The limits of child psychiatry

This morning I read an article which I mostly agreed with, but contained a brief snippet that irritated me. Sean Duggan in the Guardian rightly points out that mental health services are suffering from a crisis of under-investment. It’s all very well for politicians to talk about “parity of esteem” for mental health with physical health, but that simply isn’t translating into services on the ground. Services are being slashed to the bone, with vulnerable people being left to sink or swim, and sadly, too many them sink and drown. Duggan is entirely correct to say that this needs to be reversed.

Here’s the bit that irritated me.

Our children’s mental health cannot be left to chance. One child in 10 has a mental health problem. Three quarters never receive any treatment or support. Yet children with poor mental health go on to become adults with poor mental health. And those with the most common childhood mental health problem, conduct disorder, can look forward to dramatically harder, poorer and shorter lives than their classmates. We need to take action now to create a whole system of mental health support for children that boosts resilience and protects those who become unwell. [emphasis added]

What he says above is true. However, there’s a big problem with the way words like “conduct disorder” are used. It’s part of a whole panoply of language – a child has “an anger management problem”. “A behaviour disorder”. “Oppositional defiant disorder”. All these words may technically fit a checklist of behaviours, but do they actually tell us anything useful? Or are they no more meaningful than saying that the Ukraine is currently developing a flying pointy metal disorder?

Children display problematic behaviours for all sorts of reasons, occasionally neurological but usually psychosocial. Saying a child has a conduct disorder says nothing about the wider systemic issues. All too often the child’s behaviour is simply a flashing beacon saying that something, somewhere has gone badly wrong in the system the child inhabits. Diagnosing a child with a conduct disorder does not provide further illumination into what has gone wrong. Frequently, it confuses the issue with a false simplification. It can declare all the problems to be something within the child, when in fact that child may be displaying a natural reaction to living in a broken system.

In locating the problem within the child rather than elsewhere, the result can be that the focus is not on what the child needs, but on the problems that they cause for other people – parents, GPs, teachers, social workers – all of whom go on to insist that child and adolescent mental health services (CAMHS) should “treat his (usually his, but sometimes her) condition.” Far too often services say “this child has an anger management problem”. We don’t spend enough time asking, “What is making this child angry?”

This is not to say that there aren’t things that can and should be offered to support children with these sorts of problems – parent training, youth mentoring, specialist educational provision. Wider social action to tackle poverty, social exclusion and inequality. Provision of better resources for social services and youth offending services. But none of those require a diagnosis from a child psychiatrist. And to be fair to Duggan, he does state that in many cases what is needed is a social rather than medical solution.

We need schools to become vigilant for the signs of mental ill health, supporting healthy child development, tackling bullying and teaching emotional wellbeing. We need to invest, too, in the mental health of parents, supporting those whose children are most at risk to develop positive parenting techniques.

Child psychiatry has its share to blame for this confusion. After all, we came up with unhelpful terms like conduct disorder and oppositional defiant disorder. But it’s not the case that, as some critics suggest, psychiatry is trying to expand its remit to cover every single aspect of human behaviour – at least, that’s not the case in Britain under the current political and financial climate. CAMHS teams, as with just about everywhere else in the NHS at the moment, is having to focus its increasingly limited resources on stricter referral criteria. Many CAMHS teams simply don’t accept referrals for conduct disorder. Unless there’s evidence that the conduct is linked to an actual mental health problem, I think that’s entirely right.

There are other areas where input from CAMHS can genuinely help – depression, psychosis, eating disorders, suicidality, self-harm. There are problems with access to support in those areas too, and it’s those areas we need to fight for more resources to help with. More to the point, those are the areas where the child is likely to genuinely have a problem that they may want help with, rather than causing a problem that other people are hoping a child psychiatrist can fix.