It’s no wonder that people think psychiatrists are a bunch of hacks.
Rebecca Riley was a four year-old girl, diagnosed with bipolar disorder at the age of 2.5 (!!!), who was found dead in Hull, Massachusetts, presumably due to
“intoxication due to the combined effects” of the drugs clonidine, valproic acid (Depakote), dextromethorphan, and chlorpheniramine….
For reference, clonidine is a blood pressure medication that is sedating (and thus has been used to promote sleep and reduce (aggression in kids).
Valproic acid is a mood stabilizer and anticonvulsant (prevents seizures) that is commonly used in the treatment of bipolar disorder. Frequent side effects include weight gain and sedation. (Then there’s the minor details of possible liver inflammation and pancreatitis (inflammation of the pancreas).)
Dextromethorphan is an “antitussive” (prevents coughing). You can also get high off of it—if you consume enough of the stuff.
Micromedex tells me that chlorpheniramine (which I’ve never heard of before) is used for allergies—like Benadryl.
According to news reports, she also received quetiapine (tradename: Seroquel), an antipsychotic medication, from her psychiatrist. The major side effects of quetiapine include weight gain and sedation. It can also cause blood pressure to drop, such that people feel light-headed.
Prior to her death, school administrators had noted that she had been “a little too quiet”. Probably because she was “a little too sedated”.
There does not exist any criteria that are clearly valid or reliable for the diagnosis of bipolar disorder in children (1). The assumption is that criteria for adult bipolar disorder can be applied to kids, though researchers in that area simultaneously agree that adjustments are necessary for this diagnosis in kids. It’s kinda like saying, “It’s basically the same thing, but only different.”
The criteria that some researchers (2) use to diagnose bipolar disorder in kids include:
Elated mood:
- “… it can be very misleading to see a happy child laughing in the office in the context of a miserable history (e.g., school suspensions, family fights).”
Grandiose delusions:
- “A common presentation for bipolar children is to harass teachers about how to teach a class; this harassment is often so intense that teachers telephone parents, begging them to ask their children to desist.”
- “Another common grandiose manifestation in children as young as seven is to steal expensive items and be impervious to police officers who attempt to make them understand that what they have done is wrong and illegal.”
- “Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”
High activity level:
- “Manic adolescents will wait until their parents are asleep and then go out “partying”….
Pressured speech, racing thoughts:
- “… children state that they are not able to get anything done because their thoughts keep interrupting.”
Hypersexuality:
- “Children may masturbate frequently, initially openly, and then when told not to do it publicly will simply make frequent trips to the bathroom to continue the stimulation.”
- “Adolescents develop romantic fantasies and delusions about teachers.”
Risk taking:
“Interest in money appears in young children when they start their own businesses in school and when they begin to order multiple items, trips, and plane tickets….”
What?
These criteria significantly overlap with the range of normal. Should every kid who is experiencing difficult social stressors never laugh? Can’t kids be obnoxious and tell off the teacher? Are kids “mentally ill” for possessing dreams and aspirations? Do kids who disobey their parents have a condition that is only treatable with medications? Is distractibility a marker of pathology?
And, for the love of God, KIDS MASTURBATE. That’s part of normal—yes, normal—development. It happens. And shouldn’t we congratulate kids for changing their behavior after receiving admonitions (kindly or otherwise) and conducting their business in private? After all, at least they’re not telling their teachers how to masturbate properly.
And what kid hasn’t had a crush on a teacher? And where do kids get the idea that money is an important facet of life? Isn’t that cultural in nature?
The article that cites these criteria does list them as if they are valid and reliable—which they’re totally not. We cannot rely on these criteria for diagnosis and since diagnosis guides treatment, the treatment (medications) is faulty due to the weakness of the evidence.
And no one is jumping up to conduct a randomized, placebo-controlled, double-blinded study on kids and medications because of all the ethical issues involved (although I recall reading somewhere that Harvard had done something like that… though I can’t find the citation now). Would you want your kid (baby sister/brother/cousin/et al.) to receive medications at uncertain doses with uncertain effects with uncertain outcomes? Do we even know how quetiapine or valproic acid or whatever affects neuronal (read: brain) development? Particularly at the age of TWO? Or, heck, even FOUR? The brain is a miraculous organ that changes dramatically well through adolescence. Just what are we doing to the neurochemistry of the brain through the introduction of these substances?
We don’t even know how valproic acid works in the treatment of bipolar disorder in adults.
The only argument I can come up with as to how these researchers justify diagnosis and subsequent treatment of bipolar disorder in kids is one that is frequently used with pregnant women: “The effects of the disease may be more harmful than the effects of the medications.” (For example, non-depressed, non-anxious pregnant women get better prenatal care, have more optimized nutritional status, smoke less, use fewer drugs, and drink less alcohol (3). Suicide is also the third most common cause of maternal death in the U.S. (4) One can thus argue that the benefits of antidepressant use outweigh the risks to the fetus.) If, however, we can’t even offer valid and reliable definitions for the disease, how can we possibly argue that treatment of this amorphous disease has any benefit?
Another facet of this is that there are some adults with bipolar disorder who state that they believe they developed this condition when they were children (1). (Side note: Using the above criteria, more than 10% of kids meet those criteria for bipolar disorder… and in adults, the prevalence is closer to 1%. This means that (a) the child and adolescent criteria for diagnosis are inaccurate, (b) the condition “burns out”, or (c) we’re measuring the wrong things.) Are we invalidating these adults by stating that bipolar disorder just doesn’t exist in kids? (Of course, who is going to remember that they had symptoms when they were two years old?)
