Monday, May 19, 2008

Newsweek - Welcome to Max’s World (Bipolar Children)

I've been skeptical of the recent increase in diagnoses of bipolar disorder in children. There seems to be a lot of friction in the psychology community on this topic as well.

Here is one good critique of the situation.

You have probably already heard about these results, but they are worth repeating. In 2003, 800,000 children and adolescents were diagnosed AND AGGRESSIVELY TREATED for bipolar disorder — A 40-FOLD INCREASE. If you look at the charts documenting the rates of increasing diagnosis and treatment, you quickly realize that over the following 4 years (2004-2007), this incidence has probably doubled again, i.e., in 2007, there are likely 1.5 MILLION or more children (approximately 2 in every 100) being diagnosed — and treated — as having bipolar illness.

I’m not certain how this growth in diagnosis and treatment shall progress, but remember that once you really have a bipolar disorder, it’s for life. There’s no escaping it, folks. Miraculously, over a little more than a decade, we have ‘discovered’ that we have almost as many children with this dreadful malady as we have adults! By the time the psychiatrists are through ‘catching up’ with all of the earlier-missed identification of this illness in children, we’ll see that (Mercy, me!) 5 or 10 or 15% of our kids have it! THAT’S a plague, for certain!! Let’s hurry up and get those mind-altering, meat-ax drugs to that 5 or 10 or 15% of our kids just as fast as humanly possible, for their great benefit!!!

About half of these 800,000 treated children in 2003 were prescribed anti-psychotic drugs designed to treat schizophrenia (Risperdal and Seroquel were the most commonly prescribed). About 40% were enrolled in psychotherapy programs. About 1/3rd received “mood stabilizers”. Antidepressants and stimulants were widely prescribed. Sort of makes you wish you had a little more J & J or Astrazeneca or other Big Pharma stock in your portfolio, doesn’t it?! Sort of makes you appreciate how much a little marketing to psychiatrists (one of the most drug-oriented of all professional communities) can really pay off, doesn’t it?! Sort of helps you understand why child psychiatry is now such a flourishing practice area, doesn’t it?!

Personally, I wonder what on earth can lie in the future of a society that allows this kinds of systematic abuse of the physical, chemical and functional brains of its children. What the hell are you child psychiatrists thinking? Let’s say, just for a moment, that bipolar disorder IS increasing this rapidly in our society. Why aren’t you raising the red flag and demanding that the government determine WHY this is happening? Doesn’t it matter to you enough to get you off of your collective keisters? Are you HAPPY delivering all of these strong chemicals to the brains of the children who cross your office thresholds? And how on earth can you prescribe psychoactive drugs in various combinations that have unknown impacts on the development of human ability and spirit (but which everything tells us should variously modify or limit them) so damn casually and so extraordinarily liberally? Have THOSE impacts been measured, in the FDA trials that led to the approval of Risperdal for the treatment of bipolar disorder in children? Surely you understand that these drugs have powerful, general, brain-altering impacts. Surely you understand that their impacts are not exactly specific or selective. Surely you appreciate the fact that the brain on these drugs is not NORMAL, and that by chronically administering it, it never shall be.

The article in the New York Times stated that “symptoms (of bipolar disorder) appear earlier than was previously thought.” Balderdash. Or if so, why?


Unlike schizophrenia, we know that cognitive weakness in bipolar disease cannot be easily recorded in individuals before they develop the illness, nor in the siblings or parents of affected individuals. They EMERGE as the bipolar patients goes through the first cycles of mania and depression, and strengthen progressively as the illness progresses. The diagnosis of this newly-emergent disorder appears to be based on the contemporary child’s emotional instability and gross conduct problems (their ‘mania’). In my own view : a) it is unlikely that very many of these children have, or are truly destined for bipolar disorder, since the true mania of bipolar disorder is almost certainly linked to the changes manifested by cognitive deterioration; b) either serendipity reigns, or a treatment based on this diagnosis is going to almost always be mis-targeted; c) chronic administration of these drugs can — of course — have large-scale, enduring impacts, all on their own; and d) because antipsychotic drugs like these impact dopamine and serotonin and adrenergic and cholinergic processes that are key regulators of mood and learning and addiction and cognitive development and a dozen other things that define the operational abilities of we humans, I personally would be pretty reluctant to give them to my dog or cat — unless that was ABSOLUTELY lifesaving.

In my view, and that of others, we can't diagnose children who do not possess fully developed brains with severe disorders. My fear is that we are medicating normal childhood behavior, or worse, over-medicating dietary deficiencies. How many of the supposedly bipolar kids are lacking ANY omega-3 fats in their diets? How many have been abused? How many are acting out as a result of poor parenting?

These are valid questions to keep in mind when reading this article from Newsweek on a bipolar child named Max. Be sure to watch the video before reading the article.
Max Blake was 7 the first time he tried to kill himself. He wrote a four-page will bequeathing his toys to his friends and jumped out his ground-floor bedroom window, falling six feet into his backyard, bruised but in one piece. Children don't really know what death is, as the last page of Max's will made clear: "If I'm still alive when I have grandchildren," it began. But they know what unhappiness is and what it means to suffer. On a recent Monday afternoon, Max, now 10, was supposed to come home on the schoolbus, but a counselor summoned his mother at 2:15. When Amy Blake arrived at school, her son gave her the note that had prompted the call. "Dear Mommy & Daddy," it read, "I am really feeling sad and depressed and lousy about myself. I love you but I still feel like I want to kill myself. I am really sad but I just want help to feel happy again. The reason I feel so bad is because I can't sleep at night. And dad yells at me to just sleep at night. But, I can't control it. It is not me that does control it. I don't know what controls it, but it is not me. I really really need some help, love Max!!!!! I Love you Mommy I Love you Daddy."

