New York Times: Pediatric Mental Health Diagnosis Deficiencies – Continuing Medical Education Could Help

A recent story in the New York Times discussed the difficulty doctors are having diagnosing children who have behavioral problems, especially when they appear at young ages. The article focused on a young boy, who at the age of 18 months, was being seen by different doctors, being diagnosed with numerous conditions, and then being placed on a number of medications.

Eventually, the family and the boy enrolled into a program aimed at helping low-income families whose children have mental health problems. Through this program, the boy’s doctors gave him a more common diagnosis for children of attention-deficit hyperactivity disorder, which the author believes is proof that he should have never been prescribed such powerful drugs in the first place.  

In fact, she points to medical records the mothers boy provided to the Times “to help document a public glimpse into a trend that some psychiatric experts say they are finding increasingly worrisome: ready prescription-writing by doctors of more potent drugs to treat extremely young children, even infants, whose conditions rarely require such measures.”

For example, the author points out from a September 2009 report by the Food and Drug Administration (FDA) that more than 500,000 children and adolescents in America are now taking antipsychotic drugs. Of this large number, the author and experts seemed concerned that this number is growing not only among older teenagers, when schizophrenia is believed to emerge, but also among tens of thousands of preschoolers.

The article also references a Columbia University study, which recently found a doubling of the rate of prescribing antipsychotic drugs for privately insured 2- to 5-year-olds from 2000 to 2007. The problem this study found was that “only 40 percent of them had received a proper mental health assessment, violating practice standards from the American Academy of Child and Adolescent Psychiatry.”

From this finding, Dr. Mark Olfson, professor of clinical psychiatry and lead researcher in the government-financed study, said that “there are too many children getting on too many of these drugs too soon.”

Consequently, while the treatment of children with such drugs remains controversial, in 2006, the F.D.A. did approve treating children as young as 5 with Risperdal if they had autistic disorder and aggressive behavior, self-injury tendencies, tantrums or severe mood swings. And two other drugs, Seroquel from AstraZeneca and Abilify from Bristol-Myers Squibb, are permitted for youths 10 or older with bipolar disorder.  

One of the major problems facing psychiatrists is the difficulty diagnosing these children. As Dr. Ben Vitiello, chief of child and adolescent treatment and preventive research at the National Institute of Mental Health acknowledged, “conditions in young children are extremely difficult to diagnose properly because of their emotional variability.”

Critics of treating children with psychiatric medication blame this recent trend on physicians who “encounter a marketing juggernaut that has made antipsychotics the nation’s top-selling class of drugs by revenue, $14.6 billion last year, with prominent promotions aimed at treating children.”

This assertion however is problematic because the problem is not drug marketing. It’s the fact that doctors are too busy, and with re-imbursement lower for psychiatric treatment than other medical treatment, they simply do not have enough time for the adequate diagnosis of each child, especially when there are so many factors to consider in the first place as Dr. Vitiello recognized. Moreover, with the average psychiatrist having over $200,000 in debt coming out of medical school, their ability to individually treat each patient is severely restricted by their financial stability. In addition, with group practices becoming owned more and more by hospitals, there is little time for a physician to accurately diagnose a patient.   

Consequently, while the problem may get better with parity payments for psychiatric visits written into the health care reform law, it also could get worse with more patients going into the system and creating even less time to treat.

What is needed then, as Dr. Lawrence L. Greenhill, president of the American Academy of Child and Adolescent Psychiatry recognized, is more research. Dr. Greenhill, who is “concerned about the lack of research, recommended a national registry to track preschoolers on antipsychotic drugs for the next 10 years.” He acknowledged the need for this kind of research because “Psychotherapy is the key to the treatment of preschool children with severe mental disorders, and antipsychotics are adjunctive therapy — not the other way around.”

In addition to research, some states have already taken this matter into their own hands. For example, in Florida and California, doctors’ concerns have led to restrictions put in place on doctors who want to prescribe antipsychotics for young children. These states require a second opinion or prior approval, especially for those on Medicaid.

Consequently, while we are waiting to learn about the evidence-based impact of such drugs from the proposed research, and before states make it more difficult for doctors to treat children, our physicians, families and children need immediate solutions.

What this story demonstrates is that since doctors are having difficulty making diagnoses, what they need instead of criticism or changing of state laws is more education. Similar to the success of the program Early Childhood Supports and Services, children and physicians could both benefit from continuing medical education (CME) programs that focus on the diagnosis of child behavior. These programs could be designed to address particular symptoms and factors to look for in children, and examine approaches taken by a variety of psychiatrists, neurologists and other behavioral specialists.

There is no need to waste energy or resources attacking the drug industry for doing its job, when the real work that is needed is to train and educate doctors. By educating physicians and training them with the proper methods to identify problems in children, physicians will be better suited to prescribe the right treatment, and children and their families will be healthier and happier.