Bipolar Disorder In Children–A Diagnosis in the Doghouse

Posted on April 29, 2012 by

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Americans are used to being the butt of jokes for Europeans.

They mock our weight, our tendency to be mono-lingual, our lack of awareness of international affairs, our swiftness to call a lawyer to sue.

“Let them laugh,” we think. “Have you seen their tax rates?”

But their mental health clinicians are now getting their jollies out of our newly-developed fast-and-furious tendency to diagnose children with bipolar disorder–and it makes you wonder if they don’t have a point.

If pediatric bipolar disorder (PBD) was undiagnosed in past decades only because clinicians were missing diagnostic tools (see last post), then, once publications in international journals opened up the possibility of the illness’ existence, it should have spread equally, if those diagnostic tools are correct, in all educated societies.

But that’s not at all what has happened. The diagnosis exists–and other countries are aware of it–but they simply don’t believe the American criteria for PBD fit the bill–and they watch from afar, with almost no occurrences of the illness, as it becomes the disease-of-the-day across the ocean.

In a survey, “The paediatric bipolar hypothesis: The view from Australia and New Zealand,” non-American doctors overwhelmingly returned to the pre-1990s view of the illness: It’s strikingly rare.

The majority of participants said they had never seen a case of pre-pubertal bipolar disorder, whilst a further 28.5% estimated they’d seen only 1 or 2 cases. Only 18.2%estimated having seen 3 or more cases of pre-pubertal bipolar disorder. … Most participants were of the opinion that bipolar disorder in pre-pubertal children was either “very rare (less than 0.01%)”, “rare (less than 0.1%)”, or “cannot be diagnosed in this age group” [emphasis mine].

If bipolar in children hardly exists in other culturally similar countries–it’s tempting to ask whether it’s the doctors’ approach to diagnosis, rather than the reality of the disorder, that’s leading to the current ‘epidemic’ (recall that PBD has increased 4,000% in the U.S. since 1995)?

Well, you could ask Dr. Frances that, if you wanted an earful–but also wanted a sense of psychiatry’s historical view on PBD.

Dr. Allen Frances is never one to pull punches. Chair of the DSM-IV Task Force–and partially responsible for not including PBD as a diagnosis in that text–currently professor emeritus at Duke, he seems to have had a say in every brouhaha surrounding proposed changes to the DSM-5. On the topic of PBD, he takes no prisoners. Explaining what he calls a ‘dangerous. . and distressing fad’ in psychiatry, he says:

The causes behind the surge in childhood bipolar disorder are no mystery — a combustible combination of overly influential thought leaders, aggressive drug company marketing, desperate parents, and gullible doctors.

To step back for a moment, despite requests by the pediatric bipolar lobby, the DSM-IV-TR (with strong support from Dr. Frances) resisted the call to list pediatric bipolar as an illness until itself, and thus a child, to be diagnosed, has to meet the same criteria as an adult.

The requisite for achieving a bipolar diagnosis, then, is at least one manic episode. But while it’s fairly clear what mania looks like in adults, the gray area of how it manifests in children opened up a Pandora’s box to declaring all sorts of symptomatology manic.

The particular behavior that has led to so much diagnostic work is outbursts of anger–intense, uncontrollable, violent, and distinguishable from that exhibited by ADHD children, often just termed ‘rages.’ So rather than the cycling between mania and depression, the ‘child’s’ manic episode would involve excessive irritability, moodiness, and behavior problems.

And so, with a new framework coming from clinical research, with parents desperate to find causes for their offsprings’ rages, and with the hope that out-of-control children could be better treated and managed, child after child received a diagnosis of bipolar disorder.

But since this definition, a number of problems have appeared that question the accuracy of diagnosing certain behavior problems as manic episodes (and thus diagnosing their perpetrators as bipolar).

First, children diagnosed with these symptoms and bipolar didn’t fit the gender and racial makeups of adults with the disorder.

Joseph Blader and Gabrielle A. Carlson from the Department of Psychiatry and Behavioral Science at Stony Brook State University of New York studied trends related to hospitalization based on records from the annual National Hospital Discharge Survey.

They found that, while black adults lag slightly behind hospitalization (which I’m using interchangeably with discharge, for purposes of convenience) for bipolar than white adults, by 2003-4, bipolar related hospitalizations discharged increased so greatly for both black boys and girls that they surpassed those of white children. Individually, the rate for black boys exceeded those for white boys.

Additionally, a significant majority of females as adults are hospitalized for the illness–but a higher rate of male children. The statistics do not seem to be in alignment.

This gender gap particularly concerned the researchers:

Sex differences showing higher rates of BPD-related discharge among male children, but a predominance of females among adults, hint at a different disorder [emphasis mine].

