We knew it was coming, we were just waiting for it — mainstream media’s report on the fact that children are being diagnosed with a condition that isn’t considered a childhood diagnosis, bipolar disorder. Sure, it’s been going on for many, many years, but does that make it right?
Scott Allen, of The Boston Globe, sheds some light on bipolar diagnoses in children today.
I was disappointed to read how the article appears to paint Biederman as an egomaniac:
Biederman dismisses most critics, saying that they cannot match his scientific credentials as co author of 30 scientific papers a year and director of a major research program at the psychiatry department that is top-ranked… “Not all opinions are created equal.”
Nothing like bringing out one’s true colors when faced with real questions about one’s conclusions. Beiderman appears to be pompously suggesting that if you’re not in his category of publishing as co-author 30 scientific papers a year or are the director of a major research program, you really have no place to question his opinions. But other doctors of the same caliber, not to mention well-read professionals such as myself, are.
The diagnosis of bipolar disorder in children is an embarrassing train wreck with not enough empirical backing to be doing it wholesale, and with not enough regard for the serious adverse treatment effects.
Wait until Beiderman discovers the Internet! lol.
But the most distressing point of the article is that diagnosis of this adult condition — bipolar disorder, but in children — is based upon fairly thin empirical research:
Nonetheless, the Mass. General studies were enormously influential: their 2001 study, in which 23 children diagnosed as bipolar received the drug Zyprexa for eight weeks, became one of the most frequently quoted articles in the history of the Journal of Child and Adolescent Psychopharmacology. The study showed that the drug eased outbreaks of aggression, though children typically gained more than 10 pounds.
23 children! Sorry folks, but an N = 23 for only 8 weeks for research is about as small as you can get with a study and have it even published. To have such a study act as one of the cornerstones of this whole controversy is almost ridiculous if the stakes weren’t so serious — children can die when improperly prescribed antipsychotic medications and improperly diagnosed.
The other problem is, of course, nobody is prescribed any medication for only 8 weeks. What is the long-term impact of these very powerful drugs on a child’s development? Nobody can tell you, because the research hasn’t yet been done. Should we really be prescribing such medications wholesale without the resulting research having been conducted (and gone through the FDA approval process, which guarantees a certain safety and efficacy threshold is met)?
The rapid rise raised concerns at the National Institute of Mental Health, prompting its top officials to convene leading specialists, including Biederman, to urge them to come up with diagnosis and treatment standards. The resulting guidelines, released in 2001, acknowledged that Biederman was right: Bipolar disorder can strike before puberty. However, the guidelines also stated that identifying the disease among children is challenging because normal children are prone to be irritable, aggressive, or giddy.
Dr. Steven Hyman, who was then director of the mental health institute and is now provost at Harvard University, said he remains very concerned about the growing use of “big gun” antipsychotic drugs such as Zyprexa, Risperdal, and Seroquel on children.
Keep in mind, too, that 10 years ago, it was virtually unheard of to prescribe antipsychotic medications to treat bipolar disorder. Bipolar disorder was traditionally treated with safe, understandable (but generic) medications like lithium and Depakote. Why not try treating kids with supposed bipolar disorder with these other, older and safer medications first?
Well, that’s not where the money is. When antipsychotics were approved for treatment of bipolar disorder in adults, it seemed only natural to explore their benefits (and enhanced revenue potential) in children.
Hyman wisely concludes, “We don’t know the first thing about safety and efficacy of these drugs even by themselves in these young ages, let alone when they are mixed together.”
If that’s true — and it is — why would doctors like Biederman be so quick to prescribe them to children?
The point of the Globe article is that the diagnosis of bipolar disorder in children is tricky and, because it’s so tricky, it should be done very conservatively. Furthermore, when prescribing treatments to such children, it should be done very carefully — not as a “matter of fact” or taken for granted (especially given the FDA hasn’t even approved a single medication for treatment of bipolar disorder in children!).
And of course, the usual pharma bias argument rears its head (but I don’t think really compares to Biederman’s own ego):
Biederman has received research funding from 15 drug companies and serves as a paid speaker or adviser to seven of them, including Eli Lilly & Co. and Janssen Pharmaceuticals, which make the multi billion-dollar antipsychotic drugs Zyprexa and Risperdal, respectively. […]
Biederman’s boss said he does not believe the money affects Biederman’s judgment.
Well, there ya go! His boss says it’s okay, so it must be okay! Thanks Boss!!
