Hello, Kos community. I am a child psychiatrist and long-time Kos member - I've posted a great deal over the years on topics I don't really know much about - and I thought it might be interesting to post on a subject - child psychiatry - I have spent several decades trying to learn. This entry is cross-posted on my blog Child Psychiatry Forum
Few controversies in child psychiatry have been more controversial over the past 10-15 years – with good reason – than the application of the term "Bipolar Disorder" to emotionally unstable children. Many seasoned child psychiatrists felt that the term "bipolar" was misleading, because it falsely implied that most or all of these children would go on to develop a lifelong mental illness. The application of "Bipolar" to a child’s diagnosis became a justification for the use of antipsychotic and mood stabilizing drugs in young children. 1
Many worried that the diagnosis whitewashed the effects of adverse environmental situations – stress, neurocognitive problems, family problems, physical and emotional trauma – with a diagnosis of a supposedly brain-based "mood disorder" that was just a prescription pad away from being toned down.
Now the name, if not the problem, is in for a change. The upcoming revision of the American Psychiatric Associations diagnostic manual, the DSM-V, is likely to include a new diagnostic term "Temper Dysregulation Disorder with Dysphoria" – a term that will capture the same children, without the confusion that borrowing the "bipolar" label from adult psychiatry led to.
This is a welcome development, in my opinion. I’ve known dozens of parents who have been terrified by the "bipolar" label; and the change in the name also makes it easier to rationalize using generally safer drugs when they are needed (like the Prozac generation of SSRI antidepressants, which can be quite dangerous in true "bipolar disorder" patients).
The change in the name doesn’t address the deeper problem, however. Our present method of psychiatric diagnosis involves working down check-lists of symptoms, and matching them against templates laid out in the DSM manual. This process is "scientific", in the sense that there is an ongoing effort to statistically validate the diagnostic process – but it is fundamentally empty.
Children are complicated. Many emotionally unstable children suffer from a range of different problems – learning problems in one case, a mother who as depressed and unavailable in the child’s infancy in another, exposure to family violence in a third – one could go on and on. All of these (imaginary) children could demonstrate the kind of emotion regulation problems that would have bought a child a diagnosis of "Bipolar Disorder" in 2009, and probably will buy a diagnosis of "Temper Dysregulation Disorder" a year or two from now.
Cookie-cutter diagnostic templates have a value – they provide simple terminology which allows us to communicate quickly about a child (or adult’s) problem – just as a map can guide you through an unfamiliar town. But it’s a big mistake to mistake the map for the road, or a template for the person. And matters don’t improve when template-driven diagnoses guide the administration of psychotropic medication.
This is precisely how the concept of "Pediatric Bipolar Disorder" came to be to begin with: first the concept of adult mania was expanded to include "irritability", and in very short order irritable children became "bipolar". The uncertainty and methodological problems facing academic psychiatrists are one thing. But there is an additional problem of the money to be made by the pharmaceutical industry and other players by shaping the way treatment is conceptualized and delivered.
As soon as a diagnostic template is created, investigators will conduct pilot studies, usually with drug company support, in search of statistically-demonstrable drug effects which can be marketed as a treatment for the disorder. There are growing numbers of scandals about frank corruption of this process, including suppression of information about the dangers of pharmaceutical treatment.
I don’t mean to sound cynical – or to suggest that medication treatments cannot be extraordinarily helpful to children (and adults) who need them. But the process of diagnosis and treatment needs to be done right.
There simply is no substitute for spending time with a child and his or her family, talking to teachers, and tagging in other professionals with necessary expertise (educational psychologists, learning specialists, occupational psychologists, pediatric neurologists, for example) when they are needed. When using a psychotropic drug with a child (or adult), it’s critically important to have a clear sense of what you are trying to achieve – hopefully goals that you have developed in collaboration with a child and his or her family.
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- Pediatric Mental Health Care Dysfunction Disorder? Parens, E. et. al. N Engl J Med 2010; 362:1853-1855