The Banana Peel Project

Yesterday, I briefly commented on Jennifer Egan’s piece for The New York Times Magazine (now out in today’s print edition), “The Bipolar Puzzle,” in which Egan attempts to lay bare the current controversy surrounding pediatric bipolar disorder (it can be found here, although you may need a subscription; otherwise, it may be worth it to run down to the drug store and pick up a copy of today’s Magazine).  Although it is far from the first appearance of the controversy in the popular press, and far from the first time that the NYT has covered it, Egan’s article is notable for the ostensibly careful attention that she pays to the experience of individual families–both parents and children–as they struggle with illness.  To her credit, Egan does a great job of bringing professional opinions, diagnostic debates, educational concerns, and the experience of children together into a relatively seamless portrait.  It is absolutely critical to recognize that psychiatry is not just about what happens in the doctor’s office, and not just about the latest pill-popping frenzy.  Egan’s article reminds us that if we are to understand how and why human beings appear to be getting sicker, we have to understand illness in all its crazy articulations.

Unfortunately, this is the extent of the congratulations I can offer Miss Egan.  A closer look at the piece reveals it to be little more than an opinion piece on the limitless benefits of psychopharmaceutical intervention, a podium for entrenched viewpoints, and a call to arms for a war being fought in our minds and brains–and, crucially, in those of our children.  Let’s take a look at what Egan does in the article, and how she turns a potentially valuable piece of journalism into a psychotropic nightmare.  If you haven’t had a chance to read it yet, I highly suggest that you do.  Otherwise, you can just take my word for it.

Also, a quick caveat.  I do not wish to argue with Egan’s view on bipolar disorder as a serious, oftentimes crippling, illness with a growing significance in a culture that values cognitive, emotional, and physical independence.  Neither do I wish to argue that there is not a place for drugs in childcare or our more general emotional lives.  To the contrary, as I have argued time and again, drugs can be powerful and valuable technologies of the self, providing the means as well as the perspectives necessary to make our own decisions and to take responsibility for our own actions.  However, in this sense drugs must be seen as no different from any other technology with the power to bestow or take away life.  That is, we must understand their mechanisms and their effects before we deploy them, or we risk losing control in the worst of ways.  We–scientists, educators, users of tools–are far from understanding how any psychiatric drug works, and to forget this is to risk losing everything.

“James has never been easy,” Egan writes.  She describes James, age 10 when the bulk of her story takes place, as a violent and irritable child who has struggled with bipolar disorder “from the time he was a toddler.”  His parents, Mary and Frank, and his little sister, Claire, have been struggling to deal with James’ radical behavior for years, moving him from school to school, placing him in a therapeutic day school, and–most importantly for Egan–inundating his developing mind and body with a veritable pharmacopeia of psychiatric drugs.  Let’s take a walk as quickly as possible through James’ history of drug abuse.

When James was 4 and Claire was a newborn, his pre-school contacted Mary in the fall and told her that her son seemed hyperactive and aggressive.  After three days of testing, a developmental pediatrician diagnosed his condition as Oppositional Defiant Disorder, and prescribed Zoloft, an antidepressant. “We refused to give a 4 1/2-year-old Zoloft,” Mary said.

Yet within a year, James was seeing a pediatric psychopharmacologist, and his parents began administering Risperdal drops every night before bedtime.  Egan explains that Risperdal is a new drug that has become popular for treating manic children because “it can blunt their anger and calm them down.” Weight gain, diabetes, and tardive dyskinesia are all potential side-effects of antipsychotic drugs such as Risperdal, but “since James was underweight and oblivious to food, Mary and her husband were willing to take the risk.”

