Bipolar Disorder In Children: Why Are The Rates Rising?

Bipolar Disorder In Children: Why Are The Rates Rising?
By Michael F. Hogan, PhD, Commissioner, New York State Office of Mental Health; and
Lloyd I. Sederer, M.D., Medical Director, New York State Office of Mental Health

Recent media reports tell us that the diagnosis of bipolar disorder in children and adolescents (formerly called manic depressive disorder) is forty times more frequent than it was just ten years ago. Can the numbers of children and adolescents with this illness increase so rapidly? Are medications being over-prescribed?

The rapid increase in diagnoses in such a short period of time cannot be explained by changes in genetics, environment or families. In part it must be due to a broader definition of the illness, which now includes anger and hyperactivity.

But the signs and symptoms needed to make the diagnosis of bipolar disorder, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV) have not changed in recent years. Diagnoses are being made more liberally, perhaps to the benefit of some children but clearly also to the detriment of others.

For a reliable diagnosis to be made, symptoms common in this disorder such as mood swings, irritability and impulsive behavior must occur during a distinct period of a mood disturbance, a hallmark of this illness and the DSM IV definition. Many children are impulsive and irritable, but that in itself does not meet the criteria for this illness. These symptoms occur with other disorders found in children and adolescents, such as attention deficit hyperactivity disorder (ADHD), depression with agitation and irritability, conduct disorder, and substance use disorders.

A diagnosis of bipolar disorder in children and adolescents does not tell us if the childhood form of the illness will continue into adulthood. Many children with mood swings, depression, and irritability have been brought to physicians over many years. They have been diagnosed with various disorders, including ADHD, conduct disorder and depression, according to the trends at the time. Diagnoses made today may change for individual children as they age, and for children in the future as psychiatry matures.

What should psychiatrists do now? What should parents and caretakers expect in the treatment of their children? A heightened awareness of the existence of bipolar disorder in children may be beneficial if it helps us to recognize more cases of true bipolar disorder and institute treatment earlier. It can also cause confusion and concern in parents and psychiatrists around the use of the medications prescribed for bipolar disorder.

First, a child should be assessed directly by a child and adolescent psychiatrist with information obtained from parents, caregivers and sometimes teachers. Second, valid rating scales can help introduce some objectivity to what is still a professional judgement. The Mood Disorder Questionnaire and the Young Mania Rating Scale are specific to bipolar disorder. Scales such as the Conners’ (with parent and teacher rating forms) for hyperactivity and ADHD can help to differentiate these common conditions, even if many children and adolescents with bipolar disorder also have ADHD. The Beck Depression Inventory (children’s version) can help identify depression. Third, as noted earlier, a consultation or second opinion is another important way to confirm or refute a diagnosis made by one doctor. This is especially valuable in children whose behaviors stimulate desperate efforts to “do something.” Any doctor not open to a second opinion should be suspect.

The treatment of bipolar disorder in children and adolescents, or any mental disorder for that matter, begins with forming a trusting relationship with the child and parents. This means the physician should provide information and educate the family about mental illness, be open to questions and concerns, and share decision-making. Benefits, risks and side-effects of any treatment must be offered in a clear and understandable manner; if you as a parent or youth do not understand, say so and expect a good answer.

Medications are a primary treatment for bipolar disorder and many mental illnesses, and they can provide invaluable help. But medications are only one form of intervention, and not enough in themselves. Various forms of psychotherapy in association with medication may be helpful. In particular, “psycho-educational treatment” for the child and parents provides concrete information about the illness, its impact, and treatment options. Cognitive behavior therapy can be especially helpful in the depressive phase of bipolar disorder and is effective in reducing disruptive behaviors. Support groups for families of children and adolescents with bipolar disorder and other severe disorders also can be helpful.

In light of the rise in diagnosis of this disorder, doctors, families and youth have reason to be concerned that a diagnosis is accurate and the treatment it leads to is optimal. Families should insist on clear information, seek second opinions when unsure, and demand monitoring of care to see if the diagnosis “holds” over time. Parents and youth should expect careful observation of any prescribed medications, and recognize that medications may be a critical part of the treatment but they are not sufficient when it comes to the care of our children.