A Call for a More Radical Neuroethics: The Case of Pediatric Bipolar Disorder

Written by: scarsarestories on June 7, 2010.on June 9, 2010.

A Call for a More Radical Neuroethics:

The Case of Pediatric Bipolar Disorder

The simultaneous occurrence of interest in academia – with the publishing of several new journals devoted to the topic of child psychiatry, a sudden increase of mainstream “self-help” genre books for parents and educators, the initial proliferation of medicating children with drugs never approved for use on children[1], as well as the publishing of textbooks which push the use of Functional Magnetic Resonance Imaging (fMRI) technology to scan the brains of children for previously non-existent disorders including “Pediatric Bipolar Disorder” (PBD)[2] – can hardly be called coincidental. In this paper, the use of the fMRI to diagnose PBD specifically will be critiqued by exposing the lack of accuracy of these scans, the contradictory “evidence” they generate, and the influence of the multi-billion dollar pharmaceutical industry, demonstrating the connections between the aforementioned developments; the short history of this particualar usage of fMRI technology will be explored, incorporating two key sociological concepts than are rooted in a longer history, demonstrating that although the fMRI is quite new, the advent of PBD and the climate of excitement among certain scientific researchers to use scans for this purpose are grounded in historical events, changes in social conditions, and consistencies among past moral panics around childhood. The fact that students of psychology are no longer taught about the history of their discipline, but only about the last five to ten years of research, is a major roadblock on the way to public knowledge. I will argue that the field of neuroethics needs to take a much more radical[3] path to stop the scanning and drugging of this most vulnerable cohort of our society.

This argument is grounded in two sociological propositions describing phenomena that have risen from the forces of neo-liberalism that began in the 1980s, and have intensified over the thirty years under which society has grown under this order: 1) risk society, and 2) institutionalized individualism. Ulrich Beck explains these phenomena concisely, thus I will not be examining the material on risk society that Beck collaborated on with Anthony Giddens, whose writing is not only rather convoluted, but also quite contradictory, as Giddens has tried, and continues to try to address nearly all social developments and problems in his ever-increasing canon of macro-sociological writing.

Beck, who also incorporates the key concept of historicity (Tilly 1994), defines risk society as “a systematic way of dealing with hazards and insecurities induced and introduced by modernisation itself” (Beck 1992:21) while Giddens uses a circular definition, stating that society is preoccupied with the future and the “idea of risk” (Giddens 1999:2) Future extrapolations of the use of the fMRI on children and the consequent prescriptions these youth receive will be considered in this essay, but concern over “risk” lies deep in the history of modernization, just as individualization does, thus painting a more cohesive picture of these parallel developments.

“Institutionalized individualism” is the German counterpart for the term “individualization” – it is not intended to refer to the concept of the individual operating in the laissez-faire, free market system that also characterizes neo-liberalism and late-capitalism, but to the structures that grew out of socialization that consider only the individual and not the group, essentially destroying pre-existing traditions of community, and denying the fact that we are social beings. These structures are also examined by Michel Foucault in Discipline and Punish, as he details the historical roots of changes in educational, industrial, punitive, and other institutions that arose with modernization in the late nineteenth century, placing full responsibility on the individual for her/his conduct (Foucault 1978). Panic over “abnormal” behaviour, emotions, and “moods” lies in both notions of risk, fear about not attaining monetary success in society, and individualization, which locates such inconvenient conduct in the individual brain, not considering the conditions of the community or society at large.

It is quite plain that PBD itself is rooted in history, as its umbrella of symptoms include those that moral panics around the conduct of children throughout this period of over one hundred years, including concerns about masturbation (Hunt 1998) and childhood sexuality in the late-nineteenth century (Still 1902) (often called “hypersexuality” under the PBD heading in medical discourse), and hyperactivity disorders (the PBD criteria of “inability to concentrate” and “impulsive or reckless behaviour” mirror those that used to be listed under “Attention Deficit [Hyperactivity] Disorder), that began in the 1950s and grew to be an epidemic in the 1990s, as notions of risk among parents and teachers started to become more extreme. Also common among all of these “disorders” is the individualization and abnormalization of children. Following Foucault’s argument, the discipline of “abnormal” behaviour – what he often refers to as “the conduct of conduct” – was first enforced vertically, but came to be managed vertically and by the self (Foucault 1977).

As the fMRI has been implemented to diagnose psychiatric illness in both adults and children, the field of “neuroethics” has been revived in an attempt to combat the faultiness of these scans when used for this purpose. However, it is rarely mentioned that neruoethics is a field of study that was born out of the Second World War, when hideous experiments on the human brain were conducted under the Nazi regime – the majority of the involuntary participants in this “research” were children. Although the fMRI is nothing near the torture that was endured by those subjects, the purpose of the brain scan is not dissimilar – both varieties of “scientific” study were and are ultimately eugenicist projects, aiming to create nations of “healthy”, and therefore productive and efficient individuals. In both cases, the belief that moulding an individual into this kind of citizen should start as early on in life as possible. Furthermore, I firmly believe the drugs that parents feed their children post-fMRI and diagnosis constitute a different kind of torture, and in ways a more disturbing one, as an unsuspecting child who is fed pills does not know why s/he suddenly feels unpleasant somatic side-effects, while the scalpel et al. could be cited as the source of pain quite easily by a child strapped to a chair by a medical researcher during the Third Reich. The field was primarily concerned with human rights violations originally, but is more ambiguous about this issue now. Just as shiny instruments of medicine and torture were more explicit tools of an impingement on one’s basic rights, the fMRI at first appears benign, and the resurgence of this topic of study has only occurred very recently – whether or not the new scholars of neuroethics are a large enough collective, are voicing their concerns strongly enough to initiate change, and have arrived on the scene early enough to make a large impact on the decisions of parents to have their children tested for mental illness using brain scans is yet to be seen, but current knowledge of “treating the brain with ethics in mind” is very much restricted to academia.

