Warner on Risperdal use in children

The NYT's Judith Warner meant well with a recent blog post about Risperdal use in children with "bipolar disorder" but she was ill-served by the research psychiatrists she interviewed.

Here are some excerpts of her writing, with the less sensible parts removed ...

Tough Choices for Tough Children - Judith Warner Blog - NYTimes.com

It was disturbing to read in The Times this week that the “atypical” antipsychotic Risperdal, a tranquilizing whopper of a drug with serious, sometimes deadly side effects, is now being widely prescribed to children with attention deficit hyperactivity disorder.

.. why, according to new Food and Drug Administration data on doctors’ prescribing practices, were 16 percent of the pediatric users of Risperdal over the past three years children with A.D.H.D.?

... The biggest controversy in the controversial field of psychiatry these days ... is the issue of pediatric bipolar disorder... a group of children who are really difficult: chronically irritable, extremely aggressive, prone to explosive outbursts and out-of-control rages.

Many doctors, influenced by the work of Dr. Joseph Biederman at Harvard Medical School (whose ties to industry were detailed in The Times in June), say these symptoms are signs of mania, and call these children bipolar. Others label them with “extreme A.D.H.D.” or Oppositional Defiant Disorder or “severe mood dysregulation,” ...

... This will not satisfy the critics of today’s biological psychiatry for whom no drug use is good drug use, nor the critics of today’s culture of parenting who are sure that all the aggression, irritability and out-of-control behavior that psychiatrists call mental illness is actually nothing more than a state of “toddlerhood in perpetuity” caused by ineffective parenting practices, as the conservative family psychologist and writer John Rosemond and his coauthor have asserted in his new book, “The Diseasing of America’s Children.”

And here's what I wrote as a comment (edited) ...

It was a noble effort, but I think you were led astray by your psychiatrist colleagues.

The best writing, by far, on the problem of the "explosive child" is by Ross Greene. For a discussion of Greene, Kazdin and the NYT's own Amy Sutherland see my blog posting.[1]

Greene's book is still in print, still sells well at Amazon, and has a 4.5 star rating.[2]. that's incredible for a book that's aimed at parents with children chronically on the edge of disaster.

You know Greene's book is for real, because not all his case study children do well. Some do horribly. That makes him believable. People who need Greene already know that not all endings are happy.

I'm an expert. Honest. An MD, MS, years of experience, and a child straight out of Greene. He's on two meds and I can easily see how he might have ended up on Risperdal, but, thus far, he's holding. We owe a lot to Greene and Kazdin and our helpers.

I'm also, interestingly, a world-class expert in nosologies and classifications (yeah, it's true).

So I can tell you that every classification we can invent for these children is merely a convenience. We don't know enough about the brain and this class of brain disorders to classify them the way we do heart failure or renal failure. Pediatric brain failure isn't well suited to classification.

One of Greenes many strengths is that he realizes this, and is humble about how much the diagnostic categories like 'childhood bipolar' or ODD or ADHD or PDD or autism really mean. They're better than nothing, but not enormously better. New classifications, in the absence of new science, won't change practice.

There's a vast amount we can do to bring basic behavioral messages (extinction, reinforcement) and teachings like Greenes to psychiatrists (who know very little about this domain). We'll still need to put a significant number of these children on drugs like Risperdal though. These are children facing terrible outcomes, and if the drugs are shown to help the terrible risks are worth bearing.

I didn't bother saying anything about oxygen-sucking dolts like Rosemond. People like him are a canker sore on the parents of troubled children [1]. Enough said.

Update 11/26/08: [1] On reflection, I have an idea where Rosemond and the like get their ideas. One of our children gets more "timeouts" (really calm-down intervals generally lasting under 30 seconds, but we call them "timeouts") on a sub-average day than another child has had in her entire life -- and will probably ever have. That's not an order of magnitude difference, it's a 2-3 order of magnitude difference. A 100 to 1000 times increase in parenting challenges.

Now, both these children are abnormal -- they're just abnormal at different ends of a broad scale. If all we knew was the easier child, we might also have astoundingly stupid ideas about parenting.