One last aspect I’d like to address is how psychiatric training varies by region. The rumor mill tells me that child and adolescent psychiatry in Washington State is arguably the most conservative in the country; “play therapy” (where the thought is kids “play out” their issues under the watchful eyes of the therapist) is considered irrelevant and is generally not practiced here. Although there are certainly child and adolescent psychiatrists here who prescribe many, many medications to kids, the general push is to remove as many medications as possible and use behavioral interventions, structure, etc. in treatment. This is apparently in significant contrast to the East Coast, where apparently many more psychiatrists believe in the “bipolar child” paradigm—and as one moves out West, skepticism tramples this belief underfoot. The major proponents for bipolar disorder in kids (including the author of the above criteria) are all located East of the Mississippi River.
The case of Rebecca Riley is tragic on many different levels—it cries for reform throughout the system on many levels, particularly in the realm of education. We need to learn more about valid and reliable diagnosis for psychiatric disorders, both in kids and adults. We need to learn more about appropriate treatments—and not just in the realm of pharmacology—for these conditions. We need to provide this information—all of it, not just the parts that sound benign—to patients and their families. We also need to facilitate discussion with patients and families such that they feel comfortable asking questions about their care; this results in more thorough coverage of risks and benefits, encourages collaboration (e.g. increased frequency in follow-up, etc.), and improves the therapeutic relationship. We need to stop labeling behavior as pathological just because it causes us inconvenience. We also need to stop using diagnoses as means of absolving us of our responsibilities (”it was the bipolar that made me say those mean things to you; it wasn’t me”). We, as providers, need to stop colluding in these goals: We need to stop the belief that a pill will always cure everything.
That is all.
(1) Harris, J. Child & Adolescent Psychiatry: The Increased Diagnosis of “Juvenile Bipolar Disorder”: What Are We Treating? Psychiatr Serv 56:529-531, May 2005
(2) Geller B, Luby J: Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36:1168–1176, 1997
(3) Wisner KL, Zarin DA, Holmboe ES, Appelbaum PS, Gelenberg AJ, Leonard HL, Frank E. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry. 2000 Dec;157(12):1933-40.
(4) Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ. 1991 Jan 19;302(6769):137-40.
17 Feb 2007 |
A diagnosis of bipolar D/O at 2 1/2?!
Comment by Ari | 17 Feb 2007 @ 8:31pm
I do not work with children. It breaks my heart to hear that a baby is being diagnosed with an adult disorder. My husband has ADD which was never diagnosed. It wasn’t even heard of in the 60’s. Our oldest daughter (23) was diagnosed at age four and a half as having ADD. It was the eighties and the only options the child study team offered was, of course, ritalin. I did some research and said no, she could learn coping skills and get by without medication. We had a battery of tests to rule out physical issues and were very fortunate to find a teacher who taught her how to work. There were some good teachers and some who told me “I can’t teach her, she is too smart and already knows what I have to teach”. She continues to be very bright but has an extreme distrust of teachers and will not willingly sit in a classroom full of people. She loves to read and is a computer whiz so I am hopeful I can intereest her in an online education. She also does not drive because she is afraid and it is difficult to get around without a car here. The public transit system leaves a lot to be desired. she is happy and that is what matters to me. I am so proud of the lovely woman she is becoming.
Comment by donna lee | 17 Feb 2007 @ 10:05pm
Can I just say how completely grateful I am that I’ve never had a student tell me how to masturbate. Next time something gets me cranky, I’ll just think of that and be full of gratitude and joy.
This was absolutely fascinating. It’s especially interesting to learn a little about how different attitudes in two parts of the country are about diagnosing kids and treating them.
Did you have a sense of this difference when you chose your program (or ranked your programs)? How does knowing about this difference affect or influence your thinking about further fellowship work and where?
Comment by Bardiac | 18 Feb 2007 @ 7:32am
reminds me in a strange way about the lobotomies a certain doctor used to perform upon people with mental illness before there was medication. Meds were a miracle, but it does seem we’ve swung too far in their direction.
Comment by drcharles | 18 Feb 2007 @ 7:38am
Maria,
I can’t tell you how much I appreciate your analysis, with which we agree completely. I’ve dragged my heels so long to add you to my bloglines.com list, and now I’ve added you to my blogroll as well.
Keep up the excellent work!
Flea
Comment by Flea | 18 Feb 2007 @ 12:32pm
*standing ovation*
I think a lot of the psych stuff regarding kids is scary. There isn’t enough data and kids just act weird in general. I’m definitely more of a proponent of CBT-type techniques in kids under 18.
If you stay in Seattle (and if I end up there, as I plan), I *will* be referring patients to you. I like your philosophies.
Comment by misterbeans | 18 Feb 2007 @ 12:35pm
I especially liked the passage about “grandiose illusions”. E.g. this one:
Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”
If you expand this a bit, then everyone who dreams about being a singer, a dancer or an actress but has no talent is suffering from “grandiose illusions”.
Judging from American Idol auditions, the incidence of bipolar disorder (and not just among adolescents) must be much higher than anybody imagined.
