Introduction

More and more chil­dren in the United States receive psy­chi­atric diag­noses and psy­chotropic med­ica­tions — this is not news. With those increased rates of diag­no­sis and phar­ma­co­log­i­cal treat­ment come some­times intense debates about whether those increases are appro­pri­ate, or whether healthy chil­dren are being mis­la­beled as sick and inap­pro­pri­ately given med­ica­tions to alter their moods and behaviors.

Some of these debates are inevitable, given the con­cep­tual issues sur­round­ing the diag­no­sis and treat­ment of psy­chi­atric dis­or­ders in gen­eral and the appli­ca­tion of these diag­nos­tic cat­e­gories and treat­ment modal­i­ties to chil­dren in par­tic­u­lar. In this report, we will describe many of those com­plex­i­ties, pay­ing close atten­tion to the inerad­i­ca­ble role that value com­mit­ments play not only in deci­sions about the appro­pri­ate modes of treat­ment, but also in diagnosis.

The fact that children are developing organisms on whose behalf adults are acting increase both the stakes and the complexity of the debates.

Because psy­chi­atric diag­noses are judg­ments — first of the pan­els of experts who draft the descrip­tions of the dis­or­ders and then of indi­vid­ual clin­i­cians match­ing diag­nos­tic cat­e­gories to the child in front of them — they are nec­es­sar­ily influ­enced by cul­tural and indi­vid­ual value com­mit­ments.1 The exact bound­aries between, for exam­ple, healthy and unhealthy anx­i­ety or healthy and unhealthy aggres­sion are not writ­ten in nature; they are artic­u­lated by human beings liv­ing and work­ing in par­tic­u­lar places and times. While the extreme end of mood and behav­ioral con­tinua may be clear to almost every­one, there will always be some dis­agree­ment about whether a given clus­ter of moods and behav­iors is best under­stood as dis­or­dered, about how exactly to describe some symp­toms of dis­or­der, about which par­tic­u­lar diag­no­sis or diag­noses an indi­vid­ual war­rants, and about whether some mildly affected indi­vid­u­als are best served by receiv­ing no diag­no­sis at all. Those dis­agree­ments will be influ­enced by dif­fer­ent but rea­son­able under­stand­ings of, for exam­ple, the proper oblig­a­tions of par­ents and the proper goals of med­i­cine. The fact that chil­dren are devel­op­ing organ­isms on whose behalf adults are act­ing — some­times with and some­times with­out the par­tic­i­pa­tion of the chil­dren them­selves — and the fact that the safety and effi­cacy of treat­ments is not always clear increase both the stakes and the com­plex­ity of the debates.

In this report we will sug­gest that where dis­agree­ments are rea­son­able, they should be tol­er­ated, given the fun­da­men­tal eth­i­cal com­mit­ment to respect for per­sons. And we will insist that it is impor­tant to dis­tin­guish between rea­son­able dis­agree­ments and diag­nos­tic mis­takes, includ­ing over-, under-, and misdiagnosis.

As impor­tant as it is to rec­og­nize rea­son­able dis­agree­ments, so, too, it is impor­tant to rec­og­nize how much we can and do agree. Unsur­pris­ingly, every­one who par­tic­i­pated in the work­shops we con­ducted agreed that we share a fun­da­men­tal oblig­a­tion to pro­mote the flour­ish­ing of chil­dren, that care­ful diag­no­sis takes time, and that treat­ments should be mon­i­tored for safety and effec­tive­ness. No one rejected med­ica­tion treat­ments in all cases, nor did any­one believe that severely impaired chil­dren would be bet­ter off undi­ag­nosed and untreated.

More sur­pris­ingly, how­ever, we found wide agree­ment around the dis­turb­ing con­clu­sion that the United States’ men­tal health care sys­tem, edu­ca­tional sys­tem, and aspects of its shared cul­ture too often fail chil­dren whose moods and behav­iors are patently prob­lem­atic for those chil­dren. In these sys­tems, most chil­dren suf­fer­ing mood and behav­ior prob­lems fail to receive the kind of care that experts rec­om­mend; far too often they are not diag­nosed at all or are not diag­nosed care­fully enough. More­over, these same sys­temic and cul­tural pres­sures con­strain the treat­ment choices of clin­i­cians and par­ents and make it dif­fi­cult for them to deliver opti­mal care. Treat­ment is often only phar­ma­co­log­i­cal,2 even where a non­phar­ma­co­log­i­cal inter­ven­tion or a com­bi­na­tion of med­ica­tion and psy­choso­cial inter­ven­tion would have fewer side effects, be more effec­tive in the long run, and bet­ter reflect the par­ents’ and clin­i­cians’ value commitments.

Too often, lit­tle is done to improve children’s envi­ron­ments, even where it is clear that these envi­ron­ments are an impor­tant source of the child’s prob­lems or are key to secur­ing last­ing improve­ments. As impor­tant and inevitable as our dis­agree­ments are regard­ing the bound­aries of “nor­mal” in chil­dren, we make a pro­found mis­take if we let them dis­tract us from agree­ing that we need to remove the bar­ri­ers that stand in the way of opti­mal care for those chil­dren who are suf­fer­ing from moods and behav­iors that no one would con­sider nor­mal or healthy.

Our report is divided into three major parts. In the first, we describe the con­cep­tual and prac­ti­cal com­plex­i­ties asso­ci­ated with defin­ing and diag­nos­ing men­tal dis­or­ders in chil­dren. In the sec­ond, we describe the com­plex­i­ties asso­ci­ated with decid­ing whether and, if so, how to treat. Finally, we describe how our cur­rent ways of deliv­er­ing men­tal health care fail to pro­mote the wel­fare of chil­dren and fam­i­lies.

Ref­er­ences
  • 1. J.Z. Sadler, Val­ues and Psy­chi­atric Diag­no­sis (Oxford, U.K.: Oxford Uni­ver­sity Press, 2005).
  • 2. M. Olf­son and S.C. Mar­cus, “National Trends in Out­pa­tient Psy­chother­apy,” Amer­i­can Jour­nal of Psy­chi­a­try 167, no. 12 (2010): 1456 – 63.