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Mentally ill children.



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Background Briefing

 

Sunday 26 August 2007

Mentally ill children

 

Woman: You've heard about SARS, AIDS and bird flu. Now researchers from Australia claim we're about to be hit by a new epidemic: Motivational Deficiency Disorder.

According to the British Medical Journal one in five people are said to suffer from Motivational Deficiency Disorder, or Moded, and most don't even know they have it. Symptoms include being unable to get out of bed in the morning, being trapped on the couch, or wanting to spend the entire day at the beach.

Jane Shields: Hello, this is Background Briefing on ABC Radio National. I'm Jane Shields; and you too, or your children, may be suffering from this mental illness.

Man: The condition varies from very mild. There are people who perhaps notice a slight reluctance to get out of bed on Monday morning at the mild end of the spectrum; through to the most severe disease, which is potentially fatal. These are people who find themselves at times in an acute attack, unmotivated to breathe, and these people will die.

Moded patient: I mean, all my life people have called me lazy, but now we know I was sick, and that's why I've set up the patient group, Unmotivated Anonymous, and we've got some corporate sponsorship, we've got a website and we intend to raise public awareness about this genuine disease.

Jane Shields: You might have guessed by now that this is not actually a genuine disease. It's a fictitious disorder created to show how easily normal human behaviour can be turned into illness.

The satirical documentary was launched at a conference on disease-mongering in Newcastle last year.

The medicalisation of the human condition and behaviour is by now well established as the big drug companies hunt for more and more illnesses to cure. Society is changing too: there's less tolerance of people who are different, eccentric, slow, or a bit odd.

Children are the latest targets. Just listen to some of the many mental health disorders said to affect children:

Reader:

Separation Anxiety Disorder

Obsessive Compulsive Disorder

Tic Disorder

Pervasive Development Disorder

Conduct Disorder

Disruptive Behaviour Disorder

Oppositional Defiant Disorder

Reactive Attachment Disorder

De velopmental Co-ordination Disorder

Jane Shields: There's no doubt there are children who are more than just shy, or cheeky, or rebellious, or unusual. Some children have serious disturbances that can and should be helped. But Background Briefing has been told that in America, there are research projects looking for bipolar mood disorder in children who aren't even born yet. And advertisements like this fuel the fire.

Mass General ad.: Our problems started when he was four years old. No day care could handle our son, he was just too violent and unpredictable. I had to protect the other children from his outbursts, mood swings. I see a lot of cases like this. Your child may be facing a chemical problem that you can't manage without help. If you or someone you know is living with bipolar disorder, call us to participate in our research study. Heartbreaking, no-one understands the pain. We're Mass General. We can help.

Jane Shields: That's an advertisement from Boston's Massachusetts General Hospital. It's home to one of the leaders in diagnosing bipolar mood disorder in children, Dr Joseph Biedermann, who says that many cases of ADHD are in fact, bipolar. In America, since 1990, the rate of diagnosis of 'juvenile bipolar' has increased dramatically. But it's not just bipolar disorder that's said to be appearing more in children.

'PM' THEME

Mark Colvin: A new psychological study of modern children has found an alarming increase in the incidence of a number of mental illnesses. The Danish study of 700,000 children in the 1990s found, for instance, that the number of Tourette Syndrome cases had doubled, and there were three times as many kids diagnosed with Attention Deficit Disorder. The researchers say it's not clear whether the rise is 'real, and caused by environmental factors', or whether it can be put down to increased awareness and better diagnosis by doctors.

Jane Shields: Around the world there are indications that up to one in six children have some form of mental health problem.

But in Adelaide, at the Women's and Children's Hospital, Associate Professor of Psychological Medicine, Jon Jureidini, is worried that figures like this are misleading.

Jon Jureidini: The way in which people are more and more defining mental disorder is that any significant distress or disturbance that a person experiences, seems to be now being defined as a mental disorder.

Jane Shields: Is that spilling over into childhood mental health?

Jon Jureidini: Yes, the same thing applies in child mental health. Surveys show that anything up to 15% of children are suffering from a mental disorder at any one time. Now I think what we're doing is, we're picking up any child who's distressed or dysfunctional, but we don't really have good reason to believe that that's because they've got some kind of a disorder.

Jane Shields: Professor Jureidini says children often react to social stresses and pressures, that even adults find difficult.

Jon Jureidini: If you take a child under pressure, there's a very limited repertoire of ways in which they can respond to that. Hopefully they can talk about it and approach their parents and stuff, but when kids can't do that, it comes out in one of a very small number of ways and it can come out as behaviour problems, or it can come out as withdrawal and disengagement. And the former tends to be labelled as ADHD, or a variety of other illness labels that we have for kids with behaviour that we don't like, and the latter tends to be labelled as depression or anxiety.

