Are American kids overdiagnosed, overmedicated, overburdened with acronyms and diagnoses? In We've Got Issues, Judith Warner has a surprising answer.
It was supposed to explore "fashionable children's diagnoses" — like autism, Asperger's disorder, dyslexia, attention deficit/hyperactivity disorder, oppositional defiant disorder, anxiety disorders, and bipolar disorder — and to take aim at the "overanalyzing, the overperfecting," and "the overpathologization of America's children." Its central argument was going to be that children were, by and large, being overdiagnosed and overmedicated, and that doctors and parents and teachers and schools who colluded in labeling kids and treating them with psychotropic medication were taking the easy way out, seeking "quick fix" solutions, and turning a collective blind eye to the pathological aspects of our culture.
Then Warner started talking to parents. And what she found was not status-obsessed climbers seeking to create designer children, but frightened and reluctant people just trying to help their kids lead normal lives. She heard the story of a girl whose anxiety made her rub her skin off, so "she'd sit at the dining table crying for hours on end, blood coming through her socks." Of a boy who chased his babysitters with knives. Of another boy with separation anxiety who said, "Mommy, you don't understand. If I don't wear the other shoes, you're going to die today." Warner writes, "the parents I spoke with who ultimately decided to take their children in for treatment weren't looking at 'normal' behavior — temper tantrums, less-than-optimal grades. [...] These parents were trying to keep their kids at home. And in school. [...] In some cases, these parents were trying to keep their kids alive."
Warner had heard of parents who jumped to medicate their children at the slightest setback, but she couldn't find any of them — and when she talked to people who had criticized such parents in print, they couldn't point to any either. In fact, what she found was that children were drastically undertreated — "approximately 70% of children and teens who need mental health treatment don't receive any services at all." So what's with the prevailing wisdom that kids today are walking pharmacies and DSMs? Warner points the finger at two culprits: pharmaceutical companies, and our cultural mistrust of psychiatry.
One big reason people think kids are taking meds for trivial reasons is that drug ads seem to suggest such use — Warner cites an advertisement for the ADHD drug Strattera that depicts boys finishing a model plane. And drug company sponsorship of studies and payouts to psychiatrists have caused real and serious problems, most notably the increasing off-label prescriptions of atypical antipsychotics to children when, says Warner, "there was virtually no research to support this vastly expanding use." Warner writes, "I see the pollution of psychiatry by drug money as a tragedy, a wasted opportunity, a very self-destructive move for a profession needs to give the public trust in order to work for the public good." But, crucially, she believes that psychiatry, including the responsible use of medication, can work for the public good, and that those who reject it out of hand do children with mental health problems a disservice.
Warner writes that modern-day distrust of psychiatry has its roots partly in the very real abuses of pharmaceutical industry, but partly in something older: the idea, advanced by Ken Kesey's One Flew Over the Cuckoo's Nest, among other works, that "there really is no objective demarcation between mental illness and mental health." She writes,
Entirely missing here [...] is the notion that there is a world of difference between unique personality traits that may be quirky, annoying, or charming, and actual signs of pathology. Or that the difference between personality and pathology resides in pain, distress, and impairment.
Whether based on ignorance or intellectual dishonesty or malice, the conflation of personality and pathology is a very harmful thing. Its effect on people who suffer from mental illness — or the parents of children who do — is vicious and stigmatizing, and its effect on our culture is nothing less than toxic.
It's hard to learn much about modern-day Western psychiatry — the vagaries of the DSM, the meds with their unpredictable side effects and unclear mechanisms of action — without criticizing it, and I've sometimes fallen prey to the kind of knee-jerk mistrust Warner decries. I read with fascination, for instance, Ethan Watters's recently released Crazy Like Us, about the exportation of American and European mental health treatments to developing countries, and came away thinking that maybe American psychiatry just makes people sicker. But despite an occasional wholesale critique of American practices (mistakenly lumping the evidence-based PTSD treatment EMDR together with the quackery of "thought field therapy"), Watters's real point was that all mental illness is "culture-bound" and requires culturally compatible approaches — not that all Western psychiatry is bullshit. And Warner makes a strong case that kids need better, not less, psychiatric treatment.
This would mean giving parents more unbiased information about treatments, so that they could make informed decisions between evidence-based strategies and unproven techniques like vision therapy (about which Warner published a somewhat more sympathetic profile in the Times this weekend). It would also mean changing a system in which insurance companies control care, meaning the kids who can get treatment at all often get meds with no therapy, and little access to the kind of sustained medical attention that could really help them. What really matters for many kids, Warner found, is access to a doctor with enough time to and expertise to assess and address their "issues." The fact that most kids never see such a doctor — because managed care limits their pediatrician visits to 8-12 minutes, or because their families lack health insurance in the first place, or because their condition demands a specialist whose fees are out of their reach — is criminal, and changing this would be the first step towards helping kids. Because while it's easy to imagine that we live in a society of designer kids hopped up on drugs and diagnoses, in reality we suffer from a system where only a privileged few can get the care they need — and this, not some notion of the Med-Happy Parent, should be the target of our outrage.