This is a sad story. But it's simplistic to blame the abandoned children solely on poor mental health care. While the statistics are stunning about the incidence of mental illness in these children, another problem involved is the insufficient income of the parents, likely an inter-generational history of neglect and abuse, as well as the stigma of asking for help.

Iowa Independent

"The state of Nebraska faces a situation most parents can't comprehend. At last count 34 children, ranging in age from 20 months to 17 years, have been left at Nebraska hospitals under the auspices of a vaguely written "Safe Haven" law.

The Nebraska law, which was signed in February and became effective in July, was to be the last, given that all other states had already enacted similar legislation. During debate, however, Nebraska lawmakers took a unique slant. Instead of attaching an age to the law -- ages that some lawmakers deemed "arbitrary" -- the legislators opted to write the law so that any "child" could be handed over to the state at designated drop-off points, such as hospitals, without any legal recourse against the child's guardian.

As a result, parents have driven several hundred miles -- from as far away as Miami-Dade County in Florida and Pima County in Arizona -- in order to leave their children with state officials in Nebraska.

The children left in Nebraska come from various socio-economic and ethnic backgrounds. Twenty-two are considered white, 11 are considered black and one is Native American. Twenty of the 34 children are between the ages of 13 and 17.

They have three things in common.

1) Thirty-two of the children resided in or near an urban area.

2) Thirty of the children were living in a single-parent home.

3) Thirty of the children had previously received mental health services, with 11 of those receiving treatment above an outpatient level."

A major researcher from NIMH, Ellen Leibenluft, MD, Chief, Unit on Affective Disorders, Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, has made an unequivocal statement about bipolar disorder in children. Not surprisingly, she asserts bipolar disorder is "rare" in children. This article is a follow up to this one.

Psychiatry Weekly

"“Clearly,” Dr. Leibenluft says, “some children do meet the DSM-IV criteria for bipolar disorder. However, these children are relatively rare. Far more common, perhaps as many as 3% of children in the community, are those who are extremely irritable and have ADHD-like symptoms, but don’t meet the DSM-IV criteria for bipolar disorder. A diagnosis of bipolar disorder requires distinct manic episodes, during which time one’s mood is altered, sleep and activity patterns change, and there are differences in reward-seeking behavior. More commonly, children present instead with chronic and nearly constant irritability.” Sometimes, clinicians may diagnose these irritable children with bipolar disorder based on outbursts that occur during extreme frustration, but, Dr. Leibenluft points out, these outbursts are far too short in duration to meet the necessary criteria for a manic episode.

“One of our first steps in studying this population of chronically irritable children was to define criteria so that we could reliably identify a reasonably homogeneous clinical group. We defined criteria to capture children who don’t have clear manic episodes but have very severely impairing and chronic irritability, as well as ADHD-like symptoms. We refer to them as severely mood dysregulated (SMD). Then we recruit controls and children who clearly meet the DSM-IV criteria for bipolar disorder and compare the three groups.”

Dr. Leibenluft’s group’s research is still too new to have followed the SMD group into adulthood, but they have analyzed large, epidemiologic community-based data sets with a particular eye for individuals who, as children, were chronically irritable. “What we’ve found,” Dr. Leibenluft says, “is that these children are not, in general, at high risk for bipolar disorder as adults. Rather, they’re at significantly increased risk for depressions.”

Leibenluft and colleagues have also taken extensive family histories for the patients they see in their clinic. “I have to presage this by pointing out that what we’re doing is most decidedly pilot work,” she cautions. “We’ve actively recruited these children, so they are probably not representative of the population as a whole, and the sample is still relatively small. That said, while studies indicate that children with bipolar disorder are a great deal more likely than controls to have parents with bipolar disorder, we’ve found that SMD children have familial rates of bipolar disorder similar to what one finds in the general population. This suggests that SMD and bipolar disorder may not be genetically equivalent.”

[..]“Of course, this conclusion has treatment implications.” Dr. Leibenluft emphasizes that, prior to treatment, one must do a thorough evaluation of these patients, assessing symptoms and possible environmental stressors. It’s not uncommon for SMD children to have language or learning problems, social cognitive difficulties, and/or anxiety symptoms, all which can contribute to irritability, and some of which can be addressed through non-pharmacologic interventions. When commencing with pharmacologic treatment, one must move forward systematically and carefully.

“Since SMD is not a DSM-IV diagnosis, there aren’t controlled treatment trials in these youth, though our lab is currently investigating the efficacy of lithium. We suggest a systematic, evidence-based approach: If they have ADHD, treat that. If they have anxiety disorders, treat that, possibly with an SRI or cognitive-behavioral treatment. One needs to be very mindful that these children may become agitated on a stimulant or SRI, and so they should be treated cautiously and monitored closely. But we do not say, out of hand, that, like bipolar children, youth with SMD should not be treated with stimulants or SRI’s without first receiving antipsychotic or mood stabilizing treatment. If an SMD patient does not respond to frontline treatment, then we may switch to, or add, an antipsychotic or mood stabilizer. We also suggest that families track their child’s symptoms daily so that it’s clear whether the target symptoms are responding, and if so to which medication. These children and their condition are complicated, and clinicians should adopt a careful, systematic approach to treatment.”"

I think it is most unfortunate that so many people suffering from acute mental health symptoms are treated with medication only. Often, there is the time and the resources to provide psychotherapy first. Some problems, are best treated with psychotherapy, and in some situations, such as anxiety disorders, psychotherapy has been identified as the treatment of choice in many cases. Medication actually interferes with the effectiveness of psychotherapy of some anxiety disorders. If the problem is more emergent, certainly medication and psychotherapy could be an effective intervention in most situations.

