home
about
archives
|
DIAGNOSING CHILDREN: A CRUCIAL TOPIC IN THE FIELD OF MENTAL HEALTH
10/03/2007
My primary interests these days are politics, history, and world affairs, but that hasn't always been the case. Once upon a time I was a practicing psychotherapist.
Six years ago I retired, but Sunday night I found myself pulled back into the controversies that were partly responsible for my decision to leave the profession.
My biggest concern was over the direction the field of mental health was taking. Drugs had become the treatment of choice for nearly all disorders, and the practice of psychotherapy was relegated to an adjunct treatment, possibly helpful but not really necessary, according to many psychiatrists. And a naïve public was buying the new "state of the art" biological treatment regimen that was being aggressively marketed by Big Pharma, and providing a boon to the pocketbooks of psychiatrists, who all but abandoned doing psychotherapy to simply manage medications for their growing patient populations. How much easier it was to simply evaluate a patient according to a list of symptoms, write a prescription, wait for results, and adjust the drug recipe according to effectiveness and side effects. There was no need to learn how to do effective psychotherapy, which is an extremely difficult thing to learn to do well, and which, to be brutally honest, is not always done well.
For patients, and their insurance providers, it was much more cost effective to simply take a pill or two to solve your emotional problems (or at least reduce your symptoms) than to spend weeks or months in therapy in an attempt to make changes in your thinking, your lifestyle or your behavior. And it was easier on the ego in that you could relinquish any and all responsibility for your problems, from drug addiction to problems with attention to aggression, by simply echoing your psychiatrist, who said you had a "chemical imbalance."
At the time of my licensure, in the early 1980s, there were few psychiatric drugs that were effective and most had annoying or dangerous side effects. Psychiatry was taking a back seat to all the new talking therapies that were being developed, and psychologists (practitioners with a Ph.D. rather than an M.D.) were actually becoming more powerful in the field than psychiatrists. And then, like a miracle from on high, Prozac appeared in 1989, rescued the psychiatrists and their wallets, reduced the power of psychologists, who cannot prescribe medication, and changed the field of psychiatry and the treatment of "mental illness" forever.
Sunday night I was reminded of just how much change has occurred and just how dangerous those changes are. On the television program 60 Minutes, Katie Couric reported on the tragic case of Rebecca Riley, a four year old who at the age of two was taken to a psychiatrist and before her third birthday was diagnosed with bipolar disorder, a mental illness that until the last ten or so years, was only diagnosed in adults. She was put on three very powerful medications (an anti-psychotic, an anti-convulsive, and a blood pressure medication, all of which are used by psychiatrists to treat this disorder in spite of the fact that none have been approved by the FDA for use with children). One night, after her mother gave her Tylenol Cold medication and apparently an extra dose of the blood pressure medication, little Rebecca died in her sleep, the victim of an overdose of at least one of the medications. An autopsy revealed organ damage that had developed over time. Her parents are now on trial for murder (accused of giving her more than the recommended dose of medication) and her doctor is suspended from the practice of medicine pending an investigation.
The 60 Minutes story began with the case of Rebecca, but went on to discuss the diagnosis of bipolar disorder in children and its pharmacological treatment, both controversies within the psychiatric community. On the one side are those who believe it is wrong to diagnose children, whose brains are still developing and whose behavior is immature, with adult diagnoses and to treat them with powerful and untested medications used on adults, taking the risk of causing permanent brain and organ damage. On the other side are parents who want to help their children and don't know how, and practitioners who want to help manage disturbed behavior in children and provide some hope and relief to beleaguered parents.
I understand both sides, and know there are valid arguments to support each position, but I think the arguments are stronger on the first side, that held by practitioners and others who see the diagnosis of and treatment for bipolar disorder in children as a potentially dangerous and troubling development. Let me explain why by answering a series of questions that will reveal a lot about the psychiatric, mental health, pharmaceutical and patient communities.
WHAT IS A PSYCHIATRIC DISORDER?
Something the average layperson, including most patients, do not understand is that the vast majority of psychiatric disorders are not actual diseases, but constructs, labels attached to a collection of symptoms commonly seen by mental health practitioners. Unlike known medical conditions, like heart disease, diabetes, cancer, tuberculosis, allergy, etc., the diagnosis of which can be confirmed by lab work, x-ray, and other definitive diagnostic tests, the majority of disorders listed in the DSM IV (the current edition of the Diagnostic and Statistical Manual of Mental Disorders and the Bible of mental health practitioners), are categories of mental, emotional or behavioral problems established by committees of psychiatrists and psychologists. There are no lab tests, MRIs, or observable lesions that one can point to as evidence of the existence of one of these "disorders." Committees of practitioners meet for years, pore over journal articles and research, discuss observations of patients with specific sets of symptoms, and agree on categories, subcategories, diagnostic criteria, etc. Thus, each new DSM is different from the last. New diagnoses are added, some are changed, and a small number may be eliminated.
