And there are many well-intentioned professionals who keep supporting the “official story.”
Sometimes We Do Get It Right
Clinical Psychiatry News
As a child/adolescent psychiatrist, I want to respond to a letter by Dr. Manuel Mota-Castillo criticizing several articles in Clinical Psychiatry News about treating comorbid attention-deficit/hyperactivity disorder and bipolar and conduct disorder (“Misdiagnoses of Children Must Stop,” Letters, April 2008, p. 9).
When it comes to the usefulness of diagnoses such as conduct disorder, oppositional defiant disorder (ODD) and disruptive behavior not otherwise specified (NOS), it is important to consider several factors. These diagnoses refer to children with behavioral and emotional problems exhibiting, among other things, difficulty following rules and behaving in socially acceptable ways, and displaying openly hostile behavior. Clearly, these diagnoses are less specific than many others that we commonly treat. Dr. Mota-Castillo is right when he says many of these children ultimately receive other diagnoses, in lieu of (but sometimes in addition to) one of the “disruptive behavior disorders.” However, this is not the case for all children. Some individuals diagnosed with ODD and disruptive behavior disorder NOS go on to recover and do not receive an alternative diagnosis later in life. The beauty of child brain development is that it allows for change and potential recovery. Behavioral problems in children can be attributable to a combination of factors, including variable expression of symptoms, genetics, brain damage, and child abuse. These clinical diagnoses describe symptom patterns that have not, as of yet, been linked to specific etiologies.
Is it likely that some are misdiagnosed with these disorders? Yes. However, it is just as likely that many are not misdiagnosed, and some of them have co-occurring disorders.
If nothing else, these disorders allow a description of significant problem behaviors, independent of etiology. Also, we must remember that many symptoms of bipolar disorder and ADHD are common to both disorders. These include hyperactivity, inattention, and irritability. The severity of symptoms is usually more intense and erratic in children with bipolar disorder. Individuals with ADHD more likely have less fluctuation of symptoms and significant impulsivity, and often lack depressive symptomatology.
ADHD has been the main differential problem in prepubertal and early adolescent patients. Some contend that the difficulty in distinguishing ADHD and bipolar disorder is attributable to the high prevalence of coexisting ADHD among childhood onset bipolar patients and from the above-stated overlap of certain DSMIV criteria for mania and ADHD.
Children in earlier stages of development often express a more limited repertoire of symptoms, many of which later serve to have represented the beginning of numerous separate disorders. An example is irritability. Although irritability is one of the most frequent symptoms of mania/hypomania in all ages, it is of little help in the differential diagnosis in children. This is because of its ubiquity across several childhood diagnoses.
Finally, I find Dr. Mota-Castillo’s contention that he has been able to accurately diagnose thousands of individuals with a 0% incidence of co-occurring ADHD and bipolar disorder remarkable. That finding might be worth further study.
I like irony too but the other side of the coin is: What are you going to do with the fact that, after several years, my hundreds of patients previously misdiagnosed with “co-morbid” ADHD and bipolar continue to do well on mood stabilizers alone?