Jane Shields: And psychologists say that the quest to create near-perfect children, who are happy, and have lots of friends, and do well at school, can be counterproductive. One outspoken critic of the rush to medicalise normal temperaments and shifting moods is Professor of Psychiatry at Cardiff University in Wales, David Healy.

David Healy: Children have always been unhappy and they've been nervous and they've also had problems. But about 10 to 15 years back, words we would have used for children would have been to say that they were maybe anxious, or that they were under stress. And these words actually pointed to the context in which children lived; they actually pointed to the fact that things could have been going wrong for the child at home, or they could be going wrong actually maybe in school, and these were things that the focus of our help to these children, was on actually putting things like this right. In recent years we've actually begun to talk more about children having a mood disorder, either being clinically depressed or having a bipolar mood disorder.

Jane Shields: Even in America, not everyone is convinced about the way many children are being diagnosed. From Boston, psychiatrist Dr Jennifer Harris.

Jennifer Harris: In the field of psychiatry in general there's been a move away from therapy and Freudian analysis which had been really dominant in the '50s and '60s. There's been a move away from that, towards a more biological model, and bipolar disorder was seen as a very biological disorder, and by 'biological', I think people often mean 'genetic'. I think that focus on something more biological plays into parents' own desire to feel like they're not at fault, or it doesn't have to do with child rearing or something like that, or they don't want to feel like their child has a mental health condition; it's better to think that there's something biologically wrong.

Child: Maximum highs are better than maximum lows because maximum lows are rages, and ...

Jane Shields: Since the 1990s, America has been leading the way in diagnosing children, in some cases as young as two, with what's called 'juvenile bipolar', or 'early onset' bipolar.

Child: ... running around screaming and yelling and throwing and hitting and sometimes even biting.

Woman: Between the phone calls and the teachers and the paperwork, and the doctors, there really is a lot like behind the scenes. If people don't live it, you don't really understand it.

Jane Shields: There are websites, online parent forums, specialised clinics, and research foundations all dedicated to the disorder. There's also a best-selling book, The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder .

Its author, Dr Demitri Papolos, runs the Juvenile Bipolar Research Foundation, a charitable organisation established to investigate the causes, consequences and treatment for the disorder. Background Briefing spoke to Dr Papolos on the phone from Connecticut.

Demitri Papolos: Most children, probably about 80% of children with early onset bipolar disorder have very rapid swings of mood, abrupt, rapid changes in mood that occur within the day, and that can occur multiple times within the day. And that's one of the distinguishing features and perhaps one of the hallmarks of the condition, as opposed to bipolar disorder in adults, where there are significantly longer periods of mania and depression.

Jane Shields: Dr Papolos, whose book has sold 200,000 copies, firmly believes that there are many young children with bipolar mood disorders.

Demitri Papolos: Children, when they get manic, often get very silly, goofy, giddy and elated, and then they just as easily descend into very low energy periods of withdrawal and often intense boredom, and social withdrawal. And during those times they often have self-recriminations and sometimes suicidal thoughts. And these rapid mood shifts are pretty characteristic, and there are obviously other features that are pressured speech, racing thoughts, significant hyperactivity, easy excitability, intense emotions. Those are some of the features of the manic and hypermanic phase of the condition and the way the moods appear within the day.

Jane Shields: Some estimates say up to a million American children have bipolar and the idea of the bipolar child has captured the attention of the media there too. Here's one report from earlier this year.

CBS THEME

Host: Diagnosing and understanding mental illness is a big challenge for doctors, especially when they're treating children, which actually happens much more often than it used to.

Woman: Good morning, Hannah, that's right, one of the fastest-growing diagnoses in children is bipolar disorder. It's a mental illness that causes extreme mood swings, highs and lows that can be debilitating, and these kids can't just snap out of it.

At age 6, Hayley was diagnosed with a laundry list of psychiatric disorders: Obsessive Compulsive Disorder, Tourettes Syndrome, and above all, Bipolar Disorder. It manifests itself in sudden mood swings, with depression and anxiety, something the family calls 'episodes'.

Hayley: I always have to be doing something.

Jane Shields: Even within the American psychiatry community, there are many differences of opinion, not only about the existence of bipolar disorder in very young children, but also the ways in which it can show up, and of course, the treatment. Dr Jennifer Harris, who you heard from earlier, has worked in the in-patient child units with the Cambridge Health Alliance in Boston. She now works in private practice, but says during her time working at the hospital, she saw increasing numbers of children who'd been referred due to bipolar disorder. Most, she says, had been misdiagnosed. [This paragraph has been edited to correct an error.]

Jennifer Harris: Often when you have irritable, explosive, aggressive children they end up getting labelled as bipolar disorder. And the problem is that lots of different things can lead to kids being irritable, explosive and aggressive, or any one of those three things. But I think unfortunately, too commonly, it just gets labelled as bipolar disorder and then there's a whole host of assumptions about treatment that short-circuit really a more thorough comprehensive evaluation.

