Sunday, 28 April 2013




The publication of DSM V in 2013 (The Diagnostic and Statistical Manual) used by Psychiatrists and others in CAMHS contexts to assess and diagnose troubled young people is a significant event. But even before it was published it was attracting controversy and criticism as its development was monitored. 70 per cent of the DSM V taskforce had commercial links to the pharmaceutical industry creating potential conflicts of interest. In addition, part of their taskforce membership was a mandatory nondisclosure agreement- effectively shrouding the whole process in secrecy and preventing any challenge from concerned clinicians.

Allen Frances, a former head of DSM IV issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle,...ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". (1). He stated that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process."

Robert Spitzer, the head of the DSM-III task force, also publicly criticized the way DSM V has been secretive and not open to scrutiny. (2). And Christopher Lane (3) former director of the Psychoanalytic Studies Program in the Psychiatry Department of Emory University, warned against the expansion of mental illness categories which were pathologising normal human experiences.

The British Psychological Society stated in its June 2011 response that it had "more concerns than plaudits" (4). It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflecting current normative social expectations". The BPS noted doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".


Who decides what is abnormal: the worker, parent or child? How is the notion of sufficiently marked or prolonged measured and against what standard? Mental illness takes us into the realm of medicine and clinical guidelines and diagnostic criteria usually applied to the most serious difficulties and those that are statistically rare. Whereas, at the other end of the scale, the terms emotional well-being or emotional literacy are becoming popular among the wider public and professionals even though it would be hard to find agreement about a definition of what these terms mean.


The behaviour and emotional affect of children and young people designated with symptoms of mental health difficulty can be considered in different ways within a variety of professional discourses. The dominant discourse is that of medicine and especially psychiatry, which continues to refine classifications of symptoms into universal descriptors. Yet behaviour and expressed emotions can be interpreted widely, depending on the theoretical base of the professional involved and the specific cultural and historical context of their manifestation.


Mental illness in young people was constructed in the context of a debate among

psychiatrists about the criteria for diagnosing specific mental health problems. Previously they had relied on a constellation of symptoms based on adult measures to distinguish children and adolescents whose condition was outside the normal experience. A significant study drew attention to the limitations in psychiatric diagnosis and, by implication, the medical model it embodies (5) This study found that not all children with symptoms of mental disorder showed marked impairment and, conversely, some children had significant psychosocial impairment without reaching the clinical threshold for diagnosis.



In 1952, when the APA's diagnostic manual first appeared, it was a small text that offered sketches of such traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a definitive authority on everything pertaining to mental health. But in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested. In 1994 DSM IV culminated in many disorders deleted, created or reorganised based on empirical research and literature reviews. The evidence base informing DSM IV included very little testimony from patients or service user organisations, and young people were not consulted at all.


For CAMHS staff the major changes in DSM V include the elimination of Asperger syndrome as a separate disorder, and merged under autism spectrum disorders (ASD). Under the new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. But how are these terms defined? This change has been met with resistance amongst Asperger Syndrome specialists. There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age.


The diagnosis of Bipolar Disorder in children is a controversial topic. While some believe the DSM IV criteria should be retained others have proposed other behavioral markers specific for children. The DSM-5 may include a new type of mood and conduct disorder, Disruptive Mood Dysregulation Disorder, as a replacement for most peadiatric bipolar diagnoses. Some prominent psychiatrists, such as Dr. Stuart Kaplan and Dr. Allen Frances, advocate applying less severe and better-researched diagnoses such as ADHD and Oppositional Defiant Disorder instead of Peadiatric Bipolar Disorder.


Another origin for controversy is the rise in the number of diagnoses in recent years, almost exclusively in the USA, with several possible causes for this increase. It has been argued that factors including biomedical reductionism, neglect of trauma and attachment factors, the symptom checklist but decontextualised model of psychiatry embodied in DSM, and the pervasive influence of the pharmaceutical industry, particularly in the US health system, have contributed to the epidemic of Peadiatric Bipolar Disorder.


Hypersexual Disorder is proposed as a new category. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when a person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by medication or drugs, as well as other criteria.

