Thursday, 15 November 2012

The ethical minefield of diagnosing children

Months ago I saw this article in the New York Times 'Can you call a 9 year old a psychopath?' I was deeply disturbed by it and it's taken me this long to decide how to respond to it. It is an article about a boy named Michael who has been diagnosed as a psychopath. Here's the link:

It is perhaps a good thing that such articles are now in the public domain, particularly given the Time to Change campaign ( What this article really does is highlight how complicated and ethically complex the treatment of the mentally ill is. However it also indicates that people are working very hard toward trying to prevent mental illness in the first place. The methods used though are such that they raise deep rooted concerns precisely because medical teams even at the very highest levels do not always have enough information from sufferers to help them.

This article many find extremely chilling as it doesn't seem to bode well for the future of psychological health care. As we can never separate out genetics and physiology from the effects of the environments in which we exist it will, in my opinion, always be impossible to identify if a person of any age is 'irretrievably' ill with a permanent condition. It can seem that this attitude toward labelling people when they are still children could easily hinder progress rather than help it. Or maybe not...

The issue of early diagnosis is a tricky one. I am vehemently against labelling a anyone as mentally ill (least of all a child) due to the very real  and all too common prospect of them suffering a lifetime of stigma and discrimination; but I also feel that some kind of label is appropriate for mental health specialists to understand that there is a difficulty that needs addressing and solutions for. On the one hand if medical professionals get to the root cause and can cure or aid patients to manage their conditions for themselves that's great; on the other treatments and the attitude of 'they're ill' can so easily serve to cause or escalate the problems.

Encouraging sufferers of all kinds, from all ages and backgrounds to talk and enter into a dialogue with medical practitioners is, as I say, vital to progress with regard to refining treatments and in steering away from prejudice. Without such discussions neither party can hope to improve services to alleviate symptoms, improve the quality of their lives or discover effective cures.

Here though, I have to admit to a wariness when it comes to new American mental health care initiatives as it seems to have been the home of some of the most bizarre experiments and practises of all in mental health care history. More haste, less speed is the maxim that often springs to mind. Not that the USA has had the monopoly on strange practises at all - far from it. I don't for a second doubt the good intent and in some respects here in the UK, progress can be frustratingly slow by comparison due to the perhaps over abundance of caution and/or serious levels of sheer neglect. Sweeping things under the carpet is no better and not very helpful when a sufferer is desperate for relief from their distress.

Identifying psychopaths 

To quote from the article...

"Donald Lynam, a psychologist at Purdue University who has spent two decades studying “fledgling psychopaths,” says that these differences may eventually solidify to produce the unusual mixture of intelligence and coldness that characterizes adult psychopaths. “The question’s not ‘Why do some people do bad things?’ ” Lynam told me by phone. “It’s ‘Why don’t more people do bad things?’ And the answer is because most of us have things that inhibit us. Like, we worry about hurting others, because we feel empathy. Or we worry about other people not liking us. Or we worry about getting caught. When you start to take away those inhibitors, I think that’s when you end up with psychopathy.”

Difficult for the family to find the right professionals and what a journey that must have been. Each experience with each new medical team will have had an impact. If Michael learns to be manipulative from the dynamics of a family environment, think what he will be learning from professional boffins! If the treatment to involve isolating Michael to the extent of depriving him of social contact - hardly what one wants to do to a child and thereby lies the major difficulty. Even when hospitalised the aim should be to reintegrate where at all possible. At what point is that feasible for psychopaths or should it be given there are a significant number of them functioning in society already - notably corporate psychopaths who, it could be argued, are responsible for most of society's problems.

It is extremely difficult to help a child because their minds are still developing as you do so. A child like Michael who is that challenging can and will cause psychological damage to others if left to their own devices. And that's surely the point isn't it? His parents don't have much choice for as responsible parents they have to address that challenging behaviour somehow. In the process they have to go with whoever and whatever is on offer to try to help.