Neo-liberal economics are involved in the development and implementation of fMRI technology and the pharmaceutical industry’s interest and involvement with brain scans used to diagnose “mental illness”. In the pursuit of profit, this conglomerate of drug-producing corporations is always searching for new markets that they may open up to the distribution of these chemical supplements. They struck a goldmine with the “discovery” of selective serotonin reuptake inhibitor (SSRI) antidepressants in the late 1980s, and psychopharmacological drugs quickly became their top-sellers and biggest sources of revenue. However, since then the industry has failed to produce any “new” treatments for depression since then, they are doing two things in the place of trying to make scientific advances: 1) creating isomers[4] of the same SSRIs that are patented under new names, making the uninformed populace believe that they are newer, better “treatments”, and 2) opening up new cohorts of the population that antidepressants can be sold to, particularly the physically ill, and children (APA 2010, Healy 2008).

Finally, the effects of neo-liberal “Reaganomics” on the structure of the family have shaped the urge to find a quick fix for a child whose behaviour and expressions of emotion are time-consuming and lead to complaints from teachers. As it turned out that wealth does not “trickle down”, in combination with rapid globalization and outsourcing – once again benefiting corporate entities as they reduce the costs of production – millions of jobs previously available to North Americans have been lost. Consequently, most families with children require both parents to work full-time jobs in order to afford basic costs of living. In addition, the malignant growth and intermingling of bureaucracies requires adults to spend many unpaid hours navigating these agencies[5]. While in previous eras, parents had time to spend with their children, training them to “conform” to “proper conduct”, if that was their goal, they no longer have this luxury unless they belong to the “leisure class” – a term that refers to the small, wealthy, elite class that has non-jeopardized time with which they can choose what they would like to do with. Although having a child’s brain scanned using fMRI technology costs in the area of $3000 USD, it saves parents the time of having to deal with their child’s “issues” without the aid of psychopharmacological intervention.

The argument made by most physicians and other proponents of the use of fMRI technology to diagnose PBD in children, is that if it is discovered that they have the “chemical imbalances” and/or other “abnormalities” in brain functioning, most often in response to some kind of stimuli shown to a child while in the scanning chamber, existing medications used to treat “Bipolar Disorder” (BD) in adults can then be used to treat the child while her/his brain is still in the stages of early development, thus “curing” them, and preventing them from having to suffer the negative consequences of having the disorder during adulthood, those most cited being inability to work or hold a job, social isolation from ones peers and colleagues, and the extreme of suicide ” (ex/ Phillips 2010). As most parents want their children to grow up to become financially, socially, and psychologically stable adults, they are incredibly vulnerable to the offer that the risk of their children becoming any less can be quickly remedied with a brain scan, and the prescription of drugs.

The fact that these drugs, with the recent exception of the antipsychotic “Abilify” (Bristol-Myers-Squibb 2010), have never been tested in clinical trials on children, carry “black box” warnings in the case of SSRIs, stating that they can increase suicidality in teens implemented after many young teenagers committed suicide after taking Paxil, Zoloft and Prozac (Healy 2003), and that there is literally no proof whatsoever that they will positively influence a young, developing brain, seems to present a greater risk to the future of society, demonstrating the lack of knowledge the general population has about psychopharmacological drugs, as well as reinforcing Beck’s definition that developments like this one are influenced by the history of modernization more than critical thought about the future.

Although parents that chose to bring their children to a brain-scanning clinic are concerned with the future of their children, the reasons that they step inside are far more influenced by the history of moral panics around childhood, the individualization of conduct, and underlying economic forces. In addition, the blind belief of humans in the reliability of technology, and the idea that any technological “advances” are examples of progress in the “right” direction override viewing technology under a critical lens. We can thus say that humans have been “colonized by technology”.

The colonization of humans by technology reaches far beyond the oft-cited artifacts such as the Internet, television, and smart-phones. We are socialized from early childhood to trust medical doctors, through colloquialisms, such as “doctor knows best”, but also by our parents, who were taught this mantra before the explosion of psychopharmacological drugs on the medical scene – which also fall under the heading of “new technology”. Children and parents now both become victim to the faith in medical technologies such as the fMRI and psychotropic drugs prescribed by physicians. The fact that mainstream media and pop-psychology promotes these technologies (ex/ Luby 2006) while critical literature on the topic is not available at bookstore giants like Chapter’s in Canada, or Barnes and Noble in the United States, contributes to the ignorance of the general populace about the dangers of these technologies (Rimke 2000).

