Saturday, October 20, 2012

Kids and Mental Illness

I try to stay out of the whole Kiddy Bipolar Debate debate: none of the Shrink Rappers see children, so my knowledge of childhood psychiatric disorders is limited to what I saw during a 3 month inpatient rotation 20 years ago, what I read, and what I see of children in my personal life.  It's a messy topic.  

I brought it up today because the Wall Street Journal has an article that summarizes nicely all the issues, the issues with regard to diagnosis, the fear of over-treating, the problem with under-treating, the question of whether mood dysregulation in children should be a separate disorder.  Please see Shirley Wang's article The Long Battle to Rethink Mental Illness in Children

I'm glad they're leaning towards renaming bipolar disorder in children.  When you hear Bipolar Disorder, you think about a lifelong condition that requires medication forever.  Children have phases, behaviors occur in some arenas and not others.  Perhaps if a child's emotional life is intolerable to them, or their behaviors make it impossible to function in their worlds, it's worth the risks to administer medications.  But a kid throwing horrible tantrums, fighting, running around the room, does not necessarily evolve into the same category as an adult who has 3 episodes of depression, and 2 episodes of psychotic mania, during their lifetime.  Oh, and I'm the one who thinks we should Rethink all of the Bipolar Diagnosis, not just for kids. 

So Wang writes: 

At one of his group's first in-person meetings, the NIMH's Dr. Leibenluft, an expert on bipolar disorder in children, gave a 20-minute PowerPoint presentation with evidence for a potential new disease. She called it Severe Mood Dysregulation.
She described a decade of studying children with severe mood problems that don't fit neatly into current illnesses. Thus began a cerebral process to decide what these kids might be suffering from.
The two main options: Create a new disease, or create a variant to an existing disorder. The discussions ran for years.


L said...

We often call that emotional disturbances/disabilities (ED kids). And outside of the whitewashed castle that you inhabit, where parents can advocate non stop, and talented shrinks, pediatricians, lawyers and educators are willing to listen (be paid to listen), we stuff them into severe disability classrooms. On the flip side, some of them actually learn from behavior analytic tactics and interventions. 99% of the kids like this we see come from homes that are chaotic, or intact, but simply don't have parents willing to do what it takes (sometimes as little as being consistent) to work with the teachers, counselors, and psychiatrists. In the end of the day, the label doesn't matter, nor does the perception of the label by those in no way involved. The treatment does.

Anonymous said...

Good post.

I've always found it interesting that people my age are being diagnosed with manic-depressive disorder as often as they are. I feel the same way about all pediatric mental disorders, to be honest. Not that I believe that children are misdiagnosed; I'm just surprised at the diagnosis rate.

Perhaps if we knew what was causing the problems in children that are so common today, we would know the answers to many more questions . . .

Ann said...

Does anyone think the frantic pace of our social structure may contribute to some of these problems. It seems there was a time that even kids from chaotic families could find some respite with a neighbor or family of a childhood friend. They could find some structure and predictability there. It wasn't optimal, but was fairly consistent. Now most neighborhood moms are working, kids in afterschool care and grandmothers in nursing homes . Plus with so many destabilizing social factors (confusing role models and loose social boundaries) how can an "at risk" kid find emotional stability. Personally, I know how a lack of personal boundaries can derail a child very quickly and it can take a lifetime to recover. Thanks for the topic.

L said...

Also want to add that although a child may need and benefit from medication, that doesn't necessarily mean that s/he has bipolar disorder.

yoshie said...

Technically, I have bipolar disorder because I was diagnosed with pediatric bipolar disorder when I was young. But it's not something I think about or even consider to be a useful diagnosis in my case. I don't even report it if I see a doctor or other healthcare professional unless it is a psychiatrist. And even then it is more like a piece of trivia from my past."Hey I was diagnosed bipolar as a kid." They don't tend to care about it, and the diagnosis has basically been thrown out in my case.

The question is of usefulness. If the diagnosis is useful for a child, and the treatments work...then by all means keep the diagnosis. If it's not useful, throw it out. If a person is an adult who once had pediatric bipolar disorder, and it is no longer an issue, then there should be no qualms about throwing it out. Or at least saying that the person had pediatric bipolar disorder, and it did not later translate into adult bipolar disorder. It is no longer a useful diagnosis and it doesn't inform treatment.

Crissy said...

This really seems in line with the approach that we have taken with my daughter. She has been diagnosed with ADHD. Even though I agreed with the diagnosis, I would not accept it until I felt she had been thoroughly and adequately tested so as to actually warrant the diagnosis (some psychologists that we saw just seemed to want to rubber stamp it without actually spending time with her and I wouldn't allow that). She does take a small amount of medication to help with those symptoms, though she does not take a stimulant.

The reason for not trying a stimulant was, in part, because she was also exhibiting some symptoms that reached beyond the scope of ADHD and it was highly suspected that she may have a mood disorder. The fact that I am bipolar probably contributed to considering that as a possibility. However, neither I nor her psychiatrist wanted to rush to labeling her as bipolar. Initially, we took a wait and watch approach. We decided we would continue to monitor her and only treat with medication if there came a time that it seemed absolutely necessary. She did begin to see a therapist.

She always had a strong temper, but that wasn't something we were going to medicate for. A little over a year ago she went through a phase where she was very weepy for no obvious reason, would tell me that she was sad but didn't know why and then she began to talk about wishing she was dead. It was at that point that I reluctantly agreed to allow her to try a medication to help with her mood. She is on a very small dose. It seemed to help...although admittedly things may have improved over time with or without the medication. I do know there have been a couple of other times since she's been on medication when she got in that very sad place but it hasn't seemed to get as bad or last as long. So for those reasons, she continues to take medication. At some point we may try going off the medication to see how she handles it, but for now there are no immediate plans to try that. She seems to be tolerating the medication well. She is still a vivacious, active kid. People that meet her have no idea that she is taking medication. It hasn't taken away her ability to be busy and active, it hasn't taken away her only allows her to function at a level where she can enjoy her childhood.

Her doctors and I all agree that she has some sort of mood disorder. Her doctor has said it is quite likely to be bipolar, but neither of us feel comfortable nor see a need to make such a definitive diagnosis on such a young child (currently she is 7 years old).

I did recently discover that her doctor had placed a diagnosis of ODD in her chart. I was pretty upset because this was never discussed with me. When I asked him about it, his response was...well, it's that I want what I want and I want it now sort of behavior that she has shown in the past. I told him that yes, she had shown those behaviors, and they may have been more than the average kid but I'm not sure that they were really bad enough to warrant a clinical diagnosis and I thought he should have discussed it with me. I still feel that way. My daughter can have some challenging behaviors and has been known to throw a giant temper tantrum or even fly into what some would call a rage. She has been combative with me. But I still don't think it was to the level of giving it a medical diagnosis rather than just saying she was a challenging girl. I also think those behaviors were more closely related to her mood at the time.

charan said...

Hi Dr. Miller,

I just read your article "When children divorce parents". Its brilliant.

May I ask where I may find it online so that I may put a link to it on my site.


Michael Levin M.D.

Dinah said...

Hi Dr. Levin:

There is a link on Clinical Psychiatry News here:

and another article on Shrink Rap here:
Where the comments accrue.

Please send me a link when you are done.

adult psychology said...

kids have different kinds of characteristics so we parents should know how to deal with them..they should be well guided and parents should give them attention