The Kids Need a Diagnosis, Right?

The future will judge us for better or worse.

“Well, doctor, the thing is, my little Tricia here is eight and she has ADD, ADHD, PTSD, ODD and bipolar, with depression and anxiety. Of course, her daddy and I have schizoaffective with some ADHD and PTSD as well, and he’s bipolar but I’m not. But I have opioid use disorder, you see. Anyway, none of these here medicines are doing a thing for her. She keeps talking about dying and I really think she needs to be in the hospital for a few days to get things settled down.”

So much of this; so very much. And on the bed, a child with a coloring book and crayon, who may or may not look anxious or upset. Often, a child who is calm as can be when mom or dad aren’t in the room. Equally problematic, their parents have struggled with inner demons since their own childhoods; wounded adults, uncertain how to navigate their own problems, much less those of their children.

They grab what is offered to them. Lists of diagnoses offered by professionals. Diagnoses that frequently change over and over from year to year, crisis to crisis. Struggling parents, themselves bearers of many diagnostic labels and traumas who wouldn’t dare resist a new category if they thought it might help their children.

Now, I would never suggest that children can’t or don’t have mental illness. The last few years have brought us an explosion in pediatric and adolescent psychiatric issues. Indeed, an explosion that has far outstripped our resources and understanding. I know that most mental health professionals are doing their best in what must seem the psychic equivalent of the late pandemic. (And intricately connected to boot.)

What I don’t always get, what I struggle with, is the way our system is desperate to give these children assorted diagnoses, and to then sedate their developing brains with ever more potent drugs, the long term effects of which we really can’t begin to predict.

The field of mental health is complex. I have great respect for all of those who labor in it. However, for all of our advances psychiatric care has had a sometimes storied past. (Not throwing stones here; it’s true of all of medical science.)

Last Summer while on vacation with my wife’s family we toured the Transallegheny Lunatic Asylum, a tourist attraction in Weston, WV. From 1864 to 1994 this vast, stone building was actually a psychiatric hospital (with the term hospital being used in the loosest of manners for a good portion of its existence).

In fact, when I was in medical school at West Virginia University, a few years before the asylum closed, we actually toured this facility. I well remember the area where the criminally insane stayed; it was a sparse room where we walked past frightening and largely undressed men, milling about and sitting on bare benches.

These days it’s an interesting place that still has haunting echoes of a darker time when diagnoses of mental illness could be remarkably unscientific. (For a list, here’s a great link: https://mentalhealthathome.org/2020/02/24/lunatic-asylum-crazy-1864/)

There were times in the asylum when a man could put his wife and children away out of convenience. It was a place where PTSD might simply be diagnosed as “The War” and where even “Political Excitement” might land one in the facility. (Maybe that wasn’t such a bad one…)

Later in that dark place, where people now tour the halls on Halloween, frontal lobotomy was performed on many poor, helpless individuals. The very walls now seem embedded with suffering and loneliness, even on a Summer day.

Without a doubt, there were men, women, boys and girls who languished there with very real mental illness. And although the physicians, nurses and others did the best they knew in those times, they were wrong…a lot. Doubtless many of their therapies did far more harm than good. The unmarked graves on on the adjacent hillside are testament to the fact that all too many of those suffering in mind also perished in body in that lonely, Gothic building.

I suppose, when I see this desperate need that people have to apply diagnoses, or medications, which are not well understood, I think back to the asylum. In those days family members felt helpless in an era of limited science and had no idea how to help their troubled, frantic or catatonic loved ones; or they were nefarious and hoping to remove problematic individuals from their lives.

These days? I think the desire for even poor diagnostics and therapeutics, especially for children, has to do with several things. Of course, it’s related to the enormous amount of sympathy we try to extend to all of those with mental health issues.

In addition, it has to do with the reductionism of modern medicine in general and psychiatric care in particular. Unable to ascribe the woes of kids (or adults) to home, culture, economics, education, philosophy or theology, their problems have to be pathophysiologic. It’s why we give medications for ‘chemical imbalances’ without every really being able to see if we’ve rebalanced those naughty chemicals after all.

Finally, we have so many lonely, struggling parents and kids with a powerful need to belong to a group. Especially as the ancient bonds of family, clan and nation blow away like so much dust in the wind.

That new group may be defined by diagnoses, or equally often defined by being a caregiver for someone with a diagnosis. It’s very validating to know that one isn’t alone in the struggle. Unfortunately, I wonder sometimes if it doesn’t come much closer to Muchausen’s by Proxy as the need for an “in-group" may suggest the need for a diagnosis, rather than the opposite.

The asylum was great reminder that we have to be very, very careful when we become too comfortable in our understanding of the travails of the human psyche. It’s easy enough for us to look back on “hysteria” or “gathering in the head” and chuckle about the Neanderthals of our not so distant professional past. But I feel bad, not only for those bygone patients but for their physicians who labored in much more of a scientific fog than we can imagine.

We might be wiser to wonder who will shake their heads and ‘tsk tsk’ in the future when they see how many adults and children alike in our time walked around, on brain bending chemicals, for the often poorly understood diagnoses we so casually apply.

I fear we’re not so far from that old asylum as we might think. And that makes me sad for the brokenness and helplessness we all feel these days.