This is the story of a family: a mother, a father and a son. It is, in many ways, a horror story. Terrible things happen. People scream and cry and hurt each other; they say and do things that they later wish they hadn't. The source of their pain is bipolar disorder, a mental illness that results in recurring bouts of mania and depression. It is an elusive disease that no parent fully understands, that some doctors do not believe exists in children, that almost everyone stigmatizes. But this is also a love story. Good things happen. A couple sticks together, a child tries to do better, teachers and doctors and friends help out. Max Blake and his parents may not have much in common with other families. They are a family nonetheless. That is what has mattered most to Amy and Richie Blake since Oct. 31, 1997, the day their son took his first ragged breath.

Max came into the world with a hole in his heart. Struggling to be born, he lost oxygen, and doctors performed an emergency C-section. Recovering from the operation, Amy feared her infant son would need surgery, too, but the doctors said the hole would close with time. Four days later the Blakes wrapped their baby in a blanket and brought him home to their little house in Peabody, Mass. Richie, a former Marine, was working as a county corrections officer. Amy was a promising divorce lawyer at a firm in nearby Boston. As children, both Richie and Amy had watched their parents split up, but they had found a comfortable routine in each other: he played straight man to her comic. Marriage suited them. Amy hung a large, sunny wedding portrait in the living room. Starting a family would not be easy: there were no grandparents living nearby, and Amy could take only three months of maternity leave. Still, she thought, this was a stable home, one where Max would be safe and happy.

The mothers of bipolar kids often say their babies are born screaming. These are children who live at the extremes: so giddy they can't speak in sentences, so low they refuse to speak at all. Unlike bipolar adults, they flit rapidly between emotions; sometimes they seem to feel everything at once. At least 800,000 children in the United States have been diagnosed as bipolar, no doubt some of them wrongly. The disease is hard to pin down. The bipolar brain is miswired, but no one knows why it develops that way. There are many drugs, but it's unclear how they work. Often, they don't work at all, and they may interfere with normal brain growth. There are no studies on their long-term effects in children. Yet untreated bipolar disorder can be disastrous; 10 percent of sufferers commit suicide. Parents must choose between two wrenching options: treat their children and risk a bad outcome, or don't treat and risk a worse one. No matter what they do, they are in for uncertainty and pain.

Amy knew none of this when Max was born. She did know new motherhood was tough. Max never slept through the night, and neither did she. He cried for hours at a time. He banged his head against his crib and screamed until his face burned red. Nursing, cuddling, pacifiers—none of them helped. At 2 a.m., at 3, at 4 and 5 and 6, Amy cradled her son, trying to believe this was typical infant irritability, the kind her friends with kids had warned her about. It must be colic or gas, she thought, as Max howled another day into being. Exhausted, mystified, she made jokes—he was born on Halloween, she ate too many spicy chicken wings before delivery—trying to explain how a baby too young to hold up his head could raise such hell.

After a year, the jokes gave way to worry. Max was reaching and surpassing his milestones, walking by 10 months and talking in sentences by age 1, but he wasn't like the babies in parenting books. Richie carried his son to the backyard and tried to put him down, but Max shrank back in his father's arms; he hated the feel of the grass beneath his small bare feet. Amy gave Max a bath and turned on the exhaust fan; he put his hands over his ears and screamed. At 13 months, he lined up dozens of Hot Wheels in the same direction, and when Amy nudged one out of order, he shrieked "like you'd just cut his arm off." At day care, he terrorized his teachers and playmates. He wasn't the biggest kid in the class, but he attacked without provocation or warning, biting hard enough to leave teeth marks. Every day, he hit and kicked and spat. Worries became guilt. Amy had been overweight and dehydrated in pregnancy. Was Max so explosive because she had done something wrong?

Read the rest of this long article.

To their credit, the authors present a fairly unbiased view of the topic, although it's clear they think Max is bipolar (and he might be). Here is a description of how the illness manifests, followed immediately by a disclaimer.
Scientists now know that bipolar children have too much activity in a part of the brain called the amygdala, which regulates emotions, and not enough in the prefrontal cortex, the seat of rational thought. "They get so emotional that they can't think," says Mani Pavuluri, a child psychiatrist at the University of Illinois at Chicago. More than the rest of us, a bipolar child perceives the world as a dramatic and dangerous place. If he is shown a picture of a neutral face, he may see it as angry. Show him one that really is angry, and his prefrontal cortex will shut down while his amygdala lights up like a firecracker. The typical result: a fury that feeds on itself. Neurological research has its limits, though, and bipolar disorder still cannot be identified based on brain scans. Diagnosing it is more art than science. Many psychiatrists think that in the years since Max's diagnosis, doctors have erred on the side of seeing it everywhere, mislabeling kids and creating a lucrative market for drug companies. Even one of Max's docs says he thinks nine out of 10 kids with the bipolar label have been wrongly classified.
I think Max's doctor is correct.

If there has been an a huge increase in this disorder (among adults as well as children), then we need to be asking why? Is it just more precise diagnosis or is there something else going on? I suspect there are a variety of factors, not least of which are environmental.

Here are a few resources offered along with the article.

Advice for Parents of Bipolar Children
The Biology of Bipolar Disorder
Resources for Families Dealing with Bipolar Disorder

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