Among the misadventures of alliances between the pharmaceutical industry and academic psychiatry, the saga of Dr. Biederman’s group at Harvard and their Pediatric Bipolar Disorder craze is in the running as the paradigm of the genre. I recently looked back on it [the sound and the fury…] when I ran across some latter day ripples in the January JAACAP. The claim was that a large cohort of out of control, disruptive kids had a variant of Mania, were genetically Bipolar, and were treatable with atypical antipsychotics. If you don’t know the story, start with bipolar kids: not someone to jerk around… from a couple of years ago and read the series that follows.
Further evidence for robust familiality of pediatric bipolar I disorder: results from a very large controlled family study of pediatric bipolar I disorder and a meta-analysis.
by Wozniak J, Faraone SV, Martelon M, McKillop HN, and Biederman J.
Journal of Clinical Psychiatry. 2012 73[10]:1328-34.
OBJECTIVE: To determine the risk for bipolar I disorder in first-degree relatives of children with DSM-IV bipolar I disorder via meta-analysis and expanded controlled study.CONCLUSIONS: Our results document an increased familial risk for bipolar I disorder in relatives of pediatric probands with DSM-IV bipolar I disorder.
Examining the comorbidity between attention deficit hyperactivity disorder and bipolar I disorder: a meta-analysis of family genetic studies.
Faraone SV, Biederman J, and Wozniak J.
American Journal of Psychiatry. 2012 169[12]:1256-66.
OBJECTIVE: The existence of comorbidity between attention deficit hyperactivity disorder [ADHD] and bipolar I disorder has been documented in clinical and epidemiological studies, in studies of children and adults, and in diagnosed ADHD and bipolar I patient samples. Yet questions remain about the validity of diagnosing bipolar I disorder in ADHD youth. The authors aim to clarify these issues by reviewing family genetic studies of ADHD and bipolar I disorder.CONCLUSIONS: The results suggest that ADHD plus bipolar comorbidity cannot be accounted for by misdiagnoses, but additional research is needed to rule out artifactual sources of comorbidity. More research is also needed to determine whether comorbidity of ADHD and bipolar I disorder constitutes a familial subtype distinct from its constituent disorders, which if confirmed would have implications for diagnostic nosology and genetic studies.
I appreciate Dr. Levin [organizer of the S119. session] sending this because it’s a topic that is of interest to me over and above the whole Pediatric Bipolar controversy and the resultant overmedication question. As a volunteer in a child and adolescent clinic over the last 5 years I’ve seen some of the kids they’re describing – the "super·angry/grouchy/cranky·irritable" kids that Dr. Biederman called bipolar [bipolar kids: biedermania and super·angry/grouchy/cranky·irritability…]. Many were in the Foster·Care/Adoption set. Had I not been writing this blog, I wouldn’t have thought of Bipolar Disorder on my own as they weren’t euphoric, grandiose, or periodic – but they fit the Biederman description. They struck me as kids with various combinations of adHd, ptsd, and attachment disorder consistent with their histories. A couple had whatever we now are calling educable mental retardation. Some had been put on atypicals, some not.
So I was glad to read attachment and trauma pieces in the mix in that APA S119. That’s where I thought the action was in the cases I saw. Obviously, the treatment of either is tricky and hardly formulaic, but it’s a lot more likely to address the central problems than atypical antipsychotics in my opinion. We were able to send one such child to a residential treatment program, a kid who had been taken in and adopted by a devoted Aunt after an absurdly chaotic childhood. It’s a token economy behavioral set-up. There are several weekly therapy sessions with the child and her Aunt together. It’s a big intervention, but so far it looks as if it’s heading towards being a success story.
I don’t know what to say about the Bipolar Child story and how it will play out over time, but I feel confident that the epidemic I call Biedermania was being used to justify overmedicating kids for behavior control – whether that was the intent of Dr. Biederman and his group or not. As I’ve said before, if you’re going to use an antipsychotic drug for behavior control, and I accept that there are some situations where that is all that can be done, I don’t want people to have the excuse that they’re treating some disease with the appropriate medication. I just don’t think that’s close to proven. I want them to have to worry like the rest of us that they’re operating in a risk/benefit grey·zone and to be very careful and too vigilant.
If you want to be as historically accurate as possible, then you’d give more “credit” to Wozniak than to Biederman, or at least call it “Wozniak/Biedermania.” In child psychiatry circles, we generally talk about “Wozniak’s conception of bipolar” when we’re referring to those irritable ADHD kids. Here’s a nice brief article on some of the history of the bipolar diagnosis in kids.
I was a nanny for an attachment disordered child from the time she was five, to until shortly after her eighth birthday. He father was dying, I couldn’t take care of them both, so we had to take her to stay with her grandparents who were convinced that their stern and unbending way of child rearing was what she needed no matter the fact that it never worked.
It made us so sad. We were doing very well with her, the hardest part was the mental professionals who thought the problem was that we two adults were not “consistent” enough— until they finally figured it out and then acted like we hadn’t figured it out already— and other adults who thought we were being “too strict” or who played right into her pathologies. And, of course, her mother, until she even lost supervised visitation did whatever she could to make her daughter think we had ulterior motives for taking care of her (though the girl asked to move in with us— an option we hadn’t considered until she asked.)
