"We are suffering . . . from a shrinking tolerance for the broad limits of normality," says. Dr. Stanley Turecki, author of "The Difficult Child" and a practicing psychiatrist in New York and Massachusetts.
For such parents as Katie, that shrinking tolerance seems to have seeped into places like her daughter's Girl Scout troop as well as her own extended family, where her daughter's belligerent challenges of strangers and unpredictable episodes of fearfulness have long been a source of critical commentary. They have even seeped into Katie's heart.
"I find myself saying, 'Geez, this is not normal,' " she says. But she's equally unsure that her daughter's perplexing behavior rises to the level of mental illness. "Are people," she wonders, "just haphazardly sticking labels on kids?"
Definitions remain fuzzy
There once was a time when a pocketful of well-worn adjectives, accompanied by a shrug, would have been sufficient to describe American kids at the outer reaches of normal: shy, spirited, combative, dreamy, sensitive, fretful -- even odd. All were qualities a child might readily grow out of with guidance or a few years to mature.
The descriptors for such youthful outliers have undergone a linguistic overhaul in recent years, says Ross W. Greene of Harvard Medical School's department of psychiatry. Increasingly, talk of temperamental extremes or social skills that need to be taught or strengthened has given way to the assignment of disorders, deficits and dysfunctions. Nowadays, a kid whose behavior is problematic has to have something -- a diagnosis -- which energizes school administrators, absolves parents of guilt and too often, Greene says, dictates medicating the child with powerful drugs.
In at least four in 10 cases, according to data from the Centers for Disease Control and Prevention, parents who seek professional help for their troubled children come away with at least one prescription medication.
These diagnoses suggest clear evidence that a malfunction of the brain is the cause of the problematic behavior. But despite dramatic advances in neuroscience, that presumption still cannot be verified by a blood test or brain scan. Mental-health professionals instead must base their diagnoses on the presence of a certain number of symptoms, and on a judgment -- by teachers, parents and the professional evaluator -- that the problem behaviors impair a child's ability to function.
The boundary between troublesome behavior and mental illness is indistinct in adults, psychiatrists acknowledge; in children, whose brains are still a work in progress, it is fuzzier still.
"To tell the truth, I feel bad for parents," says Greene, who directs the Institute for Collaborative Problem Solving at Massachusetts General Hospital. "I don't think diagnoses help us understand how to help the kid."
It's a frustration felt by Katie. At times, she welcomes the diagnosis that tells her she's not a bad parent or that might solve the riddle that is her middle child. But rather than a golden ticket to a fix, she says, it feels like a can of worms.
"What is a diagnosis?" she says. "All it is is permission to medicate. We could try this drug -- and then what, if it doesn't work? Do you go to the next drug, up the dose, decide the diagnosis was wrong?"
Profession in transition
By the mid-1990s, the effort to prevent or mitigate mental illness began to focus on kids, who had long been considered too young, before adolescence, to treat with anything but love, time and therapy aimed at redirecting their behavior.
The profession's new focus would require a few leaps of faith and some significant reinterpretation of its diagnostic formulas, says Dr. Lawrence Diller, author of "Running on Ritalin" and "The Last Normal Child," two books that are critical of the trend.
Conditions such as bipolar disorder and schizophrenia were long thought so unlikely to appear in children that they were almost never diagnosed. If psychiatrists were going to start, they needed to fathom how symptoms of adult psychiatric illness might look in kids, whose brains are developing and whose social skills are immature.
For instance, troublesome behaviors stemming from extreme shyness, inflexibility, impulsiveness -- even stuttering or tics -- might prompt a diagnosis of anxiety disorder, bipolar disorder or attention-deficit hyperactivity disorder, even though those problems will recede or disappear with age for many children.
And a psychiatrist might have to reinterpret, in a child, the classic pattern of "cycling" between manic and depressive episodes that is the hallmark of bipolar disorder in grown-ups. Instead of taking months to swing from high to low, a mercurial, expressive child such as Katie's daughter might be seen as "ultra-rapidly-cycling" between mania and depression.