HOW IS A "NEW" DISORDER DISCOVERED?
There are many psychiatric conditions that have been observed in one form or another for centuries, some even longer, although they may have been called by other names. Depression, schizophrenia, panic disorders, delusional disorders (paranoia) have been recognized as aberrant mental states for a long time. But psychology and psychiatry are relatively new disciplines and the practice of identifying mental disorders and categorizing them in a similar way to physical disorders is a relatively recent phenomenon. The first DSM was only written in 1952 and listed 60 disorders.
Generally, as more and more unhappy and suffering people are willing to see mental health practitioners, and as society becomes more intolerant of aberrant behavior, new sets of symptoms are observed and categorized. Sometimes these are rare, other times not so rare. As a result, the list of disorders has grown, and in 1994, when the most recent DSM was published, there were 297 disorders listed.
Often, a diagnosis evolves over the years, going through many name changes. ADHD (Attention Deficit Hyperactivity Disorder) is one example of the evolution of a diagnosis. In 1940 the diagnosis of Minimal Brain Syndrome was created to describe hyperactive children, followed in 1957 by a name change to Hyperkinetic Impulse Disorder, followed in 1960 by Minimal Brain Dysfunction and then in 1968 by Hyperkinetic Reaction of Childhood. In 1980, the disorder characterized by inattention, hyperactivity and poor impulse control was renamed Attention Deficit Disorder (ADD) which is the name most lay persons still use. With the DSM III, the name was changed to Attention Deficit Hyperactivity Disorder and the diagnosis has actually been expanded to include subcategories of children who are not hyperactive but simply inattentive and impulsive. All of these children, it should be noted, are considered appropriate candidates for medication.
Over time, one or more practitioners who saw patients that did not fit neatly into the established categories of the current DSM developed the idea that they were seeing a new category of mental illness, or perhaps a variation of an old category. While bipolar disorder, for instance, has been an established adult diagnosis for over 100 years (although previously it was called manic depressive disorder), ten years ago it was almost unthinkable that children would be given this diagnosis. Children who exhibited out of control behavior, emotionalism, aggression, hyperactivity, or mood swings would be diagnosed with something else like ADHD, oppositional defiant disorder (which is another interesting category), conduct disorder or depression. Before the creation of the DSM, however, such children may have been called "difficult," "emotional," "incorrigible," or simply "going through a stage."
HOW DOES A PSYCHIATRIST OR PSYCHOLOGIST ARRIVE AT A DIAGNOSIS?
Ideally, a mental health practitioner should take complete family, behavioral, educational and health histories of the individual child. The practitioner should spend time observing the child in the office, and if possible in one or more other settings, such as at school and home. At the very least, the child's teacher and parents should be interviewed, and if possible the grandparents, who may have a completely different perspective, and who can speak about both the child and the parents. No child, it must be stressed, can be diagnosed with a mental disorder independent of an understanding of his parents and the quality of their parenting and their relationship with him.
With all the information in hand, the practitioner considers all the possible things that may be causing the child's behavioral symptoms. The parents may be going through a divorce and the child reacting negatively. The child may be a victim of physical or sexual abuse. The child may be neglected or feel emotionally abandoned. The child may have a physical disease, like diabetes. The child may be depressed or anxious, or hiding a terrible secret he or she cannot reveal to anyone. If all of these environmental things are ruled out, the practitioner may begin doing a differential diagnosis, that is determining all of the possible diagnoses that may fit the behavior and then ruling them out one by one until a final diagnosis is reached.
However, as there are not biological markers for most psychiatric disorders, a diagnosis is always an educated guess about what may be going on. And the guess is simply a name put on a list of (agreed upon by the "experts") behavioral and emotional symptoms for the dual purposes of better communicating with other practitioners and determining the best treatment for one's patients. It doesn't tell anyone how the disorder developed or what caused it.
With respect to the new practice of diagnosing bipolar disorder in children, there is no agreed upon list of symptoms that doctors can use to diagnose with confidence, thus the diagnosis is very subjective. And it appears that doctors take different approaches in making the diagnosis. In an April, 2007 article in the New Yorker, Dr. Jerome Groopman, author of "How Doctors Think," relates a conversation he had with Dr. Dmitri Papolos (author of the 1999 book about bipolar disorder in children) about how to diagnose bipolar disorder in children:
"Most researchers use the DSM criteria as a guideline. Dmitri Papolos…argues against applying these categorical criteria saying that their vagueness can cause confusion. 'The diagnostic category in and of itself doesn't really capture the condition,' he said. He prefers to make a diagnosis based on whether a patient's behavior matches the 'core phenotype' he has developed, which includes mania and depression, among several other symptoms. 'Once you see what this' – pediatric bipolar disorder – 'looks like, you can't mistake it,' he told me. "They call it the View. If you have the View, you get it.'…He could not immediately recall any child in this group who did not have a bipolar diagnosis, because, he said, 'the people who come to see me have read the book.'"
