Diagnosing Disagreement

In today’s New York Times, Benedict Carey offers “the second article in a series examining the increasing number of American children whose difficulties are diagnosed as serious mental disorders.â€? Refreshingly, the article is quite well-balanced in its examination of these disturbing trends and the conflicts about such that exist within the psychiatric community. While Carey does not really explore the role that environment and family history (relational, not biological) often play in the development and presentation of childhood emotional and behavioral difficulties, he nonetheless provides a valuable public service by highlighting that there is disagreement among clinicians about diagnoses such as pediatric bipolar disorder and that the huge increase in the use of these diagnoses raises significant questions about how children are being assessed and treated. The article is well worth reading, as is a related post (here) on this topic…

What’s Wrong With a Child? Psychiatrists Often Disagree

Paul Williams, 13, has had almost as many psychiatric diagnoses as birthdays.

The first psychiatrist he saw, at age 7, decided after a 20-minute visit that the boy was suffering from depression.

A grave looking child, quiet and instinctively suspicious of others, he looked depressed, said his mother, Kasan Williams. Yet it soon became clear that the boy was too restless, too explosive, to be suffering from chronic depression.

Paul was a gifted reader, curious, independent. But in fourth grade, after a screaming match with a school counselor, he walked out of the building and disappeared, riding the F train for most of the night through Brooklyn, alone, while his family searched frantically.

It was the second time in two years that he had disappeared for the night, and his mother was determined to find some answers, some guidance.

What followed was a string of office visits with psychologists, social workers and psychiatrists. Each had an idea about what was wrong, and a specific diagnosis: “Compulsive tendencies,� one said. “Oppositional defiant disorder,� another concluded. Others said “pervasive developmental disorder,� or some combination.

Each diagnosis was accompanied by a different regimen of drug treatments.

By the time the boy turned 11, Ms. Williams said, the medical record had taken still another turn — to bipolar disorder — and with it a whole new set of drug prescriptions.

“Basically, they keep throwing things at us,� she said, “and nothing is really sticking.�

At a time when increasing numbers of children are being treated for psychiatric problems, naming those problems remains more an art than a science. Doctors often disagree about what is wrong.

A child’s problems are now routinely given two or more diagnoses at the same time, like attention deficit and bipolar disorders. And parents of disruptive children in particular — those who once might have been called delinquents, or simply “problem children� — say they hear an alphabet soup of labels that seem to change as often as a child’s shoe size.

The confusion is due in part to the patchwork nature of the health care system, experts say. Child psychiatrists are in desperately short supply, and family doctors, pediatricians, psychologists and social workers, each with their own biases, routinely hand out diagnoses.

But there are also deep uncertainties in the field itself. Psychiatrists have no blood tests or brain scans to diagnose mental disorders. They have to make judgments, based on interviews and checklists of symptoms. And unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving doctors to rely on observation and information from parents and teachers.

Children can develop so fast that what looks like attention deficit disorder in the fall may look like anxiety or nothing at all in the summer. And the field is fiercely divided over some fundamental questions, most notably about bipolar disorder, a disease classically defined by moods that zigzag between periods of exuberance or increased energy and despair. Some experts say that bipolar disorder is being overdiagnosed, but others say it is too often missed.

“Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,� said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. “On an individual level, for many parents and families, the experience can be a disaster; we must say that.�

For these families, Dr. Costello and other experts say, the search for a diagnosis is best seen as a process of trial and error that may not end with a definitive answer.

If a family can find some combination of treatments that help a child improve, she said, “then the diagnosis may not matter much at all.� [full text]

One thought on “Diagnosing Disagreement

  1. I’m waiting for the day when more children are diagnosis-bearing than are not, and the social norm is that you have a diagnosis. We are headed in that direction.

    So often the social situation of these children is not discussed or addressed. This article barely touches on this aspect of the problem at all. So many children diagnosed as “bipolar” are in families that are filled with conflict or are neglectful of the child’s needs. While nominally this is represented on Axis IV of the diagnosis, in reality it is given extremely short shrift.

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