Jane Shields: Dr Harris has never herself diagnosed a pre-teenage child with bipolar disorder, and says it's very rare in younger children.

Jennifer Harris: I've probably seen two, maybe three, pre-pubescent kids who I was convinced had bipolar disorder, or thought it was highly likely that they did, out of many, many, many kids I've seen going through the In Patient Unit. I've seen many more than that come in with that diagnosis.

Jane Shields: Dr Harris recalls a case that she thinks explains where the diagnosis can go wrong.

Jennifer Harris: There's a kid I'm thinking of who I saw in my private practice who had a really severe learning disability that had been missed, and that affected his ability to read social cues, so what seemed again like unexplained irritability explosiveness, really when you understood his learning profile, you could figure out that it was coming from the way he was inappropriately reading these social cues, and once we kind of figured that out, the behaviours went away.

Jane Shields: Dr Harris doesn't deny that many of the children labelled with bipolar disorder are often very distressed, but she's concerned that the diagnosis brings with it a fast track to very serious medication. She specialises in treating children's disorders without the use of drugs that she says come with long-term side effects, including liver and kidney damage.

In the UK, Cardiff University Psychiatry Professor, David Healy, is an outspoken critic of doctors who diagnose bipolar too readily. He says bipolar illness in children is very rare, and he's astonished at the enthusiasm among some psychiatrists to look for signs of this illness in children.

David Healy: Just to give you a feel for how crazy things have actually got recently, it would appear that clinicians in the US are happy to look at the ultrasounds of children in the womb, and based on the fact that they appear to be more overactive at times, and then possibly less active later, they're prepared to actually consider the possibility that these children could be bipolar.

Jane Shields: So the obvious question is, why this search for serious mental illness in ever-younger children? One possible reason for the dramatic increase in bipolar diagnosis is that in America in the past 10 years, the more serious an illness a child has, the more likely it is that the doctor will be funded to treat it. Dr Jennifer Harris.

Jennifer Harris: One of the things that happened is that people were no longer getting reimbursed from having more benign diagnoses.

Jane Shields: Fifteen years ago, she says, it was common to diagnose distressed children with conditions like 'adjustment reaction', indicating that a child's behaviour was a short-term response to some change, or trauma, that they might have been experiencing. This diagnosis, which basically means you help the child adjust, and give it support, is no longer accepted for funding.

Jennifer Harris: I don't get reimbursed for that. On the other hand, if I put in a diagnosis of bipolar disorder, NOS, I get reimbursed. So bipolar disorder's got to be a more 'serious' diagnosis and is much more easily reimbursed. I think that is part of what drives this; it's hard to get good treatment for kids, the child mental health care system is overburdened, it's hard to access resources, and if you have a diagnosis like bipolar disorder, you're much more likely to get services; it's much more likely your insurance company is going to pay for it, you're much more likely that your school district might pay for you to go to a special school. So the financial pressures I think, are real, and impact this tremendously.

MUSIC

Jane Shields: The music you're hearing is the creation of 15-year-old Ambrose, working on his computer at his home in Newcastle. He's a little eccentric, and doesn't always fit in, but he likes who he is and his mother thinks he's great.

He's no longer taking any medication at all, but it wasn't always like that. Background Briefing went to visit Ambrose and his mother Christina at their home in an inner city suburb of Newcastle.

DOOR KNOCK

Christina: Hello, hi how're going?

Jane Shields: Not bad, how are you, Christina?

Christina: Oh, good thank you. Nice to meet you.

Jane Shields: You too.

Christina: Come in. Ambrose?

Ambrose: Yes. What?

Jane Shields: Thanks for agreeing to have a chat to us. What about we just sit down ...

Christina and Ambrose rent a modest, 2-storey terrace near the centre of the city. A small fire is fighting the cold winter's afternoon in Newcastle. Ambrose has a mop of dark hair, and is wearing a black T-shirt of 1970s punk band, The Clash, along with some Steptoe gloves.

Ambrose was put on medication when he was six, after he was diagnosed with ADHD, Attention Deficit Hyperactivity Disorder.

His mother, Christina, recalls that his teachers said they were concerned about him.

Christina: I was a new mum, I was only quite young, you know, in my early 20s, and wasn't sure what was going on, you know. I found him to be quite a normal, as in 'ordinary', kid at home, and didn't have a problem with his behaviour. And then when he hit the school, that's when it all started to happen.

Jane Shields: According to his teacher, Ambrose simply refused to conform with his classmates and was determined to do his own thing. Christina says while the school saw only a naughty child, to her he always seemed bright and independent.

Christina: Ambrose could read at a very early age. He was very articulate, he would use lots of big words, and we'd have an adult conversation; he wasn't shy at all. Didn't really care about me, or his Dad, he would just do whatever he wanted to do.

