Mental illness in children
From Acquainted with the Night:
● Problems diagnosing mental illness in children
● Bipolar disorder in children
Problems Diagnosing Mental Illness in Children
...I’m not sure why it seemed so crucial to get my son a proper diagnosis. Partly, I suppose, it was because I wanted to get him the right treatment, and I wanted to know what his prognosis was. Would he get better? Would he struggle with this for the rest of his life? Without a diagnosis, it was hard to know what to think.
Much later, I learned that the question of proper diagnosis is not an easy one to answer. Children are constantly changing, developing and growing, and so it’s hard to compare their lives before the illness with their lives afterwards. And it can be hard to sit them down for a thoughtful conversation.
In cardiology, a diagnosis can be as neat and quick as the snap of the needle on an electrocardiograph. But there is no measure for depression, no blood test to identify schizophrenia or mania. In psychiatry, diagnoses overlap and flow into one another, blurring like the colors on an artist's palette. Instead of making a diagnosis and then choosing a drug, it often seems that psychiatrists will often choose a drug to help make a diagnosis. If a patient responds to lithium, she has bipolar disorder, otherwise known as manic depression. If she does better on an anti-psychotic, she has schizophrenia. If a child seems calmer on Ritalin, he has attention-deficit hyperactivity disorder.
Psychiatrists disagree so often and so profoundly about their diagnoses that they have devised a cookbook of symptoms to help them out. This book, the Diagnostic and Statistical Manual of Mental Disorders, is unlike anything you'll find in the office of a cardiologist or an oncologist. The DSM-IV, as it's called (the current version is the fourth edition), lists psychiatric symptoms and reduces diagnosis to a multiple-choice quiz. You might think, for example, that diagnosing a manic episode in a person with bipolar disorder would be relatively simple. It seems easy enough to any parent who has had to help a child get through a manic episode. Not so for psychiatrists, however. The DSM-IV lists five criteria for a manic episode. This is the second of the five, with its seven subsidiary benchmarks:
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually)
(7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
A child with three of these satisfies one of the five principal criteria for mania. Only two, and he doesn't. The DSM-IV also includes a sly acknowledgement, in the small print of a footnote, that doctors trying to diagnose mania can just as easily cause it. “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis,” it says. In other words, if the mania was caused by something a psychiatrist administered during the trial-and-error phase of treatment, it was not really mania. It was a mistake. What the DSM-IV doesn’t do is remind doctors to apologize to these patients...
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Depression in children
...When she was in the seventh grade, my daughter was admitted to the hospital for depression, the same hospital where her brother had been treated for bipolar disorder earlier that year. As we sat in the admissions office and signed a dozen consent forms, she told me, for the first time, about a suicide attempt she had made a few weeks earlier. She talked about the emotions that had an unyielding grip on her, the despair, and the terror of facing another day at school. The hospital’s diagnosis was depressive disorder NOS (not otherwise specified). That is, her illness did not fit into any of the several recognized sub-categories of depression. It was depression; no qualifiers needed.
What she was going through was, in some sense, a wildly magnified and distorted version of the emotional turmoil that all children undergo in middle school. Girls are especially susceptible to losing their emotional gyroscopes during these difficult years. Some stop eating, finding that the pain and hunger of anorexia draws energy away from their out-of-control emotions. Others engage in what is sometimes called the new anorexia, or the alternative anorexia--a different way of using pain to deal with emotional turmoil: They cut themselves. How this provides comfort is something that I do not ever expect to understand. Sometimes cutting is accompanied by suicide, but often it is not. Self-mutilation is not failed suicide; it is something else.
I learned this from a book I’d stumbled across at a bookstore, browsing through the psychology section. I didn’t expect to find an entire book about people who deliberately hurt themselves, but there it was. It was called Cutting. I found the title repellent. When I opened it and began to read cases of people, mostly adolescent girls, who were “self-mutilators,” I was repelled by that term, too. The author, Steven Levenkron, a therapist in New York City, begins the book with stories of girls who cut themselves, story after story of behavior that seems incomprehensible to those of us who shiver at the thought of a paper cut, let alone slicing a razor blade into soft flesh. I almost put the book down; it was difficult to continue reading. Levenkron begins the book that way deliberately, to make a point. “The self-mutilator is looked upon with fear, anger, disgust and revulsion,” he wrote. Therapists often feel that way, too, he writes, when their patients engage in this behavior. The point of Levenkron’s graphic stories was to make cutting more familiar, to try to ease the disgust and revulsion that it inspires. “Desensitizing ourselves to the behaviors and the scars they inflict does not mean desensitizing ourselves to the patient’s emotional distress,” he wrote. “It is, rather, the first step necessary to seeing the self-mutilator for what she is: a person in desperate need of help and human contact.”