In 2003, the private corporation “Brain Matters Inc.” opened its first location in California. The CEO of the new company announced that “Psychiatric patients… can actually ‘see’ for the first time the possible physiological source of their own brain dysfunction feel less stigmatized by the ‘mental illness’ label they have been branded with and become more willing to comply with treatment.” (Biocompare 2003) Although the company did not advertise itself as one involved in the psychiatric treatment of children, this quickly became its most common use. Two episodes of Dr. Phil in 2006 on the wonders that the Brain Matters clinics were doing for the families of children with bipolar disorder[6] certainly helped, as both parents and scientific and medical “experts” gave emotional and convincing testimonials (Healy 2008). Many other clinics opened after Brain Matters, including “CereScan Inc.” At these clinics, parents pay for a scan, and subsequent medication recommendations are made by a psychiatrist, a process that only takes a few hours time.

When Brain Matters opened its first commercial facility, research on applying the fMRI to diagnose PBD in children had only just begun, and silenced critics stated that the ability to identify the emission, paths, and action of neurotransmitters in the brain was non-existent, beyond current scientific knowledge, such technology could, maybe exist after approximately fifteen more years of scientific research. Meanwhile, in the context neo-liberal risk society, parents with “difficult” or “different” children were, and continue to be, increasingly victimized by propaganda, having faith in pop-culture symbols such as “Dr. Phil McGraw” (Rimke 2000), who claims that this technology is a solution to the strains of parenting and the fear that their children may not be “normal”.

The cover story appeared of a 2002 issue of Time Magazine entitled ‘Young and Bipolar’ stated that “…the age of onset of bipolar disorder is sliding downward, and young bipolars are, like adults, being charged with creative burden. Time printed a sidebar of photographs titled “Manic Genius,” including the usual suspects, Edgar Allen Poe, Vincent Van Gogh, Ernest Hemmingway, et al. But Time adds a new, young manic-depressive – Kurt Cobain, who “took his band Nirvana to the pinnacle…but then took his life at the age of 27.’” (Cray et al. 2004:23)

Obviously directed at parents, considering Time magazine’s readership, the thought that “your child” may have bipolar disorder entered the public domain and crossed the minds of millions of people. Prescribing drugs used to treat bipolar disorder in adults – atypical antipsychotics, antidepressants, mood stabilizers, and tranquilizers – for children had already begun, but the specific diagnosis for these children was still in question. Suddenly, the thought that children behaving in a certain manner may be suffering from BD, a highly stigmatized “mental illness”, entered the public imagination. Sensational articles like this one set the stage for concerned parents across North America to choose to have their children’s brains scanned for fear that if they did not “correct” this “flaw”, their offspring would be plagued for life with an “illness” that may lead to the extreme of suicide.

Students of psychology and psychiatry were trained to believe in the accuracy and validity of brain scans to detect abnormalities in the brains of children even earlier. In one textbook, published in 2000, the authors state that:

“The application of magnetic resonance spectroscopy (MRS) techniques to the study of neuropsychiatric disorders in childhood provides an extraordinary opportunity to advance our understanding of the neurobiological mechanisms underlying these disorders. Recent developments in imaging technology have afforded researchers the belief that the fMRI has the capability to examine in vivo not only brain structure but also neurochemistry and functional architecture. All MR methods (MRS, magnetic resonance imaging [MRI] and functional MRI [fMRI]) rely on these basic principles. In the study of human brain all of these procedures involve the same hardware.” (my emphasis, Yurgelun and Rensshaw:52).

Meanwhile, the “silent majority” of scientists disagree that neurochemistry is testable through the use of MR methods, or at least disagree on the production and accuracy of images generated by scans, as the development involves professionals from a variety of individuals with specified knowledge of one discipline, including mathematicians, chemists, biologists, physicists, and physicans and psychiatrists (Dumit 2003) The textbook cites the claims of particular scientists, who have produced spectroscopic findings in psychiatric patients between the ages of seven and seventeen that supposedly have the ability to diagnose schizophrenia, obsessive-compulsive disorder, depression, and substance abuse risk (see p. 65 of Yurgelun and Renshaw). The successful diagnosis of structural abnormalities in the brains of infants is cited as proof that the same technology is equally as useful in diagnosing non-structural “abnormalities” that rely on the action of neurotransmitters.

These “proofs” rely on the concept of “spectrum disorders”, another problematic topic that will be promoted aggressively in the DSM-V (APA:2010). A broadening number of symptoms, and “abnormalities” in neurotransmitter activity, have become grounds to make an official diagnosis of serious psychiatric impairment, ranging from “child-onset schizophrenia” (Yurgelun and Renshaw: 67; Jacobson and Bertolino:189-204) to auditory development decficiencies in the fetus (Rogess et al. 2002: 89). Previously, all longitudinal research has demonstrated that schizophrenia only manifests itself in one’s early twenties, and is a result of environmental triggers just as much as brain chemistry (Breggin 2006:206).

The early treatment of childhood psychiatric disorders is encouraged by evidence that the brain of the fetus is affected throughout adulthood by the consumption of substances by its Mother. Extrapolated from this, the child’s brain, between birth and age ten, is said to define their experience of adulthood based on neurotransmission, especially that of serotonin and GABA, chemicals that are “thought to” determine levels of happiness and anxiety, and thus should be corrected during that period to guarantee freedom from psychiatric illness as an adult (Casanova et al. 124-130).

It is important to bear in mind that Magnetic Resonance Imaging (MRI) technology was developed to be able to provide a three-dimensional image of the internal organs of the body. Whereas previous ultrasound technology only showed two dimensions, the MRI is able to see structural aspects of the body that could not be viewed without invasive surgery before, such as the presence of cancerous tumors. However, the use of this technology to scan the brain and detect its activity was not what the MRI machine was to be used for upon its creation. When the technology is used to make propositions about the activity of particular neurotransmitters in the brain, researchers have jumped to the conclusion that the MRI depicts function, and when it is used this way it is referred to as the fMRI.

The only difference between the MRI and fMRI is that the fMRI measures the amount of blood flow to a certain region in the brain – the relationship between blood flow and neurotransmission is not known. While original MRI technology was able to provide better structural images of the inner workings of the human body, knowledge about the functioning of organs was possessed by medical doctors, based on a long history of research on the function of our anatomy, the fMRI relies on a computer to determine the functioning of the brain, and this newer technology is not analyzed using standard computer software to generate images as the MRI is.

The software used in both analyses of the body and the brain use mathematical algorithms to decode strings of digits produced by the magnetic resonance machine, in which the patient lies. However, the algorithms used to translate brain activity, via data about blood-flow to particular regions are highly contested, and different programs are used by different researchers. Problems with the validity of the fMRI do not end here. Medico-scientific studies compare a “normal” or “control” population with another population who share some common “abnormality”, in effort to discover things such as the efficacy of pharmaceuticals. The concept of “normality” is redefined when it is up to a machine to decide, and then for humans to interpret.

The most common control population, which the technology has relied on to compare various aberrant images with “normal” ones, is comprised solely of white males. These subjects are interviewed and given several standardized psychological exams, such as the MMPI, in order to determine that they are free of any mental affliction. The supposed activity of these individuals’ brains is scanned and then decoded using software of the researcher’s choice, and the array of images produced are lined up. All neural activity among these individuals that differ from one another are removed. The final control image is based on a fiction – it does not depict the functioning of any real individual’s brain. The process is repeated among “abnormal” populations, the most commonly cited examples being “depressives” and “schizophrenics” – again, any contradictory aspects of the individual participant’s brain activity, measured in blood flow, among a certain group are removed. Indeed, some of the areas discounted in the control population that are also active in the abnormal test populations, but this information is eliminated before it can be evaluated (Dumit 2003).

After its initial appearance on the scientific scene, research employing fMRI technology was quickly extended to “the usual suspects” in the realm of psychiatric “disorders”, including anxiety disorders, and mood disorders – which include depression and bipolar conditions of all varieties – Bipolar I (BI), Bipolar II (BII), and Bipolar Not Otherwise Specified (BNOS) (APA:2000). This work states that at the age of four months, the facial expressions of an infant can indicate a latent mood disorder, and the fMRI can test for such a disorder. Epidemiology used to define depression and bipolar disorder – although the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not list these diagnoses – in young children include “irritable and negative behaviour”, “refusal to do schoolwork”, “emotional outbursts at home and school”, “unexplained physical complaints such as headaches and stomachaches” (my emphasis), and “hyperactivity, impulsivity, and [a] motor-driven disposition”. (Kowatch, R. et al.:205) The last of these behaviours is said to be most indicative of PBD (ibid.), and herein we may observe a transfer of symptoms previously assigned to the categories of Attention Deficit [hyperactivity] disorder, now relabeled as a “new” disorder, opening its treatment up to a variety of new drugs.

The neurobiological framework for the application of fMRI technology to diagnose children has been established by Rogeness et al. (1992), based on a model produced by Gray et al. (1981). The extension of the use of this technology on children is simply based on the claim that adults with BP and other “mood disorders” show abnormalities in serotonergic, dopaminergenic, and noradrenergic systems when their brains are scanned. This application of technology completely discounts the possibility that these systems may function differently in the young, developing brain (if the technology is legitimate at all). Furthermore, Gray’s model was based only on experiments performed on animals, not to mention that it was published over ten years before being used by Rogeness et al. (1992), with no consideration of updates and critiques made over that decade. These very problematic violations of the scientific method have been completely ignored.

The first anatomic study of PBD using the MRI compared the brain scans of eight “manic” children and adolescents, the youngest member of the study being age five, and indicated numerous abnormalities in the flow of blood, assumed to represent neurotransmitters, to various areas of the brain; only one of the eight “manic” children demonstrated brain activity identical to that of the scan of a “normal” child’s brain (Botterson et al.:1995). Thus, in the mid-nineties the stage was set for a dramatic increase in the number of children to soon be diagnosed with this condition, based on a clinical trial involving eight subjects, a population that can hardly be described as representative, but instead may be called laughable. Unfortunately, no one contested this “data”. Not to mention that the title of their publication on the study is misleading, stating that the scans were performed on eight to sixteen year-olds, while, as stated previously, children as young as five were subjected to participation.

Other authors, suggesting directions for further research state that discoveries about PBD will no doubt be facilitated primarily by the employment of fMRI technology to address “abnormalities of brain neurochemistry that may fuel the development of rational therapies for addressing pathophysiology.” (Kowatch et al.:219). This statement in and of itself is a misnomer – no link between neurotransmission and the physiological structure of the brain has ever been established.