Treatments should only be done with the consent of the patient but severe conditions mean that patients may not be able to make such choices and a child is deemed too young to make such decisions - at least an adult has the right to refuse treatments unless it is life threatening. Parents and guardians of those children it seems are at the mercy of the latest medical opinion, but then isn't that true of physical ailments and treatments too.

What's apparent to me from this article in the New York Times and why I re-read it, is that my own emotional reaction came first with a simple 'no way' just from reading the title. By re-reading it with a more objective head I saw that there are possibilities of hope even though I remain riddled with concerns about the methods deployed. The reality for the family and patients involved almost seems secondary to the boffin's uppermost concern which is to make a study of these children. But how else can things progress? Without such studies, how are they to learn anything to be able to help? The difficulty is, how do we avoid studying any ailment without it seeming that those being studied are little more than lab rats to be experimented on?

Early diagnosis for other conditions

This article touches the broader issue of whether it is right to be labelling children with anything when it comes to mental health. It poses all manner of ethical questions, none of which have simple answers. Just as loneliness, poverty and abuse can cause adults to become ill the same is true of a child who may not be able to articulate what troubles them any better than adult sufferers can. The main difference being that medics will always be able to successfully project their theories on a child's condition far more easily than they they can over an adult and be deemed to be a reliable authority on their welfare and state of mind. Can a child defend themselves against false accusations over their responses on an intellectual level; can they debate psychology, treatment and diagnosis? Answer no. Indeed few adults can either outside or inside the medical profession.

If a child with birthmark on their face can end up with confidence and socialising problems from endless teasing at school, how much more is that true if the name calling is based on their mental health? We have a conflict of desire here for if we want to educate people away from being fearful and prejudiced, openness is called for; but such is the nature of us all that pigeon holing is almost bound to take place and boy do we love to label things to the point that one word is often regarded as sufficient to explain and encapsulate a whole of raft different things. 

I have spent over 10 times longer fighting the stigma of mental illness than I ever spent actually being mentally ill. Friends prior to my becoming ill never accepted that I was well again afterwards and new contacts on hearing that I was once ill have continually dismissed virtually every mood (be they happy or sad), thought and opinion as a symptom of illness if they were not in tune with their wishes and needs. 

Subject anyone to that and they are likely to develop mental health problems. That is precisely why I spent so much time in counselling to learn how to be assertive and to dismiss people who negate others as having unresolved issues of their own. What's sauce for the goose is sauce for the gander. That has even applied to some sections of the medical profession who remain all too attached to labels as opposed to engaging with sufferers in order to help them.

Just as a wheelchair user wants to be seen and valued as a person for what they can do as opposed to what they cannot, so too do the mentally ill. Surely a major part of the solution to mental illness is to build upon what is functioning healthily and to use that to combat what isn't.

This is why I believe the Time to Change campaign is so vital. Those of us who have suffered from any form of mental illness can help educate mental health teams toward finding more 'user friendly' methods of treatment. Generalisations and one cure fits all are never going to work for the vast array illnesses be they mental or physical. Health care of any kind must be conducted on a case by case basis at all times if it is ever to be successful. Never must the individual be thought of as anything other than a three dimensional, all living, all breathing person with the basic human right and need to be treated with the utmost respect and consideration.

I found all this an intensely provocative emotional experience. I suspect readers will too, but we cannot hope to make progress in mental health care and in fighting the stigma by avoiding these fundamental issues. I wish I had answers, I really do but it is probably better we find them collectively by teaming up with medical teams who know how to be respectful and will listen properly. They cannot hope to help though, if we hold back on what so deeply concerns us. All I have to offer is that a sense of balance should be uppermost when it comes to new initiatives when it comes to health care. It should always permit a patient their say, their dignity and whenever possible their right of choice. Choices are best made when information is provided, but if the choice is to cause harm to others then I feel it is only right to start to limit the right to choose to things which will not cause such harm.

As for Michael, well personally I think it wrong that a child that young is labelled with any mental illness, but that's not to say there isn't something wrong. Far better I think to focus on the cause and treatment and forget about labels altogether... but then that's my opinion on all mental health labels no matter what age the sufferer is. 

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