Book review: Susan Okie reviews "We've Got Issues: Children and Parents in the Age of Medication," by Judith Warner
WE'VE GOT ISSUES
Children and Parents in the Age of Medication
By Judith Warner
320 pp. $25.95
I opened Judith Warner's new book with a certain dread, fearing that I would have to slog through yet another polemic about the overuse of stimulants and other psychiatric drugs in America's children. Instead, I found a refreshing surprise: a confession by the author that she had indeed gotten a book contract and embarked on her research with that mindset, only to change her views after talking with the parents of mentally ill children. "I was erecting a whole intellectual edifice based on ignorance," admits Warner, who writes frequently for the New York Times and is also the author of "Perfect Madness: Motherhood in the Age of Anxiety."
Nowhere did Warner encounter mothers or fathers eager to medicate healthy kids for trivial reasons. Instead, she found parents struggling to find and afford decent treatment for children disabled by their symptoms or their behavior, parents who had turned to psychiatric medicines only out of desperation -- and a society that persists in stigmatizing mental illness, blames parents when kids are affected, and has done far too little to ensure that such kids can get access to treatments that have been shown to work.
Instead of an epidemic of over-treatment, Warner describes an epidemic of under-treatment of children with mental illness. "Five percent of kids in America take psychotropic drugs," she writes -- stimulants, antidepressants or other psychiatric medications -- while "five to 20 percent have psychiatric issues." (The lower fraction represents those who are extremely impaired, and the higher one includes those with at least minimal impairment.) Among the disadvantaged, the majority of mentally ill children receive no treatment at all, while many others are prescribed drugs or combinations that are inappropriate for their problems. Warner's stories attest that even belonging to a rich, well-educated family with health insurance is no guarantee that a child with autism, attention deficit hyperactivity disorder (ADHD) or depression will be properly diagnosed and treated.
But what about the startling numbers: a tripling since the 1990s in the number of U.S. children receiving mental health diagnoses, a recent government estimate that 8 percent of children have ADHD, a 3,500 percent increase between 1991 and 2006 in the number of kids identified as autistic in special education programs? Aren't they evidence of over-diagnosis? Warner argues, convincingly in my view, that much of the increase in such diagnoses is explained by better recognition and understanding of children's behavioral and emotional symptoms, as well as the development of effective treatments for disorders like ADHD, depression and obsessive-compulsive disorder, and of special educational strategies and services for children with autism and dyslexia.
Children who a generation ago might have been written off as "weird" or "bad" or "retarded" now have much to gain from being evaluated by a mental health professional, so families are more likely to seek help. Diagnostic baskets have also undeniably gotten bigger: There is now a spectrum of autism disorders, and the prevalence of ADHD nearly doubled after psychiatrists expanded the diagnosis to include kids who, while not hyperactive, are so inattentive that they can't focus on schoolwork or other activities. In addition, there may well be a true increase in the frequency of disorders such as depression, anxiety and autism in children -- but to confirm and measure such an increase, we'd need evidence from serial population-wide studies that asked the same questions and used the same definitions over decades, and such studies don't exist.
Warner traces the roots of anti-psychiatry sentiment in the United States back to the social rebellion of the 1960s, but she puts the blame for stoking public distrust on the actions of some practitioners -- and especially on recent revelations of prominent psychiatrists' financial ties with the pharmaceutical industry. She condemns the dangerous, unapproved use of certain antipsychotic drugs in children and the Food and Drug Administration's slowness to act on evidence that some antidepressants increase the risk of suicide in teenagers.
But she is even more concerned about the damage done to children through failure to recognize and treat mental illness. Untreated kids with ADHD are more likely than other children to drop out of school, to have no friends, to engage in antisocial behavior and to use illicit drugs. Children with autism who don't receive appropriate treatment and interventions are far less likely to live independently as adults than those who do. Failure to recognize and treat anxiety or depression in kids may place them at higher risk for far more serious episodes of depression later.
Interweaving stories of children and families with scientific information and well-researched arguments, Warner makes a compelling case that as a society we should do much more to make mentally ill kids feel better. Among her prescriptions: better insurance coverage (including coverage of non-drug treatments like cognitive behavioral therapy), more financial support for mental health services, an increase in the number of trained child psychiatrists, a research agenda that will speed identification of the most effective psychiatric medications in children, and quality control to reduce the frequency of inappropriate diagnosis and substandard treatment. Perhaps more than anything, she has come to believe, families of kids with "issues" need love and support from the doctor treating their mentally ill child. "The idea is almost laughable, really," she writes. "But it shouldn't have to be."
Susan Okie is a physician, a former staff writer for The Washington Post and a freelance medical journalist.