INTRODUCTION

The existing diagnostic classification systems in the fields of psychiatry and mental health have targeted children as objects of its nosology, taxonomy, and labeling. The prevailing systems are: (a) International Classification of Diseases [1]; (b) International Classification of Functioning, Disability and Health [2]; (c) Diagnostic and Statistical Manual of Mental Disorders, 5th Revision [3]; and, the psycho-analytic based tools like Psychodynamic Diagnostic Manual (PDM) and Operationalized Psychodynamic Diagnosis (OPD) [4]. All of them label and fit the child into categories. A relatively new approach for diagnosing mental disorders uses HiTOP (Hierarchical Taxonomy of Psychopathology) system [5] to overcome several significant shortcomings of traditional taxonomies and provide a better framework for researchers and clinicians. Another scheme proposed a family based diagnosis and classification [6,7].

When a child does not readily fit into any of these pre-existing categories, many diagnosticians are hesitant to use terms like “not yet diagnosed,” “could not be diagnosed” or “cannot be diagnosed.” The diagnostic process and systems in child psychiatry proceed along the lines as in adult psychiatry. Their clinical presentation may have multifactorial etiology with intra-psychic, familial, social and biological roots. Yet, the needle ultimately points to the child as cause and consequence or beginning and end of the problem. The child is viewed as the occurrence and maintenance of the problem. The child is, therefore, expected to be the focus of all treatments or interventions as well. The tools available with the diagnostician are interview with parents, teachers, caregivers, or the other significant other adult informants in the family or school. It is seldom the child. The child may undergo a physical or neurological exam, laboratory studies or even psychological testing. The question is whether the child is allowed to have a say on or about their parents?

Case history sheets are filled, developmental, academic or current mental status examinations of the child are undertaken. What about the parents? There are enough grounds to believe that the child's symptoms or psychopathology are an outcome or indication of a deeper malaise in parents and their families. Take the instances of contemporary hyper-parenting, hypo-parenting and atypical parenting that exists all around.

CASE VIGNETTE

Chotu, 8 year old, third-grader was born to a couple from inter-religious wedlock. The father came from a Hindu business community. The mother was a Christian. After several hurdles in the acceptance of their marriage, the couple lived by themselves. Navigating holidays or religious practices was a constant challenge for the interfaith partners. There were differences between the couple and their extended families about dress or appearance, whether to be vegetarian or non-vegetarian or what would be their place of worship. These points were not resolved before marriage. Their disharmony quickly spilled in front of their child. Being the lone next-generation heir for a rich paternal ancestry, the grandfather defended even if the boy refused to go to school, stole money, played truant, got into bad company, abused the elders or once even slapped the class teacher.

The child's mother was given no role in his upbringing. The father was a passive-yielding provider and only rebuked his wife in front of a child. The professionals diagnosed the child as Opposition Defiant Disorder. The parents or family was excluded from the ignominy of a diagnosis.

Anomalous or even destructive forms of parenting are frequently encountered in routine clinical practice. Following liberalization, privatization and globalization, India is witnessing the rapid socio-economic change that has impacted the  structure  and  functioning  of  its families  and parenting [8]. An emerging middle class, quick conversion of small towns into cities, copious inflow of foreign money, an upswing in gated communities, and preoccupation of people with a virtual world have all resulted in various shades and intensities of what is now dubbed as “affluenza” [9,10]. The large joint and extended family systems have given place to dyadic nuclear families and single-parent households, geographically separated homes, virtual, online and weekend parents.

The younger career-driven parents are handing over the charge of parenting their children to residential schools, paid or proxy caregivers and aging grandparents. Several atypical forms of parenting are emerging. Teenage parenting outside wedlock and old-age parenting resulting from state-of-the-art fertility treatments, adoptive or foster parenting, same-gender married partners, and divorced, litigious or estranged partners seeking custody of their wards are examples of contemporary children. Some parents have turned narcissistic, exploitative, anxious, apprehensive, or even paranoid of their children. Another lot of parents believe in myths, misconceptions, magic and superstition. The available literature on these themes is mostly biographical, recommendatory, do-it-yourself or anecdotal narratives than evidence-based scientific accounts on parenting in India [11-14].

In these changed conditions, some children are disallowed having interactions with peers, deprived of inter-generational contacts, and over-exposed to gadget-driven environments. The daily activity at home and school is prepared and driven by adults and not the children themselves. If a segment of parents pride in competing with another in sending their wards to an endless stream of coaching classes to achieve one-upmanship with another and getting a vicarious satisfaction from their achievements, there are others who continuously helicopter and leave no free-time for the kids. There are perfectionist tiger parents who insist their child should always be on the top. They must have ideal grammar; perfect table manners, put on the right dress for a given occasion or be an achiever in all fronts.

Some parents pack too many things for their growing child. Emphasis on teaching and over-expectations of performance at higher levels of formal academic reading, writing and arithmetic activities at home and school despite the presence of unachieved lower skills have placed many children continually at a disadvantage, thereby resulting as emotional-behavior problems like inability to sustain attention-concentration, restless-over activity, disturbed social interactions, poor compliance for and difficulties in schoolwork or being slow to expected speed. On several occasions, these behaviors are mistakenly diagnosed as attention-deficit, hyperactivity or opposition defiant disorder and even prescribed a long course of stimulants. Some parents micro-manage their children. They have to tell the child every tiniest detail, take decisions for them, choose their friends and guard them against failure [15]. By contrast, hands-off or free-range parents are unresponsive, unavailable and rejecting [16].