Comment by kitty | 18 Feb 2007 @ 2:09pm
I’ll agree that bipolar is diagnosed way too often, and probably because the case definition has too much overlap with normal. But I do believe there are a few kids out there with it. Last year I saw a 5-year old who would go from angel to devil and back again without any provocation, totally unpredictable, the child herself didn’t even understand it. It’s like good art: I can’t tell you what it is or what it’s about, but I know it when I see it. That being said, this was maybe the second patient in 5 years I’ve seen who I was convinced really had it.
Don’t know enough about Rebecca Riley’s case to comment, but being diagnosed at 2.5 sure sounds awfully young. Then again, I’ve heard some psychiatrists claim they diagnose depression in infants. That seems fairly ridiculous to me.
Comment by Dr. Scott | 18 Feb 2007 @ 2:43pm
Chlorpheniramine (Chlor-Trimeton) was ubiquitous in our house becasue the GP that my mom worked for got free samples. One thing I noticed about ritalin is that micro-doses (~1.25mg, 1/4 of a 5mg, for 12 to 18 hours) worked better for my allergies in Sac than anything else I have ever taken. Though I highly doubt many doctors would prescribe it off-label for that application.
Comment by Terry | 18 Feb 2007 @ 2:49pm
I’ve been reading about this case since it surfaced a couple weeks ago, and your take on it is more complete, more rational, and more human than anything else I’ve read. Thank you especially for sharing your obvious passion as well as your insight. I do hope you won’t be deep-sixing your writing from this month, because I intend to be linking to it sometime soon when I get my own blogging direction squared away and underway. Please keep up the great work; I value the voice you bring to these issues.
Comment by Joseph | 18 Feb 2007 @ 4:58pm
Wow… What a sad, sad story!! One thing that has always stuck in my mind from my nursing education is that, “Children are NOT small adults!” Now - I’m a neonatal nurse and I must say that all-too-often when we use meds, it is easy to forget that. We give meds to babies when we can’t be entirely sure what happens…but we know what happens in adults on these meds. Do the same things happen in babies? Do they suffer fewer or more side effects? For some drugs, there are studies and evidence - but not for all!
That list of criteria is absolutely ridiculous. Talk about taking normal childhood behavior and turning it into some sort of pathology. It’s such a shame… Yes, I think that mentally ill children should receive help and treatment, but I also think that between the schools, physicians, mental health system annd the media, wayyyyyy more children are labeled than should be… It’s sad…
Take care,
Carrie :)
Comment by Carrie | 18 Feb 2007 @ 6:53pm
I think that if people (teachers, neighbors, doctors etc) spent less time labeling normal although perhaps more active and more demonstrative children; and more time looking at the ones who are trying desperately to be invisable…then maybe there would be a heck of a lot less kids on meds who don’t need them. And maybe…just maybe, less kids having to run away or wait for adulthood to escape abusive homes!
Comment by Fallen Angels | 18 Feb 2007 @ 10:31pm
That is a heartbreaking story.
I have a lot of trouble with the medications given to Rebecca (this is the pharmacist in me talking, not the medical student - medical student Yay doesn’t know about psych drugs yet. But pharmacist Yay does!), but crazy prescribing aside, it’s not just psychiatry that has screwed up in this case. There must have been a lot of people involved in the care of this child - the parents, psychiatrist, paediatrician, social workers (the family had been under investigation at various points in 2005), teachers, pharmacists, non-parental caring people…
It should never have got to that point.
So the other issue is diagnosis and treatment of psychiatric illnesses in children. I think that here (Aus) we tend towards the west coast approach - I can go for weeks without dispensing any scripts for kids other than antibiotics (I’ll save that rant for a family physician’s blog). I do have a few kid patients on Ritalin/Concerta/Dex, as would be expected, but I’ve dispensed a grand total of two scripts for antidepressants for children in the last year, one for antipsychotics, a couple of clonidine… and that’s about it. And the kids who are on these medicines are on them because non-drug approaches didn’t work and their parents have seen the positive effects these drugs have on their children.
Having said that, I work in relatively affluent areas where parents of children with learning problems can generally afford to get the extra assistance they need. Things are very different in the population explosion that is the western suburbs.
Comment by yay | 18 Feb 2007 @ 10:53pm
I especially liked the passage about “grandiose illusions”. E.g. this one:
Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”
I’m going to be an astronaut when I grow up!
Comment by Coin | 19 Feb 2007 @ 2:21am
I started having emotional storms when I was around ten which I now link to my adult bipolar-II diagnosis. While my sister did not have the same pre-teen outbursts, I would think it odd if anyone had leapt upon mine with an Aha! Bipolar! pronouncement.
I became suicidal for the first time at fourteen, something else that I look back and link to my adult diagnosis. But while meds are saving my life today, I can’t think that they would have been appropriate at the time. The first time I was suicidal I felt like a fraud for not following through. By the fourth time, I had figured out that wanting to kill myself was just a feeling and that if I could wait it through that life would be worth living again - even if that was seeming impossible at the time. I’m pretty sure that being medically treated for suicidal depression and even talk therapy that put me in contact with a professional manager of emotions would have had prevented me from learning the lessons that I did.
For whatever reasons, I have had some pretty awful interactions with psych professionals as an adult and have come to the conclusion that about a quarter are damaging, half not particularly helpful and only one quarter of psych professionals I am likely to work with are actually going to be helpful to me. As an adult, deciding to take the risk of walking into a psych professional’s office is already a big deal. I would not want to send a child to see a psych professional if I thought that the chances of the interaction damaging my child were equal to those that they would help. And I have a hard time imagining an interaction with a psych professional that would have helped me at fourteen… or ten.
