A new study, led by Cheryl Dellasega, professor of medicine and humanities at Penn State College of Medicine, explores practitioners’ comfort with assessing irritability in school-aged children. The results of the study, recently published in The Primary Care Companion for CNS Disorders, suggest that family medicine providers require more training and resources to confidently and accurately assess irritability in youth.
“Due to the increased incidence of diagnosis of bipolar disorder in children and concerns about inappropriate treatment, there is a need to determine and review how practitioners assess irritability. It has been suggested that the rise in bipolar diagnosis and prescription of mood-stabilizing and antipsychotic medications may be due to the lack of availability and understanding of an appropriate diagnosis,” state the researchers.
Irritability is one of the most common complaints with pediatric patients. The authors discuss that irritability is often a “normal and developmental” experience of youth, but can also be “abnormal” for some youth and is included as a symptom in many DSM-5 diagnoses (e.g., disruptive mood dysregulation disorder, bipolar disorder). The authors note that family medicine practitioners “are often the front line in the assessment of mental health needs.” Because of this, it is important for primary care practitioners to know how to accurately assess and respond to reported irritability in youth.
Diagnosis often drives treatment decisions. Therefore, misdiagnosis can be harmful as it can lead to unhelpful interventions and unnecessarily expose youth to the significant side effects of medications like mood stabilizers or antipsychotics. According to the authors, it is essential to have a better understanding of how primary care providers differentiate “normal from abnormal irritability” and to provide these practitioners with resources to help in their assessments. This was therefore the goal of the study.
The researchers engaged in a qualitative study. They conducted in-depth, 1-hour interviews with 17 practitioners at a large academic medical center. Participants were residents, fellows, nurse practitioners, and attending physicians who specialized in either family medicine, pediatrics, or psychiatry. In addition to the interview, participants also provided information on their confidence in mental health screening, awareness of changes in the DSM-5 related to irritability symptoms, and attendance at mental health related conferences or workshops.
Family medicine and pediatric practitioners rated their confidence in assessing irritability and knowledge of the DSM significantly lower than psychiatric practitioners. Participants agreed that there is no “gold standard” for evaluating irritability in youth and many wanted clearer guidelines. Participants also highlighted that short office visits made it more challenging to assess irritability because they did not have enough time to do a thorough evaluation. Family medicine participants described how their assessment of irritability improved over time as they gained more experience.
One participant stated, “I’m saying that behaviors I might have previously interpreted as being irritability are probably not irritability, but probably just normal developmental things that I didn’t have experience with before.”
Family medicine providers tended to assess a patient’s irritability in comparison to their peer group or siblings to determine if the behavior is ‘normal or abnormal,’ whereas psychiatric providers explored the signs of irritability and potential causes. Family medicine participants were comfortable prescribing antidepressants and anxiolytics, but were more likely to refer to a psychiatrist if other medications were indicated. In general, medication prescription was more preferred by family medicine providers, and psychiatrists tended to minimize medication use and recommend therapy more often.
“It is challenging to address mental health issues in the family medicine setting, particularly when the presenting symptoms are ambiguous, as is the case with irritability,” the authors write. “In this study, family medicine providers were less confident in their mental health assessment skills and had less continuing medical education on assessment of irritability than their pediatric or psychiatric counterparts.”
The researchers also found that “the psychiatry respondents expressed a wish for primary care providers to be more involved in assessing and treating irritability, while family medicine and pediatric providers expressed a wish to learn more about assessment and treatment.”
In addition, while psychiatric providers used the DSM as their main resource, primary care providers often used UpToDate, which is an “online resource and mobile app that offers current evidence-based medication information and clinical decision support.” When the researchers searched “irritability in children” and “irritability in adolescents” in UptoDate, they received results on pharmacotherapy and pediatric bipolar disorder and concluded “there is a need for more specific information on childhood irritability.”
Although the finding that primary care practitioners feel less confident in their knowledge of psychological issues compared to psychiatric practitioners may not be surprising, it is problematic given the fact that “the majority of children receive mental health care in the primary care setting.”
The findings provide evidence that primary care practitioners need to be better trained in assessing irritability in youth and have access to more specific resources in order to avoid mislabeling irritability as ‘abnormal,’ leading to misdiagnosis and overtreatment with psychiatric medications. One solution the authors recommend is more telehealth programs that offer virtual consults with child mental health services such as pediatric psychiatrists.
“Through better understanding of how to accurately diagnose children and adolescents on the irritability spectrum, misdiagnosis will be reduced and treatment will be enhanced, leading to overall improved mental health.”