Ultimately, James was diagnosed with ADHD and was started on two stimulants (like Ritalin).  But his violent behavior refused to stop. Egan writes, “As often happens with children on psychotropic drugs, James’ behavior began to ‘break through’ the medication, requiring more and eventually different combinations of drugs to contain it.”  James was given Depakote, an anticonvulsant of the variety traditionally used to treat manic episodes, and Depakote ultimately gave way to Lamictal, a newer and more chic anticonvulsant.  The Risperdal drops were eventually changed to Abilify, a newer and brilliantly marketed antipsychotic developed for the treatment of schizophrenia.  Finally, after the realization that none of these concoctions were doing what they had hoped, James’ parents approached James’ psychiatrist once again.  “I thought I was finally going to walk away with Ritalin,” Mary told Egan. “Instead, we walked out of that office with lithium.” Eventually, neither the stimulants nor the lithium succeeded, to the great disappointment of all the players in Egan’s story.

The stimulant, which James’ psychiatrist had been planning to add for months when James’ lithium level was high enough, had made James manic–sleepless, talking incessantly, banging on radiators–and the school had immediately called and asked Mary to take him off it.  This was huge blow; both school and parents were counting on the stimulant to help James concentrate.

What can parents, educators, and psychiatrists do when so many chemicals fail to produce the child–er, effect–that they hope for?  How many interests are being contested in the minds and brains of our children?  We are social creatures, all the way down, and our brains are now apparently battlegrounds.  Egan’s story is replete with images of the violent, terrifying side of James’ personality (”I’m going to kill you.  I’m going to slice you open with a knife”).  For Egan, James is angry, not frightened.  He is dangerous, not confused.  And for Frank, James’ father, he is possessed.  “He’s 10 years old, almost 11, and he still holds my hand when we walk on the sidewalk together,” he says. “So when he comes out with guns blazing and eyes popping out of his head, I know that this poor kid has a demon that’s just blasting its way out of him.”

What are we supposed to get from this imagery?  That pouring drugs into the brains of developing children is not something that we should take lightly?  Or that kind, loving parents are bringing the devil into this world, and we are all in danger if he is not quickly and mercilessly exorcised?  In Egan’s story, James oscillates rapidly between excessive love (”James is speaking really fast and he’s mounting my leg like he’s in sexual overdrive”) and excessive hate (”You’d better back down or I’m going to smash your face in”).  What do we want from our children?  Are drugs really the way to avoid sending mixed messages when a child’s biochemistry is already refusing to listen?  It seems that for Egan, yes, they are.

Control and love are confused in Egan’s story. Frank and Mary care deeply for James, and they are willing to pollute his fragile body in order to make him happy.  This is not a decision that is taken lightly for parents of children diagnosed with bipolar disorder or any other illness. Marie, a mother of two young children diagnosed with bipolar disorder who constitute two more pieces to Egan’s puzzle, makes this especially clear.

I experience some mourning or grieving for the kids with each medicine change.  The unknowns are so daunting and somehow I feel so guilty for taking such risks.  Putting them to bed at night seems to be the worst time for these feelings.  I suppose because at that time they seem to be at their youngest and most trusting and vulnerable.  I pray for them under my breath.

But when it comes to Egan’s piece, this is not enough.  In this story, parents pray for more effective and less destructive means of loving and controlling their children, but their actions speak much louder than their wistful pleas to the great beyond.

Parents are the victims in Egan’s story.  Challenged, unhappy, violent children come into the world with a biological, genetic tendency (read: determination) for bipolar disorder, depression, and hyperactivity.  At times, Egan appears to acknowledge that there might be cultural or developmental factors involved in pediatric bipolar disorder, that there might a kind of “kindling” that occurs in which initially small cognitive events or orientations can spiral out of control in a developing mind, ultimately resulting in a disorder that is independent of external environmental influences.  But she quickly turns back to genetic determinism, even going along with Stanford psychiatrist Kiki Chang’s suggestion that “medications like lithium might actually be ‘neuroprotective’–i.e., might actually help a developing brain.”  This hope, Egan writes, “is infectious.”  Yes, Jennifer.  Maybe we’ll find a neurochemical way to exculpate ourselves.  We can only hope.