The front page of the September 4th issue of The New York Times carried a story by Benedict Carey entitled “Bipolar Illness Soars as a Diagnosis for the Young.” Carey has done a number of important pieces about child mental health over the past few years. The subject of pediatric bipolar disorder stirs strong feelings in child psychiatrists and has become a lightning rod for controversy. The NY Times article describes the findings of a new study that adds important data to the debate. Carey reports that this new study, published in the September issues of The Archives of General Psychiatry, documents a 40-fold increase in the diagnoses of bipolar disorder in children between 1994 and 2003, climbing from 20,000 cases in 1994 to 800,000 cases in 2003.
The article points out that child psychiatrists differ on their opinion about this trend. Many doctors feel that increase in diagnoses indicates an improved awareness of the diagnosis and the ability to treat these children early and with better effect. Others disagree and feel that the diagnosis has been oversold and is used to describe a lot of angry, explosive kids. The NY Times points out that, so far, other data have shown that most kids who fit this broad definition of bipolar do not seem to develop the classic form of the disorder in adulthood. In fact, most of these kids go on to develop depression, rather than manic episodes.
The impact on these kids is enormous when they are given a bipolar diagnosis. They are often prescribed medications such as atypical antipsychotics or mood stabilizers, when the research on these meds in children remains limited. Only four out of ten of the children studied were reported to also be in psychotherapy, according to the NY Times article. The drug companies are pleased with this trend and are looking for pediatric indications for medications already being used to treat bipolar disorder in adults. According to the article, a bipolar diagnosis and the resulting treatment can be good news for some families, helping them deal with very dangerous and difficult situations.
I have strong feelings on this subject and feel that it deserves some serious discussion. In my reading of the literature, we do not have any evidence that a broad definition of bipolar disorder in children is the same illness as classic bipolar disorder in adults. Over the past 15 years or so, I have witnessed this explosion in bipolar diagnoses in kids who are reactive, explosive, impulsive, often hyperactive, oppositional, and usually struggling in every part of their lives. Most of these kids do not have the classic symptoms of BP—periods of major depression interspersed with periods of mania. In fact, the “cycles” are often hours long, rather than days or weeks. They do not typically have the classic sleep changes, grandiose thinking or high levels of productivity, or euphoria that go along with mania. Most, if not all, are chronically irritable with explosive episodes, but do not exhibit sustained periods of higher levels of irritability or energy. Many do have depressive symptoms, such as hopelessness, low productivity and a very negative sense of self, as well as symptoms of ADHD—baseline hyperactivity and impulsivity. These are often more chronic symptoms, rather than episodic as required for a more standard definition of BP.
Some children do have classic manic symptoms that require a bipolar diagnosis, but they are much less common. The more typical picture with full manic or even hypomanic symptoms becomes more prevalent in adolescence and young adulthood, but these are not the kids behind the staggering increase in pediatric bipolar disorder diagnoses over the last 15 years. The kids getting over diagnosed are those who present as explosive, reactive, irritable, impulsive, oppositional, inflexible, and hyperactive. They form the cornerstone of child psychiatry practice and some of the most painful, difficult situations that we work with. Families are overwhelmed and exhausted and everyone is hurting, especially the child. In some cases, it seems that having the bipolar label has been helpful, because it offers hope for treatment and some explanation of these difficult kids. I couldn’t agree more that the benefit of this trend has been to identify that these children are truly struggling with “wiring” issues—neurobiological problems in their emotional and behavioral wiring. It has been a strong place to start the discussion that these are NOT BAD KIDS as they have so long been called and then treated as such.
There are, however, many downsides to this label if it applied haphazardly or prematurely. First and foremost, jumping to the bipolar label (often done in 15 minutes or less) eliminates a more thorough examination of all of the possible causes. Kids with anxiety, language disability, trauma, attachment issues, fetal alcohol and drug exposure, learning and school problems, and certain medical problems can have similar symptoms. ADHD and depression can often be swept into the diagnosis or missed completely. Without a careful history and examination as well as a thorough differential diagnosis, developing a treatment plan becomes shotgun affair.
