD diagnoses, a 16 percent increase from 2007. The CDC has recently announced a 23 percent increase in the diagnosis of autism spectrum disorders, estimating that 1 in 88 Americans have the disease. Something is very wrong with this picture.

Dr. Gnaulati is systematic in his analysis of the cultural and political factors at play in the increasing pathologizing of the normal behavior of children, but he does not have a political axe to grind. He seems to see the problem as an understandable phenomena arising out of factors both cultural (overworked parents and schools pressing unrealistic academic agendas) and administrative (increasingly bureaucratized mental health agencies and insurance companies).

No bad guys perhaps, but a very bad situation. Dr. Gnaulati suggests that many severe diagnoses in children can be easily explained as variants of normal behavior.

If your child interrupts and objects to waiting his turn, does he have an abnormal prefrontal cortex (yikes!), such as is supposed to underly ADHD, or is he simply laboring under normal childish narcissism, which might involve the fantasy that he is entitled to immediate recognition and gratification? Does he need amphetamines, perhaps for life, or empathy and strong rules?

Does your stormy adolescent suffer from incipient bipolar disorder or is she simply sleep-deprived, hormonal and struggling with identity issues typical of her age? Does she need mood stabilizers, or a bedtime and therapy?

Is your smart, tantrum-inclined, 5-year-old an Asperger's kid, destined for a difficult lonely life, or is he just very, very bright and sensitive?

Drawing on first-rate research and scholarship, Dr. Gnaulati makes a very strong case for going "back to normal," and taking care of our more challenging children in the ways that are most likely to help them, and the least likely to traumatize them.

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