March 2013 Archives

The 2010 American Academy of Pediatrics Task Force on Mental Health reported that 37% of children and adolescents either meet the DSM criteria for a mental health diagnosis or show some impairment in functioning. Diagnoses of ADHD and autism continue to rise.

Pediatric primary care physicians do much of the psychiatric diagnosis and prescribe most of the psychotropic medicine — but a recent survey showed that only 10% felt adequately prepared by their training to do so. They see kids for very brief visits and many are too influenced by drug marketing (as are parents and teachers). Over-diagnosis and over-treatment are commonplace.

Highly gifted children are a particular diagnostic challenge with errors that can occur both ways. When pediatric diagnoses are carelessly applied, gifted children are frequently mislabeled with ADHD, autistic, depressive, or bipolar disorders. Yet sometimes being gifted effectively hides these same conditions.

So, while some gifted kids are erroneously labeled and medicated for mental health disorders they do not have, others are unrecognized for learning or mental disorders they do have.

And many gifted children are never identified as gifted. Wasting much of their day in unsuitable classrooms, they may behave in unacceptable ways. Despite giftedness being akin to a special need, funding for it is scarce and the needs of gifted minority and poor children are shamefully overlooked. Very few articles are found in the pediatric medical literature about giftedness.

Teachers and physicians also receive minimal instruction on the identification and management of gifted children and the fact that they seem to be wired differently and have developmental trajectories that differ from the norm. Many gifted kids experience the world with heightened and vivid intensities and sensitivities that may be a big plus (allowing them to become creative artists, scientists, inventors, and humanitarians) but also can be a big minus (subjecting them to sometimes overwhelming emotions and worrisome and unacceptable behaviors.)

Normal giftedness can easily be confused with DSM mental disorder. Gifted kids may talk a lot, have high levels of energy, and be impulsive or inattentive or distractible in some settings — similar to symptoms of ADHD. It’s not unusual for gifted kids to struggle socially, have meltdowns over minor issues, or have unusual all-consuming interests — all pointing to an inappropriate diagnosis of autism. Often perfectionistic, the gifted are more likely to be introverted and may feel alone and alien in a world that doesn’t fully understand them.

Giftedness is not always seen as a socially positive and valued trait. Many gifted kids are bullied, others underachieve to hide their abilities, and some experience anxiety and depression with increased risk for self-harm. As many as 20% may drop out of school.

Here is some advice to parents, teachers, and medical professionals:

• Throw away pre-conceptions of what giftedness should look like or where giftedness is found. Giftedness is not always equivalent to high academic achievement, and isn’t limited to race, ethnicity, gender, or affluence. Gifted kids do sometimes have learning or mental health disorders.

• Throw away the idea that normal must be defined by a narrow set of criteria. Not everyone processes information and sensory inputs in the same way, nor does everyone develop along the same expected timeline. Variability does not automatically indicate a disorder. Be insistent that both weaknesses and strengths are equally acknowledged and supported.

• It is important to determine who is suffering with an observed behavioral issue — the child or those around him/her. Labels, treatments, and medications are meant to alleviate suffering in the recipients, not as a means to make those around them happy.

• It’s OK to not have all the answers. Take the initiative to find out more about giftedness and gifted misdiagnosis. Here [ http://www.sengifted.org/resources/resource-library/recommended-reading ] are some valuable resources.

• Seek out organizations like SENG, National Association for Gifted Children (NAGC), Davidson Institute, CEC-TAG, Uniquely Gifted, World Council on Gifted, Hoagies Gifted, and your state gifted associations for opportunities to learn more.

Today, our largest mental hospitals are our jails. The jail at New York’s Rikers’ Island functions as the nation’s largest psychiatric facility. Los Angeles’ jails — not its hospitals — are California’s largest providers of mental health care. State prisons alone spend nearly $5 billion annually to incarcerate mentally ill inmates who are not violent.

According to the Department of Justice, nearly 1.3 million people with mental illness are incarcerated in state and federal jails and prisons — compared to only about 70,000 people being served in psychiatric hospitals.

