Tuesday, May 20, 2008

More on Bipolar Children

Yesterday I posted on Newsweek's article about Max, the bipolar kid. This morning, Metapsychology posted a review of a new book that is critical of the bipolar diagnosis in children. I'm going to post the whole review because I think some of the essays in the book are important in assessing whether or not children can be diagnosed as bipolar.

Bipolar ChildrenReview - Bipolar Children
Cutting-Edge Controversy, Insights, and Research
by Sharna Olfman (Editor)
Praeger, 2007
Review by Benjamin J. Lovett, Ph.D.
May 20th 2008

One evening several years ago, an old friend called me up to ask, somewhat abruptly, what I knew about bipolar disorder. I gave him a simplified summary of what I had seen in many abnormal psychology textbooks. I told him it was a mood disorder in which someone cycled between episodes of depression and episodes of mania, with manic symptoms including a reduced need for sleep, great excitement, rapid speech, hyperactivity, and grand plans that might not be followed up on. I also told him that the disorder, as far as I knew, was highly genetic but didn't begin to show itself until someone's late teens or twenties. When I asked him the reason for his interest, he told me that his daughter had just been diagnosed with bipolar disorder.

This didn't make much sense to me. My friend's daughter was only 9 years old at the time, and I had never heard of children being diagnosed with the disorder. He told me that he had just heard of a book, The Bipolar Child, that he was going to get and that he would let me know more when he got a chance to read it. Rather than waiting, I did a few quick internet searches and found more literature, both professional journal articles and accessible material for parents, than I could have ever guessed was available. That was back in 2002, and since then, the public profile of child bipolar disorder has only become more prominent. Textbooks on child psychological disorders now have separate sections on child bipolar disorder, and workshops are offered to schoolteachers, psychologists, physicians, and even parents on the nature and management of the disorder.

Very little of the literature on child bipolar disorder is critical of the concept, but Bipolar Children falls into that category. Although the book's essays are generally balanced, there are no real defenders of child bipolar disorder's validity, and so the book suffers from a certain kind of one-sidedness--it should be viewed as the case for skepticism about child bipolar disorder. Sharna Olfman, the editor, opens the book with an introductory essay that lays out the issues briefly and highlights how even though little is known for certain about child bipolar disorder, many mental health professionals are confidently making the diagnosis and treating it with very powerful drugs. This theme runs through many of the essays to follow.

One such essay is by Lawrence Diller, a behavioral pediatrician known for his reflections on ADHD and stimulant medication in Running on Ritalin, among other books. In this essay, Diller shows his usual humility and, as is typical, uses clinical anecdotes to illustrate just how difficult it is to identify child bipolar disorder and to separate it from family problems, other mental disorders, and typical childhood behavior. Moreover, he points out that since the criteria used to make a diagnosis are different from the strict adult criteria for bipolar disorder, the most crucial piece of evidence for child bipolar disorder is still lacking: evidence showing that children diagnosed with child bipolar disorder grow up to develop the classic adult form of bipolar disorder. Until this evidence is available, it is unclear whether these children have a juvenile version of adult bipolar disorder or a different problem altogether.

Another thoughtful essay is by Elizabeth Roberts, a child psychiatrist. She makes a detailed, nuanced analysis of the stakeholders in the diagnosis of child bipolar disorder, focusing on parents and teachers and their roles in the diagnosis. For instance, Roberts points out that children diagnosed with bipolar disorder often suffer from an inability to deal with frustration and control their emotions, and that parents may not be aware of how their discipline practices affect these skills. Similarly, Roberts notes that once children are exhibiting extreme behavior problems, it is easy for teachers to believe that the behavior is the product of a mental disorder and to recommend medical treatment, rather than suggesting to parents that the behavior might require great changes in the way that the child is managed, both at home and at school. Importantly, Roberts does not blame parents or teachers for the disorder--she merely points out how neither its symptoms nor its diagnosis appear ex nihilo.

The points made by Roberts and Diller are refreshing, since texts on child psychological disorders treat child bipolar disorder as instantly valid and unassailable. The caution that these authors urge does not come with a refusal to consider any children as meriting the bipolar diagnosis; Diller admits to cases in which even the most powerful drugs may be an appropriate prescription for certain children, and Roberts sympathizes with families and schools who may not know how to deal with severe behavior problems except through medication. Both authors simply challenge the hegemony of a medical model that not only explains behavior as being based in the brain (an obvious truth) but fails to consider environmental contributions and related solutions.

Not all of the book's essays are as synoptic as those by Diller and Roberts; the other essays typically have a narrower focus. For instance, Toni Vaughn Heineman offers a perspective on bipolar disorder diagnosed in foster children, providing a case study of an adolescent whose life experiences were so complicated and tragic that it is difficult to see how mental health professionals should classify her resulting symptoms and begin treatment. Similarly, William Purcell's essay is a sensitive portrayal of play therapy with a five-year-old boy diagnosed with bipolar disorder, in which the therapist respected the symptoms as responses to the child's life experiences rather than viewing them as brain chemical imbalances. These two case studies certainly challenge the model of child bipolar symptoms as originating solely from biological causes, and support the ideas of Diller and Roberts in proposing a more complex model of the diagnostic category.

One major player in the construction of a diagnosis, never to be left out, is the pharmaceutical industry. An essay by David Healy and Joanna Le Noury details the ways in which new mood stabilizers--the medications often prescribed for child bipolar disorder--are marketed to parents and physicians. These include claims that the drugs will prevent the development of adult bipolar disorder (although no scientific studies have explored this, and the FDA has not approved these drugs for the prevention of bipolar disorder) and claims that various famous artists and literary figures were bipolar (although few if any ever received a formal diagnosis). The drug companies' websites are also filled with what appear to be diagnostic tools, such as "mood diary" charts that parents can use to fill in their children's emotions during different parts of the day. As Healy and Noury note, many typically developing children will appear abnormal when these tools are used to describe their behavior, and the companies are concerned with the dangers of false positive diagnoses.

All of these essays, then, should contribute to a needed dialogue about the validity of child bipolar disorder, even if certain psychiatric researchers who tout the diagnosis and medications will be put on the defensive. Indeed, while reading the book, I found myself frequently wondering how proponents of the diagnosis would respond. Most of the essays' authors are too careful and nuanced to be dismissed as anti-psychiatry zealots. We can only hope that these scholars' attempts at complicating the diagnosis of child bipolar disorder will be taken as an invitation to civil discourse on this heated topic. After all, whether or not they should be labeled as bipolar, children with severe emotional and behavior problems require our sharpest and most careful thinking.

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