BY ROB WATERS
Children in Crisis?
Concerns about the growing popularity of the bipolar diagnosis
Ten years ago, bipolar disorder was considered a disabling adult mental illness that was almost never described in children. Today child psychiatrists are diagnosing it in a growing number of children and adolescents, fueling a surge in the use of antipsychotic medications among the young. This has sparked a backlash from critics who see the rise of "juvenile bipolar disorder" as the latest fad sweeping the psychiatry field.
While the exact number of children diagnosed with the disorder is unknown, there's little doubt that it's risen dramatically. The Child and Adolescent Bipolar Foundation, a parent-led advocacy group, estimates that at least 750,000 American children and adolescents suffer from the disorder, most of them undiagnosed and untreated.
Data provided to the Networker by NDC Health Corp, an Atlanta-based firm that tracks trends in the use of prescribed medications, shows that the number of antipsychotic drugs prescribed to children and teenagers grew by 50 percent—from 250,000 to 375,000 prescriptions—between January 2002 and June 2005. While antipsychotics are prescribed to children for a variety of reasons, the most common, experts say, is to treat bipolar disorder.
Bipolar disorder was first flagged as a pediatric illness in the mid-1990s, when researchers led by Joseph Biederman of Harvard and Barbara Geller of Washington University in St. Louis published papers describing "mania-like symptoms" in young patients, many of whom were also diagnosed with attention deficit/hyperactivity disorder (AD/HD). Biederman and Geller contended that clinicians were failing to diagnose bipolar disorder in children, partly because the symptoms resemble AD/HD and partly because the disorder looks so different in children than in adults.
In the classic, adult version of the disease, people stay mired for weeks or months in a deep depression and then, almost overnight, fly into a manic phase, in which they're intensely creative, need little sleep, and exercise little control over their appetites for sex, alcohol, drugs, or gambling. With children, Biederman and Geller say, the shifts between depression and mania happen much more quickly—in days or even hours. The researchers term this "ultra-rapid cycling."
Critics scoff at this loosening of the criteria and argue that kids are being pathologized for normal behavior. "They're making a diagnosis of bipolar because a child has mood switches," say Dominic Riccio, a New York City psychologist and family therapist. "If a child goes from happy to sad and has impulsive outbursts, it's characterized as bipolar. But children have mood swings. To characterize this as mental illness is a serious flaw in scientific thinking."
Biederman and his colleagues at Harvard have redefined the disorder in another way, too. Bipolar kids, they say, are perpetually pissed off, slipping easily into explosive rages. These aren't just tantrums. Janet Wozniak, a Biederman associate and director of the pediatric bipolar clinic at Massachusetts General Hospital, describes such an episode as "an outburst with kicking, hitting, biting, and spitting that goes on for 30 or 60 minutes." Geller and her allies disagree with Biederman, however, contending that the use of irritability as the key sign of bipolar disorder in children stretches the criteria.
The debate over bipolar disorder's validity as a childhood diagnosis might have remained an obscure academic issue were it not for psychiatrist Demitri Papolos and his wife Janice, a journalist. Their 1999 book, The Bipolar Child, described the disorder as a "neglected public health problem," and put juvenile bipolar disorder on the map.
Spurred by the discussion of the Papoloses' book on morning talk shows, parents of children diagnosed with bipolar disorder created the Child and Adolescent Bipolar Foundation, with a large, active website and funding from pharmaceutical companies. Soon parents across the country began wondering whether their own children might have the disorder, and asking their doctors and therapists.
One such clinician was psychiatrist Jennifer Harris, who, in 2002, was completing a fellowship at the adolescent unit of Cambridge Hospital in Massachusetts. "We saw a huge number of kids coming in with that diagnosis," says Harris. "A lot of them turned out not to have it when you did a thorough assessment."
Harris's explanation for the increase of the bipolar diagnosis among children is that many clinicians find it easier to tell parents their child has a brain-based disorder than to suggest changes in their parenting. "The enormity of the problems many children face makes the simplicity of a biological explanation tremendously appealing," she says. "It allows us to feel we're doing something so that we can avoid feeling helpless with our most difficult patients."
Harris recently began working with a 10-year-old boy who was diagnosed with bipolar by another clinician and put on Neurontin, a mood stabilizer, and Zoloft, an antidepressant. When she probed deeper, she learned that his mother had metastatic cancer. She also found out that that child had a learning disability that made it hard for him to read social cues and, she believes, led him to erupt angrily when he felt someone was slighting him. In treating this boy, Harris did the kind of work few psychiatrists do these days: she met with his family and his teachers, worked with his counselor, and got him in a social-skills group. He's now off medications, and his behavior and moods have greatly improved.
Elizabeth Root, a social worker at a community mental health clinic in Cortland, a small town in upstate New York, has also seen a huge increase in children diagnosed with bipolar and taking medication cocktails. All of them, she says, have something in common: significant stress in their homes. "There are so many psychosocial pressures on parents and children today," she says, including divorce, family violence, and parents who work long hours with little time for shared meals or conversation. Food sensitivities and air pollution can also affect behavior, she feels. Also many children said to have bipolar disorder have previously been diagnosed with AD/HD, depression, or anxiety and put on stimulants, which are known to cause anxiety, or antidepressants, which can trigger edgy restlessness and manic behavior.
Instead of prescribing medications for seemingly out-of-control youngsters, Root says she works hard to learn about the stresses and strengths in the lives of children and their families, and to get family members to come in for therapy sessions. Mostly, she tries to get parents to use the Nurtured Heart approach designed by Howard Glasser, a Tucson-based child and family therapist.
Glasser developed his program for children with AD/HD, but says it works equally well for those said to have bipolar disorder. In fact, however, he rejects both labels; in his view, kids called AD/HD and those called bipolar are children with "more life force, more intensity, and more intense needs than they can handle. Some kids are born that way, and some kids acquire intensity living in homes that are stressful."
Glasser's approach takes typical behavior-management strategies and turns them on their head. Instead of setting out a program of escalating consequences for negative behavior, he advocates elaborately rewarding good behavior and accomplishments, while applying consequences for negative behavior in a low-key, nonemotional way.
Nurtured Heart therapy is one of several programs that offer parents techniques for supporting their children while managing their challenging behavior. Harvard's Ross Greene, author of The Explosive Child, has developed a system he calls Collaborative Problem Solving, which teaches children empathy and the ability to think through solutions before problems emerge.
Even the staunchest advocates of medication think such approaches are useful adjuncts to drug therapy. The trouble is that, in today's health care environment, medications are often the first resort, and psychotherapeutic approaches, if tried at all, are the first to fall away.
The message to all these children now being called bipolar is as distorted as is it reductionist. Instead of children's angry or disturbing behaviors being seen as essentially normal, if unproductive, responses to an increasingly fragmented and disconnected home and cultural life, the problem is located within the child. The explanation for their behavior becomes that their brains are biochemically imbalanced and need to be fixed. That's a message some parents and clinicians may find appealing, but it'll do little in the long run to address the serious family and social problems rampant today, which medications are powerless to treat.
Contributing editor Rob Waters can be contacted at firstname.lastname@example.org. Letters to the Editor about this department may be e-mailed to email@example.com.