Better safe than sorry

A dangerous paradox threatens the integrity of psychiatric diagnosis and the safety of psychiatric treatment. First arm – the younger the person, the harder it is to make an accurate diagnosis. Kids have very short track records and their individual developmental differences weigh in too heavily and too unpredictably to be very certain what their futures will bring. Second arm – despite this, diagnosing and treating younger and younger children has become an exploding growth industry. The result of the paradox – many kids are mislabeled and are treated unnecessarily, sometimes with medicines that have serious side effects and life-altering complications.

Of contextual note: all the recent fads in psychiatric diagnosis have targeted children – a 40-fold increase in childhood bipolar (Moreno et al., 2007), a 20-fold increase in autism (Wingate et al., 2012), and a tripling of attention deficit disorder (Batstra and Frances, 2012). Some of the skyrocketing prevalence doubtless represents beneficial identification of previous false- negatives, but most of the rate jumps probably result from the capture of mislabeled false-positives. Diagnostic ads always result in a big overshoot.

This brings us to the plan Australia has to embark on nationwide mental health testing for 3-year-olds. Admittedly all the proposed psychiatric prevention programs in Australia are amazingly adventurous – based much more on well meaning and blind hope than on well-established evidence that they will be effective or are safe. But pushing prevention back to 3-year-olds seems particularly absurd just on the face of it. Consider the huge individual differences in the course of normal development. Toddlers walk, talk, toilet train, and meet emotional, cognitive, and behavioral milestones at widely varying ages. Choosing an arbitrary age for testing that is so early in life will identify as pathological all sorts of very temporary lags and troubles that kids will simply outgrow if they are given the chance.

The attention deficit hyperactivity disorder (ADHD) epidemic should provide a cautionary tale highlighting the risk of medicalizing what are no more than individual differences in normal development. A large Canadian study recently found that being born in December rather than in January is a strong predictor of ADHD, especially in boys (Morrow et al., 2012). How troubling that the youngest kids in the class are being misdiagnosed as psychiatrically sick and medicated excessively – merely because they are appropriately immature compared to their classmates. Premature testing of toddlers will similarly turn normal individual differences into grist for an overly aggressive prevention and treatment machine.

The supporters of early testing provide reassurance that the tests will not be misused to promote excessive diagnosis and treatment. I am sure they mean well and that they fully believe this to be the case. But my DSM IV experience proves that once you go public, your best intentions may not predict or prevent harmful unintended consequences. If something can be misused, it likely will be misused – at least that should be the assumption that informs a careful risk/benefit analysis. My questions to the sponsors are how can you possibly predict with confidence now how the tests will eventually be used (and likely misused) and how can you guarantee there will not be harmful unintended consequences? My guess is that testing will cause considerable and unnecessary worry for parents, will distort child rearing, cause stigma, reduce expectations, and result in inappropriate use of medication. Their past history of promoting diagnostic exuberance and excessively aggressive treatment does not inspire confidence in child psychiatrists as the keepers of the safety flame, and general practitioners may be even more inclined to overvalue the clinical significance of the all too fallible toddler test results.

To an outsider, Australia’s infatuation with untested prevention models is a source of wonder and alarm. This program for 3-year-olds is just the most extreme in a series of high-stakes gambles on largely untested programs that may cause more harm than good and will skew the allocation of scarce resources. Prematurely bringing down the target age for prevention to include 3-year-olds simply doesn’t pass the laugh test.

It is hard to believe that there has been sufficient governmental, public policy, and consumer input. My DSM IV experience cautions against slavishly following the advice of experts. They are always overly enthusiastic about their pet projects – wide eyed about possible benefits, blind to risks. The radical and obviously premature concoction of 3-year-old testing is a research program, not nearly ready for prime time as national policy. It is not prudent to experiment on all the nation’s kids until you have evaluated risk/benefit with a small number. The proper preparatory research would take at least a decade to test efficacy and safety and then more years would be needed for small pilot field-testing to translate from research to the real world. Diving in headlong is always dicey and likely to lead to later regrets.

I am also surprised by parent passivity in the face of this bureaucratic threat to their parental discretion. Given the untried and experimental nature of the intervention, I think that participation should require informed parental consent after the risks have been fully described. And there should be no incentives or penalties to influence decisions. People shouldn’t be forced or induced to participate in what amounts to an unproven research study.

Simply stated, this is a bad idea on psychiatric grounds and unjustifiable as public policy. Australia will be flying blind and taking on unknown risks for probably illusory gains.