Jane Shields: One of the things he insisted on doing was wearing a strange hat to school.

Christina: He liked to wear this hat, this pork-pie hat that was his grandfather's and he wore that from Third Class, and it was quite strange for a little boy to want to wear this hat. And in the playground they had to wear a hat, it was compulsory, but he wanted to wear this pork-pie, tweed, old man's sort of hat, which he though was wonderful, and of course he used to stand out with all the other kids and the parents. And he was never shy or - he would go straight up to anybody and introduce himself, and he didn't have a problem with how he was. He didn't care that people were looking at him, he didn't care that - I think he liked the fact of wearing an unusual hat. His father used to have arguments with him where I'd just go, 'OK, if you want to wear the hat, wear the hat'. It wasn't worth an argument.

Jane Shields: His father was a bit worried about what reaction he'd get?

Christina: Yes, I think so, because he did stand out, and because he was a naughty boy, oh well, in the teacher's eyes he would make himself stand out more with this hat, you know, and he wore that right up until Sixth Class, and now those hats are cool. So.

Jane Shields: At the time IQ tests confirmed that Ambrose had above average intelligence, but while he didn't have a learning disability, he continued to cause problems for his teachers.

Christina: He wasn't a run-of-the-mill kid, he wasn't conforming like all the other kids, and he was defiant and running away and hiding, causing lots of problems. And they said to me, 'You should take him to a paediatrician', the school suggested that. And I was like, Oh my God, you know, my child, how can you say that? To me, he's perfect. And I thought really, they don't want him at this school.

Jane Shields: After visiting the paediatrician, Ambrose and his parents were told that he had ADHD. Christina says she was confused by the diagnosis.

Christina: She diagnosed him within an hour, within one consultation. Basically I took his school reports, which was the first term of kindy, and the reports that were from the preschool that they had done in the university. Basically she asked me a few questions and then she said 'He has ADHD'.

Jane Shields: What was your response to that?

Christina: Well I thought, well I've seen A Current Affair , and all those programs, and Today Tonight , and he wasn't like those children. He wasn't running around and jumping on the furniture and screaming and swearing and abusing me and hitting me; he wasn't like that at all. At home he was a good kid.

Jane Shields: Unsatisfied, Christina followed up to seek a second opinion on whether Ambrose really did have ADHD.

Christina: And the next doctor: 'That's what your son has, he has not ADD, ADHD'. So he didn't have any learning difficulties, he didn't have the aggressiveness; he just was impulsive and would just not listen. So this doctor decided that he should go on medication, which I really didn't like the idea of at all. I was really frightened; I don't know anything about it. We were really confused and upset about the whole thing.

Jane Shields: Despite her hesitation, Christina began giving Ambrose Ritalin, and things did settle down at school. But Ambrose hated taking the medication.

Ambrose: And I remember kids saying to me, 'That's mental people's drugs and only retarded people take drugs like that', that I was like a psycho or something. So what I used to do was I never used to really tell any of my friends that I had ADHD or was on medication, because I didn't want people to pick on me. That was around about Year 2, Year 3 or something.

Jane Shields: Did you feel different to the kids your own age?

Ambrose: Yes. Definitely. Like everyone else would be doing something else and I'd be, I don't know, trying to find out about, it's like they're A and I'm Q, for example in alphabet terms. So they'd be off at one side of the school and I'd be over at the other.

Jane Shields: Despite their differences, Ambrose said the kids at primary school learned to accept him as he was. But later at High School, he once again struggled to fit in and was severely bullied.

Ambrose: Even though they think that they overpower me because they're in numbers, but I think in my own mind that I am more mentally stronger, like I can see something from a different perspective when they're just 'You're a loser, you're a fag, you're nothing', pretty much, and 'We hate you' and it's like that's not cool. It's not very nice.

Jane Shields: I guess that's pretty unusual for a boy your age to be able to see that from that perspective and be pretty confident in who you are?

Ambrose: Yes. I'm pretty confident in who I am. I get on with my friends pretty well, but it's really hard for me to go out in public places sometimes. Because sometimes I see them, and for example, about a week ago I was on the bus going to see some friends, and I had some kids that know me, because I heard them talking and saying stuff like they wanted to follow me off the bus and bash me or something. But I quickly got off the bus and ran, so got away from that. But yes, I don't know, it's hard for me to get around.

Jane Shields: As his early High School years became more and more difficult, his paediatrician suggested to his mother that he perhaps should see a psychiatrist.

