Archive for the ‘pediatric’ Category

“[T]he approvable letter concerns treatment of schizophrenia in adolescents aged 13-17 and for short-term treatment of the manic phase of bipolar disorder among children and adolescents ages 10-17”.

I wonder what it’s conditional on.

This was going to be a longer post on kids and antipsychotics, but I got some very good news and am going to go celebrate instead.

Pediatric bipolar disorder has been coming up more frequently over the last few years, and the current flap is about Joseph Biederman, who is an advocate of the view that bipolar can exist as early as birth. There’s also scandal (from back in December) over a four-year-old who died from being given too much medication by her parents, and that’s being brought up in this as well.

Those are the extreme cases. I’m going to write about the typical stuff.

(But first: At birth? Why at birth? I’m pretty sure our emotional regulation systems neither suddenly turn on nor suddenly break then. I know he’s using it for dramatic effect, but it bugs me.)

The news coverage I’ve seen tends to have one of two themes:

1. “Kids will be kids”: You can’t diagnose bipolar in children because that’s just what children are like – they change by nature. (This is similar to the incorrect argument that AD/HD doesn’t really exist, because to be bored by school is to be a normal child.)
2. We’re overprescribing antipsychotics to children. They should only be prescribed for their intended purpose. (Meaning, to treat psychosis, or, even more restrictedly, to treat schizophrenics.)

I’m going to talk about the “kids will be kids” aspect, and then talk about why it actually is hard to diagnose bipolar disorder in children, and will talk about antipsychotics later in the week. I’m pulling heavily from Goodwin & Jamison’s “Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression”, second edition. The first edition is considered the classic work in the field; the second edition is just out as of a couple months ago and I heart it down to my research-loving bones.

Okay:

Bipolar disorder occurs in young children.

There are debates over how common it is, what it looks like when it happens, and whether we can diagnose it and when, but it’s not at all like being a normal child.

Here are a couple parallel normal and pathological examples from the Goodwin and Jamison book (originally from Geller et al, 2002a and if anyone really wants cite that I’ll get it for you):

Happiness: Child was extremely happy on days family went to Disneyland, on Christmas morning, during grandparents’ visits (joy appropriate to context, not impairing).

Elated mood: 9-year-old continually danced around at home, stating, “I’m high, over the mountain high” after suspension from school.

Sexuality: 7-year-old child played doctor with a friend of the same age.

Hypersexuality: Girl faxed a note to the local police station asking police to ____ her [underlines in the original]

And you can find all kinds of examples on websites for parents of bipolar children – kids trying to spontaneously jump out of cars, that kinds of thing.

It’s hard to diagnose because kids with bipolar frequently meet criteria for other disorders too

Like ADHD, conduct disorder, and oppositional defiant disorder. Some kids have a *lot* of problems, and it’s not clear whether they have one disorder that’s causing other disorders (for example, bipolar disorder can cause anxiety) or whether they have multiple disorders (bipolar disorder can coexist with a separate anxiety disorder). This happens with adults as well, but it’s particularly common for kids with bipolar-ish symptoms.

This leads to a disturbing situation that I would like to see get more press: although the popular controversy is about whether bipolar exists in kids, it should really be about what is going on with these kids who are badly impaired and difficult to diagnose and treat. It’s not about whether they’re bipolar or not, with “not bipolar” meaning “normal”, because they’re not normal. It’s about what should we be doing to help them.

Children with bipolar disorder also tend to look different from adults with bipolar disorder. They are more likely to rapid-cycle (go through many mood shifts throughout the day); to be irritably instead of happily manic; and to not have well periods between mood episodes. So they’re less likely to be recognized by practitioners whose mental picture of bipolar disorder is based on an average adult.

Another interesting question is whether the kids we’re identifying with bipolar disorder are going to grow up to look like most adults with bipolar disorder – do they have an early version of the disorder that changes as they mature? Do they have a more severe version of it that doesn’t? Or do they have something that’s just different?

From Psychiatric News: Diagnosis, Treatment of Youth for Depression Fell After FDA Alert

It’s not just that children and adolescents are less likely to be prescribed SSRIs following the alert – it’s that they’re now less likely to be diagnosed and less likely to be treated at all (there has been no corresponding increase in psychotherapy, atypical antipsychotics, or anxiolytics).

You can view the original journal article here.

In the article they suggest it’s possible that in the wake of the recommendation families may not be fully disclosing symptoms, or filling prescriptions written for them.

They also note that the rates of diagnosis are lower than the published incidence rates (i.e. how many people get diagnosed if you go and look and see, instead of only diagnosing people who come to you). So it’s unlikely that we used to be overdiagnosing and overprescribing, and likely that we are now even further underdiagnosing and undertreating.