So it seems Dr. Papolos diagnoses patients based on something he calls "the view" which is a type of intuitive feeling for what he is seeing in a child, and also based on the fact that the parents who bring their children to him have already read his book and made their own evaluation.
WHY DID PSYCHIATRISTS BEGIN DIAGNOSING CHILDREN WITH BIPOLAR DISORDER WHEN THEY USED TO CONSIDER IT AN ADULT DIAGNOSIS?
I don't remember seeing a child diagnosed with bipolar disorder over the thirty years I practiced, and I never diagnosed any of my child patients with such a serious disorder, although I had certainly seen depressed children and children with serious behavior problems. However, I was still practicing when in 1999, a psychiatrist and his wife, Dmitri and Janice Papolos, wrote a book called "The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder." The duo believed that many children currently diagnosed with ADHD and put on Ritalin (the numbers of ADHD diagnosed children were probably in the millions) really had bipolar disorder.
The book made the rounds with parents concerned about their ADHD diagnosed children, particularly if medication didn't seem to be working, or with those who had children manifesting hard to control behavior, and soon parents were arriving at their psychiatrists' office with the Papolos book in their hands. More books and articles were written and soon unapproved and untested medication was being prescribed to children who a number of psychiatrists believed manifested this disorder. Pharmaceutical companies, never willing to pass up a potential new market, began working on medications to be used with this group of children, and recommended medications already in use for adults with bipolar disorder, or for other disorders in children. Television commercials are even being aired to urge parents to get help for children who manifest the symptoms identified by Papolos and other psychiatrists furthering the legitimacy of this diagnosis.
One such psychiatrist was identified in the 60 Minutes piece: Dr. Joseph Biederman, Chief of Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the Massachusetts General Hospital. Biederman clearly believes children can be diagnosed with bipolar disorder at an early age, and has lent his considerable credentials to the acceptance of this new diagnosis for children. According to the Mass General website, "Dr. Biederman's work is supported by multiple federal and pharmaceutical industry grants." What this means, of course, is that Dr. Biederman, like many leaders in the field of psychiatry, has a close relationship with the pharmaceutical companies whose drugs he prescribes to patients.
WHY DO SO MANY PSYCHIATRISTS FOLLOW PEOPLE LIKE PAPOLOS AND BIEDERMAN AND BEGIN DIAGNOSING HUNDREDS OF THOUSANDS OF CHILDREN, AND GIVING THEM POWERFUL MEDICATION, WHEN JUST A FEW YEARS BEFORE THEY WOULDN'T HAVE DONE SUCH A THING? DON'T WE HAVE A DRUG PROBLEM WITH KIDS AND TEENAGERS?
It is important here to acknowledge the enormous pressure that is put on individual mental health practitioners by the pharmaceutical industry and the big power brokers in the psychiatric community, whose research is mostly funded by pharmaceutical companies. Once a diagnosis is proposed, even if it hasn't yet been blessed by inclusion in the DSM, and when a new drug is released, there is incredible peer pressure on all mental health practitioners to accept both diagnosis and drug. I saw this first hand when ADHD became the diagnosis du jour in the field, and later when Prozac was first released. In this section I'll address the issue of diagnoses and in a later section I will discuss the pressure to accept the use of medication for any and all diagnoses.
Patients, or the parents of patients, also put pressure on psychiatrists. ADHD, known as ADD when I first became a psychotherapist, was not well known to the general public, nor to most mental health practitioners. Over time, articles and books were written, and gradually American parents began to be convinced that their children's problems with attention and learning weren't just laziness and misbehavior, but might have a name, and might be able to be fixed. At first, it was just parents of severely hyperactive children who sought help, but soon the visits to psychiatrists were scheduled by parents of less impaired children. It was almost as if the desire to have one's child diagnosed with ADHD was contagious.
For their part, psychiatrists were all too willing to prescribe medication to help these families. I believe most psychiatrists do sincerely want to relieve the problems of their patients, and few knew what to do with hyperactive children other than medicate them. There were a few non-biological therapies that were effective, though none that had the money of the pharmaceutical industry promoting them, and in any case, most psychiatrists didn't know how to do these kinds of therapies anyway. So, in their desire to help patients, and with their lack of training in any other approach, their belief in medication, and their need to be successful and well thought of by their patients, they began prescribing a medication that seemed to help, even though it had many negative side effects.
It should be remembered that psychiatrists are medical doctors, and believe in medication. All or most of their training is in using biological therapies, rather than talking or behavioral therapies, to help patients. It is typical for a psychiatrist who is prescribing medication to a reluctant patient to say something like this: "If you had diabetes, we would prescribe insulin to correct the sugar imbalance in your body. This is no different, in that you have a chemical imbalance in your brain that we can correct with medication." (I won't get into how misleading this is now, but will address it later.)
