Insurers stepped in as gatekeepers because access to psychiatrists had to be limited. Why? For every 11,000 American children—of whom at least 1,000 to 2,000develop a mental health disorder—we have only a single pediatric psychiatrist. There simply aren't enough doctors around to provide the key treatment for explosive behavior: face-to-face time for cognitive and behavioral therapy. Just getting an appointment with a good child psychiatric expert in many parts of the country can take six to eight months.
To get attention from the dysfunctional and overburdened mental health care system, some embarked on an arms race for more dramatic-sounding diagnoses. (Many insurers, for example, won't cover old-fashioned diagnoses like "conduct disorder," but will cover the more serious-sounding bipolar disorder.) In addition, there was a strong incentive to expand drug therapy because giving pills is less labor-intensive than cognitive and behavioral therapy. The perverse result: Kids get more and more disturbing labels and medications.
In June, the American Academy of Pediatrics suggested various ways to improve mental health care for kids, such as increasing the number of child psychiatrists and constructing a more comprehensive care system. How might the landscape look if parents weren't forced into labeling kids as bipolar, and instead those kids were treated by competent, accessible therapists with the necessary time and compensation to deliver high quality care?
Ross Greene, the author of The Explosive Child, outlines one sensible model. He shies away from labels and instead focuses on what he calls "lagging skills." Outbursts, he argues, arise from developmental delays in three areas: flexibility, frustration tolerance, and problem solving. "Kids," he told me, "do well if they can." He spends a lot of time weaning his patients off multiple medications—some are taking almost a dozen of them when they show up in his office—and teaches them behavioral strategies instead. (Every now and then, he does recommend medications but only for very specific issues.)
Several child psychiatrists with whom I spoke endorsed variations of this theme: Much of the debate around bipolar disorder in kids is fixated on quixotic attempts to shoehorn complex behaviors into neat labels instead of studying and treating the various complex symptoms themselves, like inflexibility, irritability, and anxiety. We now have great behavioral tools for relieving those symptoms. But so long as the right resources are only deployed for those children who can score a label like "bipolar disorder," we're doomed to an endless cycle of coming up with new names for old problems.
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