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------=_NextPart_01C92F62.BAC0FC80 Content-Location: file:///C:/0C4BCAB3/081016BipolarKidsforEducators_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C92F62.BAC0FC80 Content-Location: file:///C:/0C4BCAB3/081016BipolarKidsforEducators_files/slide0021.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Mood Disorders: Recognition, controversies, management
Juvenile Onset Bipolar Disorder
 <= /div>
Re= cognition
Co= ntroversies
Ma= nagement
Je= ff Turley, M.D.
Ch= ild Psychiatrist
Welcom= e, Educators.  First, a few wor= ds about your lecturer:  I am a board-certified Child and Adolescent Psychiatrist trained at the Universi= ty of Virginia.  I have been practicing medicine for a little more than 25 years, and have been a child psychiatrist for 18 years.  = I have treated adults an children in outpatient and hospital settings, worked wi= th the state police on mental health issues, and was the only child psychiat= rist in the Air Force for a catchment area stretching from Europe to the Middle East.  When I started my tra= ining, bipolar disorder was considered to be so rare in children to be reportabl= e.
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file:///C:/0C4BCAB3/081016BipolarKidsforEducators_files/slide0024.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Mood Disorders: Recognition, controversies, management
Jeff Turley, MD  www.JeffTurley.com
Disclaimer
•It is dangerous to b= e right on a subject on which the established <= /span>authorities are wrong. – Voltaire
<= span style=3D'visibility:hidden'>•
Caveat= emptor!  I have a bias towards health and competence, and favor psychosocial interpretations of behavior over biological.  Accordingly, I = have watched the evolution of the bipolar spectrum disorder with some dismay.<= span style=3D'mso-spacerun:yes'>  I have trepidations about using a cluster of common, non-specific behaviors to increase the diagnostic frequency of a life-long, incurable, and potentially disabling mental illness.  As a scientist, I = am open to persuasion, but a keep a skeptic's eye on this phenomenon.=
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Jeff Turley, MD  www.JeffTurley.com
Co= ntroversies
•Is JOBD over-di= agnosed and over treated? •Under diagnosed = and under treated? •Does the = di= agnosis matter?
<= span style=3D'visibility:hidden'>•
Dramat= ic increases in the frequency of psychiatric prescriptions written “off label= 221; to younger and younger children has frightened some of the public, but parents of difficult and emotionally dysregulated children often seek services specifically for bipolar disorder and feel entitled to specific medication treatments.

Concer= ns about child welfare wax and wane.  Many authors write about a crisis of childrearing in the nation, but several studies show that American children behave no better or worse than childr= en in other countries (although they are significantly more likely to die fr= om violence).

Behavi= ors once considered the lone province of parenting are now the targets of medicati= ons designed and tested for the treatment of severe mental illnesses in adult= s.

Effect= s on children are largely untested.


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file:///C:/0C4BCAB3/081016BipolarKidsforEducators_files/slide0031.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Mood Disorders: Recognition, controversies, management
Jeff Turley, MD  www.JeffTurley.com
2 year old bipolar?
•COPS: MOM AND DAD KILLED GIRL, 4; Hull pair charged with giving daughter deliberate overdose of prescription pills
Rebecc= a Reilly:  The state medical examiner’= ;s office said the girl died from the combined effects of three drugs used to treat bipolar disorder, including Clonidine, and two over-the-counter cold medicines.

The Clonidine was prescribed by Dr. Kayoko Kifuji, Tufts New England Medical Center psychiatrist, to treat the young girl for hyperactivity and bipolar disorder. The other two drugs were Depakote and Seroquel, which a= re also used to treat bipolar disorder.
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Jeff Turley, MD  www.JeffTurley.com
What is the value of di= agnosis?
•Su= ggests etiology
<= span class=3DBB style=3D'position:absolute;left:-4.51%'>•Su= ggests specific treatment
•Su= ggests natural history
•Su= ggests prognosis
What i= s the utility of diagnosis?  Accurate diag= nosis allows a clinician to make informed decisions about treatment (choosing o= ne over others, avoiding inappropriate or harmful options), make reasoned predictions about the natural history of illness, and to predict prognosi= s.
------=_NextPart_01C92F62.BAC0FC80 Content-Location: file:///C:/0C4BCAB3/081016BipolarKidsforEducators_files/slide0027.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Mood Disorders: Recognition, controversies, management
Jeff Turley, MD  www.JeffTurley.com
In search of a gold st= andard
•DSM is a = st= andard for reliability •DSM does not su= ggest etiology or natural history <= ![if !vml]>
A R= 20;gold standard” in medicine is a test of such high sensitivity and specificity that it is thought to confirm the diagnosis beyond doubt.  For instance, a physician might = pick up evidence of a brain tumor by tapping on knee reflexes and measuring mu= scle strength (low sensitivity and specificity), confirm the presence of a mass with a CT scan or MRI (high sensitivity, moderate specificity) before surgery, and then use a gold-standard test, a biopsy analysis (pathology testing for tumor markers) to confirm diagnosis before starting chemother= apy or radiation.
Psychi= atry has no gold standards.  We have no reliable biological tests, and have only=   a few moderately reliable psychological tests for diagnosis.  Accordingly, diagnosis in psychi= atry is done phenomenologically.  By convention, psychiatrists and psychologists decide that clusters of behav= iors and subjective complaints, present in sufficient numbers, for agreed-upon durations, with sufficient evidence of impaired functioning, constitute a “syndrome” “condition” or “illness.”<= span style=3D'mso-spacerun:yes'>  The Diagnostic and Statistical M= anual of Mental Disorders (DSM) version IV-TR is the product of committees of experts using evidence ranging from weak (common practice, testimonial evidence, expert consensus) to strong (double-blinded, placebo-controlled studies, longitudinal studies, epidemiology).  DSM was strongly resisted by the psychoanalytic community as being reductionistic, but it is the closest t= he field can come to applying scientific principles to a  field still in it’s infanc= y.
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