Question:

Dear Doctor,

I have been a special educator for 30 years. I have a 2 nd and 3 rd grade special day class that includes children with disorders of language. Many of the children, through the years, have moderately severe behavioral disorders.

I have noticed over the last 20 years that more and more children have psychiatric diagnoses, including such as Bipolar Disorder, ADHD or Asperger’s Syndrome. I have several children in my current classroom who are on two or three different medications and still having behavioral difficulties. Sometimes I wonder if the medications are causing more problems instead of improving behaviors. I have one child in my class now that has gained 20 lbs and is eating all the time.

Is this only happening in our area? What has caused this shift to using many medications? It seemed, 20 years ago, that the only medications really being used were stimulant medications for Attention Deficit Disorder.

What do you think?

Your question really includes two major interrelated questions.

1. Why has the diagnosis and range of psychiatric disorders in children changed so much over the last several decades?
2. Why has the prescribing, type of medication and liberal use of medication, including multiple medications at the same time become so widespread?

The answer to these questions is complex, controversial and interesting. A book could easily be written on these subjects. I have decided to write the answer in three Ask a Specialist installments that will appear on this web page over the next few months. This first “answer” can be called “introductory: necessary basic ideas and information” and will be followed by individual answers to the two questions implicit in your email.

There are some facts about psychiatry, and child psychiatry in particular, that are necessary to understanding what has happened. Much of what I am going to say pertains to all psychiatry, but I am going to emphasize the added complications presented in the assessment of a child:

Briefly, these are the facts:

1. Psychiatric diagnosis for the most part are made by comparing a list of “symptoms” to those required to make the diagnosis. In other specialties of medicine, there are blood tests, x-rays, bacterial cultures, biopsies etc. that can either confirm or exclude the diagnoses. Thus, psychiatric diagnoses are more subjective, require more of an “art”, experience, and more time of observation than do most other specialties. For example when making the diagnosis of ADHD in a child, there is no blood test or x-ray available to support the accuracy of the diagnosis.
   
   
2. The listing of “symptoms” often requires the input of more than the patient and psychiatrist alone. This is particularly true with children. The clinician needs to obtain the most accurate list of symptoms possible, needs to talk with teachers, multiple family members, and day care providers, to name a few. One would need to observe the child. While the standard office visit usually includes the child being seen with the parent, much vital additional information can be obtained by seeing the child alone, and observing in other situations such as the classroom when the child is with peers in a familiar structure situation.
   
   
3. In traditional psychiatry, the psychiatrist has to make a judgment call about the reliability of the patient and his/her interpretation of the presenting symptoms. Standardized psychological tests can add to this information. Tests of validity (i.e. conflicting self-reporting) are built into the system. In child psychiatry, the reliability of the reporting parent, teacher, pediatrician, and social worker must be considered. We all report things differently depending on our environment and our experiences and personal relationships to the child. Parents who care very much about their child might report their child’s difficulties with peers as not a symptom, while the teacher might have a more objective perspective.
   
   
4. The child psychiatrist is placed in a situation where they are not only diagnosing the child but also assessing the parents and the extended family, the teacher and the significant others in the child’s environment. We all react to our environments and sometimes it is the reaction that is normal and the environment at fault. For example, a child who lives in a violent family situation might be aggressive at school. It is imperative to know that child’s home environment in order to interpret and eventually treat the child’s aggression.
   
   
5. A psychiatrist has to know what behavior and thoughts are within the range of normal. He/she has to evaluate the patient’s presenting symptoms and decide if they are out of the range of normal human emotions or behavior. Then, by patient interview, how severely the symptoms are affecting that individual’s life. Psychiatrists also have to know what psychiatric symptoms might be caused by physical abnormalities as well. High thyroid (hyperthyroidism) can cause anxiety. Some medications can also cause psychiatric symptoms such as depression or hyperactivity.
   
   
6. The definition of “normal” for children varies with chronological age and gender. For example, a 4 year old with an “imaginary friend” could be normal developmentally. A 11 year old might be abnormal. Other related questions serve as examples. For example :how does one differentiate between the comfortable repetitive behavior of early childhood, the same repetitive behaviors in a child with retardation and the repetitive, perhaps pathologically driven behavior of an anxious child?
   
   
7. In child psychiatry, one needs to understand what is “normal” for a child of the same age, sex and socio-economic environment. (a 5 year old of direct Chinese heritage and environmental culture would not be expected to, in a similar strange situation, react similarly to an American born child.)
   
   
8. Many behaviorally disordered children, as in your classroom, have learning, cognitive, or speech and language disabilities. A psychiatrist assessing a child should have some idea about whether a child’s cognition is within the normal range and whether they are adequately able to understand language and produce speech at a level expected for their chronological age. Developmental disabilities can directly cause changes in a child’s behavior. For example, if a child does not understand complex language, then they might not be attentive to instructions or be easily frustrated or anxious.

These are just a few of the difficulties with psychiatric diagnoses, particularly in children. When you add to this t that many types of mental health, educational and pediatric professionals are making some of the diagnoses, such as ADHD, then the situation becomes very confusing. It is easy to understand why a given child may be given several, often conflicting diagnoses.

I hope that some this information is informative. I will answer the two questions in the next few months.