Today while cleaning out my office in anticipation of my new job, I discovered that I had unknowingly been witness to to an historic moment in child psychiatry. I found a binder from a course I had taken in June of 2001 sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. Though I did not remember until I looked at my scrawled notes in the margins, on Saturday June 9th I attended a lecture given by Janet Wosniak entitled "Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children."
Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman's ideas, we would over the next nine years see a 4000 percent increase in diagnosis of this "overlooked condition." These children were described as irritable with prolonged, aggressive temper outbursts that she called "affect storms." Some children were as young as 3 and over 60% were under age 12.
As this was in a sense a new disease, there were no controlled treatment trials. Wozniak described how she and Biederman reviewed charts of children seen with this constellation of symptoms in a psychopharmacology unit from 1991-1995. Patients received tricylics, stimulants, SSRI's, and mood stabilizers. Neuroleptics were used in 10% of visits. Mood stabilizers seemed to be the most effective, SSRI's seemed to be associated with risk of inducing mania. Wozniak did not mention atypical antipsychotics.
So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.
It is not surprising that these powerful drugs are effective at controlling the explosive behavior associated with what Drs Wozniak and Biederman labeled as bipolar disorder(and is currently being redefined as Temper Dysregulation Disorder in an attempt to undo some of the damage of the storm). But this perfect storm may have prevented us from understanding these children in a way that leads to meaningful interventions.
While this storm was brewing, across the ocean in London, Peter Fonagy, Miriam Steele and colleagues were discovering, in the London Parent Child Project, that a parents capacity to reflect upon and understand her child's experience helps that child learn to regulate strong emotions. Subsequent research has shown that child may be born with a genetic vulnerability for emotional dysregulation, but interventions that address family conflict and support relationships protect against this vulnerability and facilitate emotional regulation at the level of gene expression and biochemistry of the brain.
My hope is that this storm is clearing. Our culture, realizing the potential harm of medicating so many young children with powerful drugs that have serious side effects, may now be open to new ways of thinking about these "irritable" children Dr. Wosniak described that June day 9 years ago.