17 comments
Why can we recognize that bi-polar is a nutrient deficiency? Insitol, omega-3, an others nutrients make a big difference. I guess it is Big Harma (not a typo) that does not want people to know!
Also Many aggressive kids have pyroluria, a genetic condition that almost no one knows about. It causes stress, anxiety, and uncontrollable anger.
The cause is an exertion of zinc and B-6. But the body is holding to copper, which can be a serious brain irritant.
I was told that all redheads have pyroluria, but I can find no evidence that that is true. But the ones I know sure do. That is the source of the “fiery temper” of redheads. Today there are 14,800 links on Google.
Good on you for blogging this report on reckless bipolar diagnoses and psychopharmacological treatments in children, Dr. Grohol. I don’t see any reason whatsoever to trust Biederman’s word on this issue; he is clearly heavily biased by his financial backers. Unfortunately, Big Pharma has hooks in many of the people prescribing drugs to these children, and I’ve noted that many psychiatrists are extremely cavalier about the side effects of the drugs they prescribe. Unless regulations or guidelines are passed restricting the diagnosis of bipolar disorder in children, this problem will likely continue unabated.
John – I have indeed heard some anecdotal reports that certain vitamin supplements have demonstrated effectiveness in combating some cases of bipolar disorder – one compound called TrueHope appears to have some refereed journals backing up its effectiveness. I’m not sure if it’s a miraculous panacea – I think a lot more research likely needs to be done first – but taking vitamins seems at the very least an easily implemented supplementary treatment.
I’m the parent of a bipolar child. Yes, I give my child strong medications that allow her to be FUNCTIONAL. Without those medications she would surely be dead by now. And, yes, we did try all the vitamins, naturopathy, etc. before making the very difficult decision to medicate.
Until you’ve lived with a young child asking to die because of the emotional pain they are in, you have NO right to dismiss the difficulties we face.
While cases such as the death of that little girl get headlines, the incredible struggle and stigma that faces the rest of us continues and grows. We fight every day for the lives of our children, getting them through the educational system and trying our best to make sure they become functional, responsible adults. This often means making the difficult choices to put them on medications we KNOW can cause problems. We make the difficult choice on the chance that those same meds will allow our children the CHANCE to grow to adulthood.
My daughter is fortunate that her meds have allowed her to stay out of a psych hospital, have allowed her to attend a public school, have allowed her to create friendships and, above all, to be able to enjoy her life. She still struggles with bipolar, and always will to some degree, but she is learning how to cope with those symptoms that medication can’t completely manage. At least she now has a chance.
I’m so thankful that our psychiatrist is one who believes and aggressively treats pediatric bipolar disorder. He’s one of our heroes.
Like Trecia, I am the parent of a child with Early Onset Bipolar Disorder. His biological mother is diagnosed as such as well.
If he did not take medications, he would not be able to be safe from his otherwise suicidal thoughts.
Maybe some of the non-believers need to look at some of the studies that demonstrate via MRIs difference in the brains of chldren properly diagnosed with bipolar disorder. And, until they walk a mile (or even a few feet) in my shoes, they need to get more information.
Like Debbie and Trecia I am also the parent of a child with pediatric bipolar disorder. My son was first diagnosed with bipolar at the age of four which was a diagnosis that I was not quick to accept. I sought a second opinion from a psychiatrist who diagnosed him with ADHD instead. He was only mildly successful with therapy and his drug regiment for ADHD. As time went by it was evident that my son was bipolar, by this point, he was ultra rapid cycling and committed to the hospital on three times in less than a year. Until we started trying to treat the BP he could not function in everyday life.
Before we made the decision to medicate we tried several herbal and rational therapies. And before my son was on medication for BP he was taking multi vitamins and omega-3 supplements. While I still believe in using these treatments, they alone are not always successful.
Being trapped in a medical community that is brutally divided it not easy for us parents. Instead of trying to point fingers at each other why not work together to help the lives of the victims of this disease, our children.
I always find it very interesting and disappointing that there are people in the professional community (who do not know what it is like to live with a bipolar child that is ultra-rapid cycling and is a threat to himself and everyone around him) that try to judge parents who are fighting very hard to get their children the help that they need. It is these professionals that cause parents to be reluctant about seeking help for their children when they need it. The results of not treating the children who need it can be tragic.
