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.

Prevention Initiatives and Priority Programs Development Branch

Prevention Initiatives and Priority Programs Development Branch
The Prevention Initiatives and Priority Programs Development Branch is part of the Division of Prevention, Traumatic Stress, and Special Programs at the Center for Mental Health Services (CMHS). CMHS is leading the effort to transform mental health systems and the way mental health services are perceived, accessed, delivered, and financed. A major way that the Prevention Initiatives and Priority Programs Development Branch (PIPPDB) supports transformation is through their grants and other programs that promote mental health for children, youth, and families and prevent mental and behavioral disorders for those who are at-risk.

PIPPDB currently has projects that focus on:

Youth Violence Prevention

The interdepartmental Safe Schools/Healthy Students Initiative (SS/HS) is designed to prevent school violence and foster the healthy development of children. The SS/HS Initiative is an unprecedented collaborative grant program supported by three federal agencies – the U.S. Departments of Health and Human Services, Education, and Justice. The SS/HS Initiative seeks to develop real-world knowledge about what works best to promote safe and healthy environments in which America’s children can learn and develop. It is a unique Federal program designed to prevent violence and substance abuse in our Nation’s youth, schools, and communities.

Complementing SS/HS is PIPPDB’s Youth Violence Prevention Program that provides support for grantees to form and expand on community collaborations dedicated to the prevention of youth violence, substance abuse, suicide, and other mental health and behavioral problems.

Targeted Capacity Expansion grants for the Prevention Early Intervention Grant Program aim to develop mental health prevention and early intervention services targeted to infants, toddlers, preschool, and school-age children, and/or adolescents in both mental health settings and other settings that serve this population.

PIPPDB has also developed the 15+ Make Time to Listen, Take Time to Talk campaign based on the premise that parents who talk with their children about what is happening in their lives are better able to guide their children and this can be instrumental in building a healthier and safer environment for children. The initiative has been adapted to address the prevention of bullying and the climate of fear created by bullying through a national education and dissemination project.

Suicide Prevention

Recent reports by the Institute of Medicine and the World Health Organization have revealed the magnitude and impact of suicide, citing it as the cause of death for 30,000 Americans annually and over one million people worldwide. These reports, as well as the President’s New Freedom Commission Report and the Surgeon General’s National Strategy for Suicide Prevention, call for aggressive efforts to reduce the loss of life and suffering related to suicide.

The Branch supports several key initiatives designed to improve public and professional awareness of suicide as a preventable public health problem and to enhance the capabilities of the systems that promote prevention and recovery, including:

Cooperative Agreements for State-Sponsored Youth Suicide Prevention and Early Intervention Program. Three-year grants to support States and tribes in developing and implementing statewide or tribal youth suicide prevention and early intervention strategies, grounded in public/private collaboration.
Campus Suicide Prevention Grants. Three-year grants to institutions of higher education to enhance services for students with mental and behavioral health problems that can lead to school failure, depression, substance abuse, and suicide attempts.
Cooperative Agreement for the Suicide Prevention Resource Center (SPRC). Funds the continuation of a Federal Suicide Technical Assistance Center to provide guidance to State, tribal, and local grantees in the implementation of the suicide prevention strategy; create standards for data collection; and collect, evaluate, and disseminate data related to specific suicide prevention programs.
Networking and Certifying Suicide Prevention Hotlines. This grant provides funding to manage a toll-free national suicide prevention hotline network utilizing a life affirming number which routes calls from anywhere in the United States to a network of local crisis centers that can link callers to local emergency, mental health and social service resources.
Linking Adolescents at Risk to Mental Health Services Grant Program. This initiative is one of SAMHSA's Service-to-Science Grants programs. The purpose of the Adolescents at Risk program is to evaluate voluntary school-based programs that focus on identification and referral of high school youth who are at risk for suicide or suicide attempts. Eligible applicants are local educational agencies or nonprofit entities in conjunction with local educational agencies.
Collectively, these initiatives will further awareness of suicide, will promote suicide prevention and intervention efforts, and will reduce the numbers of lives lost and disrupted by suicide.

CEU Ethics

CEU Ethics: Ethics Online CEU Course
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Law and Ethics (10 hours)
Description

This course is designed to help you:

Identify scope of practice issues and definitions
Increase familiarity with the characteristics of unprofessional conduct, negligence, and standard of care
Explore the legal issues of privilege, confidentiality, treatment of minors, record retention/storage, termination, informed consent, malpractice, and sex with clients.
Increase familiarity with HIPAA and third party reimbursement
Explore professional ethics information including CAMFT and NASW Ethical Standards.

Board/state approvals Professions
State Licensing Authority CADC I CADC II CADCA CCPS CCS CSWI LCSW LMFT LPC MFTI MHC
California California Board of Behavioral Sciences

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1. SCOPE OF PRACTICE
1A. MFT SCOPE OF PRACTICE
1B. LCSW SCOPE OF PRACTICE
2. UNPROFFESIONAL CONDUCT, NEGLIGENCE, LAW, ETHICS, AND STANDARD OF CARE
2A. UNPROFESSIONAL CONDUCT AND NEGLIGENCE
2B. LAW
2C. ETHICS
2D. STANDARD OF CARE
3. LEGAL ISSUES
3A. PRIVILEGE
3B. CONFIDENTIALITY
3C. EXCEPTIONS TO CONFIDENTIALITY: CHILD ABUSE, DEPENDENT ADULT & ELDER ABUSE , TARASOFF, DANGER TO SELF
3D. TREATMENT OF MINORS
3E. SEX WITH CLIENTS
3F. RECORD RETENTION AND STORAGE
3G. TERMINATION
3H. INFORMED CONSENT
3I. MALPRACTICE
4. HIPAA AND THIRD PARTY REIMBURSEMENT FOR MENTAL HEALTH SERVICES
5. CONTINUING EDUCATION
6. PROFESSIONAL ETHICS
6A. CAMFT ETHICAL STANDARDS PT II SECTION D
6B. REVISED CAMFT ETHICAL STANDARDS
6C. NASW ETHICAL STANDARDS
7. REFERENCES