TROUBLED CHILDREN What’s Wrong With a Child? Psychiatrists Often Disagree http://www.nytimes.com/2006/11/11/health/psychology/11kids.html?ei=5088&en=6dac9008135af907&ex=1320901200&partner=rssnyt&emc=rss&pagewanted=print By BENEDICT CAREY
Paul Williams, 13, has had almost as many psychiatric diagnoses as birthdays.
The first psychiatrist he saw, at age 7, decided after a 20-minute visit that the boy was suffering
A grave looking child, quiet and instinctively suspicious of others, he looked depressed, said his
mother, Kasan Williams. Yet it soon became clear that the boy was too restless, too explosive, to
Paul was a gifted reader, curious, independent. But in fourth grade, after a screaming match with
a school counselor, he walked out of the building and disappeared, riding the F train for most of
the night through Brooklyn, alone, while his family searched frantically.
It was the second time in two years that he had disappeared for the night, and his mother was
determined to find some answers, some guidance.
What followed was a string of office visits with psychologists, social workers and psychiatrists.
Each had an idea about what was wrong, and a specific diagnosis: “Compulsive tendencies,” one
said. “Oppositional defiant disorder,” another concluded. Others said “pervasive developmental
Each diagnosis was accompanied by a different regimen of drug treatments.
By the time the boy turned 11, Ms. Williams said, the medical record had taken still another turn
— to bipolar disorder — and with it a whole new set of drug prescriptions.
“Basically, they keep throwing things at us,” she said, “and nothing is really sticking.”
At a time when increasing numbers of children are being treated for psychiatric problems,
naming those problems remains more an art than a science. Doctors often disagree about what is
A child’s problems are now routinely given two or more diagnoses at the same time, like attention
deficit and bipolar disorders. And parents of disruptive children in particular — those who once
might have been called delinquents, or simply “problem children” — say they hear an alphabet
soup of labels that seem to change as often as a child’s shoe size.
The confusion is due in part to the patchwork nature of the health care system, experts say. Child
psychiatrists are in desperately short supply, and family doctors, pediatricians, psychologists and
social workers, each with their own biases, routinely hand out diagnoses.
But there are also deep uncertainties in the field itself. Psychiatrists have no blood tests or brain
scans to diagnose mental disorders. They have to make judgments, based on interviews and
checklists of symptoms. And unlike most adults, young children are often unable or unwilling to
talk about their symptoms, leaving doctors to rely on observation and information from parents
Children can develop so fast that what looks like attention deficit disorder in the fall may look like
anxiety or nothing at all in the summer. And the field is fiercely divided over some fundamental
questions, most notably about bipolar disorder, a disease classically defined by moods that zigzag
between periods of exuberance or increased energy and despair. Some experts say that bipolar
disorder is being overdiagnosed, but others say it is too often missed.
“Psychiatry has made great strides in helping kids manage mental illness, particularly moderate
conditions, but the system of diagnosis is still 200 to 300 years behind other branches of
medicine,” said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke
University. “On an individual level, for many parents and families, the experience can be a
For these families, Dr. Costello and other experts say, the search for a diagnosis is best seen as a
process of trial and error that may not end with a definitive answer.
If a family can find some combination of treatments that help a child improve, she said, “then the
diagnosis may not matter much at all.”
The most commonly diagnosed mental disorders in younger children include attention deficit
hyperactivity disorder, or A.D.H.D., depression and anxiety, and oppositional defiant disorder.
All these labels are based primarily on symptom checklists. According to the American Psychiatric
Association’s diagnostic manual, for instance, childhood problems qualify as oppositional defiant
disorder if the child exhibits at least four of eight behavior patterns, including “often loses
temper,” “often argues with adults,” “is often touchy or easily annoyed by others” and “is often
At least six million American children have difficulties that are diagnosed as serious mental
disorders, according to government surveys — a number that has tripled since the early 1990s.
But there is little convincing evidence that the rates of illness have increased in the past few
decades. Rather, many experts say it is the frequency of diagnosis that is going up, in part because
doctors are more willing to attribute behavior problems to mental illness, and in part because the
public is more aware of childhood mental disorders.
At the playground, in the gym, standing in line at the grocery store, parents swap horror stories
about diagnoses, medications or special education classes. Their children are often as fluent in
psychiatric jargon as their mothers and fathers are.
