1 Boring Old Man

A disease called ‘childhood’
New York Post
By DR. ALLEN FRANCES
March 31, 2013

^{Last week, The Post reported that more than 145,000 city children struggle with mental illness or other emotional problems. That estimate, courtesy of New York’s Health Department, equals an amazing 1 in 5 kids. Could that possibly be true?}

^{There is nothing tougher in psychiatry than accurately diagnosing a mental disorder in a pre-teenager. It is so easy to make mistakes both ways — to miss problems that desperately need attention and to attend to problems that are better left alone. Getting the right diagnosis and predicting its future course is especially difficult in kids because their symptoms have such a short track record and are often heavily influenced by transient factors like developmental differences: family, school and peer stress; and the use of drugs. It usually takes a while before an illness declares itself — and often, it turns out that no diagnosis is necessary because the symptoms go away without intervention…}

^{Human nature just doesn’t change that quickly, but the labels follow fashion and can escalate dramatically without there being an actual increase in symptoms. Our kids haven’t suddenly become sicker, it’s just that diagnoses are applied to them more loosely. Some of the broadening usefully captures missed cases, but there has been a big overshoot because of aggressive drug-company advertising. Once the adult market was saturated, pharmaceutical manufacturers turned their greedy attention to kids and began a sometimes illegal campaign to convince doctors, parents and teachers that every childhood problem is a mental disorder, the result of a chemical imbalance that requires a pill solution. Medication use in children has skyrocketed — great news for the shareholders, but potentially quite dangerous for the children.}

^{The biggest offenders are antipsychotic drugs, which cause an average 12-pound weight gain in just 12 weeks in kids who started out weighing 110 pounds. Childhood obesity is a strong predictor of diabetes, heart disease, and perhaps a shortened lifespan. The companies have been fined billions of dollars for marketing practices that especially impacted the most economically disadvantaged and socially vulnerable children…}

^{Parents and clinicians need to accept that there is no evidence to support the effectiveness of preventive psychiatry for children with mild or equivocal symptoms. There is considerable risk that well meaning but premature interventions can cause stigma and excessive medication treatment. Watchful waiting, simple advice, and reduction in stress are better than jumping in with inaccurate diagnosis and excessive treatment, whenever a diagnosis is in doubt.}

^{Perhaps most troubling about all this is how it is changing the definition of normal behavior. Is a kid who is more interested in playing outside than sitting in a classroom suffering from ADD — or simply 7 years old? Is a child who slams his bedroom door and refuses to come to supper suffering from depression — or having a tantrum? We should not medicalize the aches and pains of normal childhood.}

So what would preventive psychiatry be? We know sexual trauma causes PTSD [and other things]. So preventing childhood sexual abuse is preventive psychiatry. Is treating ADHD preventive psychiatry? Yes, if the kid really has it. But it’s got very fuzzy borders with just plain childhood, and that border has been massively extended into the range of "children with mild or equivocal symptoms." Is there any evidence that using medications to control behavior [Conduct Disorder, Disruptive Mood Dysregulation Disorder, Pediatric Bipolar Disorder] prevents anything? I don’t know of any such evidence. Do medications treat a cause? I know of no such evidence. It is a symptomatic treatment given to help parents or caretakers, not the children themselves – so it fits neither model. Is it possible that 1 in 5 children in New York has a mental illness of some sort? That flies in the face of common sense and scientific reality.

One of the clearest and most basic ideas in our understanding of childhood is usually attributed to Erik Erikson – that children develop through a series of stages characterized by developmental crises – normative developmental crises. I know of no refutation of this very useful concept. Childhood just isn’t easy. There’s plenty of dis-ease along the way. That’s not only normal, it’s a required part of building a personality structure that’s suited to the challenges of adult life. The oppositional two year old isn’t sick, he’s negotiating with the universe about who is in charge. The homework averse fourth grader isn’t lazy or depressed, she’s working out a building block towards the persona she’ll later take into the world.. Developmental crises are uncomfortable for children and parents alike. But the discomfort is in the service of a higher cause – not necessarily an object for diagnosis or treatment.