Not again! Unless you have walkled a mile in our shoes (the parents) or in the small sneakers of our children, stop fighting. You have no idea what it is like dealing with these emotional seizures on a 24/7 basis. This is not bad parenting or “medication education” as Mr. Cruise would say….this is a debilitating disorder that leaves everyone in it’s wake, devastated. As a mother dealing with a young son with this disorder, I can tell you we’ve turned over every single leaf. I will never, ever stop fighting for my child. Not only do you sit in a doctors office one day and get a diagnosis, but the choices you have to make are horrendous. People understand cancer, they ignore mental illness. Blame is the name of the game. If I’ve had to endure this for the sake of ignorance and to stop the stigma, so be it. My son is the one who is the real hero. He endures more daily than most people do in a lifetime. God bless him and all the little chidren who suffer. My heart bleeds and so should the rest of the worlds. These children are our future. They are smart, funny, creative, endearing. But they have a nasty little disorder that makes them “ugly” at times. They need our help, prayers, tolerance, and acceptance. I hope in my lifetime, the world grows up and starts to understand that children grow into adults. When adults have “issues” everyone assumes its something that “happened” in childhood. Well, sometimes children are born with these “issues” and their childhood is taken away.
john on june 17th suggests Omega 3’s. That is fine–for some. Just like Lithium doesn’t work for all adult patients, Omega 3’s don’t either. My mom, who is bipolar, can’t tolerate lithium, and my son who is bipolar can’t tolerate lithium either. They both take Depakote but still need an AP to completely calm the mood swings. I invite the writer of this article and anyone else to come join my life for a week (sometimes a day). Then tell me that I am being wreckless for giving my son these drugs. If I didn’t he would be in a residential treatment center somewhere. He has been hospitalized twice already. I can’t see allowing that to happen again.
What the author fails to recognize is that for many kids that have this diagnosis there is GENETIC PRECEDENCE. For those who have these kids with this challenging brain disorder it’s very real. We don’t deny the genetic predisposition of heart disease, cancers or other major illnesses. Why do we continue to ignore it when it comes to brain disorders that are currently classified as “mental illness”?
Another issue in the anti-psychiatric med camp that is never addressed is that even the “alternatives” are expensive, just as unproven, and not covered by insurance. The snake oil and pig pill salesmen are alive and well – and preying upon those who stand to benefit from it the least. they are glad to take a family’s money – but are they there when the child falls apart because of the wrong treatment?
We’ve come a long way in the treatment of bipolar disorder – and there is promise for better treatment in the future. Until we get more advanced medications, we are stuck using the ones we have – for better or worse.
I agree that in some very small percentage of children, there is something significant going on with their behavior. Whether it’s “bipolar disorder” or something else, I couldn’t say (and neither can the research, because there’s been so little done in this area). What’s needed is more research to nail this down and ensure everyone is, indeed, on the same page. It does parents no good to have 3 different mental health professionals diagnose their child with 3 different conditions, 1 or 2 of which may not even be childhood disorders.
As for genetics, I agree, if you’ve gone to the trouble of genetic testing, you can definitely use that as a data point to help both with diagnosis (although no current diagnostic criteria uses a genetic marker) and treatment options. But I know of very, very few people who have done this, and none with their children.
Lithium by itself, or lithium in combination with an antipsychotic is still considered a first-line treatment for bipolar disorder in the majority of cases, because lithium’s properties — safety and efficacy — are well understood across all ages. Lithium has been the treatment of choice for bipolar disorder for decades, and that’s for exactly these reasons. We shouldn’t be quick to move on to other, less-proven medications especially with developmentally-sensitive populations, such as children, until the extensive clinical trials have been completed.
Dr. Grohol states: “lithium’s properties — safety and efficacy — are well understood across all ages.” This is untrue. Lithium was “grandfathered in” and approved down to age 12 when it was approved by the FDA for adults. There were never any safety or efficacy studies done to support it (this is also true of nearly all drugs used in children, because it used to be regarded as unethical to test drugs in children, but most writers fail to acknowledge that fact as well). When I was executive director of the Child & Adolescent Bipolar Foundation (1999-1004) we petitioned the DHHS to fund studies of lithium in children under legislation directing the federal government to test drugs not likely to be investigated by the pharma industry. Lithium was added to this list and studies are now under way. The solution for the lack of research is to do more research, not condemn the pioneers who attempt to relieve suffering using the tools at hand. The compassionate use of drugs off-label is a time-honored practice permitted to the medical profession in appropriate cases.
A quick review of Medline shows a great many clinical trials done on lithium and children.
Keep in mind, too, lithium has been in use to treat the precursor to modern bipolar disorder since the early 1950’s and was approved by the FDA for adult use in 1970 (37 years ago). The test to ascertain lithium dosing in adults via serum levels was developed in 1973 and confirmed to work in children as well in 1995. If this was a drug we should be concerned about in terms of long-term side effects, I’d argue that after 37 years of approved use, we have a much stronger track record than with any of the newly-released antipsychotics.
We also understand how lithium works in the brain. In 1998, University of Wisconsin researchers found that lithium exerts a dual effect on receptors for the neurotransmitter glutamate – acting to keep the amount of glutamate active between cells at a stable, healthy level, neither too much nor too little.
Hi – I’m a reporter interested in writing about childhood bipolar disorder. I was wondering if any of the parents who have posted here would be willing to speak with me regarding the experience of raising a child who has been diagnosed bipolar? I am specifically interested in hearing about issues of medication – what seems to work, what doesn’t and the competing views on giving bipolar children antipsychotic drugs. If you are willing to share your story, please email me at [email protected].
Thank you.
Correct me if I am wrong, but hasn’t Lithium been fairly unsuccessful in treating children with bipolar due to the rapid cycling that children experience? I have read that Lithium isn’t as successful in treating these cycles as it is in stabilizing extended periods of mania and depression commonly seen in adults.
I agree with the other mothers who take offense to the criticism of treating bipolar children with antipsychotic medications. Once you have found your child half way out of a second story window screaming I wish I was dead, you become aware very quickly that your child does not handle the stresses of day to day life as the average child does. You understand quickly that medication is needed now. Waiting to start medication can be the difference between life altering tragedies, maybe even death and living life with some peace of mind and happiness. I have bruises on my body from being bitten and hit with heavy objects like shoes, tennis rackets, and even flashlights. I have holes in my doors and blinds torn down. I have driven down the road many times having heavy objects thrown at my head, my hair pulled and my son opening the door driving down the highway. I have been attacked in public places many times. All of this, and my son is only eight years old. Seeing your child experience such rage followed by horrible sadness and remorse is heart wrenching. Time is of the essence, and my son doesn’t have the time to sit around and wait and see if his little life will finally have some stability and harmony. I will stand by idly no longer hoping that patience, proper discipline and good nutrition alone will heal my son. He needs this in addition to medication and I will see to it that he gets the necessary treatment to better enable him to experience the joys in life he so very deserves.
I’m 25 and have been in and out of psych wards, both adolescent and adult, as well as admitted 3 times into 2 different state hospitals, been through over 10 therapists all means of community assisted programs. I’ve had severe emotional disturbance since the age of 6, and have put my parents and family through rough times.
The panic of what to do with me added to the guilt and stigma I already experienced. I’ve been diagnosed by professionals and evaluated in board meetings; ranging from PTSD,BPD,SPD,severe depression,SAD, and everything inbetween. Some sort of Bipolar spectrum disorder is what stuck; I haven’t been re-evaluated in 8 years.
Be wary of a all-encompassing diagnosis like Bipolar. A child can recieve objective and can be properly diagnosed/treated, but if that determination is rushed, you only get so many chances to second guess it before the child becomes 18.
I think it’s wrong to put kids on some of these new anti-psychotics, but only because I know how it feels to BE on them, and being in institutions seeing how many other teenagers were taking 5 or more different medications.
Have to agree with some of the parents though, it’s sad, but there are few options to calm down a young kid with psychotic or emotional behavior, and none yet good enough in my opinion.
Will someone please explain to me why ADHD, Bipolar Disorder are not prominent disorders in children living in places such as India or some Asian countries. They are basically unheard of in most African countries. Is it perhaps because there is less tolerance for an ill behaved child in the US? Each child is unique, individual and the “goodness” or “badness” of their character should not be guaged by some bell curve and/or parents schedule. I don’t doubt that mental illness does exist in children, I do doubt however, how much of it is diagnosed correctly and with enough thought.
Mental illness is not objectively identifiable, therefore, apart from symptomology, its diagnosis is contingent on the clinician’s mores and societal values. Being unsociable, disruptive, cruel etc are characteristics judged on a continuum. How cruel? how disruptive are these behaviours etc. The diagnosis of mental illness is mostly based on subjective opinion. The pharmaceutical companies are making a fortune..aren’t they?
Read Ritalin Nation… These are developmental and sensory addiction issues, that’s why it’s not cross cultural and has to do with the US lifestyle.