The three major "epidemics" of psychiatric illness occurring during the past 15 years -- childhood bipolar, autism and attention deficit disorder -- have all mainly involved children. And two new DSM-5 proposals that also apply mostly to youngsters -- "psychosis risk" and "temper dysregulation" -- may trigger the next fads in psychiatric mislabeling. Giving a name to difficult problems that are poorly understood provides a kind of false comfort, but the label often doesn't really add to the understanding and may carry risks of its own -- especially unnecessary treatment, stigma and wasted resources.
Two questions naturally come to mind. Why are the recent epidemics in psychiatric disorder all concentrated on children? And why is this happening now? Ten interacting causes together provide an answer:
1). Youngsters are inherently more difficult to diagnose than adults. By virtue of their youth, they have a very short track record of symptom presentation and evolution, often have atypical clinical pictures influenced by developmental factors, by drugs and by family, school and peer stressors, and may be unable or unwilling to freely share what they are really experiencing. The lack of diagnostic clarity invites fanciful and faddish labeling.
2). Much less scientific study has been done on the childhood mental disorders, giving greatly disproportionate weight to the little research evidence that is available. Science is a process of iteration and early findings most often fail to replicate. The much richer literature on adult disorders places us on much safer grounds.
3). Child psychiatry is a small and rather ingrown community excessively dominated by a few, too powerful thought leaders who have been able to impose their views on a fairly unresisting field.
4). Drug companies have seen in the child and adolescent market a rich new opportunity for expansion now that the adult market has already been so well saturated. Promoting childhood ills sells pills.
5). Fifteen years ago, under pressure from industry, the federal government eliminated the rules preventing drug companies from advertising directly to consumers. The U.S. is now one of only two countries in the entire world that allows this degree of Pharma influence on the public perception of proper medical practice.
6). Most of the diagnosing of, and prescribing for, mental disorders in kids is done by pediatricians and primary cary doctors who often have little training in psychiatry and insufficient time for careful evaluation.
7). Parents with difficult kids are understandably desperate for convincing answers and effective interventions, even when these may not yet really be available.
8). Teachers are also understandably eager to have disruptive kids diagnosed and treated, adding their influential voice that the doctor to "do something" to help.
9). An official diagnosis of mental disorder is usually a prerequisite for a child to receive extra school services.
10). The Internet provides a wonderful forum of support and information, but also a great means for disseminating fads.
It is best to admit that the diagnosis of mental disorders in kids continues to be largely unknown territory and not presume to overreach with answers that seem much more definitive than they really are. Let's recognize that the research in this field is still embryonic and that kids change unpredictably as they grow up. In considering new diagnoses, DSM-5 is not engaged in an academic debate. Its decisions will have a profound impact on treatment decisions -- particularly the degree to which kids are exposed to medications with unproven efficacy but troubling side effects. The DSM-5 should buck the trend and its inclinations -- it should be ending false "epidemics," not starting them.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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