Lucy Daniels Center mental health clinicians have long felt that Bipolar Disorder is overly diagnosed in children, and it now seems that most experts in our field have come to agree with us.

Many people who develop Bipolar illness—which usually appears in late adolescence or later—have had difficulties earlier in their life, such as with their mood or with controlling their anger and impulses. The problem has been that, in most situations, we cannot identify ahead of time which children who have trouble with their mood and impulses will develop Bipolar Disorder. We are now learning that most children who have such problems do not actually develop Bipolar Disorder with its deep states of depression and/or mania. It’s very possible that many children have been unnecessarily maintained on powerful medications with potential significant side effects.

Every so often, the American Psychiatric Association reviews and changes its diagnostic categories, and it is currently revising how it describes these children who cannot regulate their temper and are excessively unhappy (“dysphoria”) but for whom it would be premature to say have Bipolar Disorder. The revision proposes a new category called, “Temper Dysregulation Disorder with Dysphoria (TDD).” A recent commentary in the prestigious New England Journal of Medicine has applauded this change but is concerned that we have just created another category that will soon be thought of—without sufficient evidence—as a biological illness requiring medication.

At the Lucy Daniels Center, every year we work with scores of children who could be described as having Temper Dysregulation Disorder with Dysphoria. No one reason explains why they have these challenges, nor does one solution work for every child. Some children will benefit from medication, but most— if not all—need help to build their emotional capacities. These children’s parents often need assistance so that they can best parent their child.

In our opinion, medication is reasonable to consider if it can provide a benefit for a period of time and the potential for benefit outweighs the risks. But in our clinical view, treatment plans that provide medication without providing the help to strengthen the child’s capacities is an inadequate treatment approach.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

The relationship between certain food and symptoms the ADHD symptoms of inattention, impulsivity, and overactivity has long been a source of interest, claims, and strong controversy. Despite individual testimonials, careful an unbiased scientific studies have failed to consistently show any relationship between ADHD symptoms and such commonly suspected culprits as sugar and food additives. A recent study, however, has raised the very disturbing possibility that exposure to a very commonly used class of pesticides, organophosphates, may be related to ADHD symptoms.

A joint study from Harvard University and the University of Montreal examined the urine of a large group of children with ADHD, looking for breakdown products (metabolites) of organophosphates. Organophosphates are commonly used as pesticides. The study found a very clear relationship between the level of organophosphate metabolites in the urine of children and the severity of their symptoms of inattention, impulsivity, and overactivity.

This is a study that will certainly need to be enlarged and repeated before any definitive statements can be made. There just is not enough information at this point for us to provide any specific recommendations. However, we know that organophosphates have central nervous system (brain) activity, interfering with a key brain chemical known as cholinesterase. Parents with children with ADHD-type symptoms certainly could consider whether they want to try a diet that minimized pesticide exposure, which would involve such changes as choosing organic produce. It can’t do any harm! This can be an expensive way to go, of course, but based on this very preliminary information, it seems like an option that parents should at least consider.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

Many American parents use corporal punishment as discipline, despite overwhelming scientific evidence that corporal punishment has little value and many possible negative effects. Many cultures across the world do not use corporal punishment at all in their child rearing. In one representative poll from Survey USA, 72 percent of Americans felt that it was OK to use corporal punishment to discipline a child, although various professional organizations such as the American Academy of Pediatrics have condemned corporal punishment.

A new study adds to the mountain of evidence about the potentially toxic effects of corporal punishment. This extremely well designed study asked the question: "Does corporal punishment of young children increase their tendencies to be aggressive?" The answer turns out to be, "yes." Three-year-old children who are spanked two or more times in the month that was studied had a significantly greater chance of being more aggressive at age 5, even if all other important factors in their environment that could cause aggression were separated out from the analysis!

There are many better ways to discipline children than by using corporal punishment. If you are interested, we discuss this in much more detail in an article that is available as a pdf for download at http://lucydanielscenter.org/page/spanking-children. We also have dealt with a related aspect of the topic on this blog: see Using strong discipline with hard-to-manage children?

