The three most harmful fads in psychiatric diagnosis, during the past 20 years, have all occurred in kids. Rates of
Attention Deficit Disorder have tripled and rates of Autism and childhood Bipolar Disorder have multiplied an incredible 40 tmes.
Poweful external factors have contributed greatly to this massive mislabelling of kids. For ADHD and kiddie Bipolar, drug companies misleadingly and aggressively sold the ill to peddle their expensive and profitable pills. Their marketing strategy was based on the cynical assumption that starting a kid early on pills might make him a customer for life.
The explosion of Autism resulted from the combination of two things- the DSM-IV introduction of a much milder form (Asperger's) and the far too close linkage of the diagnosis to eligibility for enhanced school services. DSM diagnoses developed for clinical purposes are inappropriate gatekeepers for allocating educational resources. Educational decisions should be based on the child's educational need, as assessed by educators, using educational tools.
It is long past time to tame the wild DSM over-diagnosis of kids. Juan Vasen and Gisela Untoiglich are leaders of the Forum Infancias*, an Argentine organization of mental health workers dedicated to the proper diagnosis and treatment of children and adolescents. www.foruminfancias.com.ar
Drs Vasen and Untoiglich describe ten reasons why psychiatric diagnosis is much more difficult and uncertain in youngsters and how rampant mislabelling leads to over-medication and unnecessary stigma. They write:
"Special care and caution are always advisable when diagnosing kids for the following ten reasons:
1) The roles and behavioral expectations of children and adolescents have changed dramatically throughout history, and also vary dramatically across different societies in the current world. It is not necessarily an indication of mental disorder when a child doesn't fit into societal or educational roles that are recent, constraining, and quite narrowly defined.
2) Children and adolescents vary dramatically in the way they develop and in the chronology of their developmental milestones. Individuality and immaturity should not be confused with disease.
3) Problems that are really most properly blamed on defects in the educational system are instead often blamed on problems originating in the individual child. We would have many fewer children diagnosed with Attention Deficit Hyperactivity Disorder if class sizes were smaller and schools provided more physical activity recesses for children during the school day.
4) Parent and teacher perfectionism, and the desire for bland conformity, has narrowed the range of what is accepted as normal childhood behavior and has devalued diversity. We should not medicalize difference.
5) Whenever having a psychiatric diagnosis is made a requirement for obtaining special school services, the rate of dagnosis goes up dramatically and inappropriately. This may give the child a short term educational advantage, but saddles him with long term stigma and reduced expections and risks inappropriate medication prescription.
6) Biological reductionism has falsely assumed that all troubling childhood behaviors result from a chemical imbalance in the brain. Ignoring psychological, social, and educational factors leads to unwarranted medicalization and excessive diagnosis and treatment.
7) Accurate diagnosis in children and adolescents takes a great deal of time in each session and often many sessions over a number of months.
8) It is easy to give a diagnosis, often hard to erase one. if you choose a wrong name, the child will be forced to walk the wrong road.
9) In our country, laws and regulations are frequently written related to one or another specific psychiatric diagnosis. This often results in an increased rate of that disorder and excessive, misguided treatment.
10) Diagnosticians do not have a crystal ball. Often, only time will tell. Diagnostic uncertainty in kids is so great that labels should always be written in pencil."
Thanks so much, Juan and Giselle, for your poetic way of cautioning clinicians to be conservative, never careless or creative, in diagnosing kids. Mislabelling has serious and often longstanding consequences on how the child sees himself, how the family sees the child, and on the misuse of medication. Diagnosis should never be taken lightly.
Two previous blogs offer supplementary reading that I think will be very useful for clinicians, parents, and teachers.
Laura Batstra described her method of 'stepped diagnosis'. If clinicians take the time to really get to know the child and family they will make many fewer, and much more accurrate, diagnoses. http://m.huffpost.com/us/entry/1206381
And Dave Traxon provided a checklist of the important things every clinician must consider before prescribing psychiatric medication for kids. http://m.huffpost.com/us/entry/7829166
Accurate diagnosis in kids is really tough and time consuming. Misdiagnosis in kids is really easy and can be done in 10 minutes. Accurate diagnosis in kids leads to helpful interventions that can greatly improve future life. Misdiagnosis in kids often leads to harmful medication and haunting stigma.
The stakes are high and the harms sometimes permanent. The best way to protect our children is to respect their difference and to accept uncertainty. I really love the idea of writing psychiatric diagnoses in pencil.
* Forum Infancias Board is integrated by Beatriz Janin, Juan Vasen, Gisella Untoiglich, Miguel Tollo, Mabel Rodriguez Ponte, Gustavo Dupuy, Elsa Kahansky and Rosa Silver
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.