Christina: And I thought Oh gee, you know, psychiatrists, that really frightened me, just the word itself. And I thought Oh well OK then, if he still needs medication well we're going to have to do that. So we made the appointment and took him to this psychiatrist, and the psychiatrist diagnosed him and said, Oh no, he hasn't got ADHD, he has Asperger's, he's just eccentric, he hasn't got the hyperactive nature, he hasn't got learning difficulties. And said, Oh my God, he's been taking medication for ADHD since he was six years old and now he's 13, 14, and no, he doesn't need that at all, he should be taking antidepressants.

So yes, that was really hard to hear I'd been giving him one medication for all these years for the wrong illness, or so I thought.

Jane Shields: What did the psychiatrist say made him think that it was actually Asperger's?

Christina: Oh he had all of his school reports, and the psychologist reports, the school counsellor's reports, he had a couple of sessions with him and just said that he has a mild form of Autism, very mild form of it, and that he just needs to learn to organise himself and things will be a lot better for him.

Jane Shields: The diagnosis also took Ambrose by surprise.

Ambrose: Straight away he diagnosed me with having Asperger's Syndrome, and it was a bit strange, and he gave me a prescription straight away for these new drugs, and I didn't really trust them that much. Because I went and did some research about the drugs and they were really like high (what's the word?)

Jane Shields: High powered kind of drugs?

Ambrose: Yes. See, Ritalin is a moderately powered drug, but it's not like a complete brain-altering sort of drug.

Jane Shields: What were some of the things that you found out about the drugs that he recommended?

Ambrose: They said that it changed personality and it can kind of distort the way you perceive things, and I'm not sure about that really, because I don't really want to - as much as I'd like to be able to focus and maybe do my studies better and be able to concentrate better, but I don't want to have to change who I am. I'm happy with the way I am, and I think all I can do now is just continue school, get stuff done, and see what happens from there.

Jane Shields: Ambrose isn't taking any medication now. He's in Year 10 at a new school that caters especially for kids who don't cope in mainstream schools for one reason or another. Ambrose plans to finish Year 12 and then go on to study at university.

AMBROSE'S MUSIC

Jane Shields: So many children seem to have been diagnosed with ADHD that it's become fodder for comedy and satire shows, like the cult program, South Park.

Richard Shay: Hello, I'm Dr Richard Shay here to tell you about my exciting new drug-free treatment for children with Attention Deficit Disorder.

CHILDREN MAKING RUCKUS

Richard Shay: This treatment is fast and effective and doesn't use harmful drugs. Watch closely as I apply treatment to the first child.

BANG

Richard Shay: Sit down, and study!!!

CHILD REAX

Richard Shay: Sit down, and study!!!

CHILD CRYING

Richard Shay: Stop crying and do your schoolwork!!!

If you would like more information on my bold new treatments, please send away for this free brochure, entitled 'You can either calm down or I can pop you in the mouth again'.

Jane Shields: In Sydney's inner west, Background Briefing went to the Rivendell Child and Adolescent Unit at Concord.

Professor Philip Hazell has spent more than 20 years working with children with mental health problems. He's now the Director at Rivendell.

Hi Philip, Jane, from Background Briefing .

Philip Hazell: Hi, Jane.

Jane Shields: Pleased to meet you.

Philip Hazell: Welcome to Rivendell.

Jane Shields: Thank you.

The unit sits in a sandstone building on 63 acres on the shores of the Parramatta River, and provides a child and adolescent mental health service, including in-patient rooms for more than 20 adolescents, along with a high school.

Philip Hazell: The kids are in class at the moment, so ...

Jane Shields: Philip Hazell gave Background Briefing a look around the Rivendell schoolrooms.

Philip Hazell: The classes are divided according to our clinical programs, so there are two classes dedicated to kids with predominantly mood problems, two classes dedicated to kids with psychosis, Asperger's, autism syndromes, then there is a separate program for kids with disruptive behaviour disorders, those kids are not necessarily enrolled as patients here at Rivendell. And another program which is dedicated to young people who are unlikely, owing to their mental illness or other difficulties, to ever get back into mainstream school. So it's a transition program, usually into TAFE or vocational training.

Jane Shields: Back in Professor Hazell's office, he talks of his many years treating young children with behaviour problems at a specialist clinic he began in Newcastle.

Philip Hazell: There are some mental disorders which occur right across the lifespan, so they're effectively the same disorders in children as adults. Good examples of that would be anxiety and depression. But there are also some disorders which we most commonly associate with childhood so conduct disorder, oppositional defiant disorder, ADHD, attention deficit hyperactivity disorder.

While people improve and maybe grow out of their problems, some continue to have difficulties, even in adulthood. And then there are conditions which are classically childhood conditions, but continue to affect people in their adulthood, such as autism.

Jane Shields: Now you're just mentioned there conduct disorders and oppositional defiant disorders; could you explain for us what that term actually means?

