Bipolar disorder in children

Bipolar disorder in children: The hidden epidemic -- or the hidden over-Diagnosis epidemic?

The diagnosis of bipolar disorder amongst children has increased four-fold in the United States. The reasons for this remain debatable. Some researchers believe the increased publicity of the condition, the popularity of drugs to treat the ailment have resulted in misdiagnosis of attention deficit disorder, conduct disorder, and even autism as bipolarity. This paper attempts to present both sides of the issue, but ultimately believes that demographic and anecdotal data point to over-diagnosis.

Until recently, bipolar disorder was hardly ever diagnosed in children. It was once largely considered an adult condition, usually beginning in adolescence. Now, the pediatric version of the diagnosis has become common, even in children as young as six (Geller 2004). But perhaps not-so coincidentally, this spike in diagnosis also coincided with the rise in drugs designed to treat the disorder. "The spread of the diagnosis has been a boon to drug makers, according to these experts, because treatment typically includes medications that can be three to five times more expensive than those prescribed for other disorders, like depression or anxiety" (Carey 2007). From 1994-2003, the number of American children and adolescents diagnosed with the mood disorder increased 40%. The numbers of children diagnosed as bipolar swelled from 20,000 diagnoses in 1994 to about 800,000 in 2003 (Carey 2007).

This has been called one of the most striking increases in diagnosis of a mental disorder in modern psychiatric history. It is virtually impossible that the illness, which includes rapid oscillations between depression and mania, could have increased so swiftly on its own. The question is, did diagnosis and screening improve -- or were there social pressures that gave rise to this staggering relaxation of diagnostic criteria? After all, some of the symptoms of bipolarity, such as moodiness and irritability, could be applied to any mildly troubled adolescent or defiant prepubescent. The increase also makes bipolar disorder more commonly diagnosed among children than depression, the later of which is usually thought of as the most common mood disorder. Most children whose emotional problems are now diagnosed as bipolar disorder have symptoms of aggression and explosive rage, symptoms that once usually gave rise to a diagnosis of ADHD (attention deficit hyperactivity disorder) and conduct disorders rather than bipolarity (Egan 2008, p.1).

Those who claim that bipolar disorder is over-diagnosed argue that the condition "has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain" which can increase the child's risk for developing diabetes and other serious medical conditions (Carey 2007). Furthermore, given the unchartered diagnostic waters: "From a developmental point-of-view, we simply don't know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness…the label may or may not reflect reality" (Carey 2007). In fact, many of the children who are part of this diagnostic wave who are now grown do not go on to develop the classic features of adult bipolar disorder, like mania, but become depressed.

Drug companies have been aggressively lobbying physicians to screen for the disorder in children. In 2007, the Food and Drug Administration approved one of the most aggressive of these medications, Risperdal, to treat bipolarity in children. "We are just inundated with stuff from drug companies, publications, throwaways," said one doctor, adding that parents often added just as much pressure as drug companies: "if you're a parent with a difficult child, you go online, and there's a Web site for bipolar, and you think, 'Thank God I've found a diagnosis. I've found a home' " (Carey 2007).

Other demographic features point to a possible over-diagnosis trend, such as the fact that the two-thirds of the newly-diagnosed young patients are boys, who more often have conduct problems and about half the patients also had been identified as having other mental difficulties, most often attention-deficit disorder, which presents similar features as the pediatric profile of bipolarity (Carey 2007). In stark contrast, in the adult population of individuals with bipolar disorder, females outnumber males slightly (Egan 2008, p.11).These discrepancies indicate a profile of a more 'difficult child' rather than the specific disease-related pattern of manic depression. The malleable nature of childhood reality presents another difficulty in diagnosis. While a dissociation from reality is one of the manifestations of bipolarity in adults, "it's normal for children to pretend that they are superheroes, or believe that they can run faster than cars, whereas in an adult, these convictions would be signs of grandiosity" (Egan 2008, p.1).

The changing face of psychiatry is another possible social explanation for the increase in diagnosis. More and more non-clinicians are involved in the diagnostic process: a critical shortage of child psychiatrists in non-urban areas may result in a difficult child being diagnosed by a by family doctor or pediatrician. The health insurance industry is also an influence: "managed care usually pays for a single, brief psychiatric evaluation (and it strictly limits the number of therapy appointments a year) -- not nearly enough time, many say, to accurately diagnose a condition in a mentally ill child" (Egan 2008, p.4).

Clinicians with a background in psychiatry are more easily able to spot mania, and not confuse it with hyperactivity. Mania is defined in DSM-IV as a distinct period of an abnormally elevated or irritable mood, accompanied by at least three out of seven other symptoms, including distractibility, indiscretion, grandiosity, and a rapid flow of ideas, activity increase, sleep deficit and talkativeness (Egan 2008, p.5). Said one psychiatrist of a child he had interviewed who was suspected of being bipolar: "I'm not seeing clear patterns of distinct periods of being accelerated and talking and moving and thinking with an intensity of mood that just overflows and then goes back to his usual state…the intense anger outbursts can happen in kids with bipolar disorder, but they can happen with other mood disorders, or with ADHD and severe oppositional behavior. He's only 7 years old. This could be the very early signs of bipolar, and it may not be until two, three, four, five years from now" ("Egan 2008, p.5). Although he acknowledged the boy needed treatment of some kind, he was hesitant to make a formal diagnosis.