Garrison, N.Y. — According to a recent report developed from of a series of five workshops held by The Hastings Center and funded by the National Institute of Mental Health, many children with patently problematic moods and behaviors fail to receive the care recommended by experts.
The workshops, held over the course of three years, brought together an interdisciplinary group including psychiatrists, educators, parent advocates, social scientists and bioethicists from a variety of backgrounds with widely diverse views. The first and last workshops considered the controversies generally, while each of the middle three workshops looked at them in the context of one diagnosis—attention deficit hyperactivity disorder, depression, or bipolar disorder.
The resulting report, written by Hastings Center research scholars Erik Parens and Josephine Johnston, evaluates the long-running debates about how to interpret problematic moods and behaviors in children and about whether and how to intervene. Fundamentally, most experts agreed that some children exhibit patently dysfunctional moods and behaviors and that these children deserve—though too often do not get—access to recommended care.
"What we've learned is that diagnoses don't have clear boundaries—what counts as healthy and unhealthy anxiety or healthy and unhealthy aggression, for example, is not written in nature," said Parens. "Human beings living and working in particular places and times define them." "This leads to inevitable disagreements about whether a cluster of moods and behaviors is best understood as disordered, about how exactly to describe some symptoms, and about whether or which particular diagnosis is warranted," he added.
Systemic and cultural pressures compromise the diagnostic process and constrain the treatment choices of clinicians and parents, making it increasingly likely that medication is the only treatment children receive, even if the combination of medication and psychosocial treatment is recommended by experts.
But the authors also describe inevitable disagreement about, for example, exactly where to draw the line between normal and unhealthy aggression or exactly how to balance the need for symptom relief and the need for schools and communities to accommodate a diverse range of children.
"One of our conclusions is that because diagnosis and treatment decisions invariably involve value commitments, there will be disagreements, especially on the margins and in difficult cases," Johnston said. "How one weighs, for instance, the parental obligations both to shape children and to let them unfold in their own ways can influence how one responds to difficult diagnostic and treatment decisions."
The report also concludes that too little is done to improve children's environments that contribute to their problematic behaviors.
"We need to remove the barriers that stand in the way of optimal care for those children who are suffering from moods and behaviors that no one would consider normal or healthy," the authors say.
The project was designed to better understand the controversies surrounding the diagnosis of mental disorders in children in the United States, and recent increases in the use of medications to treat those disorders.
It examined questions such as: Why are these diagnoses so controversial? Why do some people feel that children are over-medicated, while others are concerned about under-treatment? As different cultures have different rates of treatment with psychotropic medications, how much of what we see in the United States is driven by context—by individual, familial, or societal values?
The report also includes commentaries from workshop participants, listed below:
- Mary G. Burke, associate medical director of the Edgewood Center for Families and Children and associate clinical professor in the Department of Ado¬lescent and Child Psychiatry at the University of California, San Francisco's Langley Porter Psychiatric Institute.
- William B. Carey, clinical professor of pediatrics at the University of Pennsylvania's School of Medicine.
- Gabrielle A. Carlson, professor of psychiatry and pediatrics and director of child and adolescent psychiatry at Stony Brook University's School of Medicine.
- Peter Conrad, Harry Coplan Professor of Social Sciences in the Department of Sociology at Brandeis University.
- Lawrence Diller, a behavioral/developmental pediatrician/family therapist and assistant clinical professor of pediatrics at the University of California, San Francisco.
- Susan Resko, executive director of the Child and Adolescent Bioplar Foundation.
- John Z. Sadler, Daniel W. Foster Professor of Medical Ethics, professor of psychiatry and clinical sciences, chief of the Division of Ethics and Health Policy in the Department of Clinical Sciences, and chief of the Division of Ethics in the Department of Psychiatry at the University of Texas's Southwestern Medical Center.
- Ilina Singh, Wellcome Trust University Lecturer in Bioethics and Society at the London School of Economics and Political Science.
- Benedetto Vitiello, chief of the Child and Adolescent Treatment and Preventive Intervention Research Branch of the National Institute of Mental Health at the U.S. National Institutes of Health
- Julie Magno Zito, professor of pharmacy and psychiatry in the Department of Pharmaceutical Health Services Research at the University of Maryland, Baltimore.
A video of Parens and Johnston discussing their report, as well as the full text, can be found at the
project's website. For more information, visit the Hastings Center