Philip Hazell: Oppositional defiant disorder I'll begin with. What that represents basically is a persistence of negativistic, tantrum-y, oppositional behaviour that is quite normal in most 2 and 3 year olds, but you shouldn't expect to still be seeing in somebody's who's 7, 8, 9, and that's what it is. It's that kind of toddler-like behaviour that you're still seeing in somebody who's quite a bit older and should really have left it behind. Conduct disorder is really a step towards delinquency or adult anti-social behaviour, so it's characterised by more sneaky, behind-the-scenes behaviour like truanting, stealing, lying, being deceitful, but can also be characterised by aggressions, some bullying, harassment, even sexual aggression to other people.

Jane Shields: Philip Hazell is among those who say that far from being over-diagnosed, mental illnesses in children are probably under-diagnosed. His research in the Hunter Valley showed only a third of the children with ADHD were picked up and treated. He thinks that ADHD stands out because other kinds of mental illnesses are even more under-diagnosed.

Philip Hazell: For example, probably only about one in ten kids with anxiety or depression ever get to specialist services.

Jane Shields: But Professor Hazell says diagnosing mental health problems in children is extremely sensitive and complex.

Philip Hazell: There is a risk that ADHD will be diagnosed when in fact the child has a different problem. And it's understandable, because ADHD's a very common problem and you tend to diagnose common things first. But there are other difficulties or other problems that could explain why a kid is not concentrating well or is hyperactive or fidgety and they include more rare conditions such as autism, also include anxiety, even depression, and I guess, a controversial diagnosis, but the possibility of bipolar disorder.

Jane Shields: There is some concern that particularly in the United States, children as young as two I've seen quoted, have been diagnosed as bipolar, and there's some scepticism about whether one can actually diagnose someone that young with bipolar. You're involved in research into paediatric bipolar; what's the latest feeling?

Philip Hazell: It would be good probably if we didn't refer to it as bipolar disorder, and found another name for it in children, because the difficulty at the moment is that by calling it bipolar disorder, there's an assumption that we're talking about the exact same condition that affects adults. Within the population of young people who might have bipolar disorder, the answer is that some probably do and the older the age of the young person, the more likely it is that it truly is bipolar disorder; the younger, the more doubt you have. At the moment there aren't sufficient long-term data of children identified with bipolar to say with great certainty, that yes, the kids we identify with bipolar in childhood, actually have the adult disorder.

So, it's a bit of a cliché, but the jury is still out.

Jane Shields: Professor Philip Hazell, Director of Rivendell Child and Adolescent Unit.

There are children who are so disturbed they may end up at a hospital. Head of the Children and Adolescent Psychiatric Unit at Westmead Hospital is Dr Jean Starling, and Background Briefing spoke to her while she was on a short break in New Zealand. She says many children come in through the Emergency Department at Westmead, and she says the most common childhood mental disorders are anxiety and depression.

Jean Starling: There's some concern that we are seeing more and more unhappiness and depression in children, especially primary schoolchildren.

Jane Shields: Is that something you've seen in your own work experience at Westmead Children's Hospital?

Jean Starling: Yes, I would certainly now be seeing children who are in late primary school who present to us because they're either desperately unhappy or sadly, they've attempted to hurt themselves.

Jane Shields: Even in primary school?

Jean Starling: Yes. It's much more common, again very sadly, in adolescence, but we would be seeing that in 10 and 11 and 12 year olds who are also very unhappy.

Jane Shields: And it's a change that you've observed only in the more recent years?

Jean Starling: Look, it does appear to be, and I suppose a little hard for us to know if that's because we weren't seeing them in the past, or if the pressures that teenagers would be under for some time are now moving down into the younger age group.

Jane Shields: Dr Starling says she's seeing more and more families under stress, and thinks that young children are sharing these adult worries with their parents. And she says, the changing dynamics of a competitive world mean there are all sorts of new pressures on children.

Jean Starling: I think one of the factors is that the pressures on life to succeed and do well are actually being put onto children younger. You see quite a lot now of children going for the select school examinations for example, and there appears to be a belief in some children that if you don't get into a selective high school, then it's somehow affected your future very severely, and that's a fairly new thing for me to be seeing, children very distressed by that.

Another reason that children can sometimes get distressed is because of bullying or difficulties in school, and I think again, that's becoming more of a problem in some areas.

Jane Shields: How do you go about distinguishing normal behaviour from 'abnormal'? At what point do you call something a disorder, perhaps?

Jean Starling: That's a really good question. And the line between what's normal and what's abnormal is quite difficult. It's very clear when somebody is very severely depressed that it's not hard to pick. But I would say that it crosses over into a disorder when it starts affecting your life, and when it lasts for a long period of time. So with a child, a child will often have a period of time for a day or so where they're unhappy about a particular situation. But when the unhappiness lasts for two or three weeks, and also it starts affecting the way they interact with their family and their friends, and it starts affecting the way they perform at school, then I think it becomes a problem. It's also a problem of course if they start feeling so bad that they think that life's not worth living or they consider hurting themselves.

