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As the title implies, Straight
Talk about Your Child's Mental Health is aimed at parents concerned about
their children's emotional and behavioral problems. It is organized in three
parts; first, an introduction to some general issues in child psychology and
the causes of childhood mental illness; second, a more detailed discussion of
different kinds of disorders; and finally a discussion of how to get good
professional help. Author Stephen Faraone is a well-known psychologist,
Director of Pediatric Psychopharmacology Research at Massachusetts General Hospital,
and is Clinical Professor of Psychiatry at Harvard Medical School. His writing
style is easily understandable, especially because each chapter is split up
into many short sections, and there are many tables and boxes summarizing
essential information. He also uses many narrative cases to illustrate his
points and readers will be able to relate to them very easily. For example,
the first child he describes is Jerry who is a "live wire." At age
8, he had difficulty at school, rarely able to pay attention for prolonged
periods and always handing in his homework late. At age 9, he is starting to
lose his friends because he lacks important social skills. He is very active,
climbing all over the furniture and running around. He is also developing a
mean streak that is further distancing him from other people. Later, in the chapter
on disruptive behavior, Faraone confirms readers' suspicions that Jerry has
attention deficit hyperactivity disorder (ADHD). The other chapters in the
middle part discuss moodiness, worry and anxiety, learning disorder, abnormal
development, and different forms of obsessive-compulsive disorders. Together,
these cover most of the common childhood mental disorder.
Faraone presents a picture of
psychiatric knowledge as uncontroversial and well-confirmed. He does
acknowledge that the label of mental illness can be stigmatizing, but he
generally argues that it is better to get a child's mental disorders diagnosed
and treated rather than to ignore a problem or just try to adjust to it. He
acknowledges that parents will often be in doubt about whether to seek out a
mental health professional, but he argues that this very doubt is a good
indication that a professional would be able to help. He explains that it is a
myth that psychiatric diagnoses are not objective and that psychiatric
disorders such as ADHD are overdiagnosed. He also emphasizes that it a mistake
to blame parents for their children's psychological problems.
When it comes to seeking
professional help, Faraone gives his readers information for dealing with
rather idealized circumstances. National trends are for prescriptions to be
handed out by general practitioners and visits with specialists to be very
time-limited. Faraone assumes that most children will go through assessment
and evaluations for mental disorders, but this tends to be the hallmark of only
the best treatment, and is often not adequately covered by health insurance or
managed care plans. He also says very little about what to do when a child has
been seen a number of health care professionals and each has given a different
opinion, which is also a common experience of parents. However, he does include
a chapter on "Working with the Mental Health Care System," in which
he spells out some of the main ways in which children's psychological
assessment and treatment is organized, including the provisions of the
Individuals with Disabilities Education Act (IDEA).
As far as treatment goes, Faraone
is dismissive about scares concerning psychiatric drugs. He says that serious
side effects are rare, but they do exist, and recommends that parents balance
that risk with the possible effects of leaving a disorder untreated. He
confirms the well-known fact that most psychiatric drugs have not been tested
extensively on children and adolescents, but says that, at least in the case of
SSRI antidepressants such as Prozac and Zoloft, doctors "have shown that
the SSRIs also help youth with depression" (p. 303). This was written
before most SSRIs were banned for use in children in the UK at the end of 2003
because of fears that they increased suicidality and the FDA in the US had
issued warnings about the use of such medications in young people, but not
before other countries had issued similar warnings.
Faraone follows this with a
remarkable argument, which is worth quoting at length.
Suppose a parent decides to wait a year before
medicating a 3-year-old for what the doctor views as a serious case of bipolar
disorder; which has clearly interfered with the child's ability to make
friendships and have normal relationships with family members. The parent's
rationale is that, despite the doctor's opinion, it is possible that the child
will outgrow the problems. The rationale resonates with common sense, but if
the doctor is correct, the parent will have added 1 year of distress and
disability to the child's life. That one year is one forth of the 4-year-old
child's life. So from this perspective, delaying treatment for this 3-year-old
is equivalent to having a 30-year-old wait 10 years. (p. 304).
The assumption here seems to be that the diagnosis
of bipolar disorder in a three-year-old boy is uncontroversial and that there
are well-confirmed treatments for the disorder. But this assumption is simply
false: during the early twentieth century has been serious doubt that young
children can be diagnosed with major mental illness, and there continues to be
considerable dispute and debate within the profession as to what the diagnostic
criteria for those disorders are in very young children, and how different
disorders should be distinguished from each other. Furthermore, while it is
possible that medication will help a child with such emotional difficulties,
there is little evidence that medications are helpful in such young children.
It is also reasonable to wonder what effects such medications could have on
Some might consider my criticisms
here to be somewhat radical so it is worth emphasizing that they are based on
data presented by the psychiatric establishment. In their chapter on
"Mood Disorder in Prepubertal Children," (Textbooks of Child and
Adolescent Psychiatry, [American Psychiatric Publishing, 2004]), Elizabeth
Weller at al. say that "little is yet known about childhood bipolar
disorder" (p. 414), and point out that there are almost no published
double-blind, placebo controlled medication studies on mania in children (p.
425). What studies there have been tend to be on school age children.
Furthermore, there have been reports of adverse side effects of medications.
Thus Faraone seems overconfident about the beneficial effects of medication. His
laboring the point that to withhold medication for a year would mean that a
four-year-old would have gone untreated for a quarter of his life is equally
problematic. A child's early life is full of changes, and to wait a year to
see if he or she settles down is very different from leaving a thirty-year-old
untreated for a decade. None of this is to say that it is wrong to medicate a
young child with emotional difficulties, but it is important to realize that it
is a decision that is being made on the basis of a lack of knowledge, as an
experiment in the hope that it might help more than it harms. Such a decision
is inevitably a risk and will be difficult to make.
The current trend in psychiatry is
for rapidly increasing numbers of children to receive psychiatric diagnoses and
to be taking psychotropic medications. Given this trend, it can be helpful for
parents to have the basics of child psychiatry spelled out in simple language,
and Faraone does an excellent job at this. However, as with much of the rest
of the medical profession, ultimately parents may need to use a wide variety of
information sources to educate themselves about their children's psychological
problems and mental illnesses. Straight Talk about Your Child's Mental
Health is a valuable resource, but it presents just one perspective, and
does not provide much of a short-cut for parents who have to weigh the various
available perspectives and different kinds of evidence when deciding what to do
if their child has emotional problems.
© 2004 Christian
Perring. All rights reserved.
Perring, Ph.D., is Academic Chair of the Arts & Humanities
Division and Chair of the Philosophy Department at Dowling College, Long Island. He is also
editor of Metapsychology Online Review. His main research is on
philosophical issues in medicine, psychiatry and psychology.