Many people are shocked to hear that anyone as young as Rebecca Riley could be diagnosed as having bipolar disorder and prescribed powerful psychotropic medications. Following are several questions I have been hearing about the case recently that are related to early childhood diagnosis and treatment followed by my answers:
Q: Do you think diagnosing a child as young as Rebecca Riley as having bipolar disorder could be appropriate in certain situations?
A: I find it hard to imagine diagnosing a preschooler with bipolar disorder, because their brains are too immature and incompletely developed to exhibit symptoms well formed enough to meet criteria for bipolar disorder. Typical preschool development includes immature mood regulation and impulse control. Sleep problems are incredibly common in toddlers and preschoolers, as are temper tantrums. How can you define a mood state as a “change from baseline” in a child so young that they haven’t even been around long enough to establish a baseline?
This is not to say that preschoolers cannot exhibit emotional and behavioral patterns that are quite atypical and that need to be evaluated and addressed. But this evaluation must focus on a wide array of specific developmental, medical, neurologic, metabolic, and environmental factors in such a young child before determining that it is primarily a disorder of mood presenting with behavioral symptoms.
Q: How does bipolar present differently in children than adults?
A: This is the million dollar question. Those who support the diagnosis of bipolar in young children have clearly said that bipolar disorder presents very differently in children. Their definition of mania is essentially mood changes that can occur multiple times per day, with bipolar primarily presenting as extreme irritability. This is a change in the use of the term bipolar disorder. The classic diagnosis of bipolar disorder must include well formed mood episodes – specifically a manic episode is necessary that lasts at least a few days, not several hours.
In adult bipolar research, people are exploring the possibility of a spectrum of bipolar disorder that includes a much wider range of mood regulation problems. However this is still early research. Most of the studies about medical treatment of bipolar disorder have been done on people with classic bipolar disorder – distinct episodes of mania and distinct periods of depression.
So the question of a more expansive diagnosis of bipolar disorder is being looked at in adults and children. However, we have few studies of any medication treatments using this spectrum model in adults and even fewer studies in children. Since we are already taking something of a leap of faith in using the medications found helpful in classic bipolar disorder for children, we are even further away from any research base when we expand our diagnostic pool so dramatically.
There is no data so far supporting the idea that these children with very atypical symptoms of “bipolar disorder” grow up to have classic bipolar disorder as adults. So whether these atypical presentations are really precursors to well defined bipolar or signs of some type of bipolar spectrum disorder in adulthood or, in fact, something else entirely remains utterly unclear.
Q: Do you think it is ever okay to prescribe psychotropic medications to children as young as Rebecca Riley was at the time?
A: Psychotropic medication in very young children is something to be extremely cautious about. There may be appropriate times to try medication when there are symptoms that are severe and causing major impairment in life and development. I will only prescribe for very young children after comprehensive evaluation, including multiple evaluators. I consider psychotropic medications for very young children only when other interventions have not worked. If the decision is made to prescribe, I will do so in the context of extremely careful monitoring, active family and environmental support and interventions, and close communication between all of the adults involved in the care and developmental needs of this child.
Q: Do you think that non-medication interventions should always be tried prior to prescribing medications for such young children?
A: As explained above, non medication interventions should be developed and implemented (especially parent and educational interventions) before looking at psychotropic medications in such young children.
Q: If a doctor does prescribe these medications to such young children, what sorts of monitoring should parents expect the doctor to do? How often should the doctor check in with the patient and in what form; for example, is a phone call to the parents standard or should the doctor actually see the child?
A: This varies from doctor to doctor, but regular office visits will be necessary. (“Regular visits” can also vary, but as a very general guideline, which does not always apply, I’d say a couple weeks from the first visit and at least monthly when actively adjusting medications.) Phone calls or emails should be encouraged between visits if family or other caretakers have questions or concerns.
Communication with all members of the team is particularly valuable and can help keep everyone aware of how the child is doing. I think of the team as including, at minimum, the psychiatrist and the family, but I find that it should also include other adults in the system, such as teachers, social workers, other school or medical supports, such as speech and occupational therapists, pediatricians, and other medical personnel.
Conversations with these people or getting reports or emails from them greatly aids my understanding and how I work with all children, but especially very young ones. Gathering collateral information is a central part of my work. Information from family members and my own observations of a small child do not give me a complete picture most of the time.
Please share your insights and opinions.
