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Treating a child's mental illness

THE ARTICLE on bipolar disorder in children ("Backlash on bipolar diagnoses in children," Sunday Globe, June 17, Page 1) raises many important questions, but conflates the personal with the scientific in a manner that does not serve the public interest. The issue of how bipolar disorder should be diagnosed in very young children is a matter of scientific investigation, and should not be piggy-backed on a discussion of specific researchers or controversial medical incidents in the news. For much of the 19th and early 20th century, the idea that children could suffer from serious depression was disparaged by many theoreticians. Today, it is well-accepted that even young children can be seriously depressed. There is growing evidence from work in several countries that young children can also suffer from bipolar disorder. However, the specific age "cutoff," symptom profile, and optimal treatment are matters for continued research, not ad hominem attacks.


The writer is a clinical professor of psychiatry at Tufts University School of Medicine.

WITH ADMITTEDLY slim evidence, Dr. Joseph Biederman would have us accept his recommendations on the use of drugs to treat bipolar disorder in children on the basis of his impeccable credentials alone. He dismisses criticism by his colleagues because they lack his MGH credentials. This haughty approach to debating the merits of his research coupled with a paucity of federal funding for it and an abundance of drug company funding, sends up a warning flare that should not be ignored. Children's lives are at stake and to use powerful drugs on a difficult-to-diagnose malady without first proving their safety and efficacy is tantamount to malpractice.


ANOTHER FACTOR that contributes to the overuse of psychiatric medication in children is the lack of meaningful informed consent. Parents are frequently not given sufficient information to make the best decision. The benefits of medications are often exaggerated. Parents are rarely informed that certain medications that are effective for adults with a similar condition may not be effective for children or FDA approved for use in children. Risks are similarly minimized. Parents may not be told about serious federally mandated black-box warnings. Alternatives are rarely discussed. In many instances, informed consent is reduced to a sham of getting a signature on a piece of paper.

If we truly empower parents to make informed decisions based on weighing accurate information about benefits, risks and alternatives, children will be protected, psychiatric medication will be used more appropriately, and its overuse will decrease.

Manlius, N.Y.

The writer is a clinical professor of child psychiatry at New York Medical College.

WHAT MOST people don't understand -- that Dr. Biederman does -- is that bipolar illness in a child is nothing short of tragic. Healthy children spend their early years developing basic skills and self-confidence, and learning to establish relationships and sound judgment that will sustain them through adulthood. But children with early-onset bipolar disorder are often unable to achieve these developmental milestones within anything approaching a normal timeframe because of poor control over their mood and behavior.

Those on the outside who stand in judgment don't see what life is like in the child's home, so they can't possibly understand the scope of the damage bipolar illness inflicts on the entire family. Children with bipolar disorder are terrified, ashamed, remorseful, and confused by their own behaviors and feelings. They may manage some control over their behavior in public, but at home -- where they feel safe enough to let their mangled emotions show -- the full devastation of this disease is expressed.

Under these circumstances, pious tirades about the moral rectitude of administering psychiatric drugs to children is unkind, uninformed, and unreal. Parents whose children are in the grip of bipolar illness are desperate to do what it takes to intervene aggressively, to offer their children a chance at a life that may at times resemble normalcy. Those fortunate enough to find competent care hope that the powerful drugs available will make enough of a difference to offset the often unpleasant side effects. These drugs are not a quick fix used by irresponsible parents looking for shortcuts. They make it possible to hope for and work toward a less tormented future.


LAWRENCE DILLER has shamefully taken advantage of a girl's tragic death to launch an irrational tirade at doctors who have dramatically advanced the treatment of mental disorders in children ("Misguided standards of care," June 19, Page A9). According to the prosecutor, the child died because her parents gave her an overdose of medication. To blame medical research every time a patient dies of an overdose obviously makes no sense, so it is clear that Dr. Diller is engaging in demagoguery to campaign against treating pediatric disorders with drugs in general, regardless of how helpful they are. Therefore, I hold Dr. Diller morally responsible for the suffering or death of every child who is denied proper psychiatric care because of his fearmongering.


DR. DILLER was finally moved to criticize a member of his profession by the tragic death of 4-year-old Rebecca Riley. It took a highly publicized case and over a decade of his own discomfort with the practice of diagnosing serious mental illnesses in very young children and treating them with powerful medications for him to raise his voice. He acknowledges the personal and professional risk he has taken: He expects personal censure and a loss of credibility as a result of what he regards as his selfless courage. How many children have died or suffered because Dr. Diller and others were afraid to rock the boat?

Glastonbury, Conn.

I AM WRITING to express my disappointment at the irresponsible journalism exhibited by The Boston Globe op-ed piece by Lawrence Diller. This kind of uninformed, inflammatory statement serves only to frighten and confuse parents who turn to psychiatrists for guidance in the treatment of their ill children. For example, since SSRIs (antidepressants) were demonized by the media in 2003, SSRI treatment of teens dropped by almost 13 percent, while the teen suicide rate rose by 18 percent, the first such increase in 20 years.

As a child psychiatrist who practices in Massachusetts and who trained at MGH, I am familiar with both academic psychiatry and private practice. Blaming Dr. Biederman for single-handedly turning psychiatry into a pharmaceutical company-driven machine is ridiculous. Dr. Diller, who is not a psychiatrist, is clearly unfamiliar with the current practice of child psychiatry. Nobody is afraid of Dr. Biederman. In fact, he has made many valuable contributions to the field, largely breaking the barriers that prevented children from being treated at all. The problem in child psychiatry is not Dr. Biederman.

Clinics like the one where Rebecca Riley was treated are often understaffed and have limited funding. Additionally, the reimbursement rates for psychiatry are abysmal and the process is extremely time-consuming. As a result, clinic psychiatrists are under productivity requirements and must churn through large numbers of patients. There is no time to contact therapists and assess the rest of a child's life. Insurance firms limit therapy sessions as well. A child like Rebecca Riley can easily slip through the cracks.

Finger-pointing and name-calling are not the answer. We need to stand back and thoroughly examine the causes of the crisis in pediatric mental health.


AS THE PARENT of a child with pediatric bipolar disorder that began "from the moment the child opened his eyes at birth," I can tell you that neither Dr. Biederman nor Dr. Janet Wozniak "inspired" the diagnosis. My father, grandfather, uncle, and sister all suffer or suffered from this devastating and highly heritable brain disorder, and I suffer from depression. My son's entire quality of life and hope for the future is tied to Drs. Biederman and Wozniak. Dr. Biederman will long be remembered and revered as the "modern father of child psychiatry" and Dr.Wozniak as his torch bearer. Shame on the Globe for perpetuating the myths, misperceptions, stigma, and prejudice tied to brain disorders in children.

Franklin, Mich.