Even assuming that by age ten I was showing early signs of bipolar II, I can’t think of any more appropriate response to my stormy pre-teen and adolescent self than adults in my circle acknowledging the inevitability of suffering, demonstrating that they cared about me, and holding me to a standard of behaviour.
Just because you can put a medical label on something if you want to doesn’t mean that treating it medically is the best thing you can do.
Ok. That was one.
Two. Maria has just said two things that puzzle me, probably because my range of experience is limited.
“We need to learn more about appropriate treatments—and not just in the realm of pharmacology—for these conditions. We need to provide this information—all of it, not just the parts that sound benign—to patients and their families. We also need to facilitate discussion with patients and families such that they feel comfortable asking questions about their care; this results in more thorough coverage of risks and benefits, encourages collaboration (e.g. increased frequency in follow-up, etc.), and improves the therapeutic relationship.”
Do Rebecca Riley’s parents sound like the kind of people who can absorb and use this kind of information? Who even care? They sound like a tumultuous family who identified one member as the black sheep / sacrificial goat. A family with very limited resources.
A woman I know worked for a while referring people to day-care services in their area. She was required to counsel them on the different kinds of day care that meet different kinds off needs, and she said that was often frustrating for her and her clientele. Her clientele were typically in extremis and just needed something - anything - and even if one form of day care would have been more appropriate than another, they really couldn’t care at that point. In other words, they were unable to participate in the counselling because the counselling wasn’t daycare and daycare was what they needed. If that’s often the case for daycare, I am trying to imagine Rebecca Riley’s parents cooperating with a psychiatrist to understand all the risks and benefits to managing Rebecca in different ways. They simply did not have the personal resources or interest, from all appearances. So talking about ensuring that parents are fully educated seems a little idealistic to me in the context.
The other peculiar statement is, “We also need to stop using diagnoses as means of absolving us of our responsibilities (”it was the bipolar that made me say those mean things to you; it wasn’t me”).”
I have never heard anyone make such a statement. Not about bipolar, not about PMS, not about depression or alchololism or anything. Everyone I know who has a diagnosis identifies with it. The bum on the street will say, “No, I don’t want coffee, I want a beer. I’m just an old alchoholic.” The asshole will say, “I’m bipolar. I can’t promise I will never be an asshole again. If that’s what you want, I can’t do it. But I can leave when you can’t stand me any more, if you’ll let me back when I’ve settled down. And I can understand that you wouldn’t want to let me back, because I’m such an asshole.” The dually-diagnosed will go on and on about how difficult (but rewarding) it is to be them and manage all their broken pieces, and about how grateful they are for the forebearance of others and for the little life that they have managed to make for themselves despite everything.
Maybe it’s a cultural thing. Maybe it has to do with the way the law is phrased in the US such that people who commit crimes because they are assholes are guilty but people who commit them because of a mental defect are not. (I thought assholism was a mental defect!) It’s probably because I am not a doctor. But the whole absolving-of-responsiblity thing smells of red herring from where I sit.
Comment by Alison Cummins | 19 Feb 2007 @ 5:18am
[…] Today in his blog, Dr. Charles brought to my attention a tragic story of a 4-year old child who died after being over-medicated for a presumed diagnosis of Bipolar disorder. The child was diagnosed at age 2, and was on multiple medications that were quite strong to treat this problem. There is a good op-ed from a psychiatrist that rightly addresses the wrong-thinking that can lead a child to be treated as such. […]
Pingback by Musings of a Distractible Mind | 19 Feb 2007 @ 5:23am
I love your mind. Would you be my doctor? You or Dr. Charles! You both rock!!
Comment by Eyes for Lies | 19 Feb 2007 @ 7:05am
I linked to you on Shrink Rap, in the comment section under podcast 11 where we discussed this case.
http://www.psychiatrist-blog.blogspot.com
Comment by dinah | 20 Feb 2007 @ 6:57am
As an allied health professional (physical therapist), your last paragraph rings loudly in my ears, especially about “absolving responsibility.” Having a diagnosis label one’s problem so often removes the inflicted from responsibility to care for themself, thus shifting it to the medical professional to “fix” him or her, be it by medications, counselling, or other therapuetic interventions. How often I walk out of a room to bang my head into a wall when another patient who fully has the capability to heal does not take the mantle of responsibility onto their shoulders and follow my advice. I want to scream, “So why did you come here anyway”. But this is the animal we have created, and change is a very difficult thing to institute. Congrats on an eloquent post.
Comment by Dan | 20 Feb 2007 @ 6:41pm
I was diagnosed BP as an adult. Life is sometimes a blur and the time passes in chunks too hard to catalogue, but I think it was three years Sept that I was dx’d.
I can also, as someone else mentioned, harken back to my younger years and see echoes of my current self.
I was given anti-D’s as a scared 16 yr old. My father found out I was taking them and said “whatever problems you have are there with or without the medication, so you better learn to deal with them”. I thought then it was wise advise. It still haunts me to this day, however, making me feel like a failure for needing the very same mood stabiliser and anti-psychotic that the poor little 2 yr old was on.
I know what my medication does to me, weight gain, and sedation…lord tunderin’ jesus, as my grandmother would have said…this is nothing for children.