No less an august body than the National Institute of Mental Health made things worse for strong proponents of PBD, and laid open to question the very foundation stone of their argument–the manifestation of a manic episode in children as high energy and moodiness.

In their “Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study,” 707 children, ages 6-12, were referred for mental health care. 621 were rated by their parents as having rapid emotional swings and high energy levels, termed “elevated symptoms of mania.” No such lability was reported by parents of the remaining 86 children.

If all was as it should be in the PBD diagnostic world, the children with elevated symptoms of mania should have been diagnosed in droves over the course of the study, 5-years long, with a full-blown manic episode, qualifying them for PBD.

That is not at all, however, what happened.

NIMH found that 75% children with elevated symptoms of mania, who should have gone on to develop bipolar, simply never met the criteria for it. They concluded that:

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders [emphasis mine].

Also, perplexingly, although bipolar is a chronic, life-long illness, that is not, at this point, curable, the number of children diagnosed with the disease should match, in longitudinal studies, the number of adults diagnosed years later–but no such congruence exists.

Rachel Klein of the New York State Psychiatrist Institute notes with her co-authors that:

. . .[T]he high frequency of PBD . . . among referrals . . . suggests that childhood PBD disappears over time since drastically lower rates occur among adult outpatients. . . In sum, longitudinal studies, and other pertinent findings, do not support the essential congruence between childhood mania as defined by the Boston group* and adult mania [emphasis mine].

(*The ‘Boston group’ is the cohort of researchers spearheaded by Dr. Joseph Biederman, Professor of Psychiatry at Harvard Medical School, and one of the ‘founding fathers,’ so to speak, of the concept of PBD.)

Finally, Dr. David Pogge, from Four Winds Hospital in NY, and his colleagues ran a study analyzing accuracy of diagnoses of manic episodes on an adolescent inpatient unit.

Their findings were less than amusing. They reported that around 50% of adolescents diagnosed with bipolar disorder did not, in point of fact, have that disorder.

That’s awkward.

Jennifer Harris, clinical instructor at Harvard Medical School, ran a detailed and published analysis of two children misdiagnosed with PBD who turned out, upon examination, to have, in one case PTSD, and in the second autism, in her disturbingly titled “The increased diagnosis of ‘juvenile bipolar disorder’: what are we treating?”

There are other concerns surrounding the validity of PBD–from a conflict of interest on the part of one of the main proponents of PBD as an illness to (see the 2008 New York Times article, “Researchers Fail to Reveal Full Drug Pay“) to a lack of congruity in family history of bipolar disorder among children as opposed to adults diagnosed.

But if PBD’s existence in meaningful numbers only in the U.S., the demographic statistics of children diagnosed not matching adults’, NIMH finding most children with potential ‘mania’ aren’t meeting criteria, and a majority of the cases ‘vanishing’ before adulthood don’t fairly address opponents’ points (and leaving out–how could I have?–drug companies’ influence in the whole scenario)–well, really, what more can one blogger do?

So if PBD, as of the latest stance of the DSM-5 (this could change right after I hit ‘publish,’ the way things are going), is out, and if clinicians are progressively more tending to avoid the diagnosis for explosive and energetic children–where are these youngsters to find a home in the mental health establishment?

Never fear–the DSM‘s way ahead of you–on this one, at least.

Ladies and gentlemen, meet “Disruptive Mood Dysregulation Disorder” (I promise-I couldn’t make it up.) You can make its further acquaintance tomorrow.

REFERENCES

Biederman J, Klein RG, Pine DS, Klein DF. Resolved: mania is mistaken for ADHD in prepubertal children [debate]. Journal of the American Academy of Adolescent Psychiatry 1998; 37(10):1091-6.

Blader JC, Carlson GA. Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996-2004. Biological Psychiatry 2007; 62(2):107-14.

Finding RL, et al. Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study. Journal of Clinical Psychiatry 2010; 71(12):1664-72.

Frances A. The False Epidemic of Childhood Bipolar Disorder.

Harris J. The increased diagnosis of “juvenile bipolar disorder”: what are we treating? Psychiatric Services 2005 56(5):529-31.

Parry P, Allison S. Pre-pubertal paediatric bipolar disorder: A controversy from America. Australasian Psychiatry 2008; 16(2):80-84.

Parry P, Furbe G, Allison S. The paediatric bipolar hypothesis: The view from Australia and New Zealand. Child and Adolescent Mental Health 2009; 14(3):140-147.

Pogge D, et al. Diagnosis of manic episodes in adolescent inpatients: structured diagnostic procedures compared to clinical chart diagnoses. Psychiatry Research 2001; 101(1):47-54.