It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM IV, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories. But who defines vindictiveness compared to say- retaliation, or an indication of persecutory child sexual abuse?

DSM V will have added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". But what does 'most' mean? For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.

Gender Identity Disorder in children is another controversial area in DSM V. Transgender support groups and organizations believe it is unethical to even have a diagnosis of GID in young people. Other critics argue that it pathologises non-conformity with orthodox binary definitions of gender, stigmatises many children and fails to tackle homophobic prejudice and social intolerance of difference which are the real problems.

DSM V and all its predecessors are peppered with distinctions such as 'severe' 'major',  'superficial' and 'short-term', to try and help users place the young person into a pre-formed category. The problem is that these terms are rarely defined and by their nature are influencing the perceptions of psychiatrists and others tasked with assessing troubled young people. They force clinicians to find a category for the young person rather than permit a more personal, descriptive assessment. This means in the final analysis they are highly subjective. Labels stick and are usually linked to treatment including medication which can have profound side effects and imply that there is a biological element to a young person's distress. This risks ignoring the social construction of mental illness, the socio-economic context of racism, homophobia, poverty, poor housing, parental mental illness, unemployment and bullying.

Steven Walker, Systemic Psychotherapist



 1. Allen, F. (2009). A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, Psychiatric Times, 26: 8



3. Lane. C. (2009). Bitterness, Compulsive Shopping, and Internet Addiction

The diagnostic madness of DSM-V. Slate Magazine, July 2009.


4.  British Psychological Association.(2011). Response to the American Psychiatric Association: DSM-5 Development. June 2011.


5. Pickles, A; Rowe, R; Simonoff, E; Foley, D; Rutter, M; and Silberg, J.(2001).Child Psychiatric symptoms and psychosocial impairment- relationship and prognostic significance. British Journal of Psychiatry, 179. 230-235




The numbers of those young people found to have committed suicide each year are a stark reminder of the painful human cost of mental illness. The loss of a young life is always shocking and distressing but in the case of suicide there is an added sense of despair and helplessness evoked. Suicide is now the second most common cause of death in young men and women in the UK.

The latest data from the Office for National Statistics (ONS) provides an opportunity to examine in closer detail what has been happening over the past 30 years, from 1981 to 2011. The official press release highlighted the recent jump in the annual number of suicides. There were 6,045 suicides in people aged 15 and over in the UK in 2011, compared with 5608 in 2010 – a rise of 437 people. The ONS figures showed that the UK suicide rate “increased significantly” from 11.1 deaths per 100,000 population to 11.8 deaths per 100,000 population. These statistics relate to the whole population, so it is worth noting that the corresponding figures for young people aged between 15 and 25 years were: 14.1 and 14.8 deaths per 100,000 population. Young people are thus more at risk of suicide than older people.

However closer analysis of the 30 year data reveals some worrying trends in the context of the current Economic crisis. For children aged 15-19 years there were on average more than 4 suicides every week, while for young people aged 19-25 there were 14 per week. Together on average nearly 3 young people between the ages of 15 and 25 committed suicide every day of the week.

In terms of the percentage of the young population this translates as a yearly average of over 5% per 100,000 for 15-19 year olds, and nearly 18% per 100,000 for 19-25 year olds. Put together the total number of suicides between 1981 and 2011 of young people between 15 and 25 years of age who committed suicide was 21,006. Or an average of over 700 per year.

These numbers disguise peaks, troughs and trends so further statistical analysis shows above average years as well as trends which can be calculated by regression analysis and other statistical models. For example there were 15 years out of the past 30 when the yearly average of suicides of young people was higher. Any link with other variables such as unemployment and economic recession could be useful for researchers and government planners in the Department of Education. The figures show that in the peak years of unemployment in 1983/84; 1992/93 and 2009/10 while there were higher than average numbers of suicides in young people, those years did not correlate with the highest numbers or averages over the past 30 years.

Another important variable is the relaxation of legal constraints related to alcohol availability and the increase in opening times for pubs and clubs which happened during the previous government's term of office. The link between alcohol, drug abuse and suicide is well established - whether it is perceived as a cause or effect phenomena. In other words a young person who is depressed may turn to alcohol and drugs to blot out their inner pain. Or excess drink and drug use could trigger a depressive episode combined with disinhibition.