A similar effect occurs on medication choices if bipolar is thrown into the mix inappropriately. It narrows the medication options dramatically, often to the detriment of the more likely underlying diagnoses. Once a child is labeled bipolar, doctors are extremely hesitant to use antidepressants, because of the risk of “switching” into mania (this is something for another discussion). The problem is, as pointed out in the article, many of these kids actually go on to develop symptoms more in line with depression than bipolar disorder. Depression is a much more common diagnosis in general than bipolar. Not that we should miss bipolar, but we seem to missing a lot of depression now because of the bipolar frenzy. Yes there are risks to using antidepressants in kids—all kids, not just those with bipolar—and if you are going to start these medications you need to work carefully and in close communication with the family. Completely eliminating them from the treatment options, however, is a big problem. Similarly, many of these kids have ADHD and need to be tried on stimulant medication, but again this is shunned when a child is labeled bipolar.
The other dark side of the medication picture with the bipolar label is that the medications that do get used “first line” are “big guns” and create a higher risk. Atypical antipsychotics are very powerful medications with significant risks—weight gain, diabetes, movement disorders—to name a few. “Mood stabilizers” such as Depakote carry their own risks and are really meant to treat a manic episode, which is not classically present in most of these kids anyway. Depakote appears to increase the risk of polycystic ovary disease if given in prepubertal girls, so making sure it is being given for a good reason is important. Lithium is a powerful tool in bipolar disorder, as well treating mania and depression and reducing cycle frequency, but it carries many risks, especially toxicity and kidney and thyroid problems. Interestingly some research shows benefits to the use of Lithium in aggressive and explosive adolescents, even without a bipolar diagnosis, so we may even use these medications in these generally difficult kids, but we don’t have to call them bipolar if they don’t meet the criteria.
Finally, a huge risk of the label bipolar is a tendency to become over focused on medications and to minimize the non-pharmacologic interventions such as cognitive behavioral therapy (CBT), family therapy, and educational planning. These complex kids, whatever they turn out to “be” and their families need enormous amounts of support and coaching to get through every day. Waiting for the “magic pill” combination is frustrating and painful and unrealistic, especially when the diagnosis isn’t really so clear after all. A broader set of interventions is essential with these kids, regardless of their “diagnoses.” In particular, a program called Collaborative Problem Solving, developed by Ross Greene PhD and Stuart Ablon PhD, in Boston, has shown tremendous benefits in working with complex, difficult children with these explosive, reactive, and oppositional types of responses. The focus in this work is on identifying the specific areas of “skills deficits” that these kids have in their emotional and behavioral functions and working with families and educators and the kids to problem solve and build these skills over time. Most importantly in this model, kids are not seen as “bad” or “not trying hard enough,” which in itself creates a new and far more positive and effective platform for working with these children. To find out more about Collaborative Problem Solving, visit www.thinkkids.org.
The bipolar diagnosis craze has had some benefits—most importantly bringing attention to the neurologic nature of the difficulties that these kids have. But the downsides have been and continue to be significant. The field faces a big challenge in trying to help these children and their families. Our research needs to work toward more comprehensive and complex understanding of the underlying neurological issues, the contexts in which these issues occur, the interaction between the brain and its “container,” and the longitudinal picture of how these children evolve over time. We need to continue to develop more effective interventions, medication-based and otherwise. But an overly simplistic label that is not accurate is likely to do more harm than good.
this is o ne of the best discussions of this issue that I have seen -also, I couldn’t agree more with your endorsement of cps -thanks!
As a mother of a son with bipolar disorder, this article is upsetting. It was a very long road for us to finally get a correct diagnosi of bipolar disorder. It finally took a SPECT scan to show us the way his brain was funtioning. I blieve tools such as that are needed in order to avoid people’s opinions and biased thoughts. If we could ahve had the correct diagnosis and tratment years prior, we could have avoided a lot fo problems and helped him much sooner. The right medication has made all the difference in the world for him. The medication is scary but living with untreated bipolar is worse. Articles like this make parents feel like they they are at fault or just imagining problems and it also gives people in or society more amunition against a mental illness diagnosis which increases stigma. I wish people were more careful with their words.
This is a well-balanced article that demonstrates Dr. Fink’s sensitivity on this issue. Dr. Fink does not rule out the bipolar diagnosis for some children, in fact, she says, “Some children do have classic manic symptoms that require a bipolar diagnosis.” Furthermore, she goes on to say, “I couldn’t agree more that the benefit of this trend has been to identify that these children are truly struggling with ‘wiring’ issues….” Dr. Fink also acknowledges in this article how difficult it is for families to deal with these issues. As she says, “Families are overwhelmed and exhausted and everyone is hurting….”
