In an article entitled “Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides,” researchers conclude that “…organophosphate [pesticide] exposure, at levels common among US children, may contribute to ADHD prevalence.” (Maryse F. Bouchard, David C. Bellinger, Robert O. Wright and Marc G. Weisskopf in Pediatrics, Official Journal of the American Academy of Pediatrics, published online May 17, 2010.)

Organophosphate pesticides are in very wide use in the USA in agricultural and residential settings. Children could be exposed to these pesticides through food products and pesticide use in their homes, schools, or even in parks or other recreational areas.

Although studies have been performed to explore the potential adverse effects of organophosphate pesticides on neurodevelopment, manifesting in behavioral problems and lower cognitive functioning, these previous studies have focused on populations with comparatively high levels of exposure. What is new about this study is that it focuses on the adverse effects of normal levels of exposure.

The researchers had access to a very large sample of children (1139 in total), but the questionable approach calls the conclusion into question:

• Exposure was determined by sampling the metabolites of organophosphates in a single one-time urine sample obtained from each study participant.
• The ADHD diagnosis was based exclusively on a phone interview with a parent or caretaker who responded to a questionnaire assessing the presence of hyperactivity, impulsivity, or inattention.
• The children or teens were not examined by a clinician for the presence of a diagnosis nor was an advanced differential diagnosis performed. In other words, the children may have suffered from a variety of mental health problems that were not excluded.

ADHD can be very difficult to diagnose even when both parents and the child are examined in person, the child undergoes a lengthy psychiatric examination, and extensive diagnostic questionnaires from parents and teachers are available.

The DSM IV concept of ADHD diagnosis requires, in addition to meeting a list of criteria, that “The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).” This “rule out” had not been done by the researchers, which renders their diagnostic impression speculative.

Given the questionable nature of the study, concluding that ADHD is an environmental issue is premature. As the authors of this study point out, more studies are needed to establish whether the association of organophosphate pesticides with ADHD is “causal.” Until then, parents would be premature to stop giving their child fruits and vegetables. Limiting exposure to all pesticides, however, is good practice. Rinsing fresh fruit and vegetables and limiting the use of pesticides in and around the home can help contribute to a healthier household.

Health insurance companies typically cover a 50-minute initial psychiatric evaluation followed by a 20-minute “med check” every three months or so. The psychiatrist’s role is to diagnose and prescribe. The more involved work of psychotherapy is relegated to psychologists and social workers. This arrangement generally has been considered the most cost effective. Unfortunately, it may not be the best approach or even the most cost effective.

In a recent article in The New York Times entitled “Mind Over Meds,” Daniel Carlat, M.D. laments the passing of “the ‘golden’ generation of psychiatrists… who were skilled at offering the full package of effective psychiatric treatments” – psychoanalysis, psychotherapies, and psychopharmacology.

According to Carlat, the introduction of the psychiatric medications Prozac, Zoloft, and Paxil marked a negative turning point in the field – the point at which psychiatry’s focus shifted from combined therapies to diagnosis and prescription. Most psychiatrists practicing today are psychopharmacologists, concentrating almost exclusively on treating the biology of mental illness, the so-called “brain chemistry.”

However, spending more time getting to know a patient through therapy can also help a doctor fine-tune the diagnosis and prescribe the right medications. Integrated psychiatric care, a combination of psychopharmacology and psychotherapy from a single provider, is both more effective and cost effective.

“Mantosh Dewan, the chairman of psychiatry at SUNY Upstate Medical University in Syracuse, found that when psychiatrists do both medication and psychotherapy, the overall amount of money paid out by insurance companies is actually less than when the treatment is split between psychiatrists and psychotherapists. When patients see only one provider, they require fewer visits overall.”

Carlat questions whether the term “psychopharmacologist” is actually doing more harm than good in the field of psychiatry and calls attention to an article in which three Harvard psychiatrists pointed out that no other medical specialty has carved out a separate ‘pharmacology’ subspecialty. As these doctors remind us, good doctoring involves all available healing skills and resources and knowing how to use them separately and together to address each individual patient’s needs, what I refer to as intensive combined therapy.