These principles are even more important when dealing with children, particularly children suspected to be suffering from bipolar disorder. Diagnosing children is a particularly thorny task. Symptoms are often not at all like adults or even like other children. The temptation to contain the child's behavior with medication may just exacerbate the condition, at least in the long run. A mis-diagnosed and vigorously treated child may become a particularly maladjusted adolescent or adult.

Psychiatric News: Letter to the Editor by Victor Schwartz, M.D.

"I read with interest the report of Blader and Carlson's study in the June 15 issue on the dramatic increase in the rates of children hospitalized with discharge diagnoses of bipolar disorder. They reported that since 1996 the rate of children discharged with the diagnosis of bipolar disorder has increased fivefold. The cause of this seems obscure. They suggested that upcoding (reporting a more pathological diagnosis to insurance companies to justify admission) might be at least partly to blame. In any case, I think most clinicians would agree that the diagnosis of bipolar disorder is currently being made significantly more frequently in children than in past years. This has occurred in spite of no change in DSM criteria for bipolar disorder. The implications of this in relation to our supposedly scientific diagnostic criteria are worth pondering.

It may be that we have only recently become adept at diagnosing bipolar disorder in children. David Axelson, M.D., is also quoted in this review (although he is not a co-author of the paper) as suggesting that the increased rate of bipolar discharge diagnoses may reflect frequent need for readmission among these children. If they are in and out of the hospital more often (because of chronic instability or difficulty in managing them), the number of discharged children carrying the bipolar diagnosis would go up.

If this claim is accurate, it may raise another concerning thought. In the September 1996 American Journal of Psychiatry, Drs. Sara Bolton and John Gunderson published a clinical case conference in which they presented a young woman who was diagnosed as bipolar. They claimed she was actually a borderline personality. They also suggested that the bipolar diagnosis resulted in the thrust of her treatment being primarily medication based, which in turn resulted in deterioration in her condition. They argued that this diagnosis resulted in a sense of the patient's being out of control of her life and emotions and that this in turn resulted in significant regression.[...]Just to be clear, I am not suggesting that bipolar disorder does not occur in children. What I am suggesting is that when bipolar disorder becomes the default diagnosis for any child who is moody, difficult to manage, or stubborn, and when the primary mode of treatment becomes mood stabilizers, we might be missing, admittedly in some ways, harder-to-treat and manage family, environmental, and personality issues, and we also may be serving our patients poorly. The bipolar diagnosis needs to be made cautiously and after careful examination. If a "bipolar" child is not responding robustly to "treatment," it is imperative to reconsider the diagnosis."

I applaud Dr. Schwartz for his leadership in what has become a runaway freight train of diagnosing children with bipolar disorder. Indeed, if a child doesn't respond robustly to medication for bipolar disorder, the diagnosis is in question.

In the case of children, there is no prevailing justification to treat children solely with medication. If an acute episode of out of control behavior requires hospitalization, certainly medication should be consider, but so should family counseling, behavior modification and parent training. I can't imagine an adequate differential diagnosis without and assessment of the family and a trial of behavior modification. While the family is assessed, I don't believe the time involved in a hospitalization necessarily provides an adequate trial of behavior modification, nor am I sure the milieu of the hospital unit is a sufficient environmental intervention.

Psychological Interventions Can Reduce Child Abuse And Neglect

"Although the prevention and eradication of child abuse and neglect is a high-priority societal goal, the fact remains that an overwhelming number of youth will become victims," Skowron said. "Results of the current study indicate that psychological treatments for child abuse and neglect are effective and can assist children and their families to regain their functioning and facilitate the development of healthy, productive lives."

These researchers review 21 rigorous studies that included over 1000 children. They found that not only did children who had suffered abuse and neglect improved with treatment, they found that parents who had parent skills training improved their parenting skills.

This is good news for victims and for programs who provide these critical services. Families at risk for child maltreatment are difficult to reach. Finding enough licensed providers to work with this population has been difficult at best. Funding has been generally been inadequate to meet the need. Often programs rely on trained and supervised para-professionals who provide home-based family therapy. This is difficult work. This study provides encouragement to a dedicated crew working with what is often a very difficult clientele. A BIG hand for family therapists!

To Treat Autism, Parents Take a Leap of Faith

Desperate parents of autistic children have tried almost everything - hormone injections, exotic diets, faith healing - in the hope of finding a cure. But more than 60 years after it was first identified, autism remains mystifying and stubbornly difficult to treat. About the only thing parents, doctors and policy makers agree on is that the best chance for autistic children to develop social and language skills is to enroll them in some type of intensive behavioral therapy. A government-appointed panel has endorsed such therapies, which can cost $40,000 to more than $60,000 per year. Parents fight to get their children placed in behavioral programs, encouraged by the claims of some therapists that they can produce astonishing improvement in up to 50 percent of cases. An estimated 141,000 children with autism receive special education services, in many cases including behavioral therapies, through public schools. Yet the science behind behavioral treatments is modest at best. Researchers have published very few rigorously controlled studies of the therapies, and the results of those studies have been mixed. While some children thrive, even joining regular classrooms, the studies have found that most show moderate or little improvement. And researchers say most parents now experiment with so many alternative treatments - including vitamins, diets, sensory therapies and computer games - that they muddy the results of behavior treatment, making it very hard to say what is causing a child to gain skills or to decline.