She does not say or even imply anywhere in this article that individual parents are somehow at fault for these “wiring issues” or for accepting the bipolar diagnosis for their children. She is only saying that the trend–a 40-fold increase the the diagnosis of bipolar disorder in children from 1994 to 2003 is disturbing.
We all need to be careful with our words, as Dr. Fink has been, but we cannot expect the experts to be silent over such an important issue.
Dr. Fink’s discussion of the juvenile-onset bipolar disorder (JOBPD) controversy is well reasoned and practical. As a busy child and adolescent psychiatrist practicing south of Boston, in the shadow of the Massachusetts General Hospital where the bipolar frenzy started, I am constantly posed with the ethical dilemma of either refuting the diagnosis of a colleague or “going along” with the trend of (over) diagnosis. The pressures to “go along” are numerous. A bipolar diagnosis takes parents and kids off the hook (where they probably shouldn’t have been in the first place). Insurance companies are more likely to pay for intensive services, especially at hospital levels of care, if the patient carries a bipolar diagnosis. One would think, with the push to diagnose so many challenging kids with bipolar disorder, that we had great treatments for the condition. Medications for this disorder are only marginally effective in kids (probably because most of them do not have BPD) and fraught with problems. All but a few cause significant obesity (a real epidemic) and many cause metabolic problems. Why so many medications? Medication interventions are discrete, active, and easy. Medications are prescribed by the professionals, like myself, who make the diagnosis. Without diagnosis and medication management, psychiatrists would have to find a new role in mental health care delivery. . Like Dr. Fink, I often feel hindered by the JOBPD diagnosis because bipolar disorder represents relative contraindications to stimulants (for ADHD) and antidepressants (for depression and anxiety). In practice, I have rarely observed these common treatments to precipitate mania and have often used them to clear up the apparent “bipolar” disorder. The trend of over-diagnosis may be shifting. The National Institutes of Mental Health recently documented concerns about over-diagnosis on their web-site. The recent Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder Journal of the American Academy of Child and Adolescent Psychiatry, January 2007 (46:1), recommends that four continuous days of mania be observed before the diagnosis of bipolar disorder is made. If we hold to this standard, over-diagnosis should be rare.
Thanks Dr. Turley for your insightful comments. I see that we share a common concern with trying to avoid the over-diagnosis of bipolar disorder, yet stay working in a community that has come to rely on this language to describe many of the difficult children whom we see in practice.
I agree completely that using some type of temporal criteria to identify “card carrying mania” as Gabrielle Carlson MD puts it will drastically reduce the diagnosis of JOBPD. Being moody and reactive is not bipolar disorder – it is not mania. It can be a real problem, but the “quick fix” of a bipolar diagnosis and the associated medications – which are hardly supported in the literature and carry numerous risks – is not the answer.
Having written a couple of books about bipolar disorder, I see a lot of kids now that have already been diagnosed with BP or kids whose parents have read up on JOBPD and think that their child has Bipolar Disorder. I spend far more time on the un-diagnosis of BP in children than I do diagnosing it. Easily 10 to 1 or more.
Thanks for joining in the conversation – it is great to know that there are more and more child psychiatrists who are trying to be rational about this discussion and provide good care to kids who are in a lot of pain.
I was diagnosed with adhd, then it was changed to BP, then back to adhd, when I resr the two disorders, it seems i have symptoms of both, many of the adhd meds wired me, such as lexipro, straterra, and ridilin, the BP mood stabilizer lithium, had no effect, some of my symptoms seem to be assosiated and UNIQUE to anxiety-panic disorder, however, none of the docs will go along with me on this, I am 30 years old and not happy with my docs and therapist
I was initially diagnosed Bipolar 2 when I was 22. The doctors ignored major facts in my life, and even created new ones for me just to make the diagnosis stick- I was told I heard voices when I was inpatient (when I didn’t) and that I was drunk, and an alcoholic when I just didn’t have the history to back it up.
It took several years before I found the right doctor; and they did not see bipolar. I was unsure of my label because I thought I was bipolar.
Having a diagnosis like bipolar carries a horrible attachment. My current family physician wants to think I am bipolar without even considering the fact my history is so spotty, and I come into her office not presenting as manic, or depressed.