Dr. Kiki Chang of Stanford University was the first to use the fMRI with the intention of facilitating immediate clinical changes in practice, to try to find a difference between the brains of children diagnosed with PBD and “normal” control children. His first discovery was that the amagdyla, the centre of the brain responsible for emotion, seemed to be smaller in children with the diagnosis. This qualifies as a structural difference. It was then Chang who suggested that psychotropic drugs, especially the atypical antipsychotics – the same drugs to suppress critical thought in POWs – could change the structure of the developing brain. He published his first articles on the topic in 2003, first trying to look for genetic markers of bipolar disorder in families where an adult was afflicted with the disorder, as well as a child. (Chang, K. et al.:2003) He then became extremely enthusiastic about using the fMRI to look for markers solely in children.

His various studies have concluded that: 1) children afflicted with PBD present with abnormalities in the frontalstiratal cortex (Manpreet et al.:2010), that the “mood stabilizer” and anti-epileptic drug Epival has no effect on the cortical volume of the amagdyla, but decreases prefrontal action and consequently “reduces depression” Chang et al. 2009), 3) that there are significant white matter alterations, in the limbic and corpus collosum, in adolescents with bipolar disorder (Barnea-Goraley et al. 2008), 4) activation in bilateral amygdalae and dorsolateral prefrontal cortices (DLPFC) for negative minus neutral pictures was correlated with the Children’s Depression Rating Scale (CDRS) scores and the mood-stabilizer Lamictal/lamotrigine decreased the amount of activation in the former area (Chang et al. 2008.) 5) children with PBD presented with increased amygdalar action when looking at fearful faces, as well as looking at happy faces and 6) children experience “possible neuronal loss” during “episodes” of either mania or depression (Chang 2006).

Chang concludes this article with the statement that “Clearly, MRI technology has allowed great scientific access to the child and adolescent brain, in a safe and detailed manner.” (Chang 2006:1141) Yet these studies have found “differences” between young “bipolar brains” and young “normal brains” in different areas of the brain each time – the amagdyla, the prefrontal cortex, the striatum, the limbic system, the corpus callosum, and the list goes on. All of the studies are based on a sample of around twenty children of each group. Is his work really anything other than a new type of phrenology that uses elaborate technology to measure difference, rather than a measuring tape?

When I was in third grade, I was sent to the “Guidance Counsellor’s Office” after the combination of my excellent scholastic abilities and my mischievousness presented cause for concern among my teachers, and I was asked to look at a poster with several yellow “smilies”, all with different expressions on their “faces”, and to identify the emotion each image conveyed. I saw no purpose in this exercise, and refused to see the counselor again, telling my parents that, “No one could make me change the way I am; only I can decide to change myself.” Children today are not so privileged to have this choice. The same array of yellow, cartoon faces is still shown to children as young as two to see how they will react to the different depictions of emotion, not in a counsellor’s office, but rather in the cylindrical tomb of an fMRI machine. The reactions they are looking for are not those that cross the child’s face, but those that occur chemically, within the brain. Men in white coats sit in a room looking at computer screens, where they claim to be able to detect extra, or less activity in a particular region of the brain, that is indicative of bipolar disorder.

Two particular studies using these “faces” along with fMRI technology produced results that the scientists who conducted them believe confirm that bipolar disorder can be diagnosed in children as young as two. The first was conducted by Dr. Pavuluri, the Founding Director of the nationally recognized pediatric mood program that includes the Pediatric Translational Research in Affective and Cognitive Neurocircuitry and Treatment (P-TRACT) lab at the Center for Cognitive Medicine, University of Illinois at Chicago. Matched by age, gender, educational level, IQ, socioeconomic status, and ethnic background, the brain activity of thirty “normal” children and young adults, age ten to twenty, was compared with that of thirty of the same aged youth who had been diagnosed with PBD. Pavluri’s hypothesis was that when presented with images of angry or upset faces, the test subjects with PBD would show less activity in the areas of the brain that correspond with cognition, and more in the amagdyla, responsible for emotion. The study was based upon the theory that when confronted with a difficult situation, bipolar individuals are overwhelmed by their emotions, to the point that it impairs their ability to “act rationally” (Pavluri 2007). The hypothesis was shown to be “true” using the image-processing software FIASCO, and the article concludes that “ this dysfunctional top-down regulation will impair the cognitive and affective circuitry interface.” Pavluri’s current research focuses on PBD-related “physiopathology”, attempting to alter it with psychotropic medication, although no results have been published.