The same process seems to be happening with bipolar disorder. Children who have emotional difficulties or who have been diagnosed with ADHD and aren't being helped with medication are now frequently being considered for a possible diagnosis of bipolar disorder, which offers an entirely new set of medications. Psychiatrists, influenced by people like Papolos and Beiderman, as well as some research studies, are feeling more comfortable diagnosing the disorder. There is also the matter of influence from the pharmaceutical companies who fund research, offer doctors free vacations/seminars, and send attractive, young reps (one student of mine who worked at a mental health facility and attended weekly dinners and lectures sponsored by these companies, called the reps "the Barbies") to doctors' offices on a regular basis to check their samples, offer literature on new drugs, and aggressively promote their "products."
As for drug problems with children and teenagers, indeed that should be a concern. In fact, it is not uncommon for teenagers who have been put on Ritalin or other stimulants to pass out their prescription medication to their friends, or for brothers and sisters of ADHD kids to steal their sibling's medication. After all, these medications are stimulants, not unlike methamphetamine, the drug so popular among many high school age kids. In fact, Ritalin affects the same neurotransmitter systems and same parts of the brain as amphetamine and cocaine. Psychiatrists, however, count on parents to monitor their children's medication and believe that these stimulants, because they are "correcting" brain chemistry and are not intended to provide a "high," are not addictive and will not become a gateway to other drugs. This, however, may be more wish than reality.
THAT EXPLAINS THE PSYCHIATRISTS' THINKING, BUT WHAT ABOUT THE PARENTS? WHY, ON EARTH, WOULD PARENTS WANT THEIR CHILDREN TO BE DIAGNOSED AS MENTALLY ILL AND PUT ON STRONG PSYCHIATRIC MEDICATION? WHAT ARE SOME OF THE REASONS PARENTS ACCEPT A DIAGNOSIS FROM A PSYCHIATRIST AND AGREE TO OR EVEN SEEK MEDICATION?
Parents have a complicated task these days, perhaps more complicated than ever before. As our society becomes more technologically complex, as well as more educated, much pressure is put on parents to raise children who are highly skilled and have a high chance of being financially and socially successful. In this age of "experts," there is no shortage of advice to parents about how they should raise their children.
There are also many more areas where children can get into trouble these days than they could a few decades ago: the internet, television, cell phones, drugs, etc. At the same time, many parents have far less time to supervise their children as so many women have entered the paid work force and as the demands of this complex society vie for their time. Little attention has been paid to the possibility that less time with parents, and more stimulation from less than desirable sources might cause children to have more emotional difficulties, but the reality is that many children do seem to be having problems these days. Add to that the pressure that is put on parents to raise perfect and successful children and you have a recipe for the demand for quick fixes.
That being said, I believe most parents want to be good parents, and try very hard to do right by their children. One of the ways society suggests parents can do right by their kids is to get them help from a mental health practitioner if they are having emotional or behavioral problems. Several decades ago, parents were blamed if their children had problems. Everything that went wrong with a child was considered the parents' fault. (This, unfortunately, was one of the legacies of Freudian psychoanalysis.) The guilt that is removed when a doctor says there is simply something wrong with your child's brain chemistry, as sad as that may seem to parents, may actually be a relief in that it takes away the guilt they may be feeling. So parents are much more willing today to secure that help for their children than they were a few decades ago, and if an esteemed medical doctor says their child could benefit from medication, most do not question it. If it can help their child, they are willing to get that help, and they readily accept the chemical imbalance model promoted by their doctors.
Let's go back to the growth of ADHD as a diagnosis and how parents began to seek help for their children. Many parents had noticed that their children were hyperactive, and had difficulty with it. (Dealing with a hyperactive child is definitely exhausting.) When they began to get reports from the teachers that their child could not pay attention or was acting out in some way, they often talked to the pediatrician, who may have referred them to a psychiatrist. Some of these children were then put on medication.
In the meantime, as teachers and school principals realized that some children in their classrooms and schools were being put on medication, often with good results (giving the teachers fewer behavior problems to deal with) they began suggesting to more parents that they take their children to see psychiatrists. So both physicians and educators were giving their blessing to the use of medication. The media caught wind of this and wrote stories about the prevalence of ADHD and the wonder drugs used to treat it. Many books came out about ADHD, making the diagnosis and medication to treat it seem quite common and mainstream. Soon, even family practice doctors and pediatricians (not trained in psychiatry) were prescribing Ritalin and other stimulants.
Parents brought their children in to see me and other therapists, suggesting they were hyperactive and, rather than asking for therapy, wanting their child to be referred for medication. Mothers talked to each other in PTA meetings and at the deli counter at the supermarket, comparing doctors and medications their children had been prescribed. ADHD had in a few short years become an epidemic, or perhaps more accurately, a fad. That isn't to say that children weren't experiencing some problems, it is simply to suggest the numbers of children diagnosed as mentally ill had gotten out of hand.