I’m of two minds (no pun intended, being bipolar and all), but I do believe that bipolar disorder can be diagnosed at a younger age than the average of late 20s to early 30s. I was clearly unipolar as a teen and if he had dug just a bit further would have seen the other markers to mania. But I also believe that children must be children and in the process of growing up, uncomfortable things happen. Things that are uncomfortable to both them and us, because change isn’t meant to be smooth. Growing up, changing, causes friction. But they just need time to learn and fit it into the greater world.
Enough of my blathering.
The girl’s death is nothing but tragic.
Comment by bp_hockey_chick | 21 Feb 2007 @ 4:36pm
On the one hand we can certainly decry the outcome in this case. On the other, I think we must take note of the degree to which our society is awash in a sea of messages saying: “medicate, medicate, medicate!” As a pediatrician I’m constantly having to “fend off” or try to “discourage” parents’ efforts to medicate their children in ways that I think are not completely necessary, and, at times, dangerous. Chlorpheniramine and dextromethorphan are commonly found in many over the counter cough and cold remedies, which are routinely given to children AND INFANTS. I’m constantly cautioning parents about the potential of side effects of such combination treatments, and always adding the caveat, “remember, none of these medicines will help your child recover from their cold faster,” which is what I think is the message, purveyed by the advertising industry, that is driving the desire to purchase and administer such meds. And what parent hasn’t at 1 in the morning sought desperately for “something to help him sleep,” when their child/baby has a bad cold? So much more so must be the impulse to help a child perceived to be suffering from a mental illness. So on the one hand I think we can condemn cases such as this, on the other I think we really need to attend to what is it within us which reaches for the “medicine,” whatever it may be, when the situation is out of control, or we ourselves are at our wit’s end.
Comment by Dilequeno | 22 Feb 2007 @ 4:39pm
[…] One of my all-time favorite blogs is intueri.org. Read this post on The Question of Bi-Polar Diagnosis in Kids for a case study on diagnostic and therapeutic trade-offs, and clinical decision making gone wrong. […]
Pingback by Health Sciences Informatics - - - - - where less is more » Blog Archive » Speaking of clinical decision making and diagnosis | 25 Feb 2007 @ 11:43am
Elated mood:
“… it can be very misleading to see a happy child laughing in the office in the context of a miserable history (e.g., school suspensions, family fights).”
Grandiose delusions:
“A common presentation for bipolar children is to harass teachers about how to teach a class; this harassment is often so intense that teachers telephone parents, begging them to ask their children to desist.”
“Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”
I believe we used to refer to kids who (a) flunk out as a result of refusing to do work that bores them, (b) get into power struggles with teachers who know less about the subject at hand than they do, and (c) laugh at illogical attempts to discipline them, as ‘gifted children’.
Comment by Ruth | 25 Feb 2007 @ 11:02pm
I hope and pray that you have no intention of going into child psychiatry. Your fundemental lack of knowledge displayed in this blog is unbelievable. You list some of the symptoms but do not seem to understand the extent to which these symptoms interfere with normal functioning in a child with early onset bipolar.
Delusions of grandeur can lead to young children jumping of decks or roofs thinking that they can fly. Hypersexuality doesn’t mean normal masturbation, it generally means obsessive masturbation that begins sometimes before the age of five. High activity level in young children means requiring five hours or less of sleep at night, getting obsessed about a “project” to the exclusion of sleeping or eating. Mania in young children is usually expressed as extreme agitation and anger - not giddiness and joy. The agitation and aggression that flows from the mania can tranlate into hours long intractible temper tantrums where children can be violent and destroy property.
You have one link to Barbara Gellar, she works frequently with Kiki Chang from Stanford University. Last I checked, Stanford is in California which is on the West Coast. Kiki Chang is doing incredible work with fMRI’s and valporic acid trying to better understand this devevasting condition. Please go look at bpkids.org and do some research into the psychiatrists associated with this life saving organization.
The Rebecca Riley case is tragic. It sounds like this family was dysfunctional and rife with mental illness and someone should have been watching them more closely.
And finally, to Ruth above me, try having a child with the symptoms that I described above that also has an IQ of 140, the school systems have no idea how to accomodate a child like that who has emotional/behavioral issues because clearly they are smart enough to know better.
Comment by Concerned Caregiver | 26 Feb 2007 @ 9:18pm
hey, you got linked on metafilter. thought you’d like to know.
http://www.metafilter.com/58975/Primum-non-nocere
Comment by Ali | 27 Feb 2007 @ 10:42am
Concerned Caregiver needs to read the text more carefully. Most “normal” children display attributes that would be highly suspect in an adult. It is part of growing up. Most “normal” children think they can fly, slay dragons, and safely leap off tall buildings - that is why children have parents - to keep them safe until they have matured enough to leave the nest.
No matter how you slice or dice it - no child can be expected to act like a “normal” adult. It isn’t in them. And, to drug them into stupification (which is happening to millions of boys in our country) is a solution that our culture and society will live to regret.
Comment by Carol | 27 Feb 2007 @ 4:26pm
I am a teacher who works with children and I also have a child who is bipolar…yes, he really is. When you read the list of behaviors, if you haven’t seen the behaviors in a child, then they could sound like normal. But these behaviors are to the extreme. Is BP overdiagnosed? Sure, but there are many legit cases. When you have a child masturbating to the point where he can’t walk, or when he paces the living room for hours at a time because his anxiety is so high he can’t sit or he can’t form a sentence because he his mind is racing so much he can’t form a thought, there is a problem that needs to be treated. I have never understood why people won’t allow the brain to be treated the same way every other organ in the body is treated. Why should the brain be exempt?