I didn’t need to be desensitized to know that my daughter was in desperate need of help. I never regarded her with disgust or revulsion, or anger. I was afraid for her, and I didn’t understand the link between cutting and suicide, if there was one. Levenkron said they were different, and other researchers agree. But she was suicidal, too. The two things together were almost too much to bear. My son was finally doing better. I thought we were going to get back on track. And now we were discovering that my daughter had been suffering, alone, for months. When she admitted to the psychiatrist that she’d been cutting herself, she wasn’t shy about showing us the scars we’d missed during those long months. Her shoulders were crisscrossed with short, jagged, irregular marks, like the scribblings of an infant with a crayon. It was heartbreaking to look at them...
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Bipolar Disorder in children
When my song was diagnosed with bipolar disorder, I began to call and to visit some of the leading figures in the diagnosis and treatment of bipolar disorder in children. I soon learned that a controversy had arisen about the diagnosis of bipolar disorder in children. Until recently, most psychiatrists believed it occurred only in adults, with perhaps a few very rare exceptions. In the 1990s, however, it became clear that there was a group of children whose symptoms didn’t fit well with the established categories of children’s psychiatric ailments.
Some psychiatrists began to argue that those children were suffering from bipolar disorder. It could be as common among children as among adults, striking perhaps one in 100, some psychiatrists argued. But there was no consensus. Other psychiatrists said these kids had somewhat unusual cases of, say, conduct disorder, or attention-deficit-hyperactivity disorder. The American Academy of Child and Adolescent Psychiatry, which might have stepped in to settle the controversy, hasn’t done so. It has no official position on the question of bipolar illness in children, partly because so many of its members disagree.
I went to see Dr. Barbara Geller, a psychiatrist at Washington University in St. Louis who has pioneered the diagnosis of bipolar disorder in children. One reason for the controversy, she said, is that the symptoms of children with bipolar disorder are different from those of adults. Adults might suffer one or two episodes or mania and depression a year, lasting days or weeks. At other times, they feel quite normal. Children are far more likely to show what psychiatrists call “rapid cycling,” according to Geller. “They can jump around and feel good, then crash to suicidal depressions with no apparent cause,” she told me.
What I’d seen had been mostly depression, not the wild mania that people talk about with bipolar disorder. But I did remember one night, earlier that spring, that seemed to me to be an example of mania. I was sitting at the piano at home, playing and singing show tunes, as I often did when I got home from work, too exhausted to do anything else. My son often sang with me, but this night he began to sing along much more boisterously, improvising new melodies, and thoroughly enjoying himself. I was delighted to see him so happy, and we played and sang until he was exhausted. It wasn’t until later until I realized that he had not only been enthusiastic, but he’d been bursting with energy and as free of inhibitions as I’d ever seen him.
After we finished singing, we went out to a nearby restaurant for dinner. He ordered fried calamari, his favorite dish, and carried on a vigorous, exuberant conversation. While he was waiting for his dinner to arrive, he quieted down. And then I watched as his mood slid into a deep pit. He became silent. His shoulders fell. He hunched over the table, with his eyes downcast. His head sagged until it nearly met the table. The entire transformation had occurred in less than 10 minutes. When the food arrived, I left to take him home. He wasn’t able to sit at the table. It was the most dramatic example I’d ever seen of a mood swing. It wasn’t frightening, because I knew what was happening, but it was sad. I sensed that he, too, was sorry to have slid from the energetic mood peak where he’d been only a few minutes before.
Many of the parents of bipolar kids don’t care how the doctors resolve the controversy over its diagnosis. They know their kids are sick, and they are convinced it is something different from ADHD. At a psychiatrists’ meeting, I met Martha Hellander, the indefatigable mother of a bipolar child and the executive director of the Child and Adolescent Bipolar Foundation, a leading parents’ group. “We don’t care what the doctors call it,” she told me. “We’re telling them, ‘We observe things you don’t observe, and you need to listen to us.’ Debating the issue doesn’t help the children.”
Increasingly, psychiatrists are accepting the view that bipolar disorder occurs in children, but there are still many questions about how to treat it. By the time I had begun to learn more about bipolar disorder in children, my son had been on lithium for more than three years, with little improvement. He had never been treated with Depakote. It didn’t occur to me that there would be much difference between the two drugs. If I’d given the matter much thought, I supposed I would have concluded that he was one of the unfortunates with bipolar disorder who didn’t respond well to treatment. But I did not give that a lot of thought. The idea that he might not get better was not an idea I wanted to pursue.