Eventually, children with ADHD were classified as disabled and by law were given more time to take tests and complete assignments at school. This was noticed by parents who wanted their children to succeed and be able to compete with those who were given extra time on tests. Some parents even suggested their children had mild forms of ADHD, but still should be put on stimulant medication because they thought it might give the children an advantage in school. And, of course, pharmaceutical companies were all too eager to cash in on this new phenomenon, putting advertising on television that targeted parents as potential customers, and prompted them to seek help for their children.
A similar pattern seems to be emerging in the growing acceptability of the diagnosis of bipolar disorder in children with both professionals and parents.
HOW HAVE PSYCHIATRIC DRUGS BECOME SO POPULAR? WHATEVER HAPPENED TO THERAPY?
Therapy has never been a perfect scientific endeavor. It is more of an art, with some people having both good training and an excellent instinct for how to help people. Some very good therapies have come out in the last few decades, but not all practitioners have been trained well in them, and some simply aren't good at applying what they have learned. Many people swear by therapy, as they had an excellent therapist who knew how to help them, while others reject therapy, possibly because it didn't help them.
Even the best therapy, however, is a relatively slow process. There are some exceptions, but these are not therapies everyone has been trained in. Because most therapy is slow, it is also expensive, and insurance companies began in the 1990s to manage the care provided by therapists and limit the amount of therapy they would pay for. At the same time, in 1989, the first of the modern drugs to treat mental illness was released: Prozac.
Prozac had few side effects and seemed promising. While research shows a huge placebo effect with many psychiatric drugs, including Prozac, the drug did seem to help many people. The drug works on the neurotransmitter Serotonin, and soon other drugs that worked on Serotonin, or other neurotransmitters, were developed and more and more people began accepting the idea of using medication for their "depression." Pharmaceutical companies marketed them aggressively to physicians, and physicians sang the praises of this new approach to depression. Soon, psychiatrists, who worked part time in hospitals, and had trouble making ends meet with a part time private psychotherapy practice, abandoned the practice of seeing patients for talking therapy and simply filled their office hours with 15 minute medication consults which the insurance companies didn't mind paying top dollar for. (It was cheaper than paying for long term therapy.)
With so many people now taking the new medication, visits to psychiatrists were no longer stigmatizing, and the use of psychiatric drugs snowballed, as did the pressure on non-medical practitioners to refer their patients to psychiatrists for medication consults.
In my own practice, I felt the pressure. I was a non M.D. therapist practicing in a small town. The one psychiatrist, who was driving many miles to work at the county facility just to make ends meet, began to see numbers of patients for whom he prescribed Prozac. In discussions I had with him, he related the propaganda: Prozac is safe, non-addictive, and corrects a chemical imbalance. You can take it and get off of it at any time, and it even helps women lose weight. Of course, some of these "facts" later turned out not to be true (it can, for example, be extremely difficult to get off of medications like Prozac), but at the time, the pressure on me – from both the psychiatrist and my own patients who were hearing about this wonder drug from their friends and family physicians - was enormous to refer patients to a psychiatrist for the new drug. Conferences touted the new drug and others that soon came along, and insurance companies began to insist on medical consults for psychotherapy patients. It became the standard practice to refer for medication, and ethics committees for the various mental health professions suggested that not referring patients could violate ethical practice guidelines.
Finally, one can't ignore the profit motive of the pharmaceutical companies. These companies have a patent on their drugs for a limited number of years. After that, generic forms of the patented drug can be released by other companies and the company that developed the drug has a sharp drop off in profit. Thus, they must always be developing new drugs. Sometimes, if they can come up with a new disorder, they can market an old drug with a new name, or an old drug with a slightly different chemical composition. So, for instance, they develop a time-release version of the drug and get a new patent. Another example occurred a few years ago when the makers of Prozac began talking about a new disorder they called "Premenstrual Dysphoric Disorder," which actually was a new name for severe premenstrual syndrome, and created the drug Serafem (which was a new name for the drug Prozac) to treat it.
WHY AREN'T CHILDREN AND ADULTS DIAGNOSED WITH THE SAME DISORDERS?
Sometimes they are. For example, both children and adults are diagnosed with depression and anxiety disorders. And we do see precursors of schizophrenia in children. However, we must be cautious in diagnosing children with disorders that previously were only diagnosed in adults for several reasons.
First, when you are dealing with children, you must take into account developmental stages. What might be abnormal in an adult is quite normal in some children at some ages. For instance, it would be considered abnormal for a 25 year old to cling to mother and not want to live on her own or get married, but a clingy three year old going to preschool for the first time would be considered normal. Tantrums, hitting, excessive emotionalism, stubborn refusal to do things and many other behaviors can all be part of normal developmental stages in children but would be considered aberrant in adults. (It is unconscionable to me that 2 and 3 year olds are being diagnosed with things like ADHD and bipolar disorder. I wonder if any of these psychiatrists have raised children or been around children in a non-clinical setting. Two and three year olds display all kinds of difficult-to-deal-with and immature behavior, including tantrums, wild emotions, aggression and stubbornness.)
