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.