A long-running NIMH initiative, the Treatment of Early Age Mania (TEAM) study presented its most recent scientific paper on October 21st, 2011, at the annual meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) in Toronto, Canada and published its findings online at the website of the Archives of General Psychiatry http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.1508 .
Below are my comments on the article and my eyewitness observations of the presentation at the AACAP meeting.
Comments on the article
The central findings appear simple and incontestable. 279 children between the ages of 6 years and 17 years (average age 10.1 years, two thirds prepubertal, one third postpubertal) with a diagnosis of bipolar disorder I were given 1 of 3 medications over an 8- week period to determine which medication worked best. The answer was clear: risperidone worked for two thirds of the children who received it, lithium worked for one third of the children who received it, and divalproex worked for one quarter of the children who received it. In short, risperidone "won."
The work is encrusted with medallions of behavioral science respectability. It was funded by NIMH, which funds the best in scientific studies of psychopathology; it was conducted at 6 leading university medical schools; and the study was written by seventeen well-respected researchers in child psychiatry. The study is published in the Archives of General Psychiatry, the most prestigious psychiatry journal in the country. The impeccable credentials of those involved with this and many other bipolar disorder studies of children have contributed greatly to the acceptance of the existence of the disorder in children by child psychiatrists.
An examination of some of the characteristics of children in the study raises questions about the study. 99% of the children are described as having daily rapid cycling. This picture of daily cycles in bipolar disorder in children is quite different from the picture of cycles in bipolar disorder in adults. Adult mood cycles on average last many months. Rare adult bipolar disorder patients shift moods as often a four times a year; these are called rapid cyclers. Yet almost all of the children in the TEAM study had daily multiple mood cycles. The daily multiple cycles described in these children are not comparable to the months' long cycles in most adult bipolar disorder patients.
Irritable children can become extremely angry, or content and happy, depending on whether they are getting their wishes met at a particular moment. Oppositional defiant disorder is a common DSM-IV diagnosis in which children and adolescents refuse to do as they are told. 90 percent of the subjects in the TEAM study were diagnosed with ADHD and Oppositional Defiant Disorder: the two diagnoses together are strongly associated with frequent displays of anger and irritability. The more likely and more commonsense alternative to multiple daily bipolar-disorder-like mood cycles is that these children instead had frequent bouts of petulance and irritability well known to be characteristic of their diagnosed Oppositional Defiant Disorder.
The authors place an important premium on the symptoms of elation (feeling excessively happy) and grandiosity (feeling too important or special) in the diagnosis of bipolar disorder in children. More than 90% of the subjects had both of these symptoms. Elation and grandiosity are important in the diagnosis of adult bipolar disorder but their meaning in childhood is more ambiguous and their pathological significance is less clear. Both are feelings found in normal childhood but there has been little systematic study of their significance.
The data were gathered from 2003 to 2008, but the results were not published until late 2011; why? In the inside world of research jargon, the findings are "old data" and researchers tend to disparage such data. Old data sometimes suggest a problem with the research. Sometimes there are problems analyzing the data or writing the article. With 17 authors and the support of NIMH it is hard to imagine that analyzing the data or writing the article was the difficulty. The delay in publication does reduce the significance of the research work. By the time of publication of this article, as the authors noted, recently published studies had already found risperidone and other atypical antipsychotics to be preferable to divalproex and lithium. These previously published studies reduce the clinical significance of this study.
Eyewitness observations of the AACAP presentation
At the 2011 AACAP meeting, a senior official from NIMH was asked if he thought the children in the study had bipolar disorder. He dodged the question by replying that the children in the study had been described in such scientific detail that it did not matter whether they had or did not have bipolar disorder. For parents and treating mental health professionals, of course, it matters greatly: it's the most important question of the study. The controversy over the existence of this disorder is bitterly contested by professionals and parents.
During the discussion, another nationally known presenter gave a wildly incorrect interpretation of defiance. The presenter claimed that defiant children are psychotic because they have a delusional belief that they can take on the far stronger adult world. Defiant children are not psychotic based on their defiance alone. They are mistaken in their belief that they can overpower the adult world, but this is a mistaken belief not a delusion. If the investigators believe that defiant children are delusional, this may explain how they found the high rates of psychosis in the children they studied (77%).
The attendance at the AACAP TEAM presentation was low: the large auditorium was almost deserted. One of the well known presenters reminded the few attendees that the previous year when the TEAM presented the room was packed, and this year the large meeting space was almost empty. Child psychiatrists seem to be abandoning their interest in bipolar disorder in children.
At the end of the presentation, a spokesperson from NIMH announced that the TEAM research would no longer be funded. Funding from NIMH has fueled the development and dissemination of bipolar disorder in children: cessation of funding promotes a return to more promising approaches to understanding and treating seriously disturbed children and adolescents.
Copyright: Stuart L. Kaplan, M.D.
Stuart L Kaplan, M.D. is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis