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  • Troubled Children:Diagnosing, Treating, and Attending to Context
  • Erik Parens and Josephine Johnston


More and more children in the United States receive psychiatric diagnoses and psychotropic medications—this is not news. With those increased rates of diagnosis and pharmacological treatment come sometimes intense debates about whether those increases are appropriate, or whether healthy children are being mislabeled as sick and inappropriately given medications to alter their moods and behaviors.

Some of these debates are inevitable, given the conceptual issues surrounding the diagnosis and treatment of psychiatric disorders in general and the application of these diagnostic categories and treatment modalities to children in particular. In this report, we will describe many of those complexities, paying close attention to the ineradicable role that value commitments play not only in decisions about the appropriate modes of treatment, but also in diagnosis.

Because psychiatric diagnoses are judgments—first of the panels of experts who draft the descriptions of the disorders and then of individual clinicians matching diagnostic categories to the child in front of them—they are necessarily influenced by cultural and individual value commitments.1 The exact boundaries between, for example, healthy and unhealthy anxiety or healthy and unhealthy aggression are not written in nature; they are articulated by human beings living and working in particular places and times. While the extreme end of mood and behavioral continua may be clear to almost everyone, there will always be some disagreement about whether a given cluster of moods and behaviors is best understood as disordered, about how exactly to describe some symptoms of disorder, about which particular diagnosis or diagnoses an individual warrants, and about whether some mildly affected individuals are best served by receiving no diagnosis at all. Those disagreements will be influenced by different but reasonable understandings of, for example, the proper obligations of parents and the proper goals of medicine. The fact that children are developing organisms on whose behalf adults are acting—sometimes with and sometimes without the participation of the children themselves—and the fact that the safety and efficacy of treatments is not always clear increase both the stakes and the complexity of the debates.

In this report we will suggest that where disagreements are reasonable, they should be tolerated, given the fundamental ethical commitment to respect for persons. And we will insist that it is important to distinguish between reasonable disagreements and diagnostic mistakes, including over-, under-, and misdiagnosis.

As important as it is to recognize reasonable disagreements, so, too, it is important to recognize how much we can and do agree. Unsurprisingly, everyone who participated in the workshops we conducted agreed that we share a fundamental obligation to promote the flourishing of children, that careful diagnosis takes time, and that treatments should be monitored for safety and effectiveness. No one rejected medication treatments in all cases, nor did anyone believe that severely impaired children would be better off undiagnosed and untreated.

More surprisingly, however, we found wide agreement around the disturbing conclusion that the United States' mental health care system, educational system, and aspects of its shared culture too often fail children whose moods and behaviors are patently problematic for those children. In these systems, most children suffering mood and behavior problems fail to receive the kind of care that experts recommend; far too often they are not diagnosed at all or are not diagnosed carefully enough. Moreover, these same systemic and cultural pressures constrain the treatment choices of clinicians and parents and make it difficult for them to deliver optimal care. Treatment is often only pharmacological,2 even where a nonpharmacological intervention or a combination of medication and psychosocial intervention would have fewer side effects, be more effective in the long run, and better reflect the parents' and clinicians' value commitments.

Too often, little is done to improve children's environments, even where it is clear that these environments are an important source of the child's problems or are key to securing lasting improvements. As important and inevitable as our disagreements are regarding the boundaries of "normal" in children, we make a profound mistake if we let them distract us from agreeing that we need to remove the barriers that stand in the...


Additional Information

Print ISSN
pp. S4-S31
Launched on MUSE
Open Access
Archive Status
Archived 2012
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