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

For some time, based on parent reports and studies, we and others in the field have believed that the very high majority of children with moderate or severe autism start showing signs at either of two times: during their first months of life or during their second year.

An important new study from the University of California, Davis M.I.N.D. Institute published in March 2010 has raised a very significant challenge to our traditional assumptions. This study found that the high majority of children who developed autism did not show signs of the condition before age six months. However, most children started developing signs between six and twelve months, and new signs of autism continued to appear until they were three.

Although this study has come up with different results than prior studies, it is worth taking very seriously because it is a “prospective” study, meaning that researchers studied the children from birth, not knowing whether they would develop autism or not. Therefore, the data that they accumulated is all based on their observations. All prior studies have been retrospective, relying upon parent reports of their observations and recollections. Parents are generally not trained observers, are busy loving their children, not doing developmental exams, and will not remember every detail of the nature and timing of their child’s development as the years go on! So, this study is the first that meets a high scientific standard.

This study should change the way doctors treat autism and parents think of it. Pediatricians and others who screen children should start to pay close attention to such evaluations during the second half of the child’s first year of life and should also have a second look a year or so later. The study also showed that the first signs of autism are usually impairments in social relations, so this area (e.g., eye contact, appropriate smiling, imitation) should be carefully assessed.

Parents should be aware that if their child has been developing normally and then begins to show autism, this development does not mean that he or she has been exposed to some toxic substance such as a vaccine. Rather, this study suggests that there may have been subtle changes that would have been evident to a trained observer even during the time when the child appeared to be developing normally.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

The use of anti-psychotic medication has been increasing at a stunning rate in recent years, for children and adults. Perhaps you have recently seen television ads promoting the use of Abilify if an adult depression has not “responded” to standard anti-depressant medication. Abilify and similar so-called second generation antipsychotic medications have begun to be used for a wide variety of diagnostic situations in childhood, including depression, anxiety, and ADHD. The possibility that these medications are being overused greatly concerns Lucy Daniels Center clinicians because the side effects of these medications are significant, even potentially (and maybe commonly) harming life-long physical health.
A December 2009 study from a team of researchers from Columbia University and Rutgers University provided a disturbing perspective on the use of anti-psychotic medication. The following is from the New York Times, on-line edition, Dec. 11, 2009:

“New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.”

There are clear and good reasons to use antipsychotic medication with children. At the Lucy Daniels Center, we do not hesitate, for example, to provide this relief in the rare instance of childhood schizophrenia, or those few occasions when one can confidently make a diagnosis of childhood bipolar illness. Children who are in impoverished circumstances do not have these illnesses at a significantly higher rate! At the very least, this study suggests that factors other than purely medical ones enter into decisions about using anti-psychotic medication in children. Medicaid reimbursements to physicians are structured so that they provide financial incentive for prescribing medications rather than longer sessions in which issues can be talked through with parents and children but for which there is less reimbursement for the time spent.

Other issues may factor in as well; talk therapies take time to show benefit, and poorer families may have difficulty managing such commitments given limited resources and less flexibility with their time. Whatever the explanations - economic, racist, classist, pragmatic – once again, our poorest and most vulnerable are not receiving the care and dignity that others of more means receive. It’s a trend that troubles us at Lucy Daniels Center, and we hope, readers of our blog as well. The Rutgers-Columbia study has been published in 2010 in the Journal Health Affairs.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary 

School bullying is no laughing matter. Fortunately, schools and governmental agencies are recognizing that bullying victims often carry scars long after the event occurs. New information supports other prior research suggesting that students who merely observe bullying can be profoundly affected.

Research reported in December 2009, based on a study of over 2,000 students in England, has found that children who have observed bullying not only have a wide range of possible negative emotional consequences, but actually have more problems than do the bullied children themselves!

It is important to keep in mind that many children who observe bullying did not have evidence of sustained psychological consequences. However, many did. These symptoms of psychological distress included anxiety, depression, bodily symptoms, drug use, and other common markers of psychological upset.