My review of Judith Warner’s new book: We’ve Got Issues: Children and Parents in the Age of Medication (Riverhead, Hardcover, February 23, 2010).

In the United States, the debate over diagnosing and treating children and adolescents for psychiatric, behavioral, and learning disorders has become very polarized. You are either for it or against it. Unfortunately, lost in the middle of this debate are children and parents who are actually dealing with mental health issues on a daily basis, including anger meltdowns, mood swings, depression, school underachievement, and suicidal tendencies, to name only a few.

Parents often feel completely lost in trying to decide what is best for their troubled child. They wrestle with the question of whether the behavior they are observing is a symptom of a disorder or just a poor attitude requiring more effective discipline. Their judgment is clouded even further when misinformed pediatricians, teachers, or family members express their opinion that the child is just fine and the behavior “typical for that age.” Instead of seeking professional help for their child, parents often seek out “less intrusive” forms of care from self-help gurus, parenting “experts,” and others who profess to have all the answers and hold out empty hopes for salvation.

In her new book, We’ve Got Issues: Children and Parents in the Age of Medication, Judith Warner calls attention to this serious problem and challenges everyone involved in caring for and raising a child to address the issues (the issues we have as a society) that often get in the way of providing a child with the best mental healthcare available.

“Children with mental disorders have become pawns in much wider adult conflicts: about psychology versus psychiatry, about education and competition, fairness and downward mobility, about the very nature of childhood and what generally viewed as the sorry state of modern parenting.”

At the core of Warner’s research (her self-described odyssey) are extensive interviews conducted over the span of five years (2004-2009) with parents of children suffering from a wide range of problems as well as with numerous experts who specialize in treating these troubled children. In We’ve Got Issues, Warner contributes valuable information and insight to this very serious debate, including the following:

• Case studies that highlight the horror of parents and children struggling with debilitating, destructive, and at times deadly symptoms. Warner presents a case study of a child who, at age six, had violent outbursts. By the age of eight, he was experiencing episodes of paranoia. In his early teens, he began holding the family hostage to his destructive rages. This and other real life descriptions remind us that we are dealing with high level dysfunction and suffering and serve as a strong reminder that these problems should be taken seriously.
• Excellent expert research. I was very impressed by Warner’s ability to track down and personally interview top experts and researchers in the field of child mental health care – individuals who have devoted their lives toward developing a deeper understanding in their respective areas of research, yet have never attained the celebrity status of those who have contributed significantly less. Leading experts Warner interviewed for her book include Dr. Ellen Leibenluft, Dr. Dan Pine, and Dr. John March. Through these interviews, Warner accurately conveys important insights into early psychopathology, the importance of early intervention, and differential diagnosis.
• Sociological exploration of the factors contributing to the current stigma and negative perception of childhood mental health care. Warner points out the negative effects that resulted from the lack of disclosure of the relationships between doctors and pharmaceutical companies. The unveiling of these relationships has led to the increasing distrust of drug companies and doctors and has called into question their real motives.Warner adds a historic perspective by interviewing historian Steven Mintz, who is a specialist at “dissecting how to weave narratives about children out of our own fears and worries and desires.” He is the author of the important 2004 book Huck’s Raft: A History of American Childhood. After the interview with him, she comes to an important insight:

“As a society we are now engaged in a similar sort of a moral panic over the over-diagnosed, over-medicated child – the poster child for our competitive, Darwinian times. Society’s alleged concern for him and others like him is a classic bit of a displacement, containing all our fears of failure, downward mobility, and innocence lost, and largely unconcerned with the truth of mentally ill children’s real challenges and needs.”

One of the conclusions that Warner arrives at after five years of research is this:

“Our culture has turned complex reality into a simple minded morality play. In this play, the actors are defined by stereotypes, good and evil are neatly demarcated, and the truth – the gray, ambiguous truth – is deeply hidden beneath prejudice, fear, and bombast.”

