An Even Bigger Epidemic?: Children’s Mental Health Disorders

There seems to be an epidemic in the use of the word “epidemic” to describe the increase in children’s mental health disorders such as depression and anxiety disorders, as Judith Warner writes in her January 19th New York Times column, An Epidemic of Misunderstanding About Children’s Mental Health. ADHD, she writes, is “the epidemic disorder of our era,” while bipolar disorder “seems poised to become the next out-of-nowhere epidemic” and still considered a “controversial diagnosis” for children.

Warner begins her article by citing the argument that “the dramatic rise in the incidence of autism in the past few decades is mostly – if not entirely – the result of more and better diagnoses” in Roy Richard Grinker’s new book Unstrange Minds: Remapping the World of Autism. The many comments on Warner’s post give some indication of what Warner refers to as “the buzz – the fury, most likely” that Unstrange Minds is “sure to unleash” (and indeed has; see this post on there being no autism epidemic). [Professor Grinker appears on the Diane Rehm show (NPR) today, Monday, January 22, 11am - 12 pm.] It certainly, as Warner puts it, “feels” as if there is an “epidemic of mental illness” among children today. She cites a 2001 National Institute for Mental Health report which stated that 20% of children in America have a “diagnosable mental disorder.” Whatever your interpretation of this figure, Warner notes that another figure noted in the report, though of much more importance, went largely unnoticed: “‘of the 20 percent of kids said to be suffering from mental disorders, only 5 to 7 percent are getting “specialty mental health services.’” (What percentage of autistic children, one wonders, are getting “specialty autism services” or, indeed, a “specialty autism education”?)

Throughout her article, Warner balances consideration of whether there really is an “epidemic”—-a dramatic and sudden increase—of mental health disorders in children, while noting that claims of such an “epidemic” can have its uses. Her words for describing the impression that many have that there is (for example) an “epidemic of autism” are “feels” and “fuzziness.” As she notes:

The fuzziness starts with the mental health institute’s much-contested 20-percent figure, which drops to 10 percent, in the same report, when what is being measured is “mental illness severe enough to result in significant functional impairment” – the level at which, many mental health professionals would argue, “disorder” actually begins.

That is, of the purported 20 percent of children who have mental health disorders, only half of those children—the 10 percent—actually have a “mental health disorder,” that is, “mental illness severe enough to result in significant functional impairment.” This is purely speculative on my part, but apply those percentages to autism: What if there are actually twice as many autistic persons as the current prevalence rate of 1 in 166 estimates, due to there being many more persons who have autism but not to the extent that this results in “significant functional impairment”? These latter cases could be those whose whose autism may be so “mild” that they do not even have an actual diagnosis of autism, whether someone who has “eccentric” behaviors and perhaps some obsessive-compulsive qualities or anxiety, or a child who is hyperlexic, is so shy that he attends social skills camp, and must have “everything Thomas the Tank Train.” (We ought, too, to keep in mind that having a diagnosis of Asperger’s syndrome and being “high-functioning” are not necessarily the same thing.)

Warner notes that the rhetoric of epidemic can have its uses, if it leads to increased awareness about childhood mental disorders, and therefore more and better services and edcuational programs. Indeed, it seems to me that there is a fear that unless we say that there is an “epidemic,” or a dramatically higher number, of autistic children, school administrators and other professionals may threaten to reduce services and programs that our children need; I believe that we need to keep making the argument that our children need these programs simply because they need them, because of their right to an appropriate, public education. But Warner also notes what may be thought of as the darker side of the rhetoric of epidemic:

What is problematic for me is when talk of epidemics starts to feed magical thinking. By which I mean: the tendency today among certain parents – and certain ideologues – to advance arguments that aren’t based upon reason and depart, potentially dangerously, from reality.

For example, the notion that autism is epidemic has led many parents to join in a crusade against childhood immunizations, based on the still-unfounded theory that the once-widely-used preservative thimerosal is the main culprit in autism’s rise. The conservative critic Mary Eberstadt (among others) has used the mental health institute’s data to buttress an argument that the movement of mothers into the workforce has sparked a “mental health catastrophe” among children. Likewise, pro-marriage advocates have used data from psychologist Jean Twenge showing a considerable rise in child “neuroticism” from the 1950s to the 1990s to bolster their claims for the quasi-magical healing powers of matrimony.

Autism rising in epidemic numbers due to the use of the mercury-based preservative in childhood vaccines—mental health disorders on the rise in children because too many mothers (like myself) work—children going “neurotic” because their parents do not stay married: As Warner indicates, each of the above explanations posed for the rise in children’s mental health disorders is based in ideas and beliefs arising from other agendas, whether concerns about vaccines (which existed before there ever was concern about an “epidemic of autism”; see Arthur Allen’s recently published book Vaccine: The Controversial Story of America’s Greatest Lifesaver), or about working mothers, or about marriage. In these cases, the rhetoric of epidemic has proved useful to incite worries and fears that, if these public health and societal ills are not addressed, serious damage will continue to infest no one less than our children.

For this reason, Warner’s continual focus on the need to address “real children with real needs”—especially those who “are not receiving help”—is one that ought to be in the forefront of discussions about topics such as whether or not there is an autism epidemic. Many parents of autistic children that I know spend a great deal of time worrying about having their other children inoculated, but they worry even more about the school placements and educational futures of their children. Somehow, we seem to spend more time in the “magical thinking” of worrying about why the prevalence of autism has increased so much, when so many children still are not getting the services and education most appropriate for their needs.

A continued lack of services for special needs kids – at a time when many treatment options are available to those with the means to pay for them – is clearly the most glaring mental health problem facing families today. If talk of epidemics brings needed resources, then more’s the better. But if, as is already happening, the hyped-up language instead fuels a naysayer backlash, then parents and children would be better served by reality-based advocacy.

In the interest of fostering something of a “productive conversation” on this topic, I think it helpful to consider the bigger picture concerning children’s mental health that Warner describes in An Epidemic of Misunderstanding About Children’s Mental Health. Too often, “debate” about topics such as “what causes autism” or “is autism really on the rise” are not so much thoughtful exchanges of differing perspectives as black-and-white back-and-forths of opposing sides who have no interest in listening to each other, and certainly not in learning from each other. And if we cannot even try to do those two things—to listen and to learn—then we will have not an “epidemic of misunderstanding,” but a chronic condition of not even being to talk to each other and to figure out real solutions for the real kids who so very much need them.