Do I think these parents were wrong? Yes, there are too many things that they did that are suspect, but are there very young, sick children? Yes. Sadly cases like these make all diagnoses suspect and that isn’t fair to any truly sick child.
Comment by Gretchen | 27 Feb 2007 @ 6:34pm
Comment by Concerned Caregiver | 26 Feb 2007 @ 9:18pm
“High activity level in young children means requiring five hours or less of sleep at night, getting obsessed about a “project” to the exclusion of sleeping or eating.”
Still sounds like your typical 140 IQ child to me!
Comment by Ruth | 27 Feb 2007 @ 8:54pm
“Still sounds like your typical 140 IQ child to me!”
Do you honestly mean that? How many kids with a 140 IQ have you met and dealt with? I really don’t think you know what it means by obsession. My highly gifted son could not get to sleep last night until midnight because he was so racked with racing thoughts, anxiety, and obsessions. He paced my living room for hours. He slept for 5 hours and he is still up right now at 8:30. He is wide awake. Does that sound typical for a 10 year old?
Comment by Gretchen | 28 Feb 2007 @ 6:20pm
Comment by Gretchen | 28 Feb 2007 @ 6:20pm
It sounds not atypical for highly gifted 10 year old, and I’ve even observed it in much younger children. Merely being alive and awake can be nothing short of an acid trip for these kids. Have a look at some of the literature on the subject, particularly that dealing with the characteristics of exceptionally gifted ( > 160 IQ) children. Intellectual, sensual and psychomotor over-excitability has long been noted in this cohort, together with a degree of emotional intensity and obsessiveness that can be extraordinarily taxing for both the child and the rest of the family. I don’t question that, I’m just questioning why so many people look to psychiatry and psychopharmacology for a solution, as I think they do far more harm than good, particularly where kids are involved.
When you induct a child into the psychiatric system, you run the risk of severely compromising their psychosocial development, even if medication is not prescribed. Concepts such as free will, personal responsibility, natural resilience, and the self in relation to others are corrupted, and ‘behaviour modification’ mostly takes the form of the subtle eliciting of symptoms that are ‘expected’ to emerge but have not yet done so, not to mention the child (if ever an inpatient) picking up from other patients all sorts of new ways to deal with their distress that otherwise might never have occurred to them, e.g. cutting themselves. Hence more diagnoses, more medications, and a further downward spiral.
Comment by Ruth | 28 Feb 2007 @ 7:17pm
Until you have a child with bipolar disorder you cannot fathom what it is like for the child and the family. Have you ever had your child get on top of the roof and want to jump at 6 or 7 years old, how about run away and dart into traffic at dusk and be missing for two hours? How about hang from the second floor staircase and want to let go because he didn’t want cheese in his burrito. Or when the child feels like they just can’t snap out of this state of mind, they start saying I wish I was never born and start smacking themselves in the face. Medication has helped dramatically, but there is not a cure, so the child will continue to suffer through these epidodes for life. You can’t fully have an opinion about medication for children with mental illness until you live with a child with mental illness.
Comment by Lisa | 20 Mar 2007 @ 3:30pm
this is one of the most heartbreaking stories I have ever heard… I cried at the thoughts of how a child could be so mistreated… the most tragic aspect of it is that this child was given absolutely no love or compassion… all the rest just seems an excuse to neglect her… the ones who need to be diagnosed here are her parents… in my opinion there is no defense for them.. in regards to the diagnoses of bipolar, @ 1/2 seems to be to young to make that determination and even then shouldn’t medication be delayed until determined necessary… also, I believe environment plays a large role in bipolar disorder.. a child with bipolar disorder needs love and understanding first and foremost.. without that no medication will make a difference
Comment by nelson | 26 Mar 2007 @ 8:22pm
I’m only a witness to a little boy age 11. He is my nephew. He has rage attacks that are so extreme my sister has to lock herself in the bathroom and her 3 other children. He then switches gears after it is all over acting as if nothing happened. It is like Dr. Jeckle and Mr. Hyde. THe smallest thing, like saying “You need to comb your hair.” When he doesn’t think it looked messy could trigger a rage episode.
She would never EVER medicate him. She would never EVER have someone label him as anything. So he will go through life having an explosive childhood, with feelings he cannot understand, and truth is I feel helpless as to how to help them.
THere is obviously something wrong. You don’t have to have a degree to see that. What will happen when he’s a teen? It’s very scary.
Comment by eva | 28 Mar 2007 @ 2:50am
whether or not rebecca was bipolar, whether or not the thousands and thousands of young children diagnosed with bipolar are actually bipolar- is not the issue. it’s a problem, sure, but the real issue here is: we are over-medicating children.
and to concerned caregiver: “Delusions of grandeur can lead to young children jumping of decks or roofs thinking that they can fly?” and so your solution is too drug them up to prevent this? how often do you hear about a child who really thinks he/she can fly? and actually jumps off a deck? my question is: how often do you hear about children taking meds that are only approved for adults?
and you said, “the Rebecca Riley case is tragic. It sounds like this family was dysfunctional and rife with mental illness and someone should have been watching them more closely…”
are the parents to blame here? absolutely. but so is her doctor. she doesn’t sound like a caregiver to me. she sounds like a criminal. how could anyone in their right mind prescribe those medications to a four-year-old??? i took seroquel in my late-twenties and i was a walking zombie. i cannot imagine taking that at four. and not one single child should take that drug, let alone the numerous other meds rebecca was taking. and how dare you say someone should have been watching her more closely. that someone should have NEVER prescribed the numerous meds she was taking. PERIOD.
i’m bipolar. i’ve overcome many obstacles, and i’ve lived with a mental illness my entire life. i’ve been in therapy since 13. i’ve spent thousands on medications, most of which numbed me. i finally took control of my body and my life. i’m on a med with few side effects and i’ve a successful career in the film industry the past eight years. i’ve come a long way and rebecca won’t have that chance. simply because her DOCTOR and her parents took the easy road. they over-medicated her to silence her.
these stories are increasing and it’s terribly saddening.
