Date: June 16 2012
How parents treat their children, how they raise them or help them when they get sick, is one of the most hotly contested issues.
When news broke this week that new child health checks would examine mental health, it was simultaneously hailed as a great leap forward in early intervention and a dangerous experiment.
Details of what the Healthy Kids Check will involve are not yet known, other than that emotional, social and behavioural questions will be part of a broader physical and developmental check. More than $11 million over five years has been promised and the government expects it will identify 27,500 three-year-olds over that time who will require further support.
The details will be revealed after July, when an expert working group will provide recommendations to the Minister for Mental Health, Mark Butler, with the test to be rolled out this coming financial year.
The president of the Australian Medical Association, Steve Hambleton, says mental health has become an ''emotive topic''.
''If you were working as a PR person you wouldn't have released this [story] in the way it came out,'' he says.
Hambleton is supportive of the check, and thinks the expert panel is mainly aiming to ease parental concerns about behaviours such as bedwetting, which is perfectly normal but can worry parents. It will also offer advice for parents worried about things such as aggressive behaviour.
''It's about recognising this concerning behaviour and looking at strategies to minimise it,'' he says.
However, he is still concerned children with problems linked to conditions such as autism or ADHD could be put on a path to inappropriate diagnosis. There is also the possibility that perverse incentives to diagnose children in order to get school support teachers could further push GPs in this direction.
Fear around the check ties into a deeper worry about the increasing medicalisation of normal behaviour, particularly among children where natural developmental differences and parental anxiety create the perfect environment for diagnostic creep.
How mental illness is defined and diagnosed is particularly contested, as the so-called ''psychiatrists' bible'', the Diagnostic and Statistical Manual of Mental Disorders (DSM), is currently being rewritten.
Public submissions on the changes - which relate to common childhood disorders such as attention deficit hyperactivity disorder and autism - closed this week.
And one of the world's leading psychiatrists and critics of the proposed changes, Allen Frances, was visiting Australia when the news about the health checks was revealed in the Sun Herald. For Frances, here for a conference arranged by health support service the Richmond Fellowship and to do a series of talks on the medicalisation of normal behaviour, the idea immediately raised a red flag.
''To do something like this you would want to have a very substantial research literature,'' he says. ''Going full-bore to a national program is really experimenting with kids wholesale.''
Frances is concerned it could lead to low expectations or stigma in families, misdiagnosis or unnecessary medication.
''Children are the most difficult to diagnose because they are in flux. If you allow the child to grow up, very often the symptoms will disappear,'' he says. He gives an example of a recent Canadian study which found being born in December rather than in January is a strong predictor of ADHD, especially in boys.
The director of the centre for community child health at Melbourne's Royal Children's Hospital, Frank Oberklaid, is a passionate advocate for child health and chair of the expert committee developing the child health check.
He is furious Frances's concerns have received so much attention.
''I don't think these concerns are legitimate at all, it's absolute nonsense,'' he says. ''Perhaps if it was eight-year-old children being screened for behavioural problems in school but these are three-year-olds. It's not about diagnosing psychiatric diseases or putting kids on drugs.''
Oberklaid points out the emotional and behavioural components will be part of a raft of questions aimed at catching developmental disorders before children reach school age or become overweight or obese and before these things cause problems.
GPs could provide information or support, or refer children to paediatricians, child psychologists and psychiatrists.
The chair of the Royal Australian and New Zealand College of Psychiatrists' Faculty of Child and Adolescent Psychiatry, Dr Nick Kowalenko, is supportive of the test.
''We need to try to ensure that these kids who are behind the eight-ball can access the help they need to get ready for school,'' he says.
He argues treatment must be delivered by child-specialist clinicians, which would ensure the tests do not lead to inappropriate treatment, but acknowledges there are currently probably not enough specialists available.
Kowalenko says a fair proportion of children with problems such as aggression will grow out of them, but that doesn't mean children, and their parents, shouldn't receive help.
When treating his patients, GP and spokesman for the Australian College of General Practitioners Michael Fasher already always checks up on a child's behavioural and emotional development.
He sees the checks as a way of formalising the process.
''The problem really is this word 'check' which suggests it is a one-off screening and that really wouldn't work very well,'' he says. ''It needs to be part of a continuing conversation with families and parents.''
Fasher, too, supports the check, but says it is vital it is evaluated down the track.
''I think it's really important … so at the end of the day it can be modified if necessary in the light of experience. The intervention that is now informed by evidence will then become based on evidence.''
Fasher says this is necessary because there is always a risk of unintentional harms in inappropriate labelling arising from screening, although such concerns have been ''overplayed''.
Butler, the Minister for Mental Health, seems a little surprised by all the criticism directed at the health check - the detail of which even he doesn't know yet.
But he says he is sure it would be evaluated. ''I'm acutely aware of the dangers of pathologising normal behaviour,'' he says. ''A whole lot of the work we are doing in this area is pretty new and really does require a good evaluation.''
He believes the debate has been blown up by the use of the term ''mental health check''.
''It conjures up a lot of images of the sort of mental health chat you might have with an older child or an adult and that is not the intention,'' he says. ''Families will welcome getting some advice about how their child is developing in social and emotional terms as well as physical terms.''
But Jon Jureidini, the head of the Department of Psychological Medicine at the Adelaide Women's and Children's Hospital, says there is a reason people are worried about the test despite not knowing the detail.
''There's nothing out there that's possibly appropriate to let loose on a population of hundreds of thousands of three-year-olds,'' he says.
One man's forward thinking, it seems, can be another's radical experiment.
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