“The change in attitude is enormous,” said Christina Hoven, a psychiatric epidemiologist at
Columbia University. “Not long ago people did all they could to hide problems like these.”
Attention deficit disorder is perhaps the most straightforward diagnosis. Elementary school
teachers are often the ones who first mention it as a possibility, and soon parents are answering
questions from a standard checklist: Does the child have difficulty sustaining attention, following
instructions, listening, organizing tasks? Does he or she fidget, squirm, impulsively interrupt,
These behaviors are so common, particularly in boys, that critics question whether attention
disorder is a label too often given to boys being boys. But most psychiatrists agree that while
many youngsters are labeled unnecessarily, most children identified with attention problems
could benefit from some form of therapy or extra help.
They are less certain about the children — perhaps a quarter of those seen for mental problems,
some experts estimate — who do not fit any one diagnosis, and who often go for years before
receiving a satisfactory label, if they receive one at all.
These youngsters collect labels like passport stamps, and an increasing number end up with the
label Paul Williams received: bipolar disorder.
Until recently, psychiatrists considered bipolar disorder to be all but nonexistent in children
under 18. Today, it is the fastest growing mood disorder diagnosed in children, featured on the
cover of news magazines and on daytime talk shows like “The Oprah Winfrey Show.”
The explosion of interest in bipolar disorder came after the approval of several drugs, called
antipsychotics, or major tranquilizers, for the short-term treatment of mania in adults.
Beginning in the 1990s some researchers began to argue that bipolar disorder was
underdiagnosed in adults. Soon, several child psychiatrists were arguing that the illness was more
common than previously thought in children too.
Some experts who made those arguments had ties to manufacturers of antipsychotic drugs,
financial interests disclosed in professional journals. But the message struck a chord, particularly
with doctors and parents trying to manage difficult children.
Parents whose children have been given the label tend to adopt the psychiatric jargon, using
terms like “cycling” and “mania” to describe their children’s behavior. Dozens of them have
published books, CDs, or manuals on how to cope with children who have bipolar disorder.
A recent Yale University analysis of 1.7 million private insurance claims found that diagnosis rates
for bipolar disorder more than doubled among boys ages 7 to 12 from 1995 to 2000, and experts
say the rates have only gone up since then.
Katherine Finn, a 14-year-old who lives in Grand Rapids, Mich., said she was grateful for the
growing awareness of the disease. Possessed by feelings of worthlessness as early as the fourth
grade, Katherine said that by the sixth grade she “threw my sanity out the window.”
She became impulsive, loud, and abrasive, she said, adding, “I would blurt things out in class, I
would moo like a cow, act like a little kid, just say the most random stuff.”
A psychiatrist promptly diagnosed the problem as bipolar disorder, after learning that there was a
history of the disease on her mother’s side of the family. Katherine began taking drugs that
blunted the extremes in her mood, and she now is doing well at a new school.
“It hit me like a Mack truck when I heard the diagnosis, but I knew right away it was correct,” said
her mother, Kristen Finn, who is writing a book about her experience.
Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families
like the Finns, it is being wildly overdiagnosed. One of the largest continuing surveys of mental
illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar
disorder and only a few children with the mild flights of excessive energy that could be considered
nascent bipolar disorder — a small fraction of the 1 percent or so some psychiatrists say may
Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance
to those in adults. Instead, the children’s moods seem to flip on and off like a stoplight throughout
the day, and their upswings often look to some psychiatrists more like extreme agitation than
“The question with these kids is whether what we’re seeing is a form of mania, or whether it’s
extreme anger due to something else,” said Dr. Gregory Fritz, medical director of the Bradley
Hospital, a psychiatric clinic for children in Providence, R.I.
Dr. Ellen Leibenluft, a research psychiatrist at the National Institute of Mental Health, argues
that children who are receiving a diagnosis of bipolar disorder fall into two broad groups. The
children in one group, a minority, have mood cycles similar to those of adults with bipolar
disorder, complete with grandiose moods, and a high likelihood of having a family history of the
illness. Those in the other group have severe problems regulating their moods and little family
history, and may have some other psychiatric disorder instead.
“It is a mistake to lump them all together and assume they are all the same,” Dr. Leibenluft said.
“It may be that the disorder has different dimensions and looks different in different kids.”