Comment by kim | 28 Mar 2007 @ 11:21am
As a pastor for more than 25 years I find this story very disturbing to say the least. Drugs are too easily given out to children who are still in the developing stage. I think it is a gross misjudgement to label a child at 2 years old with BP. God help us all!
Comment by Wfsmalt | 29 Mar 2007 @ 10:15am
Help these children out there. All I see are parents who are un-educated, ill-equipped, Lack of heart & soul finding excuses for themselves as parents saying - its the child. It’s the PARENTS! Something is wrong with the PARENTS! The children? “CHILD” Why can we not see how small they are. Life has just begun, what chance are they giving them to “live”, “grow”, “develop”
They (parents) want to drug behaviors that they them selves create. Children so-so small - no chance to let life take it course to “live”, “grow”, “develop”
These diagnosis’s are Opinions, Beliefs - Sure all drugs have effects - as do people!!!
Comment by Marie | 31 Mar 2007 @ 10:13am
http://www.stepup4bpkids.com/documents/DVP2006.pdf
http://www.stepup4bpkids.com/documents/Risperdal%20adjunct%20to%20Li%202006.pdf
http://www.stepup4bpkids.com/documents/Lamotrigine%2006.pdf
I guess these folks are doing studies because bipolar can’t exist in kids. Is it overdiagnosed? Perhaps. Is it real? Yes.
Is the Rebecca Riley case tragic? Indeed.
Comment by Concerned Caregiver | 7 Apr 2007 @ 6:01pm
IT is not the parents. IT is not the parents.
I did not do anything to create a child that screamed all night.
It is medicine that is researching all illness that manifests behaviorally as mental illness when we have epidemics of all kinds of behavioral and learning problems.
It is the non recognition of toxins by allergists and doctors, the non recognition of yeast, the ubiquitousness of chemicals in food that create a series of health insults
that accumulate until a child manifests a behavioral disorder.
But nobody is researching it outside of medications because it doesn’t make money.
I have such a child and we have spent a decade peeling back the layers which accumulate rapidly if not recognized. He has environmental illness/Chemical sensitivity and is not mentally ill.
BUt if I fed him legal substances like aspartame, and food dyes and pesticide laced cottonseed oil and put pesticides on my lawn well………
Comment by Sarah | 9 Apr 2007 @ 12:01am
It is all fine for peope to arm chair quaterback these types of situations…but unless you have walked in the shoes of families suffering thru these horrific issues you cannot understand.
It is true that we have serious problems with the medical and psychaitric care of children.
There is no standard of care. When a child exhibits the types of behaviors associated with bi-polar, a parent is left to fend for themselves. You can do your own research, listen to different opinions of doctors, psychiatrists and school teachers. Meanwhile you need guidence NOW…we are asking that parents become experts in treating a complex disorder while receiving conflicting advice, and to do this quickly.
Access to medical care is a big roadblock. Responsible parents relying on their private medical insurance have no other choice than medicate. Private insurance does not cover therapy. They cover med checks at a lower rate than they would a regular office visit. The only treatment you can get is medication. Even then many times you will spend one, two, three, even four hundred dollars a month for meds.
I have a child who was diagnosed with bi-polar at a very early age. She is treated with a conservative med therapy, behavior modification, and special education. I am constantly learning about this disorder to make informed decisions about her care……but I can’t find a solution!
The Rebecca Riley case is tragic….she was in a home with pre-identified problems (child abuse), inadequate psychaitric care (as with most children with these issues) and ill advised parents (no explanation required - just look at the outcome).
But, before we generalize all children and families with these problems, we need to look at both sides!
Walk a mile in my shoes, and you will be crawling the last half!
Comment by Toni Mall | 24 Apr 2007 @ 8:23pm
I, too, have a child that was diagnosed with bipolar disorder at a young age. What many people who do not walk that mile in our shoes don’t understand is that the descriptions seen do not make it clear what the behavior is like. It is not normal toddler behavior. It is not normal childhood antics.
Many parents of children with mental illnesses have talked to their pediatricians, and anyone else who will listen, about the behavior of their child. They are told that it is normal because they don’t see what the behavior is like.
I denied that my child had anything wrong with her for three years. She had tantrums that lasted for 2 hours, 5 - 6 times per day. These happened regardless of what I did. She was one of the “angriest” toddlers you might ever want to know. The tantrums were not just a little crying. They were full blown tantrums involving screaming, kicking, hitting and they were exhausting for both me and my family. Should you believe that it was just a matter of behavior modification that was needed, you should also understand that she did this with daycare centers, teachers, other relatives and babysitters. She was not spoiled and, quite frankly, giving in to her demand did not stop the tantrum.
After those three years of denial, when I was pregnant with my third, my then 6 year old kicked me hard enough that I thought she had broken my thumb. I was reaching for her leg to keep her from being able to kick me in the abdomen when it happened. That was enough to get me to take her to get some help.