Second, it is important to understand childhood, and how the brains and behavior of children and adults are different. Children's brains are still developing and growing, still creating new cells and neural pathways as they learn new skills and behaviors. We have no idea how some medications might affect the developing brain and so we must be cautious in prescribing them unless there is absolutely no other way to prevent a child's suicidal thoughts, severe depression, or uncontrollable and dangerous behavior.
Third, there is no way to evaluate a child's behavior and emotional symptoms in isolation. As children are highly dependent on their parents, parental behavior, parenting practices, parental and sibling illness including mental illness, can all factor into the causes of a child's behavior and must all be considered in determining what is going on with an individual child. In the case of Rebecca Riley, her older siblings had been diagnosed with psychiatric maladies, and were both on medication, which made the doctor more willing to diagnose little Rebecca with the same disorder (bipolar disorder is thought to run in families). However if Rebecca's family was one in which parents and children were all displaying abnormal behavior (Rebecca's mother was also medicated, at least after she was arrested), how can we know whether the emotional and psychological chaos of the family was influencing Rebecca to act a certain way?
A final reason we must be cautious in diagnosing and medicating children is that they cannot freely consent to treatment. They are dependent on their parents and health care providers and they are pretty much helpless to say "no" when a parent agrees to medicate them. Furthermore, when drugs have not been approved for use in children, there is an even greater danger. As for the approval process, how does one determine that drugs are safe in children without testing them on children, which brings up a whole new set of ethical concerns.
WHAT IF THE DOCTOR SAYS A CHILD HAS A "CHEMICAL IMBALANCE?" IS THAT ACCURATE, AND IF SO, WON'T MEDICATION HELP? IS THE PSYCHIATRIST LYING?
The term "chemical imbalance" is one commonly used by psychiatrists and one that has some validity, although it is something of a metaphor. Since drugs used in the treatment of mental illnesses target certain neurotransmitters (brain chemicals) it is probable that the drugs are influencing the brain chemistry, but we can't be sure as these things are difficult if not impossible to measure. We are reaching the conclusion that there must be a chemical imbalance because targeting a certain chemical in the brain with a drug seems to have some positive effect. The reality, however, is that neurobiology is extremely complex, and while new work is being done to determine how the brain works, and what structures impact specific behaviors and bodily functions, there is still much to learn. We cannot, therefore, say that we know for certain what a specific drug does to improve a patient's mood or behavior, and what it might be doing that could cause long term damage. Often, it is only through the passage of time that we are able to fully embrace or ultimately reject the use of a medication.
However, the medications used to treat mental illness are all extremely powerful chemical compounds we are introducing into the bodies of patients, and we cannot be sure that the drugs themselves don't create a type of "chemical imbalance." We know that these drugs do something to the brain, because none of them are easy to discontinue. All must be withdrawn slowly or the brain objects with a variety of unpleasant withdrawal symptoms.
Furthermore, it isn't just drugs that change the function and chemistry of the brain. Every action we take, every memory we record, every new skill we learn changes our brain in some way. In fact, there are some therapies that work by changing the way we think, and thus changing the way the brain works. The advantage of changing the brain through therapy, however, is that there are no unpleasant physical side effects, and no withdrawal symptoms when therapy is discontinued.
Finally, as a society, we object to illegal drugs because we believe they are potentially harmful, and because they tend to cause addiction which leads to a whole host of legal and societal problems. Since the composition of some of these legal psychiatric drugs is quite similar to that of the illegal varieties, we must consider that prescribing them is not the same as prescribing insulin or antibiotics. It is serious business, and in too many cases can even be deadly, and so the prescription of certain psychiatric medications must be undertaken with sobriety and extreme caution, especially when used for a new and controversial diagnosis, and most especially when the drugs have been neither tested for safety, nor approved by the relevant agencies.
As for the truthfulness of psychiatrists, I believe most psychiatrists believe they are correcting "chemical imbalances." It is a metaphor that makes sense to them, whether or not it can actually be proven definitively, and they are trying to help their patients in whatever way they can. But psychiatrists, like all professionals, can easily end up boxing themselves into a way of thinking, a way of speaking and a way of conceptualizing human problems that may not be completely accurate. This is why second and even third opinions are important, and why it might not be best to seek help from someone who specializes in only one disorder, like pediatric bipolar disorder. When people come to a psychiatrist who specializes in ADHD or bipolar disorder or any other diagnosis in the news because they expect that diagnosis, chances are they will get it. Sometimes both patients and doctors have blinders on, and only see what they are used to seeing, and what they want to see.
IF THESE CHILDREN AREN'T MENTALLY ILL AND SHOULDN'T BE GIVEN MEDICATION, WHY ARE THEY ACTING IN STRANGE WAYS, AND WHAT ELSE CAN BE DONE?