For parents with a child who is frantic and possibly dangerous, these distinctions may be
academic. The medications may blunt their child’s extreme behavior, which may be all the
For others, though, the uncertainties about childhood bipolar disorder loom larger. They wonder
whether mania really explains what their child is going through, and if not, what it is that is being
Evelyn Chase of Richmond, Va., said that a neurologist drove home his diagnosis of bipolar
disorder in her 10-year-old son by pulling out “a copy of Time magazine and slamming the article
Ms. Chase said her son seemed to react most strongly to abrupt changes in the environment and
to certain dyes and chemicals. “I used the bipolar diagnosis for school and getting services, but I
don’t think it covers his behaviors,” she said.
For Paul Williams, the diagnosis simply feels like a temporary stop. In his short life, Paul has
taken antidepressants like Prozac, antipsychotic drugs used to treat schizophrenia, sleeping pills
and so-called mood stabilizers for bipolar disorder, in so many combinations that he has become
“Sometimes they help, sometimes they don’t,” he said. “Sometimes they make me feel like another
In recent months, his mother said, Paul seems to have improved: he visibly tries to control
himself when he is upset and usually succeeds. He is an eager Mets fan who loves reading Harry
Potter and the Goosebumps series. He gets out and plays baseball and football, like any 13-year-
But he has grown tired of telling his story to doctors, and neither he nor his mother expect that
bipolar disorder will be the last diagnosis they hear.
The specialists who manage children’s psychiatric disorders are trying to bring more standards
and clarity to the field. Harvard researchers are completing the most comprehensive nationwide
survey of mental illness in minors and hope to publish a report next year. And a recent issue of
the journal Child and Adolescent Psychology was entirely devoted to the subject of basing
Given the controversies, one of the articles concludes, “we acknowledge that tackling the issue
may be tantamount to taking on a 900-pound gorilla while still wrestling with a very large
Dr. Darrel Regier of the American Psychiatric Association, who is coordinating work on the next
edition of the association’s diagnostic manual for mental disorders, due out in 2011, said that
researchers would focus on drawing distinctions among several childhood disorders, including
bipolar disorder and attention deficit disorder.
“We wouldn’t disagree that criteria for these disorders currently overlap to some degree,” Dr.
Regier wrote in an e-mail message, “and that a significant amount of research is under way to
disentangle the disorders in order to support more specific treatment indications.”
Until that happens, parents with very difficult children are left to read the often conflicting signals
given by doctors and other mental health professionals. If they are lucky, they may find a
specialist who listens carefully and has the sensitivity to understand their child and their family.
In dozens of interviews, parents of troubled children said that they had searched for months and
sometimes years to find the right therapist.
“The point is that not everything is A.D.H.D., not everything is bipolar, and it doesn’t happen like
you see in the movies,” said Dr. Carolyn King, who treats children in community clinics around
Detroit, and has a private practice in the nearby suburb of Grosse Pointe Farms.
“Kids often have very subtle symptoms they can mask for short periods of time,” Dr. King said,
“and the most important thing is to observe them closely, and get a complete history, starting
from birth and straight through every single developmental milestone.”
She added, “A speech delay can look like anxiety,” an obsessive private ritual like mania.
Or struggling children, in the end, may look only like themselves, with a unique combination of
behaviors that defy any single label. Camille Evans, a mother in Brooklyn whose son’s illness was
tagged with a half-dozen different diagnoses in the last several years, said she concluded, after
seeing several psychiatrists, that the boy’s silences and learning difficulties were best understood
“That’s the diagnosis that I think fits him best, and I’ve just about heard them all,” Ms. Evans
The label is not perfect, she said, but it is more specific than “developmental delay” — one
diagnosis they heard — and does not prime him for aggressive treatment with drugs like attention
deficit disorder or bipolar disorder would. He has not responded well to the drugs he has tried.
“Most important for me,” Ms. Evans said, “the diagnosis gives him access to other things, like
speech therapy, occupational therapy and attention from a neurologist. And for now it seems to
be moving him in the right direction.”
Revista Philosophica Vol. 29 [Semestre I / 2006] Valparaíso (287 - 303) E L C O N O C I M I E N T O D I V I N O D E L O S A C T O S F U T U R O S E N B Á Ñ E Z , M O L I N A , S U Á R E Z Y B R I C E Ñ O 1 The Divine Knowledge of Future Acts in Báñez, Molina, Suárez and Briceño MIRKO SKARICA Profesor Extraordinario, Instituto de Filosofía, Pontifi
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