Masturbation for a toddler or child is definitely normal. However, the masturbation usually involves touching themselves and finding out that it feels good. It doesn’t usually involve public displays. How many toddlers do you see that masturbate against table legs or other furniture that might be shaped that way? Some of these children will do that. Or, they will masturbate in public because that is the only solace they can find.
Because so few people are willing to believe that the behaviors being referred to are abnormal, many of us are afraid to ask for help. We are viewed as not being able to control our children. We are called bad parents. We are told that we shouldn’t medicate our child. We have onlookers make comments like “I would never let my child speak to me like that.” The unfortunate part is that this type of reaction is ignorace to our situation. They don’t understand because they have not had to walk a mile in our shoes.
That being said, I don’t think that every child that has a tantrum needs medication. I also think that there was a lot more to the Rebecca Riley story than just that they had her on medication.
I do ask that people try to open their minds to the possibility that children can, and do, have mental illnesses. As a parent, it is extremely difficult to accept that your child has a mental illness. It is also extremely difficult to consider the possibility that your child may have to be medicated for life.
Comment by Pam | 21 Aug 2007 @ 9:32am
With regard to the 3 studies linked by Concerned Caregiver - they have problems in convincing me of bipolar being the correct diagnosis in many of the subjects.
The first is of use of Valproate in an open study (no placebo) of youth with mainly aggressive behaviour. Valproate acts to increase a calmative chemical pathway in our brains - the GABA pathway - similar to Valium. The benefit found was marginal and could be non-specific and relate to non-drug factors in the study (ie placebo effect).
The second study surmises bipolar can be diagnosed in preschool children, who seem to then have been on long term Lithium treatment, but only 17 of 28 were considered to have had a beneficial reduction of their behavioural problems from the Lithium. Risperidone was added to the 21 “non-responders” and lo and behold there was a reduction in symptoms. But risperidone will reduce emotionality and aggressive behaviour in all of us, that’s why neuroleptic (from the greek meaning to “seize/hold” the “nerves/brain”) drugs which is what risperidone is, were used on political prisoners in the Soviet Union, and are used for aggression in elderly demented patients, out of control inmates in hospital with personality problems etc. - just because they are called “antipsychotics” these days doesn’t mean they don’t have a general effect on anybody.
Just because a medication suppresses behaviour, doesn’t confirm the diagnosis. In this paper it is unclear to me that the diagnoses were made in the full context of the child’s history and life. Suspicion is raised by the paper’s own findings that ADHD, abuse and younger age made response to treatment even less satisfactory.
The third paper is of only 5 cases, all given Lamotrigine with some benefit it seems. Lamotrigine is an anticonvulsant drug like Valproate that is also used for Bipolar disorder. One 15 year old really does sound like he had a manic episode. The other 4 children all became labile in their moods and hypomanic or agitated and disinhibited whilst on SSRI antidepressants. The DSM specifically states that antidepressant induced manic or hypomanic states do not count to a diagnosis of bipolar disorder. All 4 got better on Lamotrigine but they also improved the longer the SSRI was out of their system. SSRIs can have severe withdrawal effects in some people that can last for weeks. SSRIs appear to cause these problems moreso in the younger age group. An interesting study on rats showed worsening of agitation in young rats but calming effects in mature rats. The term Bipolar Disorder NOS (not otherwise specified) allows for a large section of the population to be thus categorised as bipolar. Whatever happened to traditional psychiatric formulations of people’s emotional dysregulation in terms of their trauma and attachment history or even of behavioural analysis of meaning and reward for “symptoms”?
Paediatric Bipolar (especially in young children) is thus far a mainly American phenomenon, uncommon to very rare in most other countries. There seems an overinterpretation of symptoms of distress and behavioural dyscontrol that could have several other causes depending on the child.
DSM “cookbook recipe” diagnosis is a more simplistic and initially easier way to practice psychiatry. Getting to truly understand a child’s inner world and their environment, including all the family and school dynamics, takes much more time - but is a far better way to practice paediatric psychiatry.
Comment by Aussie child psychiatrist | 24 Aug 2007 @ 5:15am
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Pingback by Musings of a Distractible Mind » Blog Archive » How to treat misbehaving child: Bad, Sick, or Uneducated? | 20 Sep 2007 @ 11:07am
Very interesting. I was diagnosed BiPolar in my twenties. I used to overreact to everything. Suicidal attempts. Now I’m 47. I’ve been through quite a few different meds and twenty years of therapy, which in the beginning, gave me relief from my craziness. I quit alcohol and drugs at the same time I sought psychiatric help. I accepted the sentence of medication for twenty years. Lithium for a few years, then Prozac, then Depakote, then Lexapro, different combinations. They all helped for a time; each seemed to run their course and I’d be back to the shrink in agony.
Today I am conscious of WHAT CAUSES ME to feel, act, think negatively. MOSTLY it’s poor diet. Too much stress, lack of sleep, no exercise, caffeine, lack of acceptance of LIFE ON LIFE’S TERMS. I am learning, step by step. I have been off the meds now for two months, after having suffered horrible withdrawal symptoms from 20 mg Lexapro daily. I am feeling better and better.
I truly believe that no human being should be prescribed medication for ANY physical or mental impairment or disease until and unless the SOURCES of those impairments are thoroughly investigated.
There is SO much research out there indicating that what you put INTO your body affects your body. Start there first.
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