Scandinaro, A. L., Hameed, U., & Dellasega, C. A. (2018). A qualitative study to assess how primary care versus psychiatric providers evaluate and treat pediatric patients with irritability. The Primary Care Companion for CNS Disorders, 20(2), 17m02227. doi:10.4088/PCC.17m02227 (Link)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
First of all, “bipolar” is a scientifically “invalid” disorder, not a real disease. One wonders how long it will take doctors to wake up to this reality.
Second, most primary care visits are 15 minutes, which is not enough time to judge another person. So the primary care doctors should NOT be diagnosing children with “bipolar.”
Third, the DSM “bipolar” drug cocktail recommendations, which include combining the antidepressants and/or antipsychotics (aka neuroleptics), can create symptoms that mimic both the negative and positive symptoms of “schizophrenia.” The negative symptoms can be created via neuroleptic induced deficit syndrome and the positive symptoms can be created via antidepressant and/or antipsychotic induced anticholinergic toxidrome.
But since neither of these medically known, psychiatric drug induced syndrome are listed in the DSM billing code “bible,” they are always misdiagnosed as one of the billable, but “invalid,” DSM disorders. Out of sight, out of the minds of the doctors.
The DSM is also problematic because child abuse or bullying, which can cause irritability in children, is considered a “V Code” in the DSM. And the “V Codes” are not billable disorders.
This has resulted in millions of child abuse victims being misdiagnosed with the billable DSM disorders, because that’s the only way the doctors can get paid by the insurance companies. Today, over 80% of those labeled as “depressed,” “anxious,” “bipolar,” or “schizophrenic” are actually child abuse victims. Over 90% of those labeled as “borderline” are child abuse victims.
Since “irritability,” which was caused by some sort of abuse or bullying, is not a brain disease. “Irritability” caused by child abuse or bullying is not cured with drugs.
But the doctors do watch the “bipolar” drugs make children and adults very sick, via the psychiatric drug induced syndromes mentioned above. Resulting in the doctors deluding themselves, their patients and their patients’ parents into believing they made a correct diagnosis.
Parents, grab your children and run away from any doctor who diagnoses your child as “bipolar.”
we haven’t learned….
we want a quick fix…
and the quick fix is there..
reality will come back to bite us..
reality does not go away…
kids brains aren’t even developed..
the kids problem is just awful..
You mean that an educated psychiatrist will be less harmful?
First, that a psychiatrist is stupid, it’s normal. 10 years of skull stuffing at the university will make psychiatrists the fools that insurance and pharmaceutical industries need.
Then I am often stupefied by the ignorance of psychiatrists, even in areas that they are supposed to master a little. Their knowledge of pharmacology is simply wrong. They believe only what they learn in pharmaceutical industry conferences, where they receive a lot of gifts. They NEVER study scientific research, they are unable to lead a serious discussion on the subject. They are complete empiricists: give the right of prescription to a carpenter and he will not do more damage than a psychiatrist.
Their knowledge in ethnology, sociology and psychology are extraordinarily weak, in any case, they rarely use them. Their sensitivity and empathy are very much below average. Although the DSM is decried, in France, psychiatrists do not even use this reference for their diagnoses! They do not use any standard test! They do no use scales to evaluate progress or degradation of patients! This is the most complete arbitrary.
But why are psychiatrists so stupid? Because they have no interest, no need to be smart. A “bad” psychiatrist does not lose his clients since he can force them to take his treatments. In addition, everything is repayable! It’s not the psychotherapists who will compete with him… In the end, the more he manages to deceive his clients and himself, the more he makes his clients dependent and disabled, the more he will get rich.
He does not need to be intelligent, and the intelligence would risk giving him some scruples, contrary to his interest.
What I notice is that theres a lot of “game playing” of mental illness, or mental illness by “clever argument” around the place.
Adults are irritable because they have children to contend with. Children are irritable because they have irritable parents.
What we need is a more highly developed technology, then you wouldn’t have to hospitalize people because they weren’t better robots.
No, the robots could do it for you.
It’s a political strategy, not a “mistake,” dear.
Childhood Bipolar Disorder has been shown to be even more delusional fiction than the adult version. “Irritability” was INVENTED as a criterion by Joseph Biedermann in service of his Big Pharma masters at J&J so they could sell more Risperdal. There was never any evidence that these kids had anything wrong with them, and longitudinal studies showed NO correlation between which kids got “bipolar” labels in childhood and those who were labeled “bipolar” as adults. “Irritability” is pretty damned common among kids (and as Frank points out, among their parents as well!) Telling doctors there is some way to “correctly assess irritability” is about as stupid as saying you can assess “emotional immaturity” or “oversensitivity” or “aggressiveness” in children. In other words, it’s meaningless, and the reason doctors are confused is because they’re being lied to!