Jane Shields: The fact that some children will actually feel so miserable and hopeless that they'll want to end their life or hurt themselves is at one end of the spectrum of mental disorders. At the other end are people who may have a disorder such as Asperger's who can with a little help, usually get along well in society.

International studies show an increase in the autism spectrum of disorders, but it's not clear whether this is from more awareness of the condition, or a real increase brought about by changes in society.

Dr Starling.

Jean Starling: One of the theories that would go along with that would be that these days you need to have a very high level of social skills to be able to function in most occupations, so the occupations where very few social skills are needed where you could work at a very simple task in isolation, such as working on a factory processing line, have now gone. And a lot of jobs these days are in the service industries, the professions, the trades where you do need to have very high levels of social skills. So it's possible that people without those skills weren't noticed in the past and they were just seen as eccentric and would somehow fit into a job of some kind where they didn't need to have social interaction.

Jane Shields: So they would just become Joe Blow, the unusual one?

Jean Starling: Yes, that's right, and Joe Blow might potter around in somebody's garden, or maybe work on a factory processing line, and he can have a successful life and have a successful job. But his options are now much less than they were.

Jane Shields: Dr Jean Starling, Head of the Children and Adolescent Psychiatric Unit at Westmead Hospital in Sydney.

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Jane Shields: Since 1983 there's been an ongoing national project investigating whether a child's temperament can predict how they'll cope with life.

Part of the team leading the research of the Australian Temperament Study, is Melbourne paediatrician Dr Frank Oberklaid, who's the Head of the Centre for Community Child Health at the Royal Children's Hospital and a Professor of Paediatrics.

Frank Oberklaid: We followed almost 2-1/2 thousand Australian children from the time they were about four to six months of age. They're now well into their 20s and having children of their own, and we were very interested to try and tease out the influence that temperament had on these kids as they got older, on their behaviour, on their adjustment, on their school performance, on the way parents managed their behaviours, and so on.

Jane Shields: It was presumed that a person's temperament is driven largely by genetics, but is also affected and shaped by the environment in which they grow up.

Frank Oberklaid: So about 10% to 15% of children are born with what we call a difficult temperament, that is, they tend to be fairly active, they tend to be intense, they have difficulty as an infant in getting into a predictable routine. So these are kids that are challenging for any parents. They're harder to manage if you like, than the 'average' child. Irrespective of how good the parents were, irrespective of the techniques they used of how confident they were, these were kids that were just generally difficult to manage, and that's not fixed in stone, so that just because kids were difficult when they were infants and toddlers didn't mean that they continued that difficulty right through life.

Jane Shields: Clearly, parenting plays a big part in the way children develop their social skills and interaction. And the study showed that the relationship between parents and children has the potential to set the foundations for later life.

Frank Oberklaid: What we did find was that irrespective of the child's actual temperament, if in the infant and toddler years parents perceived that the child was difficult, then that was a very good predictor that the child will stay difficult, In other words something, if the interaction between the young child and parents goes off the rails a little bit in those early years, irrespective of whether they're the genetic contribution or whether the child has a difficult temperament, then that is likely to go on to lead to problems later in life, certainly in the early school years. And there's also evidence as we continue to follow these children, that to some extent we can predict longer-term behaviour problems.

Jane Shields: The information collected about a child's temperament, the kind of parenting they were given in their earliest years, revealed some common elements, or risk factors, for mental health problems.

Frank Oberklaid: The greatest predictors were a combination of difficult temperament, early difficult behaviour such as aggressive behaviour in the preschool years and so on, and harsh or rigid parenting. Those combinations seemed to predict much more powerfully that these kids would go on to have greater behaviour problems, later mental health problems.

Jane Shields: The Temperament Study shows the complexity of determining the contribution of genetics, environment and parenting to a child's mental health in particular.

But Dr Oberklaid says regardless of the genetic make-up of a child's temperament, the study shows that children seem to fare best with parents who are willing to set boundaries.

Frank Oberklaid: The best parenting, irrespective of the temperament of the child, was what we call authoritative parenting, where parents set limits, were consistent in their parenting style, understood that some of the behaviour isn't wilful, that children at these developmental ages do exhibit often challenging behaviours and responded in appropriate ways.

SONG: 'Be Good, Johnny'

Man: She had become more and more explosive in his temper.

Woman: He had started having really severe rages, or he would get upset just about anything and go off.

Jane Shields: General Practitioners are usually the first to see children who have been brought in by parents who find their behaviour too difficult, or who suspect something is very wrong. North of Brisbane, on the Sunshine Coast, Dr Scott Parsons was so concerned at the poor level of special services for children, he decided to specialise as a General Practitioner working with children.