My last doctor went bipolar gung ho and called me bipolar in front of another doctor- despite knowing that I was there to rule out bipolar and seek appropriate treatment. She then recanted on the diagnosis, saying that she was only speaking figuratively. She tried to put me on lithium with her figurative thinking!
I have PTSD, dissociation, and chronic anxieties and phobias. As for bipolar, I don’t know anymore, don’t care, and will return to the hospital when it becomes apparent that I do have it.
You write, “many of these kids actually go on to develop symptoms more in line with depression than bipolar disorder.” You may be referring in part to the study by Brotman, M. et al. (2006). Prevalence , clinical correlates, and longitudianl course of smd in children. Biological Psychiatry, 60, 991-997. This study found that a bunch of youngsters with explosive rage, emotional over-reactivity, irritability, and hyperactivlty (severe mood dysregulation – smd) but without classic symptoms of bipolar disorder followed until age 18 developed depression.
Perhaps some of them will stay simply depressed. But, clinicians should keep in mind that age 18 is an early age of onset for unipolar depression and that early onset of depression is a marker for the later development of mania and hypomania. We have to wait for another 10 years of follow-up to see what these kids develop. Some of them, at least, are likely to switch to bipolar disorder. We don’t want to increase the risk of promoting an earlier age of onset of mania by giving them antidepressants.
Clinicians struggling to figure out which medications to give emotionally dysregulated kids (antidepressants vs. mood stabilizers for instance) would be more likely to make the right decision if they looked beyond symptoms to other diagnostic validators such course characteristics of the illness or family history. For instance, a depressed kid with a multi-generation family history of mood dysregulation, hyperthymic temperament, suicide or substance abuse (not to mention manic-depressive illness), would be at an expecially increased risk of developing bipolar illness at a later age.
Dr. Quinn –
Thank you for your thoughtful comments and insights. It is certainly the case that younger onset of major depression is a “red flag” for eventually developing bipolar disorder – and some of these kids will go on to manic episodes later in life but many – the majority actually – will go on to continued unipolar depression or other illnesses.
Part of my concern is that these explosive kids aren’t all depressed either – many are anxious, language disordered, traumatized or prenatally exposed to toxins, just to name a few other possibilities. The range of causes of this presentation is huge and requires careful examination, history and monitoring before exposing kids to medications like lithium and atypical antipsychotics.
As you rightly point out we use collateral data to try to assess risk of ultimately developing a manic episode in a child that we have diagnosed with depression – family history, baseline temperment etc. But our ability to predict the eventual occurence of mania is really limited – we don’t have any tools that give us more than very general ideas. And the problem is that when I am sitting with a family and child, and the child presents with depression but no evidence of mania, while I don’t know if they will eventually show symptoms of mania, I do know that if I start with a an antimanic or maintenance bipolar medication such as lithium or atypical antipsychotics I will expose the child to many potentially serious side effects. Antidepressants are far less toxic medications physically in kids, and careful monitoring of emotional and behavioral side effects can minimize problems evolving from agitation or even mania as a side effect of the antidepressants.
I am not sure how strong the data is to support the notion the treating with antidepressants accelerates the onset of manic episodes. A recent literature review (August 08 Acta Psychiatr Scand) suggests that there are no well designed studies to answer that question. I believe that we are overly frightened of this possiblity – without good evidence to support it – and that it pushes us to use the big gun meds as a first line, generating far more medical risks than necessary.
I absolutely agree that we want to catch bipolar disorder as early as possible – we don’t want to miss it and make things worse. And so careful history taking, observations and family history are essential. However I don’t believe that we have the crystal ball yet to support using such powerful medications on kids who are not presenting with current symptoms of bipolar disorder. Thinking that “maybe” they will in 10 or 15 years doesn’t validate my using dangerous medications for an illness that I am not currently seeing. If I see mania in kids I will always treat with appropriate mood stabilizing agents and avoid solo antidepressants. If I don’t see mania but I do see depression and/or anxiety I am usually going to try non-medication options such as CBT first and then antidepressants next – and take my chances, while monitoring very closely, on developing emotional or behavioral side effects that I can eliminate by simply stopping the medication quickly. Atypicals and other “big guns” are way down on my list for kids with depression for now.
This dialogue continues to be central to the field of child and adolescent psychiatry. I am hopeful that as we can move toward more neuropathology to understand mental illness we can have better tools for making these decisions.
