Review of "New Hope for Children and Teens with Bipolar Disorder"
By Boris Birmaher Three Rivers Press, 2004 Review by Christian Perring, Ph.D. on Aug 4th 2005
New Hope for Children and Teens
with Bipolar Disorder is a straightforward guide mainly aimed at parents.
As author Boris Birmaher points out in his Epilogue, until recently bipolar
disorder was rarely considered as a psychiatric diagnosis of children and
adolescents. Now the disorder is diagnosed with ever-increasing frequency. Birmaher
sees this as good, because it means that young people with emotional problems
are being diagnosed more accurately, and treated more appropriately. Others
are concerned about this trend, because it means that more young people are
taking powerful psychiatric medications with long lists of potential
side-effects, including some that can be permanent, and the labeling of young
people with serious mental illness can affect how they are treated by their
families, schools, and peers. While these controversies proceed among experts
and commentators, parents are often stuck in the middle, wondering what to do
with their children who undeniably are going through deep emotional troubles
and are behaving in alarming ways.
Birmaher is on the side of the
psychiatric establishment, which has a great deal of confidence in its ability
to understand and diagnose childhood bipolar disorder. He refers to
neuroscience, genetics, neuroimaging and pharmacology and he explains how
important it is to distinguish bipolar disorder in young people from other
disorders such as ADHD, Asperger's, oppositional defiant disorder, anxiety
disorder, borderline personality disorder, and substance abuse.
The obvious problem with such a
view is that the evidence is not so conclusive, and the diagnostic categories
for children are probably even less useful than they are for adults -- and even
for adults, it is very common for people with severe psychiatric problems to
receive a range of diagnoses that change over time, with different
psychiatrists providing different verdicts when presented with the same
patient. For children, who are still growing and changing, one may be
especially skeptical that there is any neat division between these different
diagnostic categories or even that a diagnosis of "bipolar disorder"
will shed much light on a young person's difficulties.
On the other hand, for families who
have a child who is deeply unhappy, goes through wild mood swings, endangers
him or herself and other people, behaves bizarrely, has difficulty keeping any
friends, and is doing badly at school, the chances are that they will have to
consult a psychiatrist at some point. Increasingly many families are now being
told that their child may have bipolar disorder, and they need to know what
that means and what treatments are generally provided. There's no doubt that
New Hope for Children and Teens with Bipolar Disorder provides an excellent
summary of current opinion and practice, using clear language and plenty of
examples to aid comprehension. Birmaher is clearly focused on helping children,
and helping parents who think that their child could have bipolar disorder.
The book is divided into thirteen
chapters and it has a couple of appendices. The early chapters set out how
bipolar is described in psychiatry and how it is distinguished from other
mental disorders. While the tone of the book is optimistic, Birmaher does not
cover up the fact that often there are limits to what treatment can achieve.
He quotes one study that estimates that about 44% of older adolescents with
bipolar disorder will attempt suicide, which is twice as much as those with
major depression. About 1% of teenagers are estimated to have bipolar
disorder, which translates to 400,000 teens. Thus, combining these figures,
over 150,000 of them will attempt suicide. Figures such as these are very
sobering, and one wonders how it was possible in the past that the psychiatric
establishment did not notice that so many young people suffered from such deep
The treatments outlined are divided
into biological and psychological. Naturally, there is lengthy discussion of
lithium carbonate used as a mood stabilizer and the many health problems that
it can cause. There is also considerable detail given to the anticonvulsants
that are also used as mood stabilizers. Antipsychotic and antidepressant drugs
are explained, and although the book was bound to be slightly out of date by
the time it was published, it does contain relatively current information. It
is pleasing to see that Birmaher also sets out the use of alternative
medications including St. John's Wort and the Essential Fatty Acids (EFAs).
The chapter on psychological
therapies explains cognitive behavioral, interpersonal, social rhythm
psychotherapy, family focus therapy, psychodynamic, and supportive therapy.
Each individual section is quite short, but nevertheless provides a clear
summary of the main ideas of these treatments.
Especially impressive is the
chapter on using the treatment tools, which addresses the difficult question of
how to synthesize all the ideas and approaches that are available. Birmaher
pays particular attention to the need for the whole family to be educated about
the issues, and discusses how best to do this. He also sets out particular
behavioral problems and which treatments might be especially appropriate.
There is some discussion of what to do if the child or teen does not benefit
from the treatment. The following chapter on treating coexisting psychiatric
disorders focuses mainly on the medications used for ADHD, depression and
anxiety, setting out some basic information. Maybe the most important chapter,
given the frequency of suicide attempts, is on recognizing and responding to
suicidal behaviors. It is short, but it could be helpful. Chapter 11
discusses how parents should behave towards their child with bipolar disorder,
and sets out the basic ideas of behavior modification plans. Chapter 12
focuses on what to do to help the child at school when he or she is facing
academic difficulties. The final chapter discusses dealing with health
The many short chapters in this
book can only provide readers with rather general information and hints,
pointing them in the right direction. For example, the chapter on health
insurance is just 7 pages long, but anyone who has battled an HMO or health
insurance company to get reimbursed for expenses knows very well that one
generally has to wage a war against them in order to get satisfaction, and one
must be ready to spend hours on hold on the phone, write letters and enlist
help from a variety of sources. So the advice of the book to "be prepared
to advocate for your child's needs" does not begin to describe the task
one faces. Similarly, in finding the best treatment and the best way to
interact with one's child simply cannot be set out in a few pages of a book --
one has to learn from experience and experiment, constantly ready to deal with
set backs and new challenges.
A book such as New Hope for
Children and Teens with Bipolar Disorder raises deep questions about
whether psychiatry and society is moving in the right direction if we are
treating hundreds of thousands of children with powerful psychiatric
medication. Birmaher does not reflect on such questions at any length, or
consider alternative possible routes, but he does provide a good introduction
for parents of what to expect from the psychiatric approach to treating bipolar
disorder in young people.
Perring, Ph.D., is Academic Chair of the Arts & Humanities
Division and Chair of the Philosophy Department at Dowling College, Long Island.
He is also editor of Metapsychology Online Review. His main
research is on philosophical issues in medicine, psychiatry and psychology.