Most treatment professionals working with children and adolescents are acutely aware of the rise in the rate at which children and adolescents, but most significantly pre-pubescent children, are being diagnosed with Bipolar Disorder. While estimates vary from article to article, it is interesting to note several recently reported statistics. The New York Times, in an article released in September of 2007, noted that in the 10 year span from 1993 to 2003, there was a forty-fold increase in the rate at which this population was being diagnosed with Bipolar Disorder, while a more scholarly article (Youngstrom, 2005) noted that marked increases had been found in the rate of diagnosing in children of those involved with Child Protective Services in Illinois. Other writers have pointed to this sharp increase in the rate, some positively (NYT, 2007, Papalos and Papalos, 2006), even saying that there needs to be even more of an increase. Others, however, have expressed alarm at this sharp increase, and have pleaded with professionals to have a more conservative approach to diagnosing this in pre-adults. There is much debate in the field, hotly opinioned views, and contention in the field brought on by the huge gulf between the most liberal, and the most conservative, in terms of this diagnosis. To some extent, this divide is evident between Psychiatrists and Psychologists, and indeed, the previously noted NY Times article pointed out that 90% of the diagnosing of Bipolar Disorder in children was being done by psychiatrists. However, there are many other mental health professionals, including psychologists and other non-psychiatric folk in the field, who take the liberal approach shared by many psychiatrists.
What Drives us to Diagnose Bipolar Disorder in Children and Adolescents?
For those who advocate earlier diagnosing, one of the most commonly quoted reasons is prevention: prevention of a poor childhood, prevention of academic difficulties, prevention of social failure, prevention of kindling, etc. The risk, proponents of earlier diagnosing opine, is that failure to act is a disservice to the child, and to those involved in the child's life. This has been the stated reason driving such professionals as Dr. Dimitri Papalos and his wife, Janice Papalos, and of others, and indeed, any professional with any modicum of empathy has most certainly considered this when reflecting on a case of possible Bipolar Disorder in a child or adolescent. For, if indeed, allowing a child to pass through their childhood without appropriate treatment sentences them to a substandard future, who among us would hesitate to act? The problem is that it is not entirely clear that we have gotten this right, and it is most certainly not clear that what appears to be Bipolar Disorder in children will follow the child into adulthood.
What is this animal we call Childhood Bipolar Disorder?
In adulthood, it is well-accepted that Bipolar Disorder involves discrete periods of Mania, and discrete periods of Depression. Of course, there are the murkier cases involving Mixed episodes, though it is well-accepted that such cases do indeed occur in adulthood. However, as we descend retrospectively into childhood, the waters become murkier and murkier. What does Bipolar Disorder look like in early adolescence? What about late prepubescence? And what about the very young? A review of the literature (Papalos and Papalos, 2006, Youngstrom, 2005, Danner-Ogston, et al, in press, Geller, 1997, etc.) reveals opinions that span the spectrum from the very conservative (let's keep things as they were), to the very liberal (let's diagnose in infancy). Each opinion is justified in some sort of logical argument or another, but most importantly, there is no consensus, and strong evidence supporting a call for caution.
The conservative approach to diagnosing Bipolar Disorder in children is to keep things as they are. In other words, the child/adolescent must meet the criteria for Major Depression, and for Mania, in terms of severity of symptoms, and duration of the moods. In this approach, the child would need to evidence severe depression for a week, in most cases, and would have to evince chronic mania for the better part of a week, before they could be considered for the diagnosis. In instances in which there was thought to be a Mixed Episode, these duration criteria could be waived, but the severity criteria could not.
In the more liberal approach, opinions vary, but there is a general relaxation of the duration and frequency criteria, to the point that in the most liberal approach, children can cycle from minute to minute! Also noted in the more liberal approach is the tendency to re-define what comprises depression or mania in children, with the most liberal approach defining mania as consisting primarily of chronic and severe irritation, or general anger issues. Depression, in this approach, may primarily manifest as anger, or social withdraw.
The problem with the conservative approach, in some professionals' views, is that we are potentially missing children who should have the diagnosis and treatment. And indeed, when a child or adolescent has significant emotional or behavioral issues, and is not treated, their life does often go from bad to worse. The problem with the liberal approach is that treatment, which is led by the medical approach, involves the introduction of potentially toxic psychotropics into the child's body. Most of the psychotropics used to treat Bipolar Disorder in children and adolescents are prescribed 'off label,' without the sanctioning of the FDA, and without knowledge of the potential long-term side effects of such treatment on the developing body and brain.
