Recently, a parent walked into my office with a mountainous stack of test results that purported to show that her eight-year-old son Adam has brain chemistry similar to adults who had been diagnosed with bipolar disorder. Although Adam’s psychiatrist could not diagnose him with bipolar disorder (it is not a pediatric diagnosis in the DSM-5, the current manual that psychiatrists use for diagnosing), he said that Adam should be treated with a medication used for adults with bipolar disorder. The psychiatrist prescribed Abilify for Adam.
As a clinician who has worked with children for more than two decades, I was taken aback by several aspects of this scenario.
The first thing that hit me was that, despite the high pile of paperwork, there are no tests for the “brain chemistry” of people diagnosed with bipolar disorder. According to the National Institute of Mental Health: “There are no blood tests or brain scans that can diagnose bipolar disorder.”
What a strange new world child psychiatry has become. I did not ask to read over the test results for Adam because that would be giving them credibility.
The second thing that knocked me over was that a psychiatrist had prescribed a powerful drug like Abilify off-label for an eight year old. On the home page of the drug, the manufacturer states that the only pediatric disorder for which Abilify is indicated is autism. For pediatric patients it may be used to treat manic or mixed (manic and depressive) episodes for children 10 to 17 years old. And the warning label for Abilify warns of horrendous side effects like increased risk for diabetes and tardive dyskinesia.
The third and most important thing about this scenario, however, was that Adam by no stretch of the imagination had anything like bipolar disorder or even “disruptive mood dysregulation disorder” (DMDD) which is the DSM-5 diagnosis that is a substitute for bipolar disorder symptoms in children.
After seeing the family for two sessions I came to the conclusion that what Adam was suffering from was inconsistent discipline, temper tantrums and misbehavior that were inadvertently encouraged by his parents, and, ultimately, too much power in the family. Adam was a strong-willed, moody child by temperament and he used his anger to control his kindhearted parents—even to the extent of being physically violent with them. He enjoyed conflict and enjoyed winning. Adam was like a lion and the lion needed to be tamed.
The correct prescription for Adam was not an antipsychotic medication that might cause him harm, but family therapy to help the parents implement a behavioral program that would fit Adam’s needs. Deeper family issues regarding the parent’s marriage and in-law problems would also need to be addressed.
In 2011, child psychiatrist Stuart L. Kaplan wrote an important book called Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. This book was a response to the dramatic increase in the diagnosis and treatment of bipolar disorder in children and adolescents.
Now I don’t agree with Dr. Kaplan on everything he says. For example, he believes that treating children incorrectly diagnosed with bipolar disorder with ADHD medications often helps them. I don’t think that any child should be medicated with psychiatric medications except in the case of a true brain disease like a brain tumor or meningitis.
But I do think that Kaplan’s book is important in that he does propose a family therapy-based behavior modification program for oppositional defiant children who have taken too much power in the family system by their misbehavior. And he does present a strong argument against treating children with antipsychotic medications because of their horrendous side effects.
Seven years since Kaplan’s book came out, children are still being diagnosed with bipolar disorder (now “discovered” in the child’s brain chemistry by fake tests that even the National Institutes of Health say don’t exist). Worst of all, children are being given antipsychotics in record numbers—sometimes more than one of these drugs. Adam’s pediatrician, who was as appalled at antipsychotics for kids as I was, told me that some children he saw took five psychotropic medications prescribed by psychiatrists. When I recommend to parents that they do some internet research on the drugs that have been prescribed for their child, they come back to my office and say they want their child off the drugs.
And this is the main point of this article. Before parents allow a child to be diagnosed with bipolar disorder and medicated with antipsychotics, educate yourselves on the side effects of these drugs. Then find a professional who will help you set up a behavioral program with rewards for good behavior and consistent immediate consequences for bad behavior.
Use the “count to 3” method to discourage bad behavior and make a “star chart” to reward good behavior. Disengage from arguments with your child. Use immediate consequences for disrespectful language or violence. Don’t be afraid of taking away privileges like going to a friend’s birthday party or a special outing even if they are inconvenient for you. Don’t let your child’s moods control you. Give your child lots of appropriate choices (some power) but not all the power. And remember, giving up power isn’t easy. The tantrums may increase for a while. But if you are consistent, your child’s behavior and moods will improve as if by magic.
Adam’s parents found that after two months of consistently implementing rewards for good behavior and immediate consequences for misbehavior, Adam’s behavior improved significantly. They took Adam off the medication and he still continues to improve. From a baseline score of 10 (with 10 being the worst possible misbehavior and moodiness and 1 being the best) Adam is now a 5. As I help resolve deeper family issues with Adam’s parents, I have no doubt that Adam’s behavior will improve to a 1 or 2. Sure, disciplining a strong-willed child is more difficult than giving him a pill. But Adam’s parents are finding that it’s much easier and more rewarding than they thought it would be.
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.