First of all we have to ask just how strange the actions of our children are. If our children are not always acting as we expect them to or as we are comfortable with, it doesn't always mean their behaviors are out of the normal range of childhood behaviors. It might be that we are under more stress than our parents and grandparents were, and don't have much patience for the crying, screaming, tantrums, threats, power plays, and demand for instant gratification that so characterize children. It might be that we are highly suggestible, highly influenced by television stories, magazine articles or commercials that tell us our children are abnormal.
Second, with the vastly increased numbers of children today being diagnosed with mental disorders, compared to just two decades ago, we have to wonder what is going on. Are children today all of a sudden more mentally ill they were one or two generations ago, or is something else going on? It can't be that children today have suddenly evolved different brains, as evolution doesn't proceed in generations but over hundreds of thousands of years. It can't be that they all have a genetic mutation, as mutations increase in the population over similarly long spans of time.
Is it possible that children haven't changed but that we have become so good at detecting mental illness today that we can now diagnose kids we missed many decades ago? In some cases this may be true, but I find this an unsatisfying explanation, particularly when such large numbers of children are all of a sudden being diagnosed with serious disorders. Generations of kids have gone to school and learned and grown up just fine over the last century. And not one of them before about 1980 was put on a stimulant medication to help them learn or an antipsychotic to treat bipolar disorder.
If indeed we are seeing more troubled children today, it is tempting to come up with an explanation, or at least a treatment. Today, the brain imbalance – medication paradigm is providing an answer, but is it the right one?
Is it possible, instead, that society has changed so much in the past forty or fifty years that our children cannot cope? All we have to do is look at the numbers of unhappy adults, as evidenced by various addictions, compulsions, depression, anxiety, rage and other problematic behaviors that we see every day. Adults are having problems, so it only makes sense that children might also be having problems, or reacting to what is going on with their parents. Maybe the way our society is structured today isn't good for us or our psyches. In addition to that, we need to look at changes in the way we parent our children. We enroll them in a million activities and leave them little down time, other than when they are left unsupervised at home. We give them endless choices, expect them to be the best, demand that others give them preferential treatment, and indulge them with all kinds of possessions. I believe these are all things that require looking into.
I don't think we can underestimate the changes that have taken place in our society since the burst of new technologies came on the scene after World War II. Television, for instance, changed the way families interact, lessened the amount of reading and exercise children engaged in, and even changed the family dinner table routine. The advent of TV trays and TV dinners left many families staring at the tube and not even talking to each other. It is impossible to estimate just how much children lost, how many things they didn't learn about love and life and disappointment and coping, when they lost that one family ritual.
Moving ahead a few decades, the cell phone gives children instant access to each other, and the internet and video games expose them to all sorts of things that may not be good for them. Technology makes everything move faster, making it much harder to absorb all the new information, and possibly overloading the brain circuitry of children. In addition, children are left alone for many more hours than they used to be, as both parents spend their days at a paid job. Unsupervised children, and the children of overburdened parents, tend to eat much more junk food and are developing type II diabetes in record numbers.
We expect our children to grow up way too fast, to absorb way too much in our culture that they should not be exposed to. As an example, a few weeks ago I went to see the new Jason Bourne movie and one set of parents had brought their three children, ages two to six. This movie was extremely violent and fast paced, and one of the children cried throughout. These parents, in my opinion, were behaving with neglect if not abuse towards these children by exposing them to things their minds could not easily absorb. How many more parents allow their children to see violent television shows or play violent video games in the privacy of their homes?
Unfortunately, at the same time that children are being exposed to more stimuli, they are deprived of the extra time they need with adults to process that stimuli. Parenting is an endeavor that cannot simply be done in one's spare time, but that is what is happening in many families. This may have been acceptable when most kids lived on the farm, or down the street from grandparents and aunts and uncles, all of whom helped in the rearing of the children, but it does not work today. Extended families are spread across the country, if not the world, and parents are often gone for many hours leaving the children unsupervised. When everyone gets home, there is a rush to eat, do homework, shower and get to bed. There is little time to process the events of the day, the worries and fears of children, the misunderstandings, feelings of inadequacy or even the misbehaviors. Consequently, children are left to figure many things out for themselves, many more things than their grandparents had to figure out.
There is much about the culture that might give us a clue as to why so many children are behaving with wild mood swings and difficulty sitting still or paying attention. Yes, this may be due to changes in their brains, but those changes may very well be created by the environment, not by some hypothetical inherited disease for which there is no lab test. We may never have a definitive answer as to whether the behavior of children really has changed, and if so, why. Figuring that out would take a great deal of sophisticated research and most likely the funding for such a project would be hard to get. As long as the pharmaceutical companies have such huge amounts of money to fund research, the type of projects we are likely to see are those that promote the effectiveness of specific drugs in the treatment of specific disorders.
As an alternative to medication, there are some non medical therapies that can help children, but not enough, and not always done by skillful practitioners. More work needs to be done in developing effective therapies and providing training for therapists. Again, there is not a lot of money to put into the development of such programs. Both insurance companies and drug companies, who control most of the money in the mental health field, put the focus on research and development of and payment for pharmaceuticals and other short term, inexpensive approaches.