Because of the saliency of this particular area of mental health, there has been a great deal of research in the past decade or more. NIMH, NAMI, and other organizations have funded multiple studies to answer questions related to this debate. Books have been written on this, including the infamous The Bipolar Child (Papalos and Papalos, 2006, and earlier editions), The Everything Parents Guide to Children With Bipolar Disorder, and others. So what is the state of the science? What do we know?
According to Papalos and Papalos, in an informal research study which involved polling parents who had identified their child as Bipolar, there was a great deal of diversity in what might be seen in a child or adolescent with Bipolar Disorder. Papalos identified traits of moodiness, nightmares, sleep problems, sensory integration difficulties, extreme temper tantrums, depression, food sensitivities, anxiety, hyperactivity, impulsivity, distractibility, oppositional traits, and other traits. Indeed, they were of the mind that because Bipolar Disorder spanned such an array of symptoms (many of which were found in other childhood mental disorders, such as Autism, Asperger's, Oppositional Defiant Disorder, Attention-Deficit/Hyperactivity Disorder, Posttraumatic Stress Disorder or PTSD, etc), one should diagnose this disorder first, and then consider additional diagnoses if the symptoms were not fully explained by the first diagnosis. While Papalos and Papalos's conclusions were by far the most extreme, there are many researchers who feel that a much more liberal interpretation of what Bipolar Disorder is in children, is needed, though they do not go to the extremes that Papalos and Papalos do. The consensus seems to be that children with Bipolar Disorder will not have the same measures of frequency and duration noted in adulthood. Most liberal diagnosticians maintain that children and young adolescents could 'cycle daily, and that they may not demonstrate traditional mania, and that their depression may not necessarily be debilitating. Most liberal diagnosticians also maintain that irritability is part of what may be mania, and that Bipolar Children seem to have severe anger problems. Questions that have not be definitively answered center around differential diagnoses (is it Bipolar Disorder, or PTSD, or both? etc).
What if the 'liberals' are right?
If the liberal approach holds up to the scrutiny of time and research, then there are many children who have been provided with attention and treatment, rightly so, which may prevent future problems. Such a proactive approach may well improve public opinion of the mental health field, as well, and may increase funding directed towards mental health problems, or insurance recognition of mental health problems.
What if the 'conservatives' are right?
If the conservatives are right, then we potentially have a public disaster on our hands. Treatment of children and young adolescents with Bipolar medications is unproven, sometimes-to-often ineffective, and marred by the many side effects and potential long term damage that could occur. Bipolar medications can cause agitation, increased behavioral difficulty, moodiness, weight gain, shaking, tiredness, and potentially more serious problems, such as Polycystic Ovarian Syndrome, a sometimes deadly skin disease, tremors, seizures, and death. As well, it may be that teaching a child that they have less control over their emotions and behaviors than a typical child, or that they have no control, could cause them to give up and to actually worsen in their behaviors. Also, there are some that opine that parlaying medications on children at a young age imbues in them a strong belief that substances are the answer for their ills ... and how far down the road from that is the belief that illicit substances may be the answer?
How well are we doing?
Given all the concerns, how are we doing? What do we know about the effectiveness of the more liberal diagnostic and treatment approach? Reviewing the literature, the results are not encouraging. For instance, Dr. March, of Duke University, points out that we have no idea whether children diagnosed at the age of 5 to 7 will actually be Bipolar when they are older. In the NYT article, it is noted that most of the research suggests that these kids are most likely to have depression as they get older, rather than Bipolar Disorder. Generally, it appears that medications often do not address the bulk of the symptoms, and it does appear that their strongest effect is in the sedation category, which is a double-edged sword. Specifically, the child or young adolescent is more manageable, and less volatile, but they also are sometimes less able to focus on academics, and may experience major personality shifts with undesirable effects on their social success. Mood stabilization is often an elusive goal, even with heavy psychopharmacological intervention, and in some instances the mood becomes more unstable during pharmacological treatment. The side effects also often become an issue in and of themselves, necessitating additional medications, diet changes, changes in academic approaches, and even requiring adjustments in the general expectations of the child's ability to function in their world. In some instances, the medications make the child potentially eligible for disability benefits, because of the debilitating effects they have on their functioning. As well, in many instances the pharmacological interventions are being guided by overworked and overwhelmed child and adolescent psychiatrists, who cannot spend the time needed to fully evaluate the child and their needs, and who often are pressured by pharmacological companies, directly and indirectly, to prescribe a particular medication, or to identify a certain portion of their caseload as Bipolar. Overall, even if one accepts the thinking that Bipolar Disorder in children and adolescents is under diagnosed, and that they should be treated with medications, the end result is often partial to full failure in addressing the issue.
