Over Diagnosing Children
I once read an article by Jordan Smoller called, “The Etiology and Treatment of Childhood.”[1] It was a satirical article that described childhood as a mental disorder. He noted that childhood is congenital, is characterized by temporary dwarfism, is marked by emotional instability and immaturity, and that children have knowledge deficits and legume anorexia. Mercifully, most children recover from this condition over time.
While clearly the article was meant as a spoof on the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference guide for mental health providers in the U.S., the implications of this article are quite serious. Children are being diagnosed with mental illnesses at an alarming rate and being medicated for those conditions with increasing regularity.
Over Diagnosing of Attention Deficit/Hyperactivity Disorder
Consider the case of Attention Deficit/Hyperactivity Disorder. This is a condition where a child is unable to constrain his/her behavior to the requirements of a given social context. We are not talking about criminal or psychopathic behavior, but rather the inability to sit still in a classroom, restaurant, doctor’s office, or other such environment where conformity is expected.
Fifty years ago this condition was called Minimal Brain Dysfunction (for extreme cases) and was thought to be the result of a mild form of brain compromise that was not explicitly evident but could be assumed. The term fell into disrepute when parents resisted having their children stigmatized as damaged goods.
Then, sometime in the 1980’s, the atmosphere changed and the former stigma became, for some parents, an embraced diagnosis of ADD (then called Attention Deficit Disorder, with hyperactivity as a sub-type).
Why the change? ADD was classified as a learning disability that entitled children to special accommodations in the classroom and on standardized tests. Not only were schools required by federal law to provide preferential seating in the classroom, but the students could also have less, or no, homework, extra time on exams, less rigorous exam standards, and counseling and tutoring services (also subsidized by federal funds).
I am not suggesting that all children and parents took unfair advantage of the system. Many children needed these services and greatly benefitted from them. Some students also received these services in order to give them a competitive advantage for college placements.
I am not faulting parents for trying to get what they can to make their child’s life better and their future more promising. In fact, as a psychologist, my profession has profited greatly from this boon, as have college guidance counselors, and educational therapists. No one has profited more, however, than the pharmaceutical industry, which supplies medications to enhance focus, concentration, and task performance. In my view, the issue of ADHD is only the beginning of a much larger problem—the pathologizing of children.
Over the past few decades we have seen enormous rises in the diagnosis of autistic spectrum disorders, bipolar disorders, depression, and obsessive-compulsive disorders in children and adolescents. It is possible that the mental health of this population is deteriorating at an epidemic rate. It is also possible that children are being dangerously over-diagnosed. Note also, that the rates of diagnosis are unique to the U.S. and disproportionately represented in middle and upper-middle class families.[2]
What Can Parents Do If They Think Their Child’s Behavior Is Questioned?
So what can be done?
First, parents need to step back and question the basis for a child’s diagnosis. If a child’s behavior is being called “pathological,” what is the normal standard for a child of the same age and sex? Nowhere in the DSM is there a guide for determining at what point a child’s restlessness, for instance, exceeds normal standards. The diagnostic criteria instead say “often.” Not how often, or too often, just “often.”
Second, parents and doctors need to consider the context of the child’s life. If the parents are divorced and the child lives alternatively in either home, how might that stress affect concentration and attention? Or how interesting is the classroom for the child? Maybe a different teacher or school would be a better fit for the child.
Third, how much sleep is the child getting each night? Half of the children I have assessed for “inattentiveness” were sleep deprived. The child may be going to bed at 8:00, but may be on a smartphone, iPad, or computer until late in the evening. Furthermore, a sleep-deprived child may be depressed or anxious, not necessarily “suffering” from ADHD.
Fourth, doctors, psychologists, and teachers often base their diagnosis on checklists. This can be a somewhat useful starting point, but is irresponsible as a stand-alone assessment. No checklist is a substitute for knowing the person of the child. Consider that chest pain could be a heart attack or it could be indigestion! A restless, inattentive child may be lonely, sad, afraid, etc. While these conflicts and challenges are difficult and distressing, they are not necessarily signs of mental illness.
Finally, if there is a reasonable suspicion of some mental health issue, a competent specialist should be involved to thoroughly assess the child, the family, and the surrounding circumstances. What diagnoses have been explored, evaluated, and ruled out? A range of possible interventions should be considered, with priority given to those that are the safest, least invasive, and most likely to be helpful. A child’s mental health is not the place to shop for bargains or quick fixes.
I constantly remind my graduate students that diagnosis is more about the person than the illness and that children are people, not disorders.
Professionals who want to learn more about psychoanalysis, developing an analytic mindset, and more topics for continuing education in mental health counseling, see a list of our online courses.
[1] Published in the book by G. Ellenbogen (1982), Oral Sadism and the Vegetarian Personality, a collection of satirical psychological articles.
[2] Hastings Center, Washington, D.C. (2008) found a 20% increase in prescriptions for behavioral drugs between 2000 and 2003 and a 73% increase in prescriptions for antipsychotic drugs between 2001 and 2005.
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