Stuart Kaplan, M.D., a child psychiatrist and clinical professor of psychiatry at Penn State College of Medicine, has written a new book called "Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis."
Marilyn Wedge: What inspired you to write the book?
Stuart Kaplan: The first articles describing the diagnosis of bipolar disorder in children in the mid-1990s were obviously mistaken. The children described in these articles did not have bipolar disorder, and the criteria used to make the diagnosis differed from the DSM-IV criteria for the diagnosis. In a few short years, professional meetings on the subject were filled to capacity, and the diagnosis became rampant. Training programs educated child psychiatrists in the diagnosis and treatment of the disorder. Finally, it seemed as if child psychiatry would never back away from the diagnosis; I thought a book critical of the diagnosis for parents and professionals might help.
MW: You make the interesting point that the diagnostic category of bipolar disorder (previously called manic depressive illness) is an accurate description of a disorder that exists in adults in the natural world. On the other hand, categorizing children's mood and behavioral problems as bipolar disorder is incorrect, because the diagnosis does not point to an actual biological problem in children.
SK: Categorizing children's mood and behavioral problems as bipolar disorder is incorrect because the disorder does not meet any of the required five Robins-Guze criteria for establishing a psychiatric diagnosis. Pediatric bipolar disorder is a social construction: it is a word made up by people, but it has no counterpart in the real world. It's an American disease that is largely absent in other countries. It is one of many stories we have made up to explain misbehaving children.
MW: Like the narrative therapists and family therapists like myself, you believe that culture, the media and economic forces play a large part in inventing mental health diagnoses that do not refer to something that exists in nature. How did the creation of pediatric bipolar disorder come about and how was it marketed to the American public?
SK: Many psychiatric illnesses seem to have a biological component. The diagnoses of these disorders seem to refer to a biological reality, even though this reality is not clearly understood. The diagnoses appear to actually "carve nature at its joints." Pediatric bipolar disorder, in contrast, was largely a media fiction sustained by NIMH and the pharmaceutical industry. The public was introduced to child bipolar disorder by a best-selling book, "The Bipolar Child." Parents were eager for answers about how to manage their difficult children and looked to the book for answers. Although it became a bestseller, the book was devoid of scientific information, and it contained a considerable amount of misinformation. For example, the authors claim that sleeping late in the morning is a sign of childhood bipolar disorder.
Simultaneously, NIMH seemed to embrace the concept of bipolar disorder in children and published a piece that lent support to the existence of the disorder in a widely read and prestigious journal of child psychiatry. NIMH then began funding a large number of grants to leaders in child psychiatry who wrote articles describing the disorder and told their junior colleagues how to treat it. The scientific papers published about the disorder served an important public relations role in sustaining the belief in the disorder. I don't think the pharmaceutical industry created the disorder (as has often been claimed), but they were certainly pleased to use it as an opportunity to sell more drugs.
MW: Are the long-term consequences of taking anti-psychotic medications like Lithium, Risperdal and Depakote, beginning in childhood, well-understood by doctors? These drugs are often used to treat bipolar disorder in children.
SK: The long-term consequences are not fully understood, and the short-term consequences are grounds enough for serious concern. I cannot adequately describe the side effects of these medications in this brief space. One side effect worth mentioning is weight gain, a problem for all three of these medications. Children tend to gain weight on these medications even more rapidly than adults -- as much as half a pound a month to one pound a month. Children taking these medications can quickly become obese and are vulnerable to developing diabetes, hypertension and other disorders related to obesity.
MW: You propose that children currently diagnosed as bipolar are more accurately categorized as having focusing, attention and behavioral problems.
SK: The most ardent proponents of bipolar disorder in children acknowledge that up to 90 percent of the children have Attention Deficit Hyperactivity Disorder, which can be treated with relative ease with stimulant medications. Proponents of childhood bipolar disorder deny this treatment to the patients in the mistaken belief that stimulants will make bipolar patients worse.
MW: As a family therapist, I am fascinated by your behavior modification program for treating oppositional and defiant children. You observe that when parents modify their parenting and cease to unintentionally reward their child for misbehavior, the child starts to improve.
SK: I begin with the simple, common sense notion that children misbehave because they enjoy it, and parents unintentionally reward children for the misbehavior. I switch the family economy around such that children are richly rewarded for behaving well and deprived of rewards on the occasions they misbehave.
MW: You observe that parents of an oppositional and defiant child often differ in their philosophy of parenting, with one parent being strict and the other more soft-hearted. During your behavioral program, at least, the parents must come to agreement about how they will parent.
SK: Parents rarely discuss child-rearing strategies before marriage. It is not surprising that they disagree about managing children over the course of their children's development.
MW: How did you become interested in family therapy? Is family therapy generally included as part of a psychiatrist's training?
SK: I did one year (1968-1969) of my child psychiatry training at the Philadelphia Child Guidance Clinic, a national center for family therapy training at the time. I was a staff psychiatrist there from about 1972 to 1974. Most child psychiatry residents have little interest in family therapy. Family therapy and child psychiatry divorced several decades ago. This divorce seems to have been a great loss for both fields.
MW: What will parents gain from reading the book?
SK: This book will help parents deepen their understanding of how bipolar disorder is (mis) diagnosed in children and adolescents and the science behind the psychiatric treatment of the disorder.