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I would love to have the time and the resources to conduct a study that correlates the frequency of diagnosis of bipolar disorder in prescoolers with elements of the treatment setting. My hypothesis is that the less time spent with the patient the more likely a bipolar diagnosis is to to be given. I also believe that there is a correlation with what kind of specialist is being consulted e.g. pediatrics, neurology, psychiatry and the strucure and content of the treatment visits/sessions.
Treating preschoolers is a serious endeavor. After ruling out medical and psychiatric differential diagnosis, I have used extensively approaches described by Dr Ross Greene in his book The Explosive Child. They are powerful but take time and a lot effort. The upside: there is no weight gain, no tardive dyskinesia, and no sudden death!
Thanks for the opportunity to share on your blog.
Yitzhak Shnaps, M. D.
Skillman and Princeton, New Jersey
http://www.PrincetonPsychiatrist.com
Dr. Shnaps – I couldn’t agree more that how much time a clinician spends with achild will make a big difference in how the child will be viewed and approached.
I would also like to support the use of Dr. Greene’s approach – I use it as my primary approach to these children – and i find it extremely helpful – families and children feel supported and encouraged not judged and labeled.
American Family Rights Association has long maintained that drugging children is absurd.
We maintain a web page dedicated to the horror stories titled “Doping the Kids- The Pharmacaust”
http://familyrights.us/info/doping_the_kids.html
The malicious and malfeasant use of psychiatry in the politics of family destruction is PANDEMIC.
“Quite often the social doctors become part of the disease.” -Eric Hoffer
Leonard Henderson, co-founder
American Family Rights Association
http://familyrights.us
“Until Every Child Comes Home” ©
“The Voice of America’s Families” ©
I have a child who is now fifteen years of age.As a toddler, she was thrown out of daycare for biting other children.When she was five years old, she was thrown out of kindergarten for unruly behavior. It was obvious to me that she had psychological issues, but after multiple visits to counselors, psychiatrists,etc- she could not be diagnosed properly because she was TOO YOUNG, and all professionals agreed on that fact.I do not believe for a second that diagnosing a toddler or pre-schooler with Bipolar disorder is possible, let alone pumping them full of psychotropic medications.
The psychologist is just as guilty of murder as the parents, off label use of these drugs is dangerous and completely unethical. In certain cases of depression, opiates have been known to treat the disorder in the best possible manner, yet a drug such as, Buprenorphine cannot be used for that purpose because it would be considered “off label” usage and therefore, illegal. The same rules should apply to all psychotropic drugs-case closed!
Regarding Mr. Henderson’s comment that drugging children is absurd – I would like to be quite clear that the appropriate use of psychotropic medications in children who are suffering – in the context of comprehensive treatment and work with families and caregivers – can be lifesaving and/or dramatically life changing in positive ways. I am not in any way saying that all prescribing for children is inappropriate. It is important to understand that these are complex situations and simple black and white pronouncements are meaningless and counterproductive.
Well Candida, unfortunately my “meaningless and counterproductive black and white pronouncements” have the weight of the Evidence.
To the best of my knowledge, to this day the only one of the anti-psychotic drugs given to kids that have FDA approval is Methylphenidate (Ritalin). And even it is not recommended for children under 6 years old.
So far as I know, none of the other drugs are approved for use in children under the age of 18. Everything else is “off label” use.
I am sticking with my characterization of doping little kids as ABSURD. There’s nothing “complex” about it. We know what doping kids is about, and it’s NOT for their “safety”.
Leonard Henderson, co-founder
American Family Rights Association
“Until Every Child Comes Home” ©
“The Voice of America’s Families” ©
Mr. Henderson,
I am willing to engage in a rational discussion on this topic, but after reading your two comments and visiting your website, I can see that rational discussion with you on this topic would be impossible. I know the risks of treating young children with powerful psychotropic medications and have written extensively on the topic. I also know the risks of not treating children with medication when they need it and have seen many children and their families who have benefited from such treatment. This is all I will say. I haven’t the time nor the inclination to engage in fruitless debate.
Candida, I wasn’t aware that we were having a fruitless debate.
I am merely relating HOW IT IS down here at the “consumer” level.
How does that become not having a “rational debate”?
I am an “old guy” and I have been highly involved in this for 25 years. I have NEVER SEEN a child that needed to be “medicated”.
