Sioned’s home life had always been tough. From a young age, she and her brother watched silently as their parents fought for hours. When things escalated, the violence would be directed at them, too. Her parents eventually got a divorce, and with her father absent, it seemed like conditions might improve. However, her mother went into a deep depression, forcing Sioned to take responsibility for the family. The conflict Sioned witnessed between her parents led her to feel depressed and anxious. She found it difficult to function normally and later attempted suicide. She was placed in a psychiatric hospital and worked with a therapist to overcome her diagnoses (1).
Unfortunately, stories like Sioned’s are not uncommon. Millions of children are diagnosed with mental illnesses annually, each with their own tragic tale. In the U.S., around 22% of children experience a mental illness that impairs function (2). Over the past decade, depression rates have significantly increased among adolescents, with one study finding a shift from 8.3% to 13.2% between 2005 and 2017 (3). The COVID-19 pandemic exacerbated the crisis, leading to dangerously high hospitalization rates due to mental health emergencies for children, with increases of 24% and 31% for different age groups (4). In 2021, these alarming trends pushed the American Academy of Pediatrics to declare a national emergency in children's mental health (5). These statistics illustrate that understanding childhood mental illness should be a pressing concern for the current medical community.
Awareness of ethical issues of diagnosis and treatment is crucial for all medical professionals. It is particularly important, however, in psychiatry due to the heavy topics it deals with. Practitioners must take extra caution, as they deal with people in their most vulnerable state. Increased concern for such issues will lead to better outcomes for patients (6).
Given the urgency of this crisis, one important factor researchers should focus on is the differential ethical issues that arise when providing psychiatric diagnoses to children versus adults. While there are similar ethical considerations, many issues are unique to children (7). Compared to adults, there are often more individuals involved in the case of a child with a mental illness. This, combined with the vulnerability and immaturity of children, results in distinct conflicts involving the child, parent, and practitioner (6).
One such issue is the lack of specificity in diagnostic criteria for mental illnesses among children. The Diagnostic and Statistical Manual (DSM) is the standard guide for the classification and diagnosis of mental illnesses. Despite being widely accepted, the handbook is often scrutinized by the scientific community. One common critique is the vagueness of diagnostic criteria for many disorders, especially with regards to children. The symptoms listed for conditions are often aimed towards adults and thus hard to apply to children. While child-specific conditions have been added to the DSM-5, they are only a small portion and do not encapsulate all the disorders children may have (8). According to family therapist Dr. Marilyn Wedge, issues arise when practitioners attempt to use adult criteria for young patients. This leads to misdiagnosis or overdiagnosis because the provider is unsure how to fit their patient into the DSM model (9). The lack of child-centered criteria for each condition creates challenges for the clinician and, consequently, the child.
Furthermore, because children must be under the care of an adult and cannot make their own medical decisions, there are added issues of confidentiality and autonomy. Although all patients are entitled to confidentiality, there are limitations for children (10). Due to their young age, their parents must authorize treatment and are therefore legally entitled to know the details of that treatment (11). This creates complications for the child being treated. Children who are victims of abuse, for instance, may not be transparent about their trauma for fear of exposing their guardian. Alternatively, a child may lie about risky behaviors they know their parents would disapprove of, such as smoking or being sexually active (10). These privacy issues make it difficult for minors to receive proper care and be truthful to their provider. Moreover, children lack decision-making capacity and thus have little say in their care decisions. If the parent and child have different opinions regarding treatment, the practitioner may struggle to decide the next steps (6, 10). It is unfair to force a child into something they don't want, but the decision ultimately lies with the adult.
Although there is little research on it, another emerging question is whether it is even ethical to diagnose a young child with a mental illness, when their disorder is the result of failures of their guardians and society. Many children who develop psychological conditions had turbulent childhoods and experienced risk factors such as abuse, neglect, and poverty (12). In these cases, their symptoms of depression and anxiety can be seen as normal responses to their distressing situations. How, then, is their behavior ‘disordered’? Do kids like Sioned deserve the label “mentally ill” when her symptoms are the result of external forces, such as abuse and neglect by her parents? There are no exact answers to these questions, but they are important ones to keep in mind.
These are just a few of the ethical issues associated with the diagnosis of mental illness among children. Increased awareness of these topics and possible solutions are essential to ensure the best treatment for children like Sioned.
References
1. Sioned. (n.d.). Sioned’s story. National Society for the Prevention of Cruelty to Children. https://www.nspcc.org.uk/what-is-child-abuse/childrens-stories/sioneds-story/.
2. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017.
3. Patalay P., & Gage S. H. (2019). Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study. International Journal of Epidemiology, 48(5), 1650–1664. https://doi.org/10.1093/ije/dyz006.
4. Leeb R. T., Bitsko R. H., Radhakrishnan L., Martinez P., Njai R., & Holland K.M. (2020) Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1-October 17, 2020. Morbidity and Mortality Weekly Report, 69(45), 1675–1680. http://dx.doi.org/10.15585/mmwr.mm6945a3.
5. American Academy of Pediatrics. (2021, October 19). Declaration of a National Emergency in Child and Adolescent Mental Health. American Academy of Pediatrics. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/.
6. Goldsmith, M., & Roberts, L. W. (2016). Ethical Issues in Child and Adolescent Psychiatry. Focus (American Psychiatric Publishing), 14(1), 64–67. https://doi.org/10.1176/appi.focus.20150032.
7. Perring, C., Wells, L.. (2014). Diagnostic Dilemmas in Child and Adolescent Psychiatry: Philosophical Perspectives. Oxford University Press. https://doi.org/10.1093/med/9780199645756.001.0001.
8. Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance. Substance Abuse and Mental Health Services Administration. https://pubmed.ncbi.nlm.nih.gov/30199184/.
9. Wedge, M. (2011, May 23). Six Problems with Psychiatric Diagnosis for Children. Psychology Today. https://www.psychologytoday.com/us/blog/suffer-the-children/201105/six-problems-psychiatric-diagnosis-children.
10. Disla de Jesus, V., Liem, A., Borra, D., & Appel, J. M. (2022). Who’s the boss? ethical dilemmas in the treatment of children and adolescents. FOCUS, 20(2), 215–219. https://doi.org/10.1176/appi.focus.20210037.
11. Behnke, S., & Warner, E. (2002). Confidentiality in the treatment of adolescents. Monitor on Psychology, 33(3). https://www.apa.org/monitor/mar02/confidentiality.
12. Bethell, C. D., Garner, A. S., Gombojav, N., Blackwell, C., Heller, L., & Mendelson, T. (2022). Social and Relational Health Risks and Common Mental Health Problems Among US Children: The Mitigating Role of Family Resilience and Connection to Promote Positive Socioemotional and School-Related Outcomes. Child and adolescent psychiatric clinics of North America, 31(1), 45–70. https://doi.org/10.1016/j.chc.2021.08.001.