Pediatric (or child) psychiatry involves the diagnosis and treatment of children with psychological problems. It is akin to taking a picture of runner in motion: symptoms are blurry and difficult to decipher, because a child is in the process of development, psychologically and biologically. Many adult illnesses, psychiatric or otherwise, express themselves only partially in childhood, or not at all. In the case of some psychiatric conditions, like schizophrenia or bipolar mood illness in particular, some early (“prodromal”) symptoms are seen in adolescents and even sometimes in younger children (preadolescents defined as ages 7-12). Psychological symptoms in younger children into preschool years usually reflect irritability or hyperactivity or anxiety, and are quite difficult to classify into diagnoses that have a scientifically solid basis into adulthood. Infant studies suggest that developmental aspects related to psychological experience are definable, but the relevance of those developmental experiences (such as “attachment” to the mother), though long debated in psychiatry, is not clearly on solid scientific work based on following children into adulthood.
The most common approach to the practice of pediatric psychiatry today is to treat symptoms with medications, and to engage in psychotherapies or other interventions aimed at family structures. This perspective is a not unreasonable response to the runner-in-motion problem that the developing child’s symptoms are difficult to interpret from the context of adult psychiatric diagnoses.
Symptom-oriented treatment, although very popular, breaks the Hippocratic tradition in medicine, and causes more harm than good.
It is a commonplace, especially in Europe and Australia but also in the US, to use this developmentally sound perspective as a reason to refuse to diagnose, in most or sometimes all cases, any psychiatric disease in children.
These days, the most common attitude is a strong anti-bipolar diagnosis perspective. Prodromal psychosis and childhood bipolar illness are discussed further elsewhere.
In contrast, childhood ADHD is more commonly diagnosed and supported by most pediatric psychiatrists; problems with overuse of this diagnosis and harms associated with amphetamines are described elsewhere.
“Depression” or “major depressive disorder” (MDD) are also commonly diagnosed in children. It is not commonly appreciated that depression in children often reflects bipolar illness (without any mania), as explained further here. This fact may relate to potential inefficacy or harms with antidepressants, which have been associated with suicidality in children and young adults, as proven in randomized studies analyzed by the FDA.
Other diagnostic labels are common in children, and are used to describe behaviors without having a scientific basis as representing validated diseases: these labels included “oppositional defiant disorder” (ODD), DMDD as mentioned above, and conduct disorder.
In sum, many clinicians who are averse to giving drugs to children do not wish to diagnose psychiatric illness. Others who wish to give drugs do so by diagnosing with psychiatric labels (especially ADHD and MDD, or other labels like DMDD or conduct disorder).
The Psychiatry Letter has two perspectives:
1) In many children, clinicians should not diagnose any psychiatric label at all, viewing “symptoms” as developmental changes which cannot be further clarified until adolescence or adulthood.
2) In some children with known risk factors (most importantly genetic risk for bipolar disease or schizophrenia), early symptoms of known psychiatric diseases like bipolar illness or schizophrenia can and should be diagnosed; but labels based on symptoms, without corresponding diseases in adulthood, like DMDD or conduct disorder or ODD should be avoided.
In both cases, where diagnoses are not made and where they are, treatment should either be avoided entirely as long as possible, or it should be minimized to the lowest doses or the most effective proven treatments. Examples are provided elsewhere on this website.
A summary maxim would be: Be willing to diagnose disease, even in children, but don’t necessarily treat. And, if needed, treat as minimally as possible. This contrasts with the current status quo of either not diagnosing and not treating, or diagnosing too much and treating too much.