Are we missing something?
Researcher completed by Martin Teicher, M.D., Ph.D., (2000) suggests that early trauma, be it sexual, physical, or verbal, has a potentially long-term effect on the developing brain. Indeed, his research indicates that such trauma, and particularly (interestingly) verbal abuse, effects long-term changes in the corpus callosum, and in the precuses, as well as in the hypothalamus, as well as in other areas. The corpus callosum is important in balancing out the right and left brain, and those with underdeveloped corpus collosi tend to be very reactive or unbalanced in their approach to problem solving (interpret: overly emotional and emotionally reactive ... in other words, more likely to be angry, violent, or irrational). Those with underdeveloped precueses tend to be less logical, less integrated in their personality, and generally inappropriate in their reactions. Thus, in his view, many of the behavioral and mood issues that we see in the prepubescent or post-pubescent child may be a result of those early childhood experiences. In other words, he is proving something clinicians on the front line have thought all along: subjecting a child to abuse tends to cause them to experience major personality shifts, and they are often violent and emotional. If Dr. Teicher prevails at the end of the day, it may well be that what we thought was Childhood Bipolar Disorder was actually a trauma disorder. And the implications of that: The difference between labeling the child as potentially temporarily impaired, or permanently impaired.
There is much debate about the frequency by which Childhood Bipolar Disorder occurs in children and adolescents. There is no questioning the conclusion that this is an important area to explore, as the implications for this disorder over the lifetime of a person are serious. However, we need to get it right, because if not, we will either have undiagnosed cases that permanently alter the child's/adolescent's chances for success, or we will have over medicated children struggling to progress under the weight of the side effects of unnecessary medication. Ultimately, it is science that should clear the air ... good, logical, replicable science that will show us what Bipolar Disorder probably looks like, if it indeed exists, in Children. Until we have a scientific consensus, however, caution seems advisable, and the more conservative approach would be to consider other, less long-term conceptualizations for the child's symptom set.
Allen, Michael H. Approaches to the Treatment of Mania. Medscape Today CME activity. Sept 2003, medscape.com
Boodman, S. - 2005 - Going to Extremes - Experts Question Rise in Pediatric Diagnosis of Bipolar Illness, a Serious Mood Disorder. The Washington Post, 2/15/05. pg HE01.
Carey, Benedict - September 3, 2007 - More Children Being Treated For Bipolar Disorder - New York Times.
Costello, E.J.; Angold, A.; Burns, B.J.; Stangl, D.K.; Tweed, D.L.; Erkanli, A.; Worthman, C.M. (1996). The Great Smoky Mountains Study of Youth. Goals, design, methods, and the prevalence of DSM-III-R Disorders. Archives of General Psychiatry, V53, n12.
Danner-Ogston, S., Young, M.D. & Fristad, M.A. (in press). Assessment of bipolar disorder in children. In J. Matson, F. Andrasik & M.L. Matson (Eds.) Assessing Childhood Psychopathology and Developmental Disabilities, NY: Springer.
DelBello, Melissa P, Strakowski, Stephen M, Zimmerman, Molly E, Hawkins, John M, Sax, Kenji W (1999). MRI Analysis of the Cerebellum in Bipolar Disorder: A Pilot Study. Neuropsychopharmacology (1999) 21 63-68.
Dennison, Z.; Teskey, G.C.; Cain, D.P. (1995) Persistence of kindling: Effect of Partial Kindling, retention interval, kindling site, and stimulation parameters. Epilepsy Research, V21 (3), pp171-182.
Dopheide, Julia A. (2006). Recognizing and Treating Depression in Children and Adolescents. American Journal of Health-System Pharmacy. 2006; 63(3): 233-243.
