Diagnosing very young children

Last week Rebecca Riley’s mother went on trial, accused of deliberately overdosing her 4 year old daughter.  Although most of the media coverage has so far been focused on the facts, I keep waiting for the other shoe to drop.  What might also end up on trial is the practice of diagnosing and treating young children.  

As little as 10 to 15 years ago the public found it difficult to believe that elementary and middle school children could experience depression or be diagnosed with mental health disorders.  Childhood is supposed to be a time of happiness, right?  The combination of increased media coverage, targeted studies and consequent data have helped increase public acceptance that children can and do experience depression, anxiety and mood disorders as well as ADHD.  However, the public doesn’t really accept that young children can have mental health problems and has no idea what that looks like if they do.

Eight years ago PAL and Health Care for All issued a report, Speak Out for Access.  We surveyed families whose children had identified mental health needs about their experiences.  We were surprised to find that almost half (48%) of the parents who responded said that their child showed signs of mental health problems by age 4.  Let me say that again:  almost half the parents said their child with mental health needs showed signs or symptoms by age 4.  When they brought their worries to their child’s doctor, many felt their observations were dismissed.  Some felt that earlier treatment would have reduced many of the problems they faced later.

This is a topic that is near and dear to me.  When my own son was three, he had a bedtime ritual that lasted 20 to 25 minutes.  It involved an empty spray bottle and a series of spots we had to spray to banish monsters.  If we missed a spot or were interrupted, the ritual had to begin again from the beginning.  He cried and was terrified if we skipped the ritual and then couldn’t fall asleep — often for hours.  His pediatrician assured me he would grow out of it.  He did, but other fears and rituals immediately took its place.

Last Friday, a journal article authored by Mark Olfson of Columbia University, reported that the number of children aged 2 to 5 who have been diagnosed with bipolar disorder and treated with psychiatric medications has doubled over the past decade.  The study also noted that fewer than half the preschoolers had received a mental health assessment or a therapy visit, which is worrisome but unsurprising.  After all, where do you go to find help for a 3 year old?

There is a difference between prevalence (how often something is diagnosed) and incidence (how often something actually occurs), although we confuse the two.  According to the journal report, young children are being diagnosed more frequently.  According to parents in our report, a large percentage of children, later diagnosed with mental health disorders, show symptoms quite early. 

Parents want to help their children, especially when they see them hurting.  They spot the intensity or unusual length (like my son’s ritual) of a behavior.  A diagnosis often feels like a double edged sword;  it can open doors to treatment and services but brings the stigma of a label.

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2 thoughts on “Diagnosing very young children

  1. The difficulty with early childhood mental health problems is that, while those who turn out to have problems had mental health diagnoses had odd behaviors as young children, many children with odd behaviors turn out not to have mental health diagnoses. At 21 months of age, our son spoke little and was very happy to go out of the back deck and place all of the pebbles from his pebble box in lines on the ground. At 24 months, he began to use complete sentences, recite the alphabet and moved from rocks to lining up matchbox cars all around the house. All the time. He was also really upset when we intruded on the order he was creating. We worried a bit, but he actually did grow out of it- he is now 22 years old, and an electrical engineer with no known MH diagnosis. Waiting and worrying worked for us, and I expect it works for others as well.
    As a pediatrician, I know that mental illness starts young, and is developmental in its expression. I also know that the range of early childhood behavior is wide, and it is actually really hard to predict how a child will develop (and to diagnose a 2 year old with any degree of certainty). Doctors need to walk with their patients, and have great humility as they try to help parents understand the development of a child’s psyche. Diagnosis may open the door to treatment; it can also limit our understanding of the child’s development and alter that path in ways that we will later regret.

  2. My son is a 19 year old with a diagnosis of bipolar after years of many of labels. I have often thought that each diagnosis he has had fit at the time and that he grew into the bipolar. Yes he had problems as a young child but a major mental health diagnosis and way to much medicine as is the case with Rebecca Riley would not have helped him grow into the young adult he is today (goes to community college getting C & B’s, works part-time for gas & lunch/dinner when not home). I have worked in early intervention for years so I also see the side of families facing unknown diagnosis/why is my child doing this? Families need the help of services like EI and the Rosie D home based behavioral supports before medicines are started with 2 & 3 year olds. Two year olds are very “quirky” and show a range of behaviors for so many reasons that any doctor could say that in any one moment that a tantruming 2 year is Cybil.
    This case so sadly illustrates the lack of services and supports for families and failures in our child protection services. Many people were reporting something wrong before Rebecca got sick and then died.

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