Another study, by PBD researchers Dickstein et. al. (2007), focused on the same types of brain activity. 23 children within the same age range and diagnosed with the condition were contrasted with 22 controls, matched by gender, ethnicity, and I.Q[7]. As in the other study, the subjects were shown faces displaying a variety of emotions, but were then given a “surprise memory recognition quiz” thirty minutes later. Again, the children viewed the faces while in an fMRI scanner. The study found that the children and adolescents with PBD were poorer at the quiz, having a “reduced memory for emotional faces”, especially fearful faces. When analyzing the images produced by the scans, the research team concentrated on the frontal-striatal activity, which is involved in the release of dopamine when one experiences being “rewarded”, and is also believed to be responsible for “novelty-related decision making procedures” (ibid.). However, the fMRI results did not correspond with the memory test results, as no difference was detected in frontal-striatal activity between the two groups when presented with fearful faces. This paradox is downplayed, as a difference between the two groups’ activity in the region was detected when happy or angry faces were shown – those diagnosed with PBD demonstrated increased activity in the region. The research paper that summarizes the project concludes with the statement that “Our results extend what is known about memory and face emotion processing impairments in PBD subjects by showing increased fronto-striatal activation during encoding of emotional faces.” Thus, it is suspicious when looked at as a whole, as the PBD subjects’ inability to recall fearful faces is presented as a scientific breakthrough enabled by fMRI technology, while in the end, the technology does not show any results that confirm this is associated with activity in the brain. Still, the researchers propose future studies involving the effect of drugs that chemically alter the functioning of the brain to improve the memory of fearful faces. The assumption is made that since there was a difference in the level of activity when shown the happy and angry faces, the difference in ability to recall fearful activities also reflects some “disorder” that lies in the brain.

Ernst, Dickstein et al. conducted another study to look at the “abnormal” functioning of children with PBD when presented with a situation involving rewards, however it did not employ the fMRI or other brain-scanning apparati. It involved the same number of children with PBD and unafflicted children playing a “wheel of fortune” game together, during which they were awarded with small amounts of money after winning a round. The research team expected to find that children with PBD exhibited more “risky” behaviour while playing the game, but rather only found that subjects with the diagnosis were less confident that they would spin a positive outcome, and were “more emotional” about the game, although it is not specified in what way in the article summarizing the study. This most recent publication by (Dickstein 2009) points to abnormal “affective regulation” as the key marker of the disorder, and also suggests that these children have learning disabilities, although these studies did not employ brain scanning technology.

The latest study on PBD employing fMRI technology focuses on attention and concentration, the subsequent publication stating in the introduction that ADHD and PBD are “commonly comorbid”. Using “Go/No Go” computer software, which measures a participant’s capacity for sustained attention and response control – for example, a go/no-go test that requires a participant to perform an action given certain stimuli (e.g., press a button – Go) and inhibit that action under a different set of stimuli (e.g., not press that same button – No-Go). Children with PBD, this time between ages 9 and 18, showed increased activity in yet another area of the brain compared with “normal” controls, the right dorsolateral prefrontal cortex. The authors state this means that areas of the brain responsible for other, executive functions are monopolized in order to accurately inhibit responses.

The outcries of critical scholars in the field of neuroethics have thus far been no match for those from the powerful, fMRI research teams. It is distressing that a line of study deriving from experimentation on children during the Second World War has let similar experiments using the fMRI slip under the radar for several years, perhaps because the event was not nearly as sensational or bloody. Children have died after being medicated for PBD, but again, this information has been suppressed by mainstream media. The viewership of Dr. Phil is certainly larger than that of Frontiline, the only program I know of that reported the death of a six year-old girl, who simply stopped breathing when on a cocktail of several different medications. Dr. Judy Illes, who holds degrees in physiological psychology, is widely recognized as the scholar responsible for the reopening of the topic of neuroethics to the academic community in 2002, her call for attention driven by neuroimaging technology (Illes et al. 2003). Thus, her early work lays a basis for the meaning of the term, that had never before been applied to the study of brain imaging technologies, drugs and other devices for neuroenhancement, cross-cultural scans, neuroimaging in the private sector – like that which takes place in Brain Matters’ clinics – and personalized medicine. If that is the “neuro” half of the picture, the “ethics” side is slightly harder to define – we all have an abstract idea that it refers to what is “right” and what is “not right/wrong”, but individual and disciplinary definitions of the term differ, as do more specific individual interpretations.

In “Nietzsche, Genealogy, History”, an essay based on an interview with Foucault, he argued that society needed to decouple “ethics” from “morals”, and turn towards an ethics of personal freedom as truth, rather than viewing our freedom as granted by a particular “truth” established in the hegemonic books of society – in this case, those of the powerful discipline of psychiatry, the medical textbooks read by future physicians and medical researchers, and the overarching influence of the psychopharmacological industry, that influences both of the former, as well as perpetuating its own propagandistic discourse (Foucault 1971).

In contradiction to this clear definition of the word “ethics”, no definition for “neuroethics” has ever been agreed upon although they all look at the same brain-related technology. Definitions that have been posited by major figures in the field include “the examination of what is right and wrong, good and bad about the treatment of, perfection of, or unwelcome invasion of and worrisome manipulation of the human brain” (Safire, W. Visions for a New Field of “Neuroethics” Neuroethics Mapping the Field Conference Proceedings. May 13-14, 2002. San Francisco, California), and “more than just the bioethics of the brain…the examination of how we want to deal with the social issues of disease, normality, mortality, lifestyle, and the philosophy of living informed by our understanding of underlying brain mechanisms” (emphasis in original, Gazzaniga, M. S. (2005). The Ethical Brain. The Dana Press.). The first definition falls into an argument about morals using Kantian logic – the kind that Foucault attempted to reject in his conception, while the second is abstract to the point of weakness, and seems almost in favour of brain-scanning technology.