Interpretation of these data is always problematic. For example the way Unemployment is calculated has been changed more than 30 times over this period of time by successive governments, making comparisons and extrapolation very difficult. The recording of suicides by coroners is also variable around the country and is understood to be an under-representation of the actual number of suicides in young people due to the lack of evidence in many unusual deaths of a corroborating note, or other indication of intent. Coroners are reluctant therefore to record an official suicide verdict where there is any doubt and also to protect the feelings of grieving parents and family.

Other factors associated with suicide can include parental mental illness, alcohol and drug abuse, childhood sexual abuse, a history of depression, early-onset psychosis, chronic neglect and poor attachment. All of these can be exaggerated by poverty, unemployment, poor housing, bullying and undiagnosed learning or developmental disabilities. Longitudinal studies conducted by Universities and Research Institutes can provide the fine grain needed to illuminate useful aspects from the raw data. However they are very expensive to undertake and sustain, and they can only offer interpretations based on the best available evidence and research methodologies.

The previous government launched the National Suicide Prevention Strategy  in 2002 with a target of reducing suicides by at least 20 per cent by the year 2010. This period combined with an unprecedented increased in NHS funding and specific hefty increases in CAMHS budgets. That target was achieved in terms of suicides in young people, and it happened to co-incide with a period of strong Economic growth. We are now in a period of Economic crisis combined with heavily-reduced CAMHS budgets. This does not bode well.

Steven Walker, Systemic Psychotherapist, Youth Enquiry Service, Essex.

Reference: Office for National Statistics, (2012). Suicides in the United Kingdom- 2011. London, ONS.



Social Exclusion and Mental Health



The effects of social inequality- mental health problems affect 3x as many lower class children compared to higher class, 1 in 10 children suffer from a poverty related mental health problem, UK IS fourth from bottom of poverty league table, govt aim to abolish child poverty by 2021 has now been abandoned......

Mental health problems affect three times as many children in social class V (manual and unskilled) compared with those in social class I (professional) according to the authoritative Social Trends report (ONS 2012). It is important therefore to consider the external context of child and adolescent mental health problems and acknowledge that the impact of service provision in some families is mediated by factors such as unemployment, poor housing and poverty. They all contribute to the level of resilience and capacity for resourcefulness of children and families (Eamon 1994, Dunn 1999, Micklewright & Stewart 2000). A report on social inequalities from the Office for National Statistics revealed that one in ten children in the United Kingdom suffers from a poverty related mental health problem (HMSO 2000). According to other research the UK is fourth from the bottom of a list of relative poverty among the nineteen richest nations (UNICEF 2010).


The previous government target failed to reduce child poverty by a quarter by 2004, to halve it by 2010 and unlikely to have helped to abolish it by 2021. The calculations for defining poverty, relative poverty and absolute poverty are complex and subject to much statistical interpretation and debate. The current measure for calculating relative child poverty (defined as children living in households with incomes below 50 per cent of the national median) does not reveal anything about the depth of poverty. In other words every household below the 50 per cent threshold would be counted regardless of whether they were just below or in complete destitution. Also it fails to measure how long children have lived in poverty. This is important given the cumulative psychological effects of persistent social exclusion.

 Socially excluded children and their families


Black children- Govt inspections reveal inadequate assessment of the needs of black children and families: are your agencies following these recommendations?

Ensuring that services and staffing are monitored by ethnicity to ensure they are provided appropriately and equally

Involving ethnic minorities in planning and reviewing services

Training in anti-racist and anti-discriminatory practice

Investigating and monitoring complaints of racial discrimination or harassment

Explicit policies are in place for working with black families


Research by the NSPCC revealed (Barter 1999):

Racism and racial bullying are commonplace within the lives of ethnic minority children and young people

The most common expression of racism is through racist name-calling previously considered by adults as trivial but the impact is now known to be profound

Racial bullying frequently involves the use of violence

Violence against ethnic minority groups is persistent, patterned, and long-term in the way it affects individuals and the places where they live