DSM-IV-TR - American Psychiatric Association - 1994
Geller, B; Luby, J. (1997). Child and Adolescent Bipolar Disorder: A Review of the Past 10 Years. J. Am Acad Child Adoles Psychiatry 36: 1168-1176.
Haugaard, Jeffrey J. (2004). Recognizing and Treating Uncommon Behavioral and Emotoinal Disorders in Children and Adolescents Who have been Severely Maltreated: Bipolar Disorders. Child Maltreatment, 9; 131.
Hazell, PL; Carr, V; Lewin, TJ; Sly, K (2003). Manic Symptoms in young males with ADHD predict functioning but not diagnosis after 6 years. Journal of American Academy of Child and Adolescent Psychiatry, 42 (5), 552-560.
Hlastala, S; Ellen, F; Kowalaski, Jeanne; Sherrill, J.T.; Tu, Xin M.; Anderson, B; Kupfer, D.J. (2000) Stressful Life Events, Bipolar Disorder, and the Kindling Model. Journal of Abnormal Psychology, vol. 109, n. 4, pp. 777-786.
Kowatch, Robert A. , Fristad, Mary, Birmaher, Boris, Dineen Wagner, K; Findling, Robert; Hellander, M (AND THE WORKGROUP MEMBERS) (2005). Treatment Guidelines for Children and Adolescents With Bipolar Disorder: Child Psychiatric Workgroup on Bipolar Disorder. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(3):213-235.
Lewinsohn, Peter M, Daniel N Klein, John R Seeley (2000) Bipolar disorder during adolescence and young adulthood in a community sample Bipolar Disorders 2 (3.2), 281-293.
MacReady, N. (2006). Mapping the Brain's Mysteries: At the forefront of today's imaging revolution, mind explorers use a futuristic atlas to discover how healthy and diseased brains work. Neurology Now. Vol 2 (3), May/June 2006, pp 10-13.
McNicholas, F.; Baird, G. (2000). Early-Onset Bipolar Disorder and ADHD: Diagnostic Confusion Due to Co-Morbidity: Clinical Child Psychology and Psychiatry. 5; 595.
Miklowitz, D. J.; Otto, Michael W; Frank, Elllen; Reilly-Harrington, Noreen A.; Wisniewski, Stephen R/.; Kogan, Jane N.; Nierenberg, Andrew A.; Calabrese, Joseph R.; Marangell, Lauren B.; Gyulai, L.; Araga, M.; Gonzalez, J.M.; Hierley, Edwin R.; Thase, Michael E.; Sachs, Gary S. Psychosocial Treatment for Bipolar Depression: A 1-year Randomized Trial From the Systematic Treatment Enhancement Program. Arch Gen Psychiatry 2007;64:419-427
Papalos, D; Papalos, J. The Bipolar Child. Broadway Books, 2006 Third Edition.
NIMH Website: nimh.nih.gov/publicat/bipolarupdate.cfm
Trillian's Depression Page. concernedcounseling.com/communities/bipolar/trillian/lithium_2.htm
Tillman, R; Geller, B; Nickelsburg, M.J.; Bolhofner, K; Craney, J.L.; DelBello, M.P.; Wigh, W. (2003). Life events in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. Journal of Child and Adolescent Psychopharmacology. Fall; 13 (3): 243-1.
Wagner, K (2000). Childhood Bipolar Disorder. Psychiatric Times, May 2000, Vol. XVII, Issue 5
Wikipedia - Occam's razor. en.wikipedia.org/wiki/Occam's_Razor
Youngstrom, E.A., Findling, R. L., Calabrese, J.R., Gracious, B.L., Demeter, C., DelPorto Bedoya, D., Price, M. (2004). Comparing the Diagnostic Accuracy of Six PotentialScreening Instruments for Bipolar Disorder in Youths Aged 5 to 17 YearsJ. Am. Acad. Child Adolesc
Copyright June 2008. These articles cannot be used in any fashion without the explicit permission of the author, except for individual use.
Disclaimer: This information is not intended to diagnose or treat any condition, and is for the sole purpose of providing alternate perspectives. If you feel that a mental health condition exists in yourself or the person you are reading this article for, you are advised to seek out psychological or psychiatric services.
Jonathan M. Gransee, Psy.D.