about time…

Posted on Tuesday 26 July 2011

Mommy, Am I Really Bipolar?
by Stuart L. Kaplan, M.D.
June 19, 2011

In the autumn of 1994, a novel idea was afoot in my profession. At the annual conference of the American Academy of Child and Adolescent Psychiatry, I attended a workshop on bipolar disorder in children. About 10 of us attended the meeting, held in a small, poorly lit room. Only one or two doctors reported having actually seen a child with bipolar disorder, but we all agreed to keep our eyes open for other sightings. Three years later I attended another session about bipolar disorder in children at the academy’s annual meeting. In a large ballroom beneath a gleaming chandelier, several hundred child psychiatrists buzzed with excitement. As a mainstream concept, the diagnosis had arrived.

I have been a child psychiatrist for nearly five decades and have seen diagnostic fads come and go. But I have never witnessed anything like the tidal wave of unwarranted enthusiasm for the diagnosis of bipolar disorder in children that now engulfs the public and the profession. Before 1995, bipolar disorder, once known as manic-depressive illness, was rarely diagnosed in children; today nearly one third of all children and adolescents discharged from child psychiatric hospitals are diagnosed with the disorder and medicated accordingly. The rise of outpatient office visits for children and adolescents with bipolar disorder increased 40-fold from 20,000 in 1994–95 to 800,000 in 2002–03. A Harvard child-psychiatry group led by Dr. Joseph Biederman, a prominent supporter of the diagnosis, recently insisted, “Juvenile bipolar disorder is a serious illness that is estimated to affect approximately 1 percent to 4 percent of children.”

I believe, to the contrary, that there is no scientific evidence to support the belief that bipolar disorder surfaces in childhood. In fact, the opposite seems to be the case: the evidence against the existence of pediatric bipolar disorder is so strong that it’s difficult to imagine how it has gained the endorsement of anyone in the scientific community. And the effect of this trendy thinking can have devastating consequences. Such children are regularly prescribed medications that are not effective in kids and have unwelcome side effects…

Once the medical establishment started buying into the idea of bipolar kids in the 1990s, the diagnosis gained unusual force. In 2000 the National Institute of Mental Health convened a roundtable of researchers in pediatric bipolar disorder and financially supported several controversial propositions, including the practice of asking bipolar adults to date the origins of their own disease. The creation of a new source of funding generated frenetic activity among university psychiatrists, and in a twinkling it created stakeholders in the diagnosis. Big Pharma viewed the development of this new diagnosis with great interest. Drug companies offer lucrative opportunities to doctors who give talks to other doctors. It was through these industry-sponsored talks that many child psychiatrists received instruction in the diagnosis of pediatric bipolar disorder. The talks were sponsored by companies that made drugs approved for use only in adults, but it appears the drug companies correctly anticipated that child psychiatrists would make the association and then prescribe the drugs to children. It’s now big business: hundreds of thousands of children in the U.S. have been given the diagnosis.

The tide may be turning. The American Psychiatric Association is deliberating intensely on new criteria that would dramatically restrict this fad diagnosis. One step the association is recommending is a new diagnosis called temper dysregulation disorder, a more accurate way of describing extreme irritability in children. If mental-health professionals can be persuaded to consider these alternative diagnoses, many thousands of children could be spared an unwarranted, stigmatizing label that sticks with them the rest of their lives.

Kaplan is a child psychiatrist and a clinical professor of psychiatry at Penn State College of Medicine. This article is an adaptation from his book, Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis.
I haven’t read the book yet, but if this article is any indicator, it looks to be a winner. I posted it for this comment which has occurred to me over and over as I’ve wandered at the literature:
Because these children are being treated for what they don’t have, they often don’t get treated for what they do have. An estimated 60 to 90 percent of children who have been diagnosed with bipolar disorder are also diagnosed with ADHD. It has been demonstrated for decades that, dosed correctly, 80 percent of children with ADHD respond favorably and safely to stimulant medication. Yet those who champion the cause of bipolar disorder in children often caution against the treatment of ADHD. With no good evidence to buttress their case, they have insisted that ADHD medication will aggravate the patient’s manic state and lead to a drastic worsening of bipolar disorder. As a result, the one class of medication that is helpful is often withheld.
It’s a shame that something like a psychiatric diagnosis in children has to be litigated in the popular press, but it is what it is. Good for Dr. Kaplan for entering the fray…
    July 26, 2011 | 8:12 AM

    I can imagine a piece in Newsweek, written some time in the future that says, in part, “Because these children are being treated for what they don’t have, they often don’t get treated for what they do have. An estimated 60 to 90 percent of children who have been diagnosed with ADHD are also diagnosed with rambunctiousness. It has been demonstrated for decades that, dosed correctly, 80 percent of children with rambunctiousness respond favorably and safely to behavioral modification…”

    July 26, 2011 | 8:54 AM

    Yes, let’s medicate for ADHD, because that course of care has worked wonderfully (not!) – see Whitaker’s summary of the MTA trial at http://www.psychologytoday.com/blog/mad-in-america/201005/summing-the-nimh-trials-evidence-effective-paradigm-care.

    July 26, 2011 | 4:31 PM

    I saw this article. While I think it’s inspiring that a psychiatrist is calling out the pediatric bipolar thing as the toxic fad that it is, Kaplan still smacks of a psychiatrist through and through. Later in the article he drops this whopper: “My view is that a diagnosis of bipolar disorder in a child is almost always a case of severe ADHD combined with severe ODD, both fairly common in elementary-school children.”

    Sorry, doc. Severe ADHD and severe ODD are not “fairly common” in elementary-school children. That’s just kids being kids. Now, I’m not saying it doesn’t exist AT ALL, but it’s far from “fairly common.” .

    I think what most kids have is what pediatrician Larry Diller calls “Tom Sawyer ADD,” as explained in Dan Carlat’s UNHINGED:
    “[Tom Sawyer ADHD] refers to kids who are definitely struggling in school, have some problems with impulse control, have interests and talents that are not necessarily what the adults want, but when these kids are interested in something, they focus fine.”

    “As I recall,” I said (Carlat speaking here), “both Tom and Huck focused well when it came to tasks like finding hidden treasure.”

    Diller gave me an impish grin. “There is no question in my mind that Tom Sawyer and Huck Finn would be taking medication today.”
    I honestly think this concept explains the vast amount of kids “diagnosed” with ADHD today. I certainly remember those kids in grade school, and I doubt they all turned out as grocery-bagging recovering methadone addicts.

    July 27, 2011 | 7:57 AM

    Some of them turned out to be heroes and Olympic track stars. Take a look at Unbroken by Laura Hillenbrand. Amazing story. Amazing man. And her account of his childhood makes me believe in today’s world, he would be HEAVILY medicated. So sad.

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