Thursday, December 20, 2007

Is Pediatric-Onset Bipolar Actually a Behavioral Disorder?

Every now and then, someone like John Rosemond will blast the diagnosis of Bipolar Disorder in children, saying that it is labeling toddler behavior with a psychiatric diagnosis.
Here is one such article, Maybe child isn't bipolar, just bratty as normal in which he lists behaviors commonly associated with bipolar in children (the same, by the way, that are commonly associated with autism) as if they were the diagnostic criteria.

John Rosemond blasts the book, “The Bipolar Child” by Papolos and Papolos. He does not state the diagnostic criteria for bipolar, such as severe depression, mixed states, suicidality, and mania or hypomania, along with greatly disturbed sleep and commonly accompanied by hallucinations, and even, in these children, temperature dysregulation (indicative of a hypothalamic dysfunction). Instead, John Rosemond brings up, out of context, commonly associated behaviors of these children, such as having severe tantrums, being oppositional, distractible, and having separation anxiety.

Those are not the diagnostic criteria for childhood-onset bipolar disorder, just the commonly associated behaviors.

If I had horrific nightmares that would not stop, severe depression, mixed states and hallucinations, I might also have the behaviors commonly associated with these bipolar children, too.

Dr. Papolos did not enter this field from a psychology point of view. Rather, he was studying genetic problems with early symptoms, called Velo-Cardio Facial Syndrome (VCFS). This genetic problem is also highly associated with “schizophrenia”, and has even been called one of the leading causes of it.[1]

It is possible that some children with behavioral problems due to poor parenting, or a mismatch in parenting styles, are getting MIS-diagnosed with bipolar disorder. The fact that the DSM-IV includes purely “behavioral disorders” of children which can be corrected by changing parenting tactics, complicates public understanding when other problems of a completely different etiology, yet with some behavioral repercussions, are listed in the same volume.

I appreciate John Rosemond advocating that parents not abdicate their parental responsibility to teach appropriate behavior. But I wish John Rosemond was not trying to throw the baby out with the bath water.

When my little girl was diagnosed with bipolar disorder (however briefly), it was not based on any behavioral issues. In fact, she was extremely well-behaved, and of all the adjectives ever used to describe her, “bratty” had never been one of them. The diagnosis was based on severe depression cycling with periods of hypomania and very little sleep, mixed states and hallucinations. She also had other common symptoms described in the book by Papolos and Papolos, such as nightmares that would not stop, and temperature dysregulation.

Did she have “meltdowns” and anxiety? You bet! The worse her depression and horrific hallucinations were, the worse her anxiety and tolerance for frustration got (note – it was internal frustration, NOT due to what anybody else said or didn’t say or what she could or could not have).

The diagnosis is supposed to be based on “diagnostic criteria”, not on associated behaviors which may or may not be present.

John Rosemond describes those behaviors commonly associated with bipolar disorder in children as those seen during the "terrible-twos". He has a point. But he stopped in the analysis too soon. These same commonly associated behaviors are seen when an autistic child cannot cope and has a "fit".

In fact, we saw the same regression in our own child when overwhelmed by psychosis, nightmares and resulting terror.

The research showing that kids who have severe tantrums--ones that go beyond the range of "normal" as evidenced by their intensity, chronicity, and not being able to be soothed in a timely manner, can indicate that the child actually suffers from yet another symptom--depression. And DEPRESSION is a symptom that something may be BIOLOGICALLY - MEDICALLY - going awry.


Some Temper Tantrums Can Be Red Flags: Study: Kids' Violent Temper Tantrums May Indicate Depression (ABC News) says that healthy children tend to have less aggressive tantrums and their tantrums are generally shorter. They warn that parents of children who hurt themselves or others or children that cannot calm themselves without help, should seek medical help.

Just as people would not ridicule an autistic child acting younger, he thought it was appropriate to ridicule a bipolar child doing the same thing. There is something going terribly wrong neurobiologically when a normal articulate bright child keeps having episodes during which ... yes... he/she acts very much like an autistic one in regards to not being able to cope and having hypersensitivity to inputs and internal feelings.

In any case, my daughter’s “bipolar” was as "neurodevelopmental" or "biological" as we now know autism to be.

She was a mature, well-behaved, kind, sweet, loving little girl with no psychological or "behavioral" problems. But she understands how easily another child without her compulsivity to NOT be "bad" might easily have been labeled as such. And, maybe because she compulsively controlled herself to NOT have "bratty-looking" tantrums, perhaps she caused herself more stress, distress, and more "meltdowns" in the long-run!

Unless others really know the details--all the details-- of what lies behind a diagnosis... others have no right to judge.... in my opinion.

From my experience with my child and others diagnosed with bipolar based on actual diagnostic criteria—the actual diagnostic criteria are severe and those children diagnosed using them are severely suffering. And their families are suffering along with them.

