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 problems.

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 insurance.

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.

Christian 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.

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