Thanks for your thoughts –
Candida Fink MD
Dr. Fink, I am trying to help my son. He is in the process of being diagnosed with bipolar disorder. I took him to see a psychologist she suggested we see a psychiatrist. The psychiatrist sent him for a variety of tests blood work, thyroid, ekg, & neuropsycological testing. We are supposed to return to the psychiatrist in a few weeks. The diagnosis for now “mood disorder NOS” In all of the research I have done I can honestly say I don’t see him fitting the bipolar diagnoses. ADHD maybe, odd maybe, anxiety yes. He lacks several of the symptoms of bipolar. He struggles in school, difficulty staying on task, failure to complete assignments. I can go on & on, but basically I am quite certain when we return to the psychiatrist in a few weeks I will be given prescriptions to treat bipolar for my son. I find your article completely refreshing & I can now confidently make a decision as to what is best for my child. I failed to mention his age, he recently turned 15. Thank you for writing this article I believe there has been an alarming rise in bipolar diagnoses in recent years. I will exhaust all options before resorting to the risk of medicating my son for bipolar. We will continue with therapy & I would consider medicine for the previously stated disorders that I mentioned that he seems to meet the criteria for possibly having.
Thank You,
Elizabeth
I was diagnosed bipolar when I stopped drinking in 1992, which I did to self medicate and mask my symptoms of bipolar mania and depression. I have read everything I can find on the subject and been with and without medication, and have inquired of my psychiatrist the answers to many questions about the subject of bipolar. I am bipolar 2 and now my children are seeing my psychiatrist also. my 15 year old son behaves exactly as the article was describing, explosive, tantrums, emotional, angry, hyperactive, depressed, severe mood swings. He has adhd and now “non-specified mood disorder”. The child is so obviously bipolar! I wish so much that my mother had done something to help me when I was a child! I told my mother that I was “sad” when I was 10 or 11 and was SO sad for months. She told me to “pick myself up by the bootstraps.” I appreciate the opinion that it is not good to jump to conclusions about diagnoses, especially with children, but like I said, I would have given anything if my mother would have taken me to a psychiatrist when I was a child. It would have saved me years of self medicating with alcohol and years of misery. I have now been sober for years, on medication and fairly stable. I hope my son will have a better life because he has been taken to the psychiatrist and diagnosed. Because he is only 15 the Dr. does not want to actually diagnose him bipolar, but we know he is; he is taking depakote, and seems to be better, however we have a long road a head of us to get him stabalized I have a feeling. I know there is much that needs to be disclosed by him in counseling. He did have certain symptoms as a baby, severe separation anxiety, I could not leave him even to the bathroom, he would become hysterical. He cried all the time, did not sleep through the night until he was about 2 yrs old. I knew something was not right. As he grew older, he had a terrible time in school, but the child is brilliant! Very artistic, creative and extremely smart. Just lazy and moody. So, like I said, I know we have a long road ahead of us, but hopefully we are on the right path as he begins high school. Thank you for your article and opinions. Sincerely, Alisa Drinkard
I have a daughter who is 11yrs.old,she will be 12 in aug,she is (ADDD,Bipolar,optional definite disorser symdrome,definite disorder symdrome) too and she takes depakote for bipolar but she still has really bad outbrusts. I was wondering if someone could help me with some suggestions cause depakote is not working for her.I also have a son who is 10yrs.old,he is (ADHD,Bipolar,Optional definite disorder symdrome,definit disorder symdrome too).But my son takes lithium for his bipolar. My chidren are a challenge and my daughter is now being suspended from school now cause of her behavior. I want to help her, dont want to see her get in too much trouble or hurt anyone else. PLease email me need some advice.
Hi Cindy – I wonder if you are working with a therapist as well as a psychiatrist – these challenges in children need a comprehensive treatment approach that includes therapy with the child and family – in addition to medications.
And if the medications are not making a difference by your observation I strongly recommend that you have a talk with the doctor who is prescribing to consider all the options – and possibly consider a second opinion or consultation to get some other ideas about medications and the overall treatment approach to children with these types of symptoms.
Your school or pediatrician are good places to start to find out about possible therapists who could work with you and your family. And the school setting is also important in helping your children so communicating with them about the difficulties is also very important. Suspension is rarely useful in children whose behavioral problems are related to psychiatric illness – so it will be valuable to work with the school to consider alternative approaches to your daughter’s behavioral symptoms.
Good luck to you and your family.