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Pathological Child Psychiatry and the Medicalization of Childhood

BMJ 2002; 325 doi: (Published 02 November 2002) Cite this as: BMJ 2002;325:1043

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Review of Pathological Child Psychiatry and the Medicalization of Childhood by Sami Timimi

Sami Timimi's book Pathological Child Psychiatry and the Medicalization of Childhood is far better than the BMJ review by Charles Essex makes out.1 I am sorry that the conceptual arguments of the book, as Essex says, "went over his head". Essex may be right, although I am not so sure, that many parents welcome a diagnosis of ADHD (attention deficit hyperactivity disorder) and other childhood diagnoses, such as dyspraxia, dyslexia and autistic spectrum disorder. Many doctors, such as Essex, may also welcome the apparent simplification.

Does it matter that Timimi expresses his own views - or even that they may be cathartic for him? Just to be clear about my own position, I have indulged in similar comments about my training in psychiatry,2 albeit not as extensively as Timimi does in his book. Surely Timimi is right to comment on the stranglehold of a "scientific" medical training. He may feel he is alone in his "act of resistance", but there is a consensus for the kind of interpretative approach he takes in child psychiatry, however dominant the alternative positivist paradigm may be in medical practice.

I am not happy with the title of the book. I think either of the clauses "Pathological child psychiatry" or "The medicalization of childhood" on their own would have had more of a direct impact than the combined long title.

Nor am I totally satisfied with the way Timimi appears to embrace post-modernism. He takes his cue from "post-psychiatry",3 but I think the strength of post-psychiatry is its "post-positivism" rather than its links with post-modernism as such.

This minor cavilling should not detract from the refreshingly honest, engaging nature of the book. The fact that a jobbing neurodevelopmental paediatrician like Essex found it difficult to relate to the book says more about the nature of medicine than about the book itself. It may be worth quoting in full the sentence to which Essex took exception because the single sentence occupied the whole of a paragraph. It clearly describes Timimi's perspective:-

So I came to realise that what I had been taught and trained in was a faith, a belief system, a system of values, a way of judging people, pathologising people, a way of developing and maintaining certain social behaviours and practices, a way of defining conformity and deviance, a way of liberating you if you believed and could opt into these values, a way of terrorizing you if you couldn't, a way of upholding the economic system, a way of jollying you up by changing your thinking or chemically manipulating your brain so that you can return to the misery that drove you over the edge, a way of colluding with the elite, the snob, the colonizer, a way of joining a fraternity, of belonging, a way of changing, a way of staying the same, a way of life.

I suspect that using dictation as the method of writing has led to this long sentence. However, I found Timimi's writing style direct and easy to follow. It must be more the message of the book to which Essex objects.

As Essex himself notes, the substance of the book is in the chapter on ADHD. Reference to the literature in the field is extensive. Essentially the argument is that ADHD is a cultural construct. The strength of the book overall is its emphasis on cross-cultural and anthropological perspectives. From his own research, Timimi found only one article which acknowledged that culture is an important dimension out of a total of about 1600 journal articles published over 5 years in two leading mainstream academic child psychiatry journals: the Journal of the American Academy of Child and Adolescent Psychiatry and the Journal of Child Psychology and Psychiatry. For Timimi, the psychiatrist's role is to be a cultural interpreter, by which he means giving meaning to what people do and say through the use of an interpretative framework. Most of the psychiatrist's work is "about people's life stories, their aspirations, their joy, their passions and tragedies" (p81). Instead, current psychiatric practice operates as a cultural defence mechanism, avoiding important issues and regulating such areas as suffering in childhood.

Interestingly, Timimi starts the book from when he read RD Laing's The Divided Self as a medical student. This book has been the reason for many present-day psychiatrists' choice of career. Psychiatry is still struggling with its legacy in "anti-psychiatry". Timimi offers a valid and appealing synthesis out of this dilemma.

Timimi argues for a critical debate within the profession to humanize and detechnicalize many aspects of practice. The culture blindness of neuropsychiatry needs to be challenged. I am not sure what sort of "shake-up" Charles Essex thinks that child psychiatry needs. He may well be right that Timimi's message will not be heard in clinical practice. However, he should not add to its marginalisation by giving the book a poor rating. The book deserves to be more widely read.




  1. Essex C. Book review: Pathological Child Psychiatry and the Medicalization of Childhood BMJ 2002;325:1043 (2 November) [Full text]
  2. Double DB. Training in anti-psychiatry. Clin Psychol Forum 1992; 46: 12-14
  3. Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001; 322: 724-727 [Free Full Text].

Competing interests:  
Member of Critical Psychiatry Network, as is Sami Timimi

Competing interests: No competing interests

05 April 2003
D B Double
Consultant Psychiatrist
Norfolk Mental Health Care NHS Trust, Norwich NR6 5BE