Mr. Henderson,
I must ask, have you ever encountered a child in your family with bipolar-like symptoms? I must assume that you have not by your responses toward medicating children. You say you have been highly involved for 25 years and that you are relating at the “consumer level” but I must inquire, are you also relating at the parent level? My husband was diagnosed at the age of 15 with bipolar disorder. It is a proven fact that this disorder is hereditary. My middle son began to show signs of early onset. He began to have hallucinations, severe rage, severe highs, severe depression. All of this in a matter of 1 day. These symptoms progressed for over 1 year leading to multiple attempts at suicide. He’s only 10. We explored the alternatives to medication because, like you, I thought I was never going to be “one of those parents.” (I work in the pharmaceutical business and see parents “doping their children” on a daily basis.) My son’s situation was not improving with any of the alternatives. The psychiatrist recommended Abilify. I was floored. All I knew was that I couldn’t allow my son to continue to feel the way he was feeling. If medication was going to help, so be it. My son went from a raging, depressed, on top of the world child who wanted to die to a child with even-keel emotional behaviors. He went from physically beating on his family and cutting his wrists to being able to discuss issues as a typical 10 year old.
I agree, not every child should be prescribed medication. However, please do not judge those who are. You do not know what their experience is or what they have tried.
As I stated before, I see over-medicated children every day. But I now realize that I am judging those parents. I do not know what is going on with that child. It is not my place to cast shame or blame on anyone – it is my place to educate. I would encourage you to not stereotype. You do not know each individual circumstance.
– Regards
Christi-
Yes, unfortunately I have way too much experience with Bi-Polar. My wife has it, and it is severe. Her 3 sons from her previous marriage have developed similar conditions, one of whom was diagnosed as Schizophrenic.
She herself started having difficulties at 19 after the death of her father. Her oldest son developed his condition at college at the age of 21. Her middle son developed his condition at 15. He is the one whose behavior caused CPS to become destructively involved in my life.
Her youngest son is 25 now and he has some problems developing, but nothing like his mother and 2 brothers.
The children we have had together have been fine. The oldest of “ours” is 22.
So the answer to your questions are **sigh**, yes I have experience with mental illness in my family. Way too much of it.
The last time my wife went “off meds” again was 3 years ago.
At the Emergency Room, the County Social Worker, yet another cosmic feminist demanded to know what *I* did to make my wife this way.
**sigh**
I have had some really bad experiences with the “professionals”, their arrogant attitudes and politics.
Otherwise, my attitude about drugging children comes from my experience helping people at American Family Rights Association.
Mr. Henderson,
I am truly sorry for what your family has endured. I, too, have an extensive history in mental illness with my family. It is not easy and the last thing we all need is to feel guilty for the way we are treating the disorders with those closest to us. I thank God every day that he blessed people with the knowledge to create medications and other alternative forms of treatment for the various illnesses that my family faces. I have also had some negative experiences with professionals, but I’ve also had just as many positive experiences with professionals that have a heart for those with mental illnesses.
You say your attitude about drugging children comes from your experience helping people at American Family Rights Association. I am not familiar with that group, but I would encourage you to hear out those who do have children on medication. It doesn’t always have to be a negative situation.
Thank you for sharing your story and helping those who are in need. Sometimes we don’t realize how far our word spreads and what benefits or hindrances they may cause. I hope that my words are encouraging to others who are going through similar situations. Every trial in life can be used for good and to educate others. It sounds like that is exactly what you are doing with what you have been through.
ok i was reading on this here is what i think.yes some parent’s go straight to the med’s but here it is some parent’s are at fault but alot of dr’s these day’s have not realy done there job my son is mr(mentally retarted with bipolar and my daughter is bipolar as well when i take my kids the dr spends 10-15 minutes with my kids and that is not enough time.then they gave my son a high dose and he ended up at the hospital with and overdose and i gave him his medicine as perscribed so we took him off asap.i am the type of mother that reads up on all medical problems as well as meds and if i wouldn’t of i would of never new the dr perscribed way to much and i have family that is a nurse as well as a dr.so that was helpful.i am just saying that it’s both way’s and now my son has been off all meds for 8 months cause when i call to get him in i get told that they don’t have time for 2 months to call back and it goes back and forth.my son need’s back on his med’s cause he is getting very abusive right now and i am worried.so what to do.that’s why i moved back to my home town cause of what happened to my son but my hometown is no better.and still no dr will take my kids what does a person have to move out of state to get medical help for themselves and there children.
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