A true challenge to the “hard scientific” field of neuroscience and its use of the fMRI, PET, and other types of scans cannot appeal to “morals”, as all individuals in our fragmented society possess different morals, and the economic interests driving the pharmaceutical industry and private corporations that use the fMRI are not concerned with morals. One has to take a radical position to contest scientific technology and its applications, and one that refutes the scientific claims made by these institutions. It seems it would be easy to do so, considering Dumit’s explanations of the fundamental problems with the scan – claims to truth made by the science of the fMRI and its applications are essentially falsities. In addition, arguments about individual freedom are important, and they agree with the conception of individualization.

Much of the neuroethical literature is concerned with neuroeconomics – the use of neuroscientific knowledge to draw consumers to a certain product (ex/ Camerer, C.F. 2005; Huettel et al. 2006; Yechiam et al. ,2005,)the use of the fMRI in lie detection tests, scanning the brains of criminals to try to find a correlation between criminality and neurotransmission[8], and “mind-control” strategies outside of the realm of pharmaceuticals, giving it a slightly conspiratorial tone. These are certainly frightening prospects, and neuromarketing is already in practice, but it seems the field is more concerned with future projections than what is happening right now, and why it is happening. One explanation for this is the lack of knowledge of history that the field incorporates. Other articles are overly philosophical – classic examples of academic writing that has no purpose other than to join the annals of a certain journal. Many of such articles do ponder questions of free will, but fail to make the connection between what is currently happening and the will of the individual – they are merely speculative about future applications of the fMRI (ex/ Greene 2010).

Illes’ own article on brain-scanning technology and children, “No Child Left Without a Brain Scan” (Illes and Raffin 2005), uses several points to raise doubt about fMRI scans, particularly when used on the unborn fetus to detect possible abnormalities in the nervous system such as those that may affect hearing, including the strong arguments that the image may be interpreted differently by different brain scientists, and that problems with population selection render much of the data unreliable. However, she ends the article with the possibility of “false or missed results”, giving a degree of credence to the scan. Another recent article, specifically on using the fMRI to diagnose PBD, emphasizes that diagnoses shouldn’t only be based on scan results, but accompanied by changes in behaviour, cognition, and mood. Other “critical” articles on pediatric usage of the technology, including one that Illes contributed to, call for “appropriate follow-ups” (Kim et al. 2002).

There is a hole in the literature – aside from the damning evidence about the validity and reliability of the scans – the claims that suggestions for medications for children to permanently change their brain have not been challenged within the field of neuroethics. This is absolutely mystifying, as no evidence whatsoever supports the proposition that the antipsychotics, antidepressants, mood stabilizers, benzodiazepines, or any other psychotropic drugs prescribed to treat PBD, often following a brain scan, causes any positive changes in brain development, never mind the claim that such psychopharmacological treatment is capable of “curing” someone of “bipolar” or any other “disorder”.

Now that some adults have been taking these drugs for twenty years, it has been discovered that antipsychotics cause type-II diabetes, heart attacks, lower white blood cell counts while raising blood lipids, and many recent projections state that they take twenty-five years off of one’s life (Breggin and Cohen 2007) As for SSRI/SNRI (Serotonin and Norepenephrine Reuptake Inhibitor) antidepressants, the key benefit of them stated by researchers for pharmaceutical companies – that they are not at all addictive drugs – was long disproven, and some find the withdrawal syndrome so unbearable that they chose to continue taking the drugs for life (ibid, Healy 2008, Wyeth 2008). As for the last class, giving a six year-old child Valium (diazepam) sounds like something out of a fictional crime drama about severe parental negligence – but doctors instruct parents to do so everyday. In Canada, two million off-label prescriptions for psychiatric medications for children were distributed in 2006 (IMS Canada 2006). This seems like a call for alarm, and to immediate action, yet it has not been addressed.

Are the pharmaceutical companies that lie at the top of the hierarchy in the distribution of psychopharmacological substances to children so powerful that one cannot publish work on the degree to which this impinges on a child’s freedom, constitutes a human rights violation, and may damage their brains for life? If our concern is about the future, why are there no concerns about the risk of the “scan and drug” method? Finally, is psychology so dissociated from its history that it does not remember the results of experiments conducted on the brains of children during World War Two? None of the neuroethical literature mentions this connection. One must then ask, will it not be until after numerous tragic results of children harmed or murdered by drugs given to them post-scan are revealed until this issue enters public and academic discussion to a larger degree, just like information about the children that endured psychosurgery in Nazi Germany was not released until after the damage had been done?

Meanwhile, the use of the technology to detect PBD is growing exponentially. Canadian issues of BP magazine, a free publication that can be found in the waiting rooms of many doctor’s offices, sponsored by Astra-Zeneca Neuroscience and pharmaceutical giant Pfizer, previously only discussed “bipolar disorder” among adults. However, over the past year, advertisements to have the brains of children scanned to detect the condition have joined the barrage of ads for psychopharmaceuticals for adults. A full-page advertisement featured in the magazine over the past several months shows a picture of a very young child, perhaps age five or six, lists the “symptoms” of PBD, and offers parents and their children free accommodation and paid travel expenses to visit the main centres for research on the “disorder”, where they may have their children’s brains scanned, and then, depending on whether or not the scans indicate PBD, offer free experimental psychopharmacological treatment for the condition (BPHope 2009-2010). Although the most prominent private MRI scanning corporation in Canada, Mayfair Diagnostics Inc., does not advertise scanning to diagnose psychiatric disorders in children, finding out whether or not the company does or does not practice this would require further inquiry. With the invasion of a “private/public” health-care system in Canada over the past several years, the use of the fMRI for psychiatric diagnoses for those that can afford to pay will no doubt become more and more common.