I’ll be posting later about research showing some biological overlaps between autism, bipolar disorder and schizophrenia (see some links below under "Additional Reading").

The parents of children with autism, fought long and hard for that diagnosis to be brought out of the dark ages, and removed from the bucket of “mental” illnesses. The same needs to be done for our children with these other neurobiological disorders.

Additional Reading:

References:


[1] Genetics of Childhood Disorders: XXV Velocardiofacial Syndrome. Doron Gothelf, M.D., and Paul J. Lombroso, M.D. J Am Acad Child Adolesc Psychiatry,40:4,489-491 April 2001 (http://www.med.yale.edu/chldstdy/plomdevelop/genetics/01aprgen.htm )

See also: "Brain Scans May Predict Mental Illness in Children with VCFS" 

Updated: 23 Jan 2013

4 comments:

Herb said...

While you have made your point exremely well, as a long time admirer of Rosemond, I'd like to offer something in his defense, in that I do believe that what punches his buttons is when behavioral problems, in children, are diagosed as "mental" problems and medicine is immediately prescribed. I suspect that there may b e more common ground between you and Rosemond than you think.

Jeanie said...

You are right - we do have much common ground - except that Rosemond talks only about the "horses", and I am concerned about the "zebras".

I also highly respect John Rosemond. I completely agree with his no-nonsense, common-sense approach to parenting and discipline (which translates into teaching and guiding). I agree that parents need to step up to the plate and not abrogate their responsibility as mature, responsible parents whose job it is to properly raise children.

However, I do not agree with throwing out the baby with the bath water.

It is possible that many children who are immature and lack impulse control are getting labeled with medical diagnoses when their problems are due to lack of proper parenting.

However, there still are, were, and will be, children whose lack of impulse control, is due to an actual defect of the brain. This used to be referred to as "minimal brain damage" or "minimal brain dysfunction". It is very sad, and very difficult for the families of these children to keep them safe, alive, and teach them to function in a more appropriate matter. This minimal brain damage is what morphed into "ADHD".

There are others who really do have "bipolar disorder".

I agree that it is sad when behaviour problems get diagnosed as a medical condition. But that also does not mean that children don't exist with these medical conditions.

A properly diagnosed case of ADHD or bipolar disorder is NOT a case of "behaviour" or bad parenting. In fact, it takes monumental parenting to help these children in spite of their problems.

That is a point which John Rosemond is not acknowledging. In order to make his point, he is simply ridiculing the diagnoses entirely as being based on "behaviours". This is a disservice to the children with true organic-based problems that may have certain "associated behaviours". It is also a disservice to all the families struggling to help these children.

From my perspective, his end does not justify his means.

Herb said...

In a way, you are both on the same side of the issue. You're both saying that "It's Not Mental"

I suspect that, because your's is a rather new approach to so-called mental illness, Rosemond has just not been exposed to the possibility that even behavioral disorders could be physical in origin, or even mediated by poor nutrition, etc.. I wonder if we can get Rosemond to join in this discussion, I identify so much with him that I feel he would be open to looking at your point of view.

Jeanie said...

I am actually not talking about behavioural problems at all, but medical symptoms that may affect behavior. That concept is not at all new. And, it is not what John Rosemond wishes to make people aware of. That is not his "crusade".

John Rosemond brought up some associated behaviours that commonly (but not necessarily) are seen in children with bipolar. Thse are not the symptoms upon which the diagnosis is supposed to be made according to the DSM-IV.

I appreciate that Rosemond is bringing up the fact that those associated symptoms do not mean that the child actually has bipolar, but he ridicules the diagnosis in general. He didn't mention that those are not the diagnostic criteria for bipolar disorder.

I do have a problem with ridiculing the diagnosis based on some behaviours without even mentioning the actual symptoms on which the diagnosis of bipolar is properly made(mania, mixed states, depression, mood-associated hallucinations, and suicidality).

Also not mentioned were some other associated medical symptoms which may accompany it such as disturbed sleep and temperature disregulation.

I am sure he knew exactly what he was doing, and I do respect the intent. The intent was to ridicule the doctors making snap diagnoses based on some possible "associated behaviours", and chastising the parents for abrogating their jobs as disciplinarians.

His object was not to enlighten people about the diagnosis of real bipolar disorder (even if it is in a child), nor about the need for better medical diagnostics in order to properly diagnose and properly treat these children.
There are entire books written on those subjects.

He had to make his point in the limited space of a commentary in a newspaper. The need to make the point he made was urgent. I do not fault him for that.

I am just presenting another side, of which, as an educated person, I am sure Rosemond is already aware.

The children I have seen given the diagnosis of bipolar actually did NOT have ANY of the "associated behaviours" he listed as being used for the diagnosis. Instead, these children had exactly what the DSM-IV lists. Periods of time with depression, mania, and mixed states. In addition, they had sleep problems and hallucinations.