Tuesday, June 21, 2011

The Child Bipolar Diagnosis is Under Attack - Yet Again

It’s the silly season again, when people who attack the child bipolar diagnosis come out in force. Trust me, any time a child is labeled with a very serious lifetime  psychiatric condition is always cause for concern, but the operative word is “concern,” not propaganda based on hidden agendas masquerading as concern.

The first attack is in the form of a June 8 article in the New Scientist by author Jon Ronson. “Bipolar Kids: Victims of the Madness Industry?” it reads, drawn from his new book, The Psychopath Test. “The problem is the apparent epidemic isn’t real,” Ronson asserts.

Oh, really?

The next is a June 19 article in Newsweek by Stuart Kaplan MD, who has expert credentials as a child psychiatrist. The article - "Mommy, Am I Really Bipolar?" - is adapted from his new book, Your Child Does Not Have Bipolar Disorder. “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood,” Kaplan flatly asserts.

Except, perhaps, for a whole bunch of kids who cycle in and out of depression and mania?

Oh, THAT evidence. Well, no, says Kaplan. These kids are really ADHD or oppositionally defiant. Or have something called “temper dysregulation disorder.”

This is much the same argument Ronson makes, the anything-but-bipolar argument. It cannot possibly be bipolar. It has to be something else. “Attention deficit disorder,” he quotes a friendly doctor.

Close enough.

Except when it misses by a country mile. This from Julie from about ten years back, whose six-year-old kid was diagnosed with ADHD:

Doctors will not officially diagnose a child this young with bipolar. ... No one can possibly relate to the problems a mother must endure for a child like this. I ask God several times a day why couldn't I have just had a normal child. Why must I fight to get his medicine right? Why must I miss work to care for him? Why can't we go out to eat without an episode? I also have two girls (ages two and 12 ) that must watch his behavior escalate to the point where he knocks holes in the walls, pees in the closet and tears up his and their favorite toys. I feel so alone and drained. I have nowhere else to turn.

At least these days no one save the antipsychiatry movement is advancing a conspiracy theory having to do with Pharma pathologizing and medicating “normal” kid behavior to boost revenues. Kids who knock holes in walls and pee in closets definitely require some kind of therapeutic intervention. No one is seriously arguing otherwise.

Back in the 1990s, Joseph Biederman of Harvard began publishing articles to the effect that some of the so-called ADHD kids in his clinic were behaving in ways that more closely resembled bipolar. The issue is extremely complex and confusing, as ADHD and bipolar symptoms overlap plus a good many kids would qualify for both diagnoses.

Coincidentally, a good many parents were noticing much the same thing in their own kids. The ADHD meds weren’t working their customary pharmaceutical magic. Antidepressants were making them even worse. Based on the reports of these parents, Janice and Demitri Papolos did their own investigations and published “The Bipolar Child.”

Ronson and Kaplan respond with saddles blazing, replete with the oft-cited tragic death of four-year-old Rebecca Riley (Ronson cites 60 Minutes’ shameless spin as if it were authority). The two authors predictably attack Biederman (and Kaplan the Papoloses) for failing to accomplish Mission Impossible, namely in coming up with a fool-proof universally acceptable and objective diagnostic standard. Earth to Ronson and Kaplan: Diagnostic psychiatry is all sloppy and controversial and subjective.

To bolster his case, Ronson takes the bizarre step of interviewing the two most subjective diagnosticians of all time - Robert Spitzer and Allen Frances, who headed up the DSMs III and IV, respectively. Anyone who is vaguely familiar with Dr Spitzer is aware of his pathological resistance to even the slightest changes to what he regards as his baby. Dr Frances, on the other hand, has come across in recent writings and interviews as a sinner in search of some kind of war crimes tribunal to plead guilty to.

Really, there needs to be a DSM diagnosis for people who head up DSMs.

Dr Kaplan at least grounds his criticisms in his own clinical experience, or so he claims. But, then again, is Dr Beiderman’s own clinical experience no less valid? Isn’t the real point that when it comes to kids in distress, there are no easy answers? That our diagnostic and assessment tools are very blunt instruments at best?

If only bipolar meds did for bipolar kids what ADHD meds do for ADHD kids, we wouldn’t be having this argument. Alas, with bipolar - in kids and adults - there is no quick chemical fix. A kid diagnosed with bipolar is not going to simply get better with bipolar treatment. Quite the opposite, bipolar meds are likely to make the kid worse. We all like easy answers. The easy answer is to flatly deny that bipolar in kids even exists. That it has to be something else: ADHD, conduct disorder, even a new DSM-5 diagnosis concocted totally out of thin air - “temper dysregulation disorder with dysphoria.”

Anything but bipolar. It would certainly be a much happier world if that were the reality. Alas! Reality ...