The more controlled our environment, the more narrow her choices, the more sure and swift the natural consequences of her efforts to control and manipulate; the calmer and happier she became. In order to stay on top of the household, the schedules, the responsibilities, and to be a good parent to her; I had to learn not to let her upset me. She could smell bad feelings. Had I spent three years in a monastery, I could not have learned that discipline and would not have found it so rewarding.
Luckily for me, her school counselor had worked with attachment disordered children for ten years. We both had a relative with mental illness, and often discussed the value of not being afraid of it .
The work of helping these children at all must be whole-hearted. If there were an army of adoptive parents trained and financed to take good care of these children, and a movement to prevent it; we might run out of sociopaths.
What could be more terrifying and lonely than being an infant who is not loved and cared for? We take our conscience for granted. The architecture was built for us through attentive, responsive, empathetic care.
Nice story, Wiley, thank you. I take your use of the word “whole-hearted” to mean love, the only factor not for sale, as humans still are, in this world of ours, kids too, vulnerable, dependent on presumptively wiser grown-ups.
News from the USA are negative, most often, this morning more than ever, Boston, Texas, Congress voting down a watered down bill on gun controls. And a report from UNICEF placing US, the richest country in the world, in the bottom pile of rich countries, in measures of quality of children’s lives. SAD and BAD.
So the corruption also of child psychiatry is another symptom of the greater malaise of corruption where money is seen to trump humane values of love, compassion, care.
Therefore, daily reading humane blogs and humane comments, resisting, building defenses against the evil of quack-science, is encouraging. Thank you!
The news now are seemingly equally breathless on violence and carnage in Boston, Justin Bieber in Oslo, a girlfriend of his, former or anew, drowning out smaller notices of greater carnage in Iraq and Afghanistan, next to nothing on the US drones and killings in remote villages, by a Nobel Peace Prize laureate and American president. Fish rots from the head, is a saying applicable to child care and psychiatry. .
Yes, Berit— love and beyond. Love itself is not enough. I don’t know how being attuned can be taught, or resourcefulness, or discipline, or insight, or patience, or the kind of self-awareness that prevents a person from letting themselves be manipulated by a child for an ego boost, or the realism that allows an adult to see a child as an individual that may not all be what the adult thinks that “children” are.
What is good enough advice for attached children is anathema to a family with an attachment disordered child. That road is over-paved with good intentions, folk psychology, and pop psychology about “children” are.
Thankyou Dr 1BOM for highlighting our symposium.
What a thoughtful comment by wiley.
Indeed attachment, maltreatment, trauma – especially “complex” attachment related trauma – is almost absent from the extensive pediatric bipolar literature – as I discovered in a literature review – http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf
Ed Levin and I reflected on the wider aspects of the PBD epidemic in another open access article – http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826
When at the international congress of child psychiatry and allied professions in Paris in 2012 – I attended a symposium by Prof Biederman and his colleagues. I and another attendee asked about attachment factors and borderline personality disorder in the adult relatives of PBD diagnosed subjects in their studies. Prof Biederman implied attachment theory was not proper science and refused to discuss the issue, he did say they had not assessed for borderline personality disorder in their research, but again refused to discuss the issue.
At the American Academy of Child & Adolescent Psychiatry conference in Hawaii in 2009 another prominent PBD researcher presented neuroimaging data of children with “PBD” compared to children without “PBD”. The findings (overactive amygdala alarm centre and reduced frontal lobe rational control in the right hemisphere of the brain) were identical to research findings of children with early attachment trauma histories. But that other body of research did not seem to be referenced. When I and other attendees asked why couldn’t these children simply be called “affect dysregulated” rather than presumed “bipolar” – the researcher agreed they could and that would be a more neutral term – but she added “if we don’t call them bipolar we won’t get funding for our research”.
That really sums up the world of marketing-based medicine we live in.
No, thank you for having it. The lack of substantive challenge to the epidemic PBD diagnosis has gone on much too long.
That would’ve been after he was censured by Harvard [Mass. General disciplines three psychiatrists]. Humility is not Dr. Biederman’s strongest suit.
Actually, Biederman as much as said a similar thing to Katie Courik:
I’m thinking that Attachment Theory is a lot closer to science than that assumption…
Thanks Mickey.
The lack of consideration of attachment and trauma extends to the literature on the new Disruptive Mood Dysregulation Disorder diagnosis.
Dr. Parry,
Along those same lines, look up “Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.” This is the most recent ADHD practice parameter from the AACAP:
Carefully read through recommendations #2 and #5 (they are too long to copy in full here). Note that the line below is the ONLY reference to trauma history in these sections on evaluation – or in the entire practice parameter for that matter:
“Information regarding any physical or psychological trauma the patient may have experienced (including multiple visits to the emergency room) should be gathered as well as any current psychosocial stressors.”
That’s it. The line above is the only reference to trauma in the entire document.
There is no reference to Post Traumatic Stress Disorder, simple or complex, whatsoever.
Contrast that to the degree of discussion of bipolar disorder as part of the differential, or as a co-morbidity.
Dr. Parry,
Also, if you think that the past 10 years with the push to diagnose and treat bipolar disorder in children and adolescents have been something, you haven’t seen anything yet. It’s about to go much younger. I hope that people do not wait around to take a historical perspective 10 years down the line on this. People know where this is going to lead.
The AACAP Back to Project Future is “developing a consensus around priorities and action steps for AACAP in three key areas: Service/Clinical Practice; Training and Workforce; and Research. The project will be completed when its report is submitted to the AACAP Council for consideration at the 60th AACAP Annual Meeting in 2013.” This is the Research Subgroup:
Neal Ryan, Leader
Kiki Chang
Melissa Del Bello
Mary Margaret Gleason
Young Shin-Kim
Daniel Pine
John Walkup
Bonnie Zima
This looks a lot like a team you’d put together to discuss prophylactic psychopharmacology of very young children, as delivered by primary care providers, to target possible emerging mood and autistic disorders.
In light of the last 10 years we will not be able to say in 10 years that we didn’t know what was coming.
http://1boringoldman.com/index.php/2012/12/13/a-formidable-opponent/#comment-232974
That there is a consideration of whether the approach brought to bear for the last 10 years by these academicians is the approach clinicians wish to see brought to bear in undiluted form for the next 10.
http://1boringoldman.com/index.php/2012/12/13/a-formidable-opponent/#comment-233032
There are no voices in child mental health warning against this.
http://1boringoldman.com/index.php/2012/12/13/a-formidable-opponent/#comment-233077
We’re heading towards debates like these for toddlers
http://1boringoldman.com/index.php/2012/12/13/a-formidable-opponent/#comment-233079
Until journals and professional organizations feel a need to engage around these issues it seems clear that they will simply avoid discussing them and/or with trumpet fake fixes. It is hard then to believe that the next 10 years will bring something substantively different than the last.
Except, perhaps, that the children being impacted may be much younger.
http://1boringoldman.com/index.php/2012/12/21/hide-and-go-seek/#comment-233459
CHAIR OF THE APA DSM-5 TASK FORCE:
DR. DANIEL KUPFER
“The talk itself was a discussion of “where we need to go” in the management of bipolar disorder in the future.”
“He also introduced a potential way to “stage” development of bipolar disorder (similar to the way doctors stage tumors), suggesting that people at early stages might benefit from prophylactic psychiatric intervention.”
http://1boringoldman.com/index.php/2012/12/16/worth-pursuing/#comment-233635
FROM THE MEMBERS OF THE AACAP BACK TO THE FUTURE RESEARCH WORKGROUP:
DR. MELISSA DEL BELLO
“Putative risk factors for developing bipolar disorder include having a first-degree relative with a mood disorder, physical/sexual abuse and other psychosocial stressors, substance use disorders, psychostimulant and antidepressant medication exposure and omega-3 fatty acid deficiency. Prominent prodromal clinical features include episodic symptoms of depression, anxiety, hypomania, anger/irritability and disturbances in sleep and attention.”
“Together, extant evidence endorses a clinical staging model in which subjects at elevated risk for developing mania are treated with safer interventions (i.e. omega-3 fatty acids, family-focused therapy) in the prodromal phase, followed by pharmacological agents with potential adverse effects for nonresponsive cases and secondary prevention.”
http://1boringoldman.com/index.php/2012/12/16/worth-pursuing/#comment-233636
DR. KIKI CHANG
“Similarly, psychotropic medications may decrease negative sequelae of stress and have potential for neuroprotective and neurogenic effects that may contribute to prevention of fully expressed BD. Further research into the biologic and environmental mechanisms of BD development as well as controlled early intervention studies are needed to ameliorate this significant public health problem.”
http://1boringoldman.com/index.php/2012/12/16/worth-pursuing/#comment-233637
DR. DANIEL PINE
“And that’s where we are today. The issue of diagnosis of depression in preschoolers is being looked at very carefully right now.”
“Is it right that rather than treat children for depression, clinicians wait and see what might happen three or four years down the road?”
http://1boringoldman.com/index.php/2012/12/16/worth-pursuing/#comment-233704
DR. NEAL RYAN – CHAIR OF THE WORKGROUP
“Q: Do you think the prescription of antidepressants by family MDs and pediatricians are part of the problem?
A:No. I think it is critical that we find treatments that primary doctors can use. They are the 1st line of therapy for uncomplicated depression.”
http://1boringoldman.com/index.php/2012/12/16/worth-pursuing/#comment-233704
DR. KIKI CHANG
http://1boringoldman.com/index.php/2013/02/20/system-psychiatry/#comment-237412
http://1boringoldman.com/index.php/2013/02/20/system-psychiatry/#comment-237414
At least you’ll have a lot to talk about at your next historical perspective session 10 years from now.
Finally this:
http://1boringoldman.com/index.php/2013/04/04/still-on-the-books/#comment-239916
http://1boringoldman.com/index.php/2013/04/04/still-on-the-books/#comment-239917