A kind of

12th October 2007 at 01:00
Juvenile excitement, adolescent angst or in need of help? How do we define what is normal behaviour in our class, asks Oliver James

Workplaces in the 1960s often had humorous signs displayed saying: "You don't have to be mad to work here but it helps." In those wild and wacky times, blurring the lines between sanity and madness did not have a very scientific basis. But more recent work has revealed that there are, indeed, no hard and fast lines, even when it comes to major mental illness. Comforting though a doctor's diagnosis may seem to all concerned, it is not necessarily helpful or meaningful.

For example, a recent issue of the scientific journal Development and Psychopathology was devoted to bipolar disorder (BD) in children (BD: massive swings between manic omnipotence and depression). The statistics intriguingly suggest that bipolar disorder often becomes evident quite young. Between 15 and 28 per cent of people diagnosed with the illness in adulthood had it before the age of 13, and 60 per cent before the age of 19.

However, a telling paper in that issue, by Daniel Dickstein et al., calls into question the significance of psychiatric diagnoses. A fundamental element in diagnosing BD is an elevated or expansive mood, known as euphoria. As anyone who has spent much time in the company of children will know, most healthy children get high as a kite from time to time. Our three and six-year-old offspring sometimes get incredibly overexcited when tired shortly before bed, or if an exciting event (tea party, visit to friends) is imminent.

Dickstein points out that a high proportion of adults or children who meet the criteria for a diagnosis of BD also qualify as suffering from other disorders, such as Attention Deficit and Hyperactivity Disorder (ADHD), anxiety, antisocial behaviour and depression. For instance, 29 per cent of children diagnosed with ADHD and followed from aged 10 also qualified for a diagnosis of BD by the age of 16.

Nor does it seem very likely that distinguishing these states in children, if indeed they do exist as discrete entities, will ever be possible by neuroimaging. Thus far, there have been inconclusive results of attempts to establish that there are different patterns of brainwaves from those normal in children with different illnesses, or that different bits of the brains are bigger or smaller.

As Richard Bentall, the respected British psychologist, puts it in his exhaustive book Madness Explained: "Everywhere we look, it seems that the boundaries between sanity and madness are indistinct and permeable... abnormal behaviours exist on continua with normal behaviours and experience". He reaches this conclusion only after thorough examination of the evidence, revealing that the overlap between symptoms of schizophrenia and BD is so great that they are almost meaningless as discrete categories. He also shows that large portions of the general population display one or more of the symptoms from time to time.

For example, what are technically regarded as delusions are commonplace. One quarter of Americans believe in ghosts and over half agree with the statement that: "the Bible is the literal and actual word of God". And at least 10 per cent of us "rational" Europeans have experienced a hallucination (visual or audio); in a large sample of French people, 69 per cent said they had at some time believed someone else not to be who they claimed to be and 47 per cent had experienced telepathy.

Despite frequent claims to the contrary, the most recent studies of psychopaths suggest that they do not constitute a discrete group of people but exhibit behaviour on a continuum of normally occurring traits. Similarly, claims that ADHD is due to abnormalities of patterns of brainwaves of particular bits of the brain simply do not stand up when evaluated scientifically.

There is little doubt that some of the children you teach are liable to be jammed for more of the time on the extreme end of the human continuum, whether you call it ADHD, bipolar, conduct disorder or all three at once. But how to select the ones who really need help and are not just going through normal juvenile excitement or adolescent angst? And what are the best methods for helping them? These are subjects to which I shall retur *

Oliver James is a child clinical psychologist and author of Affluenza How to be successful and stay sane


Development and Psychopathology: 2006, Volume 18, Number 4.

Recent evidence on psychopaths: Murrie, D.C. et al, 2007, Child Psychology and Psychiatry, 48, 714-23.

ADHD not identified by neuroimaging: Dickstein, S.G., 2006, Child Psychology and Psychiatry,, 47, 1051-62.

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