From 1994 to 2003, there was a forty-fold increase in the treatment of youths for bipolar disorder — from 20,000 to 800,000 young people in the United States alone. In almost all cases, these children were treated with medications that had not been extensively tested for use in the very young. Thus, nearly one million children and adolescents were treated as adults despite decades of research that clearly identifies the unique developmental trajectory of the pre-adult years.
Many argue that by medicating the very young, mental disorders are caught early, saving the child, and his or her family, years of unnecessary suffering. Yet it is unclear if what is identified as bipolar disorder in children correlates with what is identified as bipolar disorder in adults.
Few children and adolescents actually meet the criteria for adult bipolar disorder. Instead of altering between the intense moods of depression and mania that characterizes adult bipolar, children tend to rage, behave aggressively, and are often hyperactive (hence the likelihood of also being diagnosed with ADHD). Rather than questioning the correlation between adult bipolar disorder and what is being witnessed in children, the diagnosis in children has been changed to incorporate these differences. Dr. Joseph Biederman of Harvard University — who came under fire for failing to report $1.6 million in consulting fees he received from pharmaceutical companies — redefined the symptoms of bipolar disorder in children to include extreme irritability, recklessness, sleeplessness, and hyperactivity. Nevertheless, Dr. Biederman did not suggest a novel treatment to complement his child-centric understanding of bipolar disorder. The method of treatment remained the same as the standard treatment for adults: prescribing medications.
The logic of this approach baffles me. If a new set of diagnostic criteria are needed, why not also identify what is occurring in children as a new disorder? Increasing the number of psychiatric disorders has been the trend in psychiatry the past half century. In 1952, there were 112 diagnoses in the DSM; in 1968, there were 163. The 1994 printing of the DSM listed 374 diagnoses.
One reason to name a set of behaviors in children as bipolar disorder might be because it allows psychiatrists to prescribe medications they suspect might alter behaviors in a desired direction. The parallel between adults and children would thus rest on the drugs’ effects—not the symptoms of the disorders.
Perhaps more disturbing than the use of medications to subdue problematic behavior is the disregard of children’s developmental trajectory. There is every possibility a child will ‘outgrow’ a mental disorder without treatment with potentially lethal medications, largely because of the profound influence the environment plays in the lives of children and adolescents.
According to John March, Chief of Child and Adolescent Psychiatry at Duke University, “from a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age five or six or seven will grow up to be adults with the illness.”
A 1999 report of Surgeon General David Satcher, Mental Health: A Report of the Surgeon General, emphasized the difficulties with diagnosing children and adolescents with adult mental illnesses precisely because children are constantly changing:
“The science is challenging because of the ongoing process of development. The normal developing child hardly stays the same long enough to make stable measurements. Adult criteria for illness can be difficult to apply to children and adolescents, when the signs and symptoms of mental disorders are often also the characteristics of normal development.”
Satcher also wrote:
“Even more than is true for adults, children must be seen in the context of their social environments, that is, family, peer group, and their larger physical and cultural surroundings. Childhood mental health is expressed in this context, as children proceed through development.”
According to Satcher, several adverse experiences are known to impact a child's mental health:
“Dysfunctional aspects of family life such as severe parental discord, a parent’s psychopathology or criminality, overcrowding, or large family size can predispose to conduct disorders and antisocial personality disorders, especially if the child does not have a loving relationship with at least one of the parents…. Economic hardship can indirectly increase a child’s risk of developing a behavioral disorder because it may cause behavioral problems in the parents or increase the risk of child abuse…. Exposure to acts of violence also is identified as a possible cause of stress-related mental health problems…. Studies point to poor caregiving practices as being a risk factor for children of depressed parents….”
These potential threats to a child’s well-being are often ignored when the primary form of treatment is medications, which leads me to question the ethical implications of medicating children and adolescents for bipolar disorder and other mental disorders. Shouldn't psychiatrists and other mental health workers be responsible for asking about conditions in children’s homes before treating them as if the problem resides in their brains? Shouldn't we care for children before assuming they need to be cured?
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