Children remain a mystery: We really don't know much about their mental health

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The recent news that the Sandy Hook shooter, Adam Lanza, was obsessed with video games and may have wanted to out-kill Anders Breivik, the deranged 2011 Norwegian murderer of 77, doesn't help us understand Lanza's motivations. In fact, it demonstrates how little we know about the many young people suffering from severe mental health disorders. We can't even agree on the definition of a disorder and how many are affected.

According to the U.S. surgeon general, about 15 million children and adolescents in the United States today experience signs or symptoms of a mental health problem. The National Health Interview Survey on Disability put the number at 4.1 million in 2004.

But numbers tell only part of the story, according to Ronald Dahl of the University of California at Berkeley, a leading expert in adolescent brain development. Dr. Dahl points out that we still lack a precise definition of a mental disorder.

"There are a lot of smart and well-motivated scientists who disagree vehemently about what a mental disorder actually is," he says. "Does it require something to be wrong in the brain and if so why don't we call these 'neurological disorders' rather than 'mental disorders'? Does any behavioral or emotional (or habit) problem that interferes with an individual's ability to function qualify as a 'mental disorder?' "

If we wait until a set of problems is bad enough to call it a diagnosable "mental disorder," Dr. Dahl maintains, "we actually missed the most important window of opportunity to intervene (i.e., early intervention/prevention). Yet, if we try to identify (and intervene early) in high-risk youth who are on their way to serious disorders, do we risk labeling and stigmatizing them too quickly?"

Another unanswered question relates to the affordability and options for treatment. According to the National Association of State Mental Health Program Directors, mental health spending by the states has decreased by $4.5 billion over the past four years, even as the price of treatment has risen rapidly. Total expenditures on mental health services increased nearly 64 percent during that period -- this from the Agency for Healthcare Research and Quality based on a survey of Americans and what they pay for mental health services.

An aspect of the issue that muddies the water is the use -- or suspected overuse -- of medications, especially for those who are underprivileged and uninsured. Foster children, for example, according to a report by the Government Accountability Office, receive psychiatric medications up to 13 times more often than kids in the general population. The GAO report also discovered that infants were being medicated. Can we count them in our "mental disorder" classifications? Really ... infants?

Another point, related and disconcerting: Many of these drugs lack an FDA-recommended dosage for certain age groups. Thus, another issue: Children are too often treated like little adults when they are very different biologically and psychologically. Treatment can be totally hit or miss -- a guessing game.

Who is the most qualified to guess? The American Academy of Child Psychiatry estimates there are only 7,000 child psychiatrists practicing in the United States today. By 2020 we will need 13,000 -- but only a little more than 8,000 will be available.

That said, child psychiatrists spend the vast majority of their training doing adult psychiatry. If the goal is to recognize problems early and intervene effectively within the developmental framework of childhood and adolescence, then this is the wrong way to do this. Perhaps child psychiatrists should be pediatricians first -- and then take an extra year or two to be board-certified in psychiatry?

Authorities may know if and to what extent Adam Lanza was treated by a therapist, but if so, the therapist certainly didn't know enough to predict Lanza's devastating actions. Yes, Lanza was a loner, obsessed with video games, and yes, he had access to a large cabinet crammed with guns. But why did he want to kill -- and why were parents, friends, neighbors and school administrators unable to help him?

As for how and when the experts will be able to predict and prevent the next Adam Lanza from entering the Breivak (or Lanza) murder sweepstakes -- no one seems to have the slightest idea.

opinion_commentary

Lee Gutkind, a professor emeritus at the University of Pittsburgh and the distinguished writer in residence at the Consortium for Science Policy Outcomes at Arizona State University, is the author of "One Children's Place: Inside a Children's Hospital" and "Stuck in Time: The Tragedy of Child Mental Illness" (www.leegutkind.com).


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