Disagreement and Consensus

Through the Doorway, by Tilly Willis

Through the Door­way, by Tilly Willis, oil on can­vas, 2005. (Pri­vate Collection/ The Bridge­man Art Library)

We have described some of the com­plex­i­ties asso­ci­ated with the cur­rent approach to diag­nos­ing emo­tional and behav­ioral dis­tur­bances in chil­dren. Most of the diag­noses artic­u­lated in the DSM were based on obser­va­tion of symp­toms in adults, but symp­toms of what psy­chi­a­trists con­sider to be the same dis­or­der may look dif­fer­ent in adults and chil­dren. Also, the DSM’s cat­e­gories cap­ture het­ero­ge­neous phe­nom­ena, and they over­lap; fur­ther, because symp­toms and impair­ments are expressed along con­tinua, there are no bright lines between healthy chil­dren and those who war­rant diagnoses.

Informed, trained, car­ing peo­ple will thus some­times have rea­son­able dis­agree­ments about where to set diag­nos­tic thresh­olds and about whether a mildly affected child — a child in the “zone of ambiguity” — would ben­e­fit from a diag­no­sis. These dis­agree­ments can occur when peo­ple have dif­fer­ent value com­mit­ments or just give dif­fer­ent emphases to shared value com­mit­ments (regard­ing, for exam­ple, the goals of psy­chi­a­try or the goals of par­ent­ing). Such value dif­fer­ences or emphases can play out in the con­text of treat­ment deci­sions as well.

As impor­tant as it is to rec­og­nize such dis­agree­ments, it is also impor­tant to rec­og­nize how much agree­ment there can be among peo­ple as diverse as those who con­sti­tuted our work­ing group. For one thing, there is agree­ment that chil­dren can indeed have seri­ous psy­chi­atric dis­or­ders and that med­ica­tions can be an essen­tial part of appro­pri­ate treat­ment plans. For another, no mat­ter how impor­tant it is to tol­er­ate rea­son­able dis­agree­ments, it is essen­tial to avoid the sorts of mis­takes that involve patent over­diag­no­sis, mis­di­ag­no­sis, and under­diag­no­sis, which result in many chil­dren not receiv­ing the care they need. These mis­takes are facil­i­tated by sys­temic forces that bear on clin­i­cians and fam­i­lies and restrict the time avail­able for care­ful diag­noses. Specif­i­cally, these forces can make it tempt­ing to base a diag­no­sis on the pres­ence of symp­toms alone, as opposed to doing the sort of care­ful eval­u­a­tion that can deter­mine whether those symp­toms impair the child. Those same sys­temic forces strongly favor med­ica­tion treat­ments over psy­choso­cial ones, so that chil­dren too often receive phar­ma­co­log­i­cal treat­ment only, even when other treat­ment plans are sup­ported by evi­dence and reflect their or their family’s deep­est value commitments.

Our ethical obligations to children require that we  remember that we have the power to change the contexts in which children are embedded.

Improv­ing the qual­ity of the U.S. pedi­atric men­tal health care sys­tem would include sup­port­ing the devel­op­ment of psy­choso­cial treat­ments, com­par­a­tive effec­tive­ness and post­mar­ket­ing research on approved treat­ments, train­ing clin­i­cians in sophis­ti­cated med­ica­tion man­age­ment and deliv­ery of psy­choso­cial inter­ven­tions, and insti­tut­ing reim­burse­ment poli­cies that enable clin­i­cians and fam­i­lies to access both treat­ment modal­i­ties. As all mem­bers of our work­ing group could read­ily agree, chil­dren deserve “devel­op­men­tally appro­pri­ate and com­pre­hen­sive assess­ments” to deter­mine whether a psy­chi­atric diag­no­sis is appro­pri­ate. More­over, if chil­dren are diag­nosed with emo­tional and behav­ioral dis­tur­bances, they should have access not only to med­ica­tion treat­ments but also to “empir­i­cally sup­ported psy­choso­cial and behav­ioral ser­vices.”91

As we attempt to improve our sys­tems of deliv­er­ing men­tal health care to chil­dren, we should remem­ber that, even though some dis­agree­ments about diag­nos­tic and treat­ment deci­sions will per­sist, there is fun­da­men­tal agree­ment that chil­dren and fam­i­lies deserve access to care­ful diag­no­sis and mul­ti­modal treat­ment approaches that are safe, effec­tive, and reflect their value com­mit­ments. Our eth­i­cal oblig­a­tions to chil­dren require that we — includ­ing policy-makers, edu­ca­tors, med­ical pro­fes­sion­als, and par­ents — remem­ber that in addi­tion to chang­ing chil­dren (by phar­ma­co­log­i­cal or psy­choso­cial means), we also have the power to change the con­texts in which chil­dren are embed­ded, which can be key to last­ing improve­ments in their men­tal health.

  • 91. M. Olf­son et al., “Trends in Antipsy­chotic Drug Use by Very Young, Pri­vately Insured Chil­dren,” Jour­nal of the Amer­i­can Acad­emy of Child and Ado­les­cent Psy­chi­a­try 49, no. 1 (2010): 21.