I’ve about given up on doctors period, no matter what their specialty is supposed to be. An entire generation of children is being drugged with toxic drugs posing as “medicines”. What effect is this going to have on our society and country when they become adults? I know that it’s not easy to be a parent, but I feel that it’s time for parents to stand up for their kids instead of listening to doctors who seem to be out to drug them regardless. We knew that you couldn’t trust psychiatrists to know anything about what they said and now we have to worry about GP’s. I’m very careful about letting any doctor do anything to me today.
Bipolar is FICTION. Irritability is too mild a response to such psychiatric lies.
It’s got to be fiction as the rates of bipolar were miniscule years ago.
You know, I wish I could believe that children were safer in the hands of “specialists” in child psychiatry, and less vulnerable to a really harmful mis-diagnosis. But I really think it’s exactly the opposite. When it comes to a dangerously flawed concept like Childhood Bipolar Disorder, lack of confidence is the beginning of wisdom!
It is precisely the “confidence” of the specialists that makes them dangerous. They feel comfortable prescribing drugs two or three at a time, drugs that aren’t approved for children, drugs with black-box warning, etc. etc. Things your GP wouldn’t dare do, because he or she is not enough of a specialist.
As for “mistakes” vs. “correct diagnoses” — it all depends on who’s doing the counting! It’s fairly easy for a child psychiatrist to label a GP’s decision (however sensible) as wrong. And hard as hell for a GP to label a child psychiatrist’s decision (however bizarre) as wrong. That’s just how the medical hierarchy works. The specialist is right BECAUSE he is a specialist, hallelujah, amen.
The same problem comes up in managing “chronic non-cancer pain” (from injuries, arthritis, etc.) Too many people think the whole problem of reckless over-prescribing of opioid pain pills comes from letting mere GPs handle it — and the solution is to turn all such decisions over to Board-Certified Pain Management Specialists. In reality, most of the time, it’s when you meet the Board Certified Specialist that your troubles REALLY begin … because those bastards are Confident. Oh boy, are they confident!
You are so correct in all that you state here.
“In this climate of profoundly disrupted relationships the child faces a formidable developmental task. She must find a way to form primary attachments to caretakers who are either dangerous or, from her perspective, negligent. She must find a way to develop a sense of basic trust and safety with caretakers who are untrustworthy and unsafe. She must develop a sense of self in relation to others who are helpless, uncaring, or cruel. She must develop a capacity for bodily self-regulation in an environment in which her body is at the disposal of others’ needs, as well as a capacity for self-soothing in an environment without solace. She must develop the capacity for initiative in an environment which demands that she bring her will into complete conformity with that of her abuser. And ultimately, she must develop a capacity for intimacy out of an environment where all intimate relationships are corrupt, and an identity out of an environment which defines her as a whore and a slave.” – Judith Herman in Trauma and Recovery
I guess we would all be irritable under these circumstances
The problem is not who diagnoses bipolar disorder in children and adolescents. It is the diagnosis itself that is wrong. Bipolar disorder in children was a big cash cow for psychiatry. Lifetime diagnosis and years of medications that we know have negative effects on the growing brain as well as further victimizing children for reactions to their environments, i.e. home, school, peer group. These environments are the problem, not the children. Loving, nurturing environments are the key not years of medications and deferring to psychiatrists and family medicine physicians. Do not put absolute trust in MDs. I work with family medicine MDs and with psychiatrists in the past, they think within a box. We need to love our children, empower parents to be more effective, nurturing caregivers, not medicalize normal childhood behaviors or reactions to negative, traumatic environments.
It’s more or less officially acknowledged; and in the media nearly every day of the week in the UK, that people are being driven into more serious Mental Disorders (such as “Bipolar” and “Schizophrenia” i.e. “Madness”) through initial use of anti depressants and anti anxiety type drugs.
I’m sorry if I’m slightly off topic here – but this phenomenon is gaining momentum.
It might seem counter-intuitive, and it is, but some of the most “loving” (seemingly) homes and families do the most damage to children. These families create the APPEARANCE of being kind, normal, loving, nurturing, etc.
Everything LOOKS good on the outside, and to the public. Plenty of food, clean clothes, toys, etc., But it’s all a charade, an act, a play. Behind closed doors, the relationships within the family are TOXIC. And who are the VICTIMS? The children. These are the kids most likely to get a bogus psych “diagnosis”, and DRUGS….
Their parents usually have plenty of $$$, and INSURANCE!….
What a scam psychiatry in particular, and medicine and PhRMA in general, have become.
Money, power, control, and greed…. Oh yeah, the ignorance of propaganda, too….
probably not many doctors are talking about nutrition and irritability…