The current psychiatric hospital inpatient population is only 5% of what it was at its height. We have about the same number of psychiatric hospital beds now as we did in 1850. Some of this 'deinstitutionalization' comes from the availability of medication and improved outpatient treatment, but most of the change is no more than a switch of institutions from hospital to prison.

Every year, tens of thousands of people try in vain to get access to mental health treatment. It can take months just to get an outpatient appointment and people desperately in need are routinely turned away at the hospital door because there is so little funding for psychiatric beds.

Where has the money for treatment gone? Much of it has been funneled directly into, and wasted on, our prison system. Prisons and jails have taken on behemoth proportions, bloated with nonviolent and even non-offending people who in earlier times would have been treated in hospitals — we are the poorer for it and no safer.

The mentally [ill] are far more likely to be the victim of a crime or to harm themselves. Their over-representation in the criminal system results from their poor ability to communicate with police, lack of adequate legal representation, self-medication with drugs and alcohol, enacting symptoms in public, and lack of any other place to put them. As a Florida judge pointed out — jails are the one institution that can’t say no to admitting someone — so the mentally ill are dumped there, often without treatment, and then have a criminal record to boot.

And some mentally ill people spend time in jails without having committed any offense at all. Several states authorize the police to arrest mentally ill people who have not broken any law, simply to promote public order. More commonly, hospitals transfer patients to jails to handle overflow. Even children may be confined in criminal detention centers because there are so few treatment facilities for severely mentally ill children. This reliance on the criminal justice system as a surrogate mental health system wastes life and treasure and conflicts with basic notions of justice.

So, why are we so irrational in our misallocation of resources? Why don’t we invest instead in proven alternatives to prison, like assertive community-based treatment programs and access to supportive housing?

The problem is that housing and treatment sound like 'entitlements' — while prison sounds like (and is) punishment. As a culture that prizes self-reliance, we are cautious about extending benefits and suspicious of rewarding people for what looks like bad behavior. The punishment of people with mental illnesses who act out in public might also seem to fit with a certain notion of public order and personal responsibility.

And it fits with our fears: We look at a handful of national tragedies and conclude that mentally ill people are irresponsible and dangerous — that a law-and-order response is appropriate and necessary. With visions of school shooters before our eyes, we don’t see the typical mentally ill person — someone who is mostly likely to be poor, female, and non-violent.

According to the Bureau of Justice Statistics, three out of four women in state prisons have a mental health problem, compared to just over half of male prisoners. Yet women are not driving the mass violence problem in our country.

Our current moment is reminiscent of 1998, when New York State Governor George Pataki responded to the tragedy of a schizophrenic man pushing a woman to her death in front of a subway train. ‘What can we as a people,’ the governor asked, ‘do to protect individuals from themselves and to protect us as a society?'

It’s time to turn that question around and ask how we can protect mentally ill people from our dangerous preference for punishment over treatment, for prisons over hospitals, for cleaning up tragedies rather than preventing them.

Let’s provide effective treatment for people with mental illnesses, not make them the stalking horse of our fears. If we focus on access to treatment instead of punishment, we may all be safer and live in a better society.

Image courtesy of Casey Konstantin via flickr.

Photo credit: Robbie Wroblewski

The bad news is that it takes recurring tragedy to restore interest in a sane gun control policy. The worse news is that any meaningful legislative relief remains very much a long shot. Hypocritical politicians are likely to do nothing at all or find cosmetic excuses to avoid the hard choices necessary to protect us and our kids from this epidemic of avoidable violence.

1. While they are somewhat more prone to violence than the general population, the mentally ill account for only a small percentage of homicides.

2. It is impossible to predict in advance who is likely to become violent and when.

3. The mentally ill most likely to commit violence often avoid mental heath contact and likely won't leave a computer trail to alert authorities.

4. It is impossible to guarantee security once the gun is sold. The Newtown killer used weapons purchased legally by his mother. If enough assault weapons find their way into American households, some will inevitably wind up in the wrong hands and repeated mass murders will be the unhappy result.

5. The boundary between mental illness and normality is fuzzy and arbitrary, providing no practical way for deciding how much restriction should be applied to whom.