Straight Talk about Your Child's Mental Health

by Stephen V. Faraone
Guilford Press, 2003
Review by Christian Perring, Ph.D. on Jun 4th 2004

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 developing brains.

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.

Christian 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.

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