To return to issues of theory, busy, stressed parents are far more concerned with the “risk” of their child being stricken with historically stigmatized “mental illnesses” than the risk of handing them brain-altering and brain-disabling drugs with their breakfast each morning. It is difficult to find a medical doctor or psychiatrist who is critical of psychopharmacological intervention. Furthermore, children who exhibit unsavoury behaviour or a high degree of emotionality are individualized for their conduct – environmental and social conditions are absolutely ignored. For example, no one has drawn a connection between the incidence of the symptoms listed under PBD occurring simultaneously with decreases in the amount of physical activity children are able to participate in, foods lacking nutrition taking the place of healthy lunches in schools[9], or the rather upsetting state of the world at large. Children can provide important cues to the ills of society, following the age-old saying, “out of the mouths of babes.” We have stopped listening to them, and have started to feed them drugs that will silence their thoughts.

One can only hope that papers such as this one expose the fact that using fMRI technology to scan infants and children for PBD is absolute pseudoscience, and the recommendation of off-label prescriptions for psychiatric medications based on the scans is truly insane, as there is no data on what effect these drugs have on the developing brain. The “new” field of neuroethics, concerned in part with brain-imaging technology, must take a firmer stance on this practice, not only because the situation is absolutely unethical if the freedom of the child is considered, but because fighting against the powerful industries of medicine, psychiatry, and psychopharmacology, requires firm arguments grounded in science if they are to present a real challenge. This use of the fMRI, and its incredibly numerous faults and dangers must also be exposed to the public through more mainstream publications and media if parents are to think twice before scanning the brains of their children and drugging them. Finally, the disciplines of psychology and psychiatry must be reformed to incorporate their own history if mistakes of the past are not to be repeated, using new technology to repeat the same tragedies.

Appendix A

Symptoms of PBD, as explained by the National Institute for Mental Health (NIMH), considered the foremost authority on mental health and illness by the American Psychiatric Association (APA), which publishes the DSM (NIMH 2010).

Bipolar mood changes are called “mood episodes.” Your child may have manic episodes, depressive episodes, or “mixed” episodes. A mixed episode has both manic and depressive symptoms. Children and teens with bipolar disorder may have more mixed episodes than adults with the illness.

Mood episodes last a week or two—sometimes longer. During an episode, the symptoms last every day for most of the day.

Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels.

Children and teens having a manic episode may:

Feel very happy or act silly in a way that’s unusual
Have a very short temper
Talk really fast about a lot of different things
Have trouble sleeping but not feel tired
Have trouble staying focused
Talk and think about sex more often
Do risky things.

Children and teens having a depressive episode may:

Feel very sad
Complain about pain a lot, like stomachaches and headaches
Sleep too little or too much
Feel guilty and worthless
Eat too little or too much
Have little energy and no interest in fun activities
Think about death or suicide.

Bipolar disorder in young people can co-exist with several problems.

Substance abuse. Both adults and kids with bipolar disorder are at risk of drinking or taking drugs.
Attention deficit/hyperactivity disorder, or ADHD. Children with bipolar disorder and ADHD may have trouble staying focused.
Anxiety disorders, like separation anxiety. Children with both types of disorders may need to go to the hospital more often than other people with bipolar disorder.
Other mental illnesses, like depression. Some mental illnesses cause symptoms that look like bipolar disorder. Tell a doctor about any manic or depressive symptoms your child has had.

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[1] The prescription of a drug that has never been approved for a certain cohort of the population, or a particular medical condition, is referred to as “off-label” usage. This term will be used throughout this paper.

[2] See Appendix A for a full list of the “symptoms” of PBD.

[3] Radical as eloquently defined by William Carroll, as “getting to the root of an issue” (Carroll 2004:7) – not the common conception of radicals being dogmatic, irrational, extremists.

[4] For example, venlafaxine or “Effexor”, released fifteen (Healy 2008) years ago, and devenlafaxine or “Pristiq” that was released in 2009. The latter is simply a reverse isomer of the former drug.

[5] For example, time spent on the phone being transferred from one worker to the next, often waiting “on hold” for long periods of time; the splitting of Canada Student Loans into three separate agencies that the individual is required to act as a middleman between; or the drastically more difficult processes, involving the collection of information from a multitude of bureaucratic entities, that is now required to receive Employment Insurance, Worker’s Compensation, or Social Assistance.

[6] At this point the title of “Pediatric Bipolar Disorder” had not yet been established. “Early-Onset Bipolar Disorder” was the initial term that referred to the condition. Perhaps an actor-network theoretical analysis, similar to Ward’s in the article, “The Creation of Self-Esteem”, would reveal why PBD became the official term.

[7] It must be noted that different studies match children using much different demographic characteristics, rendering their generalizability very questionable, just as using only white males in studies of mental illness in adulthood does.

[8] A critical scholar of criminology may see the clear link between these new studies and the studies Dugdale conducted on the “Juke family” during the early twentieth century, the results of which have long been considered a joke in the field.

[9] Interestingly, the corporations now in charge of many, many school cafeterias, such as Sodexo and Chartwells, are the same ones that provide food services in prisons and hospitals.