CASELET #6

Anu was self-diagnosed by her IT-savvy parents as autism when she was four. They believed that MMR vaccine brought the development of their single-child. From 1 or 2 word utterances, her speech was reduced to spontaneous babbles. At three, they approached a Montessori School and were denied admission since the child had no speech. They were told to get back after she learned to speak. The mother started homeschooling for a rigorous 5-6 h schedule on picture reading, number pointing, miming nursery rhymes repeatedly played on a device, pointing to shapes and colors. There was no peer group for play. Social interactions were restricted and limited between mother-daughter. The father was available at weekends. Google enlightened them about GFCF-diet. Feeds were regulated or timed. Since she showed poor eye-contact, startled for loud sounds, and avoided crowds, they presumed that these “sensory” issues could be handled by sensory-integration therapy.

By next year, even though the child had used only 5-7 single words mostly parroted after the mother, the play school reluctantly gave admission. The mother was to serve as a ‘shadow’ teacher for 2-3 h in the morning session. For the rest of the day, the child was immersed in-home tutoring. At one point, another two years down the lane, the mother started to claim that the daughter can count till thousand, add one to two digits orally, and read grade three level 5-7 word spelling list in English. Anu picked the correct answer using a script method from an array of three-four alternatives placed in front of her. Moreover, the mother-daughter claimed to possess an uncanny way of ‘reading each other’s mind’ by touching the shoulder!

Over-investing parents typically end into an enmeshed relationship with their child. Children become the center or sole purpose of their life. Their happiness is determined solely by the children. They want to know everything their child does. A long term enmeshment can result in an emotional backlash or negativism. Child-led reverse parenting occurs when the kids become decision-makers. In India, it is not uncommon for biological parents to hand over their newborn or older children to someone in their kith or kin. Such proxy parenting may be temporary or permanent and may not happen legally. At times, ‘fake’ parents are hired by the ‘real’ parents to take ‘tests’ or attend ‘interviews’ for toddlers seeking admission into prestigious pre-schools!

Grandparents donning the full-time role of parents for the second time for their grandchildren are a growing phenomenon in modern India. While the parents are off to work, grandparents are left to babysit at home. They re-live their earlier parenthood with their grandchildren [17]. Online and weekend dads or moms are increasingly becoming the order of the day. Once the weekend fun is over, the parents detach and get back to their devices. Such parents never get into the deeper, difficult, unpleasant, and emotional parts of parenting. Such things are left to the other partner or whosoever caring routinely for the child [18,19]. In addition, there is a steady erosion of child-rearing practices as applied to infants, toddlers, preschoolers, and young children. It has resulted in the pampered child syndrome. In the phenomenon of a latchkey kid, the child is in an empty home most of the time during a day without any supervision after school either because the twin parents are working or ever busy or that the child is in the care of grandparents or a paid babysitter [20].

In sum, this commentary argues the need for a paradigm shift whereby parents, rather than their children, ought to be made the objects of extensive, incisive, in-depth and elaborate case-study before any nomenclature, classification, and diagnosis of the child is attempted. The intention of this proposal is not to castigate professionals for their diagnostic incompetence or the parents and family systems. It is only to highlight their role in the unfurling of the parenting and family psychopathology vis-a-vis their children. When such a paradigm shift happens, it entails that case files or clinical records are maintained not in the names of children but on or about their parents or as a family unit on the whole.

1.       World Health Organization (1992) International Classification of Diseases ICD-10. 10^th Edn. Geneva.

2.       World Health Organization (2001) International classification of functioning, disability and health: ICF. Geneva.

3.       American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. 5^th Edn. Washington DC.

4.       Kotari VO, Kotan Z, Bilgili GO (2018) Diagnostic classification systems based on psychoanalytical principles. Arch Neuropsychiatr 55: 91-97.

5.       Kotoy R, Krueger RF, Watson D (2018) A paradigm shift in psychiatric classification: The hierarchical taxonomy of psychopathology (HiTOP). World Psychiatry 17: 24-25.

6.       Tseng W, Arensdorf AM, McDermott JF, Hansen MJ, Fukunaga CS (1976) Family diagnosis and classification. J Am Acad Child Psychiatr 15: 15-33.

7.       Pollak O, Brown R (1960) A family diagnosis model. Soc Sci Rev 34: 19-31.

8.       Kapadia KM (2005) The family in transition. In: Patel T (Ed.), Family in India: Structure and practice. New Delhi: Sage Publications, pp: 172-203.

9.       Hamilton C, Denniss R (2008) Affluenza: When too much is never enough. Australia: Accessible Publishing Systems.

10.    Sherman J (2006) Affluenza. New York: Samuel, French.

11.    Choudhury D (2017) Parenting tips for Indian parents: pre-conception to adulthood. Chennai: Notion Press.

12.    Seshadri S, Rao N (2012) Parenting: The art and science of nurturing. Delhi: Byword Books.

13.    Dange G (2010) ABCs of parenting: A parenting primer. Delhi: Jaico Publishing House.

14.    Pandya MA (2005) The Indian Parenting Book: Imparting your cultural heritage to the next generation. Chennai: Meera Publications.

15.    Glass GS, Tabatsky D (2014) The over-parenting epidemic: Why helicopter parenting is bad for your kids and dangerous for you too. New York, NY: Skyhorse Publishing.

16.    Skenazy L (2009) Free-Range Kids, How to Raise Safe, Self-Reliant Children (Without going nuts with worry). San Francisco, CA: Jossey-Bass A Wiley Imprint.

17.    De Toledo S, Brown DE (2013) Grandparents as parents: A survival guide for raising a second family. New York: The Guilford Press.

18.    Southwood C (2016) The weekend Daddy: A guide to single parenting. Carolina, US: Create Space Independent Publishing Platform.

19.    Hewitt D (2006) The practical guide to weekend parenting: 101 ways to bond with children while having fun. Hobart, NY: Hatherleigh Press.

20.    Venkatesan S (2019) Parenting: A caselets based narrative. Singapore: Notion Press.