Disabled children

Disabled children and those with learning difficulties are more likely to have mental health problems than other children. Disabled children and adolescents are twice as likely to have emotional and behavioural problems. There are a growing number of disabled children and young people living in the community who need high levels of support. Partly this is because more of these children are surviving infancy, and partly because there is no longer the assumption that disabled children should be cared for in hospitals or other institutions. Lone parents with disabled children, families from ethnic minorities, and families caring for the most severely disabled children have the highest levels of unmet need, and live in the poorest conditions. The mental health needs of disabled children are often masked by a narrow focus on their disability through a medical, rather than social model of disability. Behaviour causing concern can often be ascribed to the physical or intellectual disability rather than a separate psychological need.


Young Offenders

According to recent figures there were 11,500 young people aged 15 to 20 in jail in England and Wales in 2010, of those 90 per cent had a diagnosable mental health disorder, and many had substance abuse problems as well as personality disorders (Lyon et al 2010). 60 per cent had anxiety and depressive illness with 10 per cent suffering from a severe psychotic mental illness such as schizophrenia. 20 per cent of these young men and 40 per cent of young women will have attempted suicide prior to their imprisonment (Farrant 2001). Young offenders are among the most socially excluded groups in society and the evidence suggests that imprisonment simply makes matters worse not better. Within two years of release, 75 per cent will have been reconvicted and 47 per cent will be back in jail (Social Exclusion Unit 2002). If some of these young people become homeless or end up in insecure accommodation, they are between eight and 11 times more likely to develop mental health problems (Stephens 2002). Low take up of preventive mental health services among socially excluded families means that minor problems can develop into major problems. Over 90 per cent of recidivist delinquents had a conduct disorder as children


Looked After Children

Nearly 60,000 children were being looked after by local authorities for the year ending 2011. About 60 per cent of these children had been abused or neglected with a further 10 per cent coming from ‘dysfunctional families’ (DOH 2011). Abuse of this nature can lead to self-harming behaviour, severe behavioural problems and depression. Evidence confirms that the mental health needs of these children and young people are overlooked and that many have established mental health problems prior to coming into local authority care (Dimigen et al 1999). 38,400 of these children were in foster placements and 6,400 were in children’s homes, yet foster carers and residential staff are among the least qualified and supported people left to manage sometimes extreme behaviour. Specialist CAMHS services often decline to help because of the uncertain and possibly temporary nature of the child’s placement which contra-indicates successful intervention. The dilemma is that without input, placements often break down as carers cannot cope, invariably leading to more placements and further deterioration in the child’s mental health.


A recent research study emphasised the importance of a preventive approach with children in the public care system who are more likely to be excluded from school following emotional and behavioural difficulties (Fletcher-Campbell 2001). Teacher training that fails to adequately prepare newly-qualified staff to respond to the mental health needs of pupils is considered to be a factor in the increased use of school exclusions (OFSTED 1996).  Social workers using a preventive approach could be helpful to teaching staff and organise collaborative work aimed at preventing difficult behaviour escalating. Unless the mental health needs of these children and young people are addressed as part of a strategy that effectively nurtures children’s inclusion in school the risk of deterioration is high. The risk factors for looked after children are probably the most extreme of any socially excluded group, they include (Richardson & Joughin 2000):


Developmental delay

School failure

Communication difficulty

Low self esteem

Parent/carer conflict

Family breakdown



Parental mental illness

Alcohol/drug abuse




Refugee and asylum seeking children
The number of applications for asylum from unaccompanied under 18s almost trebled between 1997 and 2011 from 1,105 to 3,469. DOH figures indicate that there were 6,750 unaccompanied asylum- seeking children supported by local authorities in 2001. Further evidence shows that many of these young people were accommodated and receiving a worse service than other children in need (Audit Commission 2000). Very little research has been done to ascertain the mental health needs of this group of children. However there is some evidence of the symptoms of post traumatic stress syndrome being present before they then experience the racist xenophobic abuse of individuals and institutions incapable of demonstrating humanitarian concern for their plight. This combination can shatter the most psychologically robust personality. It has been estimated that serious mental health disorders may be present in 40-50 per cent of young refugees (Hodes 1998).