In the absence of more money available for the development and use of alternative therapies, as well as the training of therapists, parents can reach out to each other and form advocacy and support groups, either in person or on line, and work together to achieve the following goals:
1. Determine what is normal behavior and what is abnormal behavior, what can be handled with changes in parental practices, the application of behavioral or family therapy, or simply the passage of time, and what is so serious that it must be handled by a qualified medical professional.
2. Learn new methods for handling childhood behavioral problems by sharing ideas and success stories with others. Offer support and comfort to each other in much the same way an extended family used to offer such support.
3. Get referrals to therapists or other professionals, such as educators, who know how to work with certain types of children. Get referrals to quality parenting classes, that teach realistic and common sense strategies for dealing with children in today's busy world.
4. Find ways to spend more family time and individual one on one time with your child, without interference from television, computer or video games.
5. Work with the school and individual teachers to set up creative programs for vulnerable children that will help them learn and prosper. Work with the community to set up supervised after school programs for kids.
SO, BOTTOM LINE, IS THERE SUCH A THING AS BIPOLAR DISORDER IN CHILDREN?
The most accurate answer any psychiatrist can give to a parent is "no one knows. There are behaviors in children that may resemble symptoms and behaviors of what we call adult bipolar disorder, but remember, these are constructs only. There is no brain imaging test, no blood test, no x-ray, no identifiable virus or bacterium that we can say is the marker for bipolar disorder or almost any other psychiatric disorder. Doctors and other mental health professionals make a diagnosis based on observations and reports of patients and their family members regarding behaviors and symptoms. On the basis of that information, doctors make educated guesses and give an agreed upon name to the collection of symptoms. No one really knows what causes the emotional and behavioral symptoms and if they are the result of environment, brain abnormalities, or some other unknown variable.
The best any psychiatrist who is honest can really say is this: "Your child is showing some extreme behaviors that some professionals think are a manifestation of an underlying mental illness or abnormal mental state we have chosen to call "bipolar disorder." We do not know what causes it, if it even exists, or if it might be an unusual manifestation of something else. There is medication that is used to treat bipolar disorder in adults, but none of those medications have been approved in children and all of them have serious side effects that may make them inappropriate for children whose brains and bodies are still growing and developing. In addition, we do not really know why these medications work and indeed sometimes they do not work.
It's possible that the behaviors shown by your child are due to some process within the brain, or it is possible that your child's behavior is a reaction to something in his environment. Since the body (including the brain) is influenced by the environment and vice versa, and since behavior is a response to that interaction, there are probably multiple reasons for the behavioral symptoms. Medication is one way to approach your child's problem, but changing the environment (with the help of a good therapist) is another approach with far fewer side effects. It may take longer to achieve results (as medication works much faster) but in the long run it may be the better choice."
That is what I would expect a good psychiatrist to say, at least until more can be discovered that confirms or denies the existence of a pediatric bipolar disorder.
Whether or not there is such a thing as pediatric bipolar disorder, the reality is that there are many children who suffer through their childhood. While some unhappiness, moodiness, and anger is a normal part of childhood, excessive amounts over long periods of time are not, and should be taken seriously. Any child who is suicidal, who exhibits uncontrollable mood swings that interfere with school, home or play, who is violent, or who is severely depressed, is a child in pain who needs help. There are many excellent practitioners out there, both psychiatrists and non-medical therapists, who may be able to offer assistance to both parent and child. If the first one you see doesn't say the right things, go somewhere else. If you believe they are prescribing medication too quickly, without taking a thorough history and considering multiple possibilities, get a second opinion.
The bottom line is this: parenting is tough work and not all children get through their childhood without encountering problems. Some children have more to deal with than others, and some children as well as parents truly do need the help of highly trained professionals. But medication isn't going to solve everything, and any psychiatrist who simply prescribes medication, without getting to know the family and trying to understand all the environmental factors that may be impacting the child, and without insisting on a course of appropriate psychotherapy and possibly parenting classes, is not doing his or her best for the family and especially for the child.
So it doesn't matter what we call something. What matters is that we treasure our children and explore the best possible ways we can help them. Sometimes it will mean changing the way we do things at home. Other times it may mean seeking help from teachers or mental health professionals. But because of the vulnerable nature of the immature brain, and the dependency of the child on the behavior of the adults around him, only in rare cases should it mean diagnosing a child with a serious mental disorder and prescribing potentially dangerous medication.
We in the mental health, education, and parenting communities shouldn't be about trying to put new labels on children, and developing new drugs to control emotions and behaviors, we should be about doing what is best for children, even if it means we will have to make some profound changes in our lives, in ourselves, and in the way we do things as a society.
-Ellen Terich, Ph.D.
All content © 2005 outragedcitizen.com
|