Further reading from McManweb:

Child Bipolar I
Child Bipolar II
Child Bipolar III
The DSM-5 - Grading Child Bipolar
Are We Over-Medicating Our Kids?
Spitzer and the DSM


Lizabeth said...

One of my nephews was diagnosed with ODD, which in his case I honestly think was really overprotective and overscheduling mother disorder. He is now in the US Marines so I really, really, hope my diagnosis is correct.

My talk therapist called ODD a "garbage diagnosis" used when the therapist doesn't know what else to say.

John McManamy said...

Hey, Lizabeth. Your comment prompted me to go to the DSM-5 background paper on childhood disorders.


Clearly, there is a lot of confusion. There was talk of folding ODD into conduct disorder.

By contrast - at least in terms of symptoms - child bipolar is far less confusing. This seems to really piss off the old time child psychiatrists such a Kaplan.

The only thing that is certain about childhood mental illness is the territorial food fights among those who have staked claims in conduct disorder, ADHD, bipolar, etc.

Anonymous said...

Hi John,

I recall being somewhat alarmed by a psychiatrist stating with empathetic certainty that he could diagnosis bipolar in a 2 year old. Of his position on medication I cannot recall with certainty … it was one of the Steven Fry programs.
Equally alarming is the position that “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood,” ……
Just realising, so two psychiatrists of expert credentials hold diametrical opposed scientifically based positions practice in the one profession, that is just so refreshingly eclectic. An eclecticism I suspect that the mother of the six year old would not have the luxury of being afforded of she were to meet either.
To my mind diagnosis would be one of reflection, an art drawing on the objective and subjective, relative and absolute, scientific and non scientific.
Beholding to any one of these seems to be taking self protective sanctury. They are all mental formations afterall.
As for medication, well that would be best erring somewhat to the scientific end of the spectrum.
For my part I have only witnessed (in supporting a relative with a dual diagnosis) absolutism that shields itself with the imperious righteousness of the one who knows.

Whatever, to book end any conversations regarding psychiatry with the reflections "Diagnostic psychiatry is all sloppy and controversial and subjective." and "Really, there needs to be a DSM diagnosis for people who head up DSMs" may help suitably ground conversations!


John McManamy said...

Hey, Neil. "Absolutism" is the word I was looking for. Many thanks for finding it for me. :)

Gina Pera said...

re: Ronson. Yes, I read his latest book. Well, I read as much as I could stomach. Of course he drags out the Rebecca Riley case in a highly distorted fashion. That told me all I needed to know about his inherent biases. But some people will do anything to grab a headline.

Gina Pera said...

Another problem is that psychiatrists and other medical specialists have gotten, well, too specialized.

They don't know how to integrate myriad health factors, including nutrition, food allergies, exposure to chaotic behavior in the parents, and other environmental factors that can affect brain function. Some can't even identify symptoms of comorbidities, preferring to "specialize" in one diagnosis and make all evidence fit that one diagnosis.

I bet 1 in 1,000 child psychiatrists don't even think to ask questions about diet or test for Vitamin D levels.

This areas of myopia only serve to create doubt and confusion about legitimate diagnoses.

Gina Pera said...

Lizabeth -- ODD is certainly not a "garbage diagnosis." And it's worth paying attention to in children because with age, ODD can develop into conduct disorder and antisocial personality disorder.

It is highly comorbid with unrecognized/untreated ADHD, for example. There is some evidence of heritability with ODD.

Oftentimes, though, the ODD arises when neither the child with ADHD nor the parent receives support or education in understanding the challenges and treatment strategies. For example, parents assume the child *will not* clean up his room when really the child *cannot* clean up his room. When the parent has unrecognized/untreated ADHD, the power struggles can intensify to a frightening degree, exacerbating the ODD.

John McManamy said...

Hey, Gina. Ronson shamelessly milked Rebecca Riley for all it was worth in his New Scientist article, as well. The guy is an unprincipled idiot in the proud tradition of at least one (thankfully retired) antipsychiatry blogger we know.

Re specialties - exactly. We have a lot of unproductive food fights going on right now. No doubt kids are being misdiagnosed all over the place and then made worse with inappropriate treatments.

And, as you said, more than one thing is typically going on, and clinicians need to be trained to pick it all up.

One major problem - no matter what it is, kids are not in positions to impose self-discipline. They're not going to exactly practice mindfulness and regulate their sleep or have the wisdom to walk away from a fight, for instance. Often, they're powerless to change their environments. This means no matter what is ailing them - ADHD, bipolar, conduct disorder, etc - they are likely to suffer much more than adults with the same dx.

Re checking for allergies, etc - yes. I mention this in one of my child bipolar articles. Mold, a new carpet - it could be almost anything. Check what your child eats and drinks. Kids typically bounce of walls and ceilings and crash as a result of high-sugar junk foods.

The last thing we want to do is give an antipsychotic to a kid with bipolar. Let's try everything else first, including getting the kid off the sugar.

I could go on and on ... :)