Why would an observer of bullying suffer as much or even more than the victim? All we can do is to speculate about this, but some have wondered whether children who observe bullying are left with guilt feelings for not having intervened, or whether these children tend to worry that they will be next on the bully’s list.

Whatever the explanation, this study provides more evidence that bullying is indeed toxic to the victim, by-standing observers, and – don’t forget – the bullier himself who is dealing with his own problems in a psychologically and morally problematic way.

Perhaps you have some reasons to have thought about the topic of bullying. We invite you to contribute to a discussion on the topic.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

Few things in our contemporary world terrify parents as much as the prospect of serious violence occurring in their school. It seems that hardly a year goes by without a shooting incident at a school somewhere or other. It has become customary for mental health professionals to come to a school in mass when such tragedy strikes. The mental health professionals typically meet with groups of children, providing opportunities for them to debrief and share reactions. Other types of services may also be provided. It is now expected that the shrinks will show up – but does it do any good?

For the first time, a group of researchers in Canada studied this question. (See Szumilas, Magdalena, Wei, Yifeng, Kutcher, Stan. Psychological debriefing in schools. Canadian Medical Association Journal (CMAJ) 2010.)  It turns out that psychological debriefing that allows children an opportunity to express their reactions and recall the events if they wish does not help at all. In fact, there is some reason to even worry that in some situations, such an approach may interfere with a child’s effort to overcome the situation. There are some other kinds of interventions that show promise, but more research is needed to know if they will be of help.

Lucy Daniels Center clinicians believe that mental health assistance, properly applied, can have benefits – after all, that’s what we do ourselves. But, we are also aware that mental health professionals have their time and place, and that the people who can most help children at times of high stress are the people with whom they have the most loving and trusting relationships – their parents. The take-home lesson is that just sending in the shrink does not necessarily help!

We have discussed the ways that parents can help children at these times, and we would refer you to a past Ask Lucy Daniels column, or visit the Lucy Daniels Center Web site for a pdf version.

Perhaps you have some thoughts about violence in our schools, and the effect that it has on children. If so, please share them!

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

How many children experience mental disorders? Over the years, many studies have tried to answer this question. Such studies are always difficult and expensive. The best estimates in the field have been that somewhere about 10 to 15 percent of children experience substantial emotional interference in their development. If we include children who are having some clear emotional struggle but for whom the situation is not as serious, the best estimates have been that the percentage of affected children may rise to about 20 percent.

A recent and important study jointly conducted by the NIMH National Institute of Mental Health (NIMH) and the Center for Disease Control and Prevention (CDC) sheds important light on this issue. This study, reported in December 2009, was unusual in that information was collected from children as well as parents. Many thousands of children ages 8 to 15 were studied. Children were assessed for the presence of one or more of six conditions: generalized anxiety disorder (GAD), panic disorder, eating disorders (anorexia and bulimia), depression, attention deficit hyperactivity disorder (ADHD) and conduct disorder.

What were the results? In the past year, 13 percent of children appeared to have experienced one of these conditions. Less than half had received any form of medical or psychological attention for these problems!

All numbers always need interpretation. We interpret these results to indicate that the conventional wisdom about the incidence of significant emotional conditions in childhood has been on target and, if anything, has underestimated the incidence. For one thing, there are many more emotional conditions than just the six that were tracked in this particular study, and so this 13 percent figure does not include the children affected with these other emotional conditions. For example, among the children that we help at the Lucy Daniels Center are many with PTSD symptoms. Children with this problem would not have been counted in this particular study, unless they also had one of the other conditions.

Another reason we think there could be more than 13 percent of children burdened with emotional conditions is that emotional symptoms wax and wane. For example, some children with anxiety or depression have enough symptoms to reach the diagnostic threshold in a given year but not another. In other words, even within the six categories that were tracked, some children who are still struggling with a very significant problem would not have been counted.