Scott Parsons: The waiting period to see a paediatrician was blowing out to six to 12 months for a child mental health disorder, and the same for the child psychiatrist. And so it really was a case whereby basically to try and assist some of these desperate parents and children, I had to start taking on some of the role of helping out with some of these child mental health issues.

Jane Shields: For a GP, how do you begin to train yourself to make those distinctions between what might be a psychiatric issue, could be a parenting issue, or it could be a behavioural problem?

Scott Parsons: Yes, you've really nit the nail on the head there Jane, especially in GP land where we really do only have a 15 minute appointment, which is obviously completely impossible to fully assess a situation. But you basically have to realise that what is a child mental health disorder, and the word there is 'disorder', and the child is not functioning to his age-related abilities. The first thing I'll do is get a fairly brief history and often parents are feeling guilty and feeling like a failure, or there's a lot of negativity associated, or they're particularly angry at either other people or the child, and so the first thing to do is to make them feel like those feelings are all very natural and yes, we're going to try and help you with those feelings.

Jane Shields: Dr Scott Parsons says if he finds the problems are only at school, or only at home, that is often good news.

Scott Parsons: I'll try and say 'Well look, that's really good news', because that's less likely that we're dealing with a mental health disorder and more likely dealing with the challenges that the parents are facing with managing their own relationship with the child. If it's clear that the parents are indicating that the school is desperate for help and the childcare is desperate for help, yes this child's probably got some sort of disorder whereby the child is providing too much of a challenge for the school and the peer group and for the parents.

Jane Shields: Scott Parsons wants to see more extensive and formal training available for all GPs, to enable them to better care for children's mental health needs. There are already specialist GP diplomas in other things, such as obstetrics.

In Adelaide, Associate Professor Jon Jureidini says he too would like to see more recognition of the part that GPs play in handling mental health problems.

Jon Jureidini: GPs know a lot about the kids who come to see them. They often know the kids themselves, but even if they don't, they often know the family and they know the community that the child comes from. And building on that understanding is something that we think GPs can do very readily, but too often, the approach to teaching psychiatry to GPs is about teaching them tricks with drugs and so on, and I don't think that's the right approach for them to take.

Jane Shields: Jon Jureidini is Professor of Psychological Medicine at the Women's and Children Hospital in Adelaide, and has worked as a child psychiatrist for 20 years.

During that time, he says there's been benefits and costs to the changing recognition of mental health problems.

Jon Jureidini: There's an increased recognition and the recognition is made up of at least two components. The first positive component is that we're recognising some mental disorders that previously we were missing, but the second, and by far the larger and the more worrying component is that we're labelling a lot of stuff as mental disorder that hasn't always been labelled as such.

Jane Shields: He's particularly concerned with the move away from treating environmental factors.

Jon Jureidini: There are harms and benefits to any label, and sometimes making an appropriate diagnostic label is a huge relief to people because it makes sense of something they've been experiencing. But it also carries costs and some of the costs include the attribution of problems to things that can't be dealt with, so if you understand a child's behaviour problem because of their biological make-up and they've got ADHD or ODD, or whatever, then that takes you away from trying to understand that problem in terms of the life circumstances that might have led the child to get there. So you might miss something and if you drug them in a way that improves their behaviour and makes them less of a problem to other people, then that may mask other things that are happening.

Jane Shields: Meanwhile, at Cardiff University in Wales, Psychiatry Professor David Healy continues to be very vocal about what he calls the medicalisation of childhood.

David Healy: What we've lost in the process is the capacity for both parents and actually the doctors that they go to see, to say, Well look, wait a minute here, children always have been unhappy, they always have been nervous, but that's actually part and parcel of being a child. You have to go through these things. This is now we learn to cope with the problems of life.

Jane Shields: He says that it's important to remember that severe mental illness in children is rare and that most children with a mental health problem do not need to be treated with medications.

David Healy: These children can be helped best and in actually the safest way, if they're just seen and if they actually have the opportunity to talk about their problems, and if they get basic and sensible input about how to perhaps help them cope with these problems. And it is useful to have pills in reserve for the children who don't respond to these kind of approaches, but at the moment the problem is that we seem to be actually picking up children ever earlier, where it's actually leading to children being picked up and put on pills, who really don't need to be on these pills and who are going to be injured by them.

Jane Shields: Do you think in the 21st century that there is an over-diagnosis of mental health problems within the Western world's children's population?

David Healy: Yes, I do. And I think actually the problem is hugely disturbing. I think possibly 10 to 15 years up the road, we're going to be looking at a generation of children who will have been seriously injured by the treatments that they appear ever-increasingly likely to be put on now.

Jane Shields: Background Briefing 's Co-ordinating producer is Linda McGinness. Research, Anna Whitfeld. Technical producer, Mark Don. And Executive Producer, Kirsten Garrett. I'm Jane Shields and this is ABC Radio National.