It is a very sad conclusion, but a very important one.

I believe Warner’s biggest contribution is in providing important research and points of view that are crucial for parents to better understand what they are dealing with and to know where to turn when their child is exhibiting symptoms related to their mental health. It contains important information and insights that will help patients make better decisions for their children. I am sure it also has the potential of saving at least a few young people’s lives.

The book is engaging, and the presentation makes all the scientific information very accessible. If you are a parent raising a child you feel may be suffering from mental health issues, We’ve Got Issues: Children and Parents in the Age of Medication is a valuable resource that can help you develop a better understanding of the problems at hand and choose the most effective course of action for your child’s well being.

Concerned parents often ask me, “Does my child have bipolar disorder?” Over the past 11 years, since the publication of the first edition of The Bipolar Child in 1999, this question has become more and more prevalent. Parents who struggle with this question face a serious dilemma – they are reluctant to have their children labeled “bipolar,” yet, they want an explanation of what is going on and a treatment plan that helps their children be as successful and happy as possible.

Mental health professionals, including psychiatrists and psychologists, also struggle with this question. Because we have no definitive biological test for bipolar, we must rely on diagnostic guidelines – those published in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and on the insights of leading researchers in this area.

Unfortunately, as the diagnostic criteria set forth in DSM-IV are the same criteria used to diagnose adults, the usefulness of DSM-IV in establishing a diagnosis in children has been problematic.

Promising developments are in the works to provide mental health professionals with clearer and more precise guidelines for diagnosing troubled children and teenagers. After a great deal of research and deep reflection, the DSM-5 Task Force recently released its proposed revision of the Diagnostic and Statistical Manual of Mental Disorders – DSM-5. This new edition, scheduled to be published in May, 2013, includes a new diagnostic entity under the category of “Disorder Usually First Diagnosed in Infancy, Childhood, and Adolescence.” The new diagnostic entity I refer to is “Temper Dysregulation Disorder with Dysphoria,” which provides more precise diagnostic guidelines specifically for children and teens.

Although DSM-5 will no doubt help publicize these diagnostic criteria, and I welcome the addition of these new guidelines, they are not exactly groundbreaking. I have been using this concept in my practice for the past years since the publication of “Defining clinical phenotypes of juvenile mania,” by Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, and Pine DS, in the American Journal of Psychiatry, 2003 March;160(3):430-7. In their study, the authors “suggest criteria for a range of narrow to broad phenotypes of bipolar disorder in children, differentiated according to the characteristics of the manic or hypomanic episodes, and present methods for validation of the criteria.” In other words, the authors open the possibility of not just one diagnosis of “Childhood Bipolar” but any of several different childhood bipolar diagnoses each of which has its own unique set of presenting symptoms. The broad phenotype in their description is very close to the currently proposed DSM-5 diagnosis of Temper Dysregulation Disorder with Dysphoria.

I have found the concept of mood/temper dysregulation in children and adolescents very useful in performing an advanced differential diagnosis and critical in developing an effective treatment plan and accurate prognosis for each patient. So the answer to the question “Does my child have bipolar disorder?” is more involved than a simple “Yes” or “No.” An advanced differential diagnosis, performed by a qualified professional, is essential in arriving at a precise diagnosis and delivering the most effective treatment.

Recently, patients have been asking me about reports floating around the Internet that question the effectiveness of antidepressants. The source of most of these reports is a recently published study entitled “Antidepressant drug effects and depression severity: a patient-level meta-analysis.” The report concludes (emphasis mine):

“The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”

Most of my patients needed some clarification, but one even asked whether she should go off her antidepressant in view of the conclusions drawn in the study. The short answer is “No.” The study does not conclude that antidepressants are ineffective. In addition, this particular study has some severe limitations, which make its clinical correlation at least a bit questionable, including the following:

• The authors of the article did not report data from their own clinical research. This article is based on calculations they performed on OPS’s (Other People’s Studies). They implemented several inclusion criteria and ended in selecting six studies in which patients took only one of two antidepressants: Paxil (an SSRI antidepressant) or Imipramine (an old Tricyclic antidepressant). None of the many other antidepressants were included.
• The studies were done in a trial setting rather than in a clinical setting, thus eliminating other key ingredients of successful treatment, including the compassionate, empathetic relationship with a clinician who frequently uses supportive measures and/or psychotherapy in combination with medications. In other words, antidepressants may be more effective in combination with other non-medication interventions.
• Selection bias: Study directors frequently use their discretion regarding who they included in the study. Unfortunately researchers, at times, try to include patients even if they do not meet the criteria fully, as indicated on page 52 of the article: “…when a minimum score at intake is required for study entry, study diagnosticians sometimes inadvertently inflate the scores of patients whose true score is just below the cutoff.”
• Compared to clinical setting (outpatient clinic, private practice) where many criteria are used to evaluate improvement with treatment, the present study analysis relies exclusively on one questionnaire called Hamilton Depression Rating Scale. The assumption is that improvement in scores on the questionnaire truly correlates with clinical improvement. Many experts in the field doubt the accuracy of this assumption. Even the authors of the present study quote some articles that express this doubt specifically (references # 22 and 23).

It is therefore surprising to me that with so many limitations in the present study design, the authors decided to summarize their findings in such strong language, stating that in patients with mild or moderate depression the effect of antidepressants is “minimal or nonexistent.” When quoted in the media, such statements often lead people to quickly jump to premature conclusions that are not in their best interests.

I therefore advise caution in reading medical news and offer the following advice: Always consult your doctor before deciding on any treatment changes or discontinuing any medications.

In an article published in December 2009 in the Neuroscientist titled “The Medial Prefrontal Cortex and Integration in Autism,” Dr. Dorit Ben Shalom, a researcher from Ben-Gurion University of the Negev, Israel offers a novel conceptual framework of known atypicalities in individuals with autistic spectrum disorders (ASD).

The prevailing approach has tended to focus on deficits in the capacity for “Theory of mind” (roughly, “emotion”) as the main hallmark of the ASD diagnosis. Ben Shalom asserts that more domains contribute to the deficits frequently seen in these disorders. She proposes a total of four domains that are substantially impaired in most or many individuals with ASD, which include the following in addition to “emotion”:

• Memory
• Sensation-perception
• Motor skills

Ben Shalom’s basic premise is that the impairment consists of an “arrest” in the development of one level of processing in each domain. She draws from the previous work of Damasio who in 1995 described three levels of emotion processing in the brain: basic, integrative and logical. Ben Shalom extends the concept to perception, memory and motor skills. She proposes that in people with ASD there is a developmental arrest at level one (basic) and that the integrative level (two) is never reached (although logical compensations (three) are possible in people with high functioning ASD).This might explain phenomena frequently seen in individuals with ASD, such as difficulties with episodic memory (memory domain), sensory integration problems (perception domain ) and dyspraxia (motor domain).

Dr Ben Shalom hypothesizes that part of the core impairment lies in a specific brain location – the Medial Prefrontal Cortex that subserves the integrative functions of all four domains. A part of the article includes a graphic summary of the main anatomic hypothesis of the article (page 8).

Commentary
As the integrative functions normally develop at age 1-5 years, this article highlights the dire need for early diagnosis and early intervention for children with ASD. It also calls for a closer evaluation of all four domains (emotion, memory, perception and motor skills) as part of the diagnostic assessment of individuals with suspected ASD. While in some instances the diagnosis is clear cut, in many others establishing an ASD diagnosis becomes very difficult. Frequently the evaluating clinician struggles to establish a differential diagnosis between ASD and other diagnoses such as Bipolar Disorder, Depression, Attention Deficit Hyperactivity Disorder (ADHD) and Tourette’s Syndrome. Extending the scope of the evaluation to all four domains rather than the narrower scope of DSM4 will result in earlier, more accurate and more successful diagnosis and treatment.