The New Yorker's lead story in the April 9th issue is by Jerome Groopman and is called, "What's Normal?" with the subheading, "The difficulty of diagnosing bipolar disorder in children." While the issue of diagnosing bipolar in children has gotten attention in other mainstream media outlets (most notably in a Time Magazine article from 2002, which The New Yorker article discusses) this is the first time I have seen it addressed in The New Yorker. Since The New Yorker has led the way on uncovering thorny mental health issues in the past (I'm thinking of the coverage they did about ten years ago on PTSD/false memory syndromes and daycare/sexual abuse scandals), I'm hoping that this is another instance of a big issue being opened up for more public debate.
Groopman interviews a number of specialists in research on bipolar disorder in children. All of them discuss the difficulty of differentiating bipolar disorder symptoms from normal fluctuations in mood and behavior for children. He also discusses the 1998 book "The Bipolar Child" which has apparently influenced many parents to seek out pediatric psychiatrists and have their child examined for signs of bipolar disorder.
The best parts of the article for me were the last two sections. Here is where I heard voices resonating with concerns similar to mine (and David's) about the risks we are taking by diagnosing children and then altering their behavior primarily by medicating them. Unfortunately, the article is not available online, but here are a few snippets.
April Prewitt, a child psychologist who trained at Harvard and practices in Lexington, Massachusetts, also spends a good deal of time "undiagnosing" children who have been told they are bipolar. In the past three years, Prewitt says, she has seen thirty children and adolescents diagnosed as having bipolar disorder. In her opinion, only two had the malady. "It has become a diagnosis du jour, as ADHD was five years ago," Prewitt told me. "Not only is the diagnosis being made incorrectly but it's being made in younger and younger children."
The article also cites the December 2006 death of four-year-old Rebecca Riley due to overdose with psychiatric medications, a story which David covered here. But back to Prewitt, who offers the following case example of a misdiagnosis of bipolar:
Prewitt recalled a seven-and-a-half-year-old boy she saw, who lived in an affluent Boston suburb. Max (a pseudonym) had trouble concentring and was refusing to go to school. His pediatrician had diagnosed bipolar disorder and begun treating him with Risperdal and Seroquel. "it turned out that the diagnosis was 'a divorce situation,'" Prewitt said. Max's parents had separated and were undergoing bitter divorce negotiations. "Max had put on twenty pounds because of the medication, while he was being shuttled back and forth, one week with mom and one week with dad."
What I see are families where parents are often not married, where there has frequently been major domestic violence, where parents often have long histories of DCYF involvement and/or involvement in the legal system. The kids go through constant emotional upheaval because of the instability of their environment, or are suffering from long-term attachment problems because of early and severe neglect and abuse. What I also see is that they are frequently tried on many, many medications and they still have major mood swings and behavior problems. Medication is often not effective when the problem is not properly diagnosed, and when environmental factors are not addressed (and sometimes they are next to impossible to address).
Back to Prewitt, and this is almost my favorite quote of the article:
Prewitt maintains that it may not be possible to diagnose bipolar disorder with certainty in a preadolescent child. "After all these years, I am not sure of the diagnosis of bipolar disorder until a chld is well into adolescence," she told me. "I've never seen a seven- or eight-year-old that I would be comfortable definitively diagnosing with bipolar disorder. The changes that children undergo, both in the biology of their development and in the need to adapt to changes in environment at home and at school -- interactions with parents, siblings, and other children -- all can trigger behaviors with rapid and wild swings of mood."
I have only 10 years of practice under my belt and yet I also do not feel comfortable with the diagnosis of bipolar disorder until the end of adolescence. Mood swings in young children are normal. Many children up to age 7 or 8 cry every day about something, and can be fairly quickly helped out of sad or angry emotional states. Many adolescents are struggling with new hormone fluctuations that significantly alter their mood. Peer issues have an enormous influence on adolescent mood and behavior. And, of course, family dysfunction can create major mood and behavior problems in children of all ages.
Finally (finally!) in the last section of the article, the ugly specter of drug company influence is raised, thanks to Phillip Blumberg, a psychotherapist in Manhattan.
Blumberg, who for two years was a vice-president at ABC Motion Pictures, believes that advertising by pharmacerutical companies has influenced the public's view of bipolar disorder. (Eli Lilly, in particular, has come under fire for its marketing practices. The drug company is currently the subject of lawsuits that claim that the company attempted to hide Zyprexa's side effects, and promoted the drug for off-label uses. Lilly has denied the accusations.) Blumberg described recent ads, for drugs like Zyprexa, that include a list of symptoms characteristic of the disorder. "But, of course, we all have these symptoms," he said. "Sometimes we're irritable. Sometimes we're excited and elated, and we don't know why. With every form of advertising, the first goal is to make people feel insecure. Usually, they are made to feel insecure about their smell or their looks. Now we are beginning to see this in psychiatric advertising. The advertisements make frenetic, driven parents feel insecure about the behavior of their children."
As I have discussed in previous posts, the advertising to parents is subtle and very effective, and involves (among other things) drug companies funding sites such as bpkids.org which downplay the role of environmental factors influencing the behavior of children and reassure parents that bipolar disorder is a medical condition located in the brain and treatable with one or two or three medications.
This is my absolute favorite quote from the article, from psychiatrist Steven Hyman:
"The problem with describing a kid who is up-and-down and irritable and sullen and wild and then grandiose is that he could indeed be rapid cycling between mania and depression, but it could be an awful lot of other things, too. Bipolar disorder in children represents the intersection of two great extremes of ignorance: how to best treat bipolar disorder and how to treat children for anything. It's really important that we define the kids with bipolar disorder and treat them, but it's also important that we not begin to diagnose kids with excess exuberance or moodiness as having the disease. We have to realize that we are risking treating children who could turn into obese diabetics with involuntary movements. There is something very real about the kids with devastating and disruptive symptoms, but the question is still the boundaries. You can do more harm than good if you treat the wrong kid."
There is so much unknown about how the brain develops and what the long-term risks are of medicating children. As prelude to the above quote, Dr. Hyman also says, "The DSM always has an out in its definitions, a category called N.O.S. -- "not otherwise specified." While the "out" is an admission of the ignorance that we suffer from in analyzing and naming psychiatric illness in children, I also see how this "out" gets abused. Many children are given an "NOS" diagnosis (frequently Mood Disorder NOS) and then treated with polypharmacy. The medical establishment gets an "out" in making their diagnosis, but the child does not get an "out" from being put on meds. A better "out" for psychiatry would be to defer diagnosis on Axis I (mood disorders) and allow for more consideration of the environmental factors which may be heavily influencing the child's behavior. But then psychiatrists can't get paid, because insurance companies will generally only pay for problems that are located within the body or mind of an individual. Unfortunately, the way the system works now, the money is in the diagnosis.