Bottom line – the evidence continues to mount about the extent that our children experience limiting emotional conditions. Unaddressed, these problems will usually continue in some form in adulthood.

Do you have some thoughts about this matter of importance to all of us? If so, please share your comments.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

This study was published online ahead of print on Dec. 14, 2009, in the journal Pediatrics. We have addressed related aspects of this topic, and you might be interested in our guidelines about when to seek professional help, or the many other Lucy Daniels Center articles on particular emotional conditions in the Carolina Parent archives or in pdf formats on the Lucy Daniels Center site.

Twenty years ago, autism was a rare condition that parents rarely thought about. Now, most parents know or know of a child diagnosed with autism. Their children may attend a school with a special classroom for autistic children. As many as 1 in 150 children are said to have this condition. Is it an epidemic?

No one knows the answer for sure. What we do know is that we have changed the definition of autism from what it was 20 years ago or more, and we now include many children within the “autistic spectrum” who would not have received this diagnosis years ago. From that standpoint, we are comparing today’s apples with yesterday’s oranges. We also know that awareness among professionals and parents is immensurably higher now than in prior years –we have many more apple-pickers than we had. There is no controversy among professionals and others about these two factors. There is controversy about whether the change in the diagnostic criteria and the greater awareness sufficiently accounts for the greater incidence of autism. It is for this reason that there is a search for possible additional explanations, such as the misguided concerns about a relationship between autism and childhood vaccinations.

A recent study in California, while not resolving the question whether there is an actual increase in incidence of autism or not, does strengthen the case that greater awareness is an especially important factor. In a very carefully designed and conducted study published in the online Journal Autism Research this month, the researchers found that 10 areas in California had an especially high incidence of autism. These areas were associated with more educated parents and the presence of an autism center. It does indeed seem that more education and awareness, by parents and in the community (professionals in the vicinity of an autism center tend to be more knowledgeable about the signs of autism) make an important difference.

We will have more to say on the important topic of autism in subsequent postings. Meanwhile, won’t you contribute your own thoughts? Perhaps you have had some experiences or points of view, or questions that you would like us to address at some point.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary

About 7 percent of American children are receiving medication for ADHD. Aside from all the controversies about the diagnosis and treatment, this is the current reality. In the last several years, a small—thankfully, very small—number of children receiving one of the standard ADHD first-line medications (psychostimulants) have experienced effects on their heart, including sudden death. Because this tragic event is so rare, controversy remains among medical professionals about whether cardiac health is indeed affected by psychostimulants, or whether there is a similar incidence of cardiac events in the untreated pediatric population.

Although there are a bewildering number of products for ADHD, the front-line treatments fall into two main, very closely chemically related groups: the psychostimulant called methylphenidate (for example, Ritalin); and the psychostimulant known as amphetamine salts (for example, Adderall). A July 2009 study in the Journal of Pediatrics addresses one question of great importance to parents and physicians: Is either methylphenidate or amphetamine salts safer? Although this study did not provide the final answer, its analysis of Emergency Room visits between 1994 and 2004 for children receiving Medicaid in Florida did not show any differential in the risks associated with the two main classes of medication.

So what’s a parent to do when the medical experts can’t agree among themselves? The Lucy Daniels Center believes that the American Heart Association (AHA) struck a very sensible note with its guidelines, which have been endorsed by the Academy of Pediatrics. The AHA recommends that pediatricians and family physicians obtain a thorough cardiac history and perform a routine physical cardiac exam assessment of all children. If patient history, family history, or physical exam is suggestive of cardiac disease, further evaluation is advised, and careful thought should be given to the benefits and possible risks of using psychostimulants.

On the other hand, if there is no reason to be concerned about cardiac health on the basis of history and exam, the AHA does not recommend routine ECG’s or additional cardiac evaluation but recognizes that a pediatrician or family physician might still recommend further evaluation. The bottom line: if your child is taking psychostimulant medications, be sure that you and your child’s physician have addressed these issues of cardiac health.

– Mental Health Matters! is written by the Lucy Daniels Center for Early Childhood in Cary