SYDNEY: Behaviour and social-emotional functioning assessments have been added to a regular health check for three-year-olds in Australia.
Last year’s National Mental Health Reform pledged $11 million over the next five years to expand the Healthy Kids Check, a universal voluntary health check, adding elements to ensure toddlers’ social and emotional development are on track.
With the start of the new fiscal year, an expert panel of clinicians and researchers is making its final recommendations to the federal Minister for Mental Health and Ageing, Mark Butler, but the very concept of a mental health check for preschoolers has been called into question by visiting American psychiatrist Allen Frances.
“Completely impossible to realise”
“The preventive efforts that are being considered by the government, which I think have a noble goal, seem to me to be completely impossible to realise, and likely to cause a great deal more harm than good,” warned Frances, who presented his views to a hall full of medical professionals at the Garvan Institute in Sydney on June 19th.
Frances was leader of the task force on the most widely used diagnostic manual in psychiatry, the DSM-IV, and is emeritus professor at Duke University, in North Carolina.
While visiting Australia, he gave several lectures on diagnostic inflation – the rapidly escalating rates of mental illness globally – which he believes has more to do with overambitious doctors and opportunistic pharmaceutical companies than a worldwide epidemic.
Toddlers in very changeable time of life
When asked about the Healthy Kids Check, he responded, “Here, diagnostic inflation is expanding so fast that it may actually burst the balloon.”
“The three-year-old is in a very changeable time of life. The fact that a three-year-old needs a nightlight, or is having trouble separating from a parent shouldn’t be panicking everyone into thinking that they have the precursors, prodromes for psychiatric disorder,” said Frances. “It’s way too early to be predicting, and I think that it’s just a little bit weird that this idea has gained that much traction.”
“I want to dispel the notion that this is a mental health check. It’s not a mental health check,” said Frank Oberklaid, director of the Centre for Community Child Health at the Royal Children’s Hospital Melbourne and chair of the multidisciplinary expert panel developing the program.
50% of adult problems begin in childhood
Instead, said Oberklaid, the changes are a response to the concerns of parents and criticisms that the existing check, conducted at four years of age, came a little bit late. The Healthy Kids Check will continue to check height and weight, immunisation status, nutrition, hearing and vision, but will now also provide parents an opportunity to air concerns about sleep problems, temper tantrums and their children’s interactions with peers.
“We know that 50% of adult mental health problems begin in childhood,” said Oberklaid. “There may be clues in those early years, at the age of three or four, when things are starting to go off track.”
“The developmental milestones for kids have tremendous individual variation. Kids don’t talk at the same age, they don’t walk at the same age, they don’t toilet at the same age,” said Frances.
Frances’ own grandchildren were in the audience, visiting Australia with him on a family vacation. “You should have seen these guys at two years. They were late talkers, late walkers, everything that could go wrong. He’s really smart now and he was in special OT [occupational therapy], PT [physical therapy] and all kinds of stuff. He’s the most brilliant graduate of that program,” laughed Frances as his grandson, now in his teens, sunk deeper into his chair.
“The program could take great credit for it, or maybe nature took its course and myelinated [strengthened] some of his nerve cells.”
Contact with health professionals important
Frances pointed to a recent study, published in the Canadian Medical Association Journal this year, which found age was the best predictor of whether a child received a diagnosis of ADD or not. “If you’re the youngest kid in the class, especially a boy, you’re much more likely to get the diagnosis of ADD and [be] treated for it with medication,” he said, “a development difference based on nothing more than age … treated with a pill.”
“You have to worry about that,” said Frances. “The parallel here is pretty close. If this can happen with five-year-olds, the same thing can happen with three-year-olds.”
“We know that many of the concerns parents have about their child’s learning, or development, or behaviour are transient and of no consequence,” said Oberklaid. But he says the stress on parents is very real, and “reassurance about that is pretty important.”
“We’re not diagnosing kids,” he emphasised, “we’re not saying this three-year-old has a problem, you better get some help, and this kid doesn’t have a problem.” But there is a small proportion of children where concerns will lead to more serious things, said Oberklaid, and the fact that parents have established contact to talk to a health professional is important in and of itself.
“The professionals on the committee are very skilled, we know absolutely the potential of labelling and of doing harm, we know the research literature about early detection, we know world’s best practice … we’re not naïve to these sorts of issues,” said Oberklaid.