Time to reexamine bipolar diagnosis in children?

Special to the Los Angeles Times

They are some of the most troubled children that psychiatrists ever see. They have raging tempers and engage in reckless behaviors that frequently land them in the principal’s office, even the hospital. But are they bipolar?

In the last 15 years, diagnoses of bipolar disorder in children have skyrocketed as much as fortyfold, according to some estimates. The condition — defined by severe mood swings, between depression and mania, lasting for weeks or month at a time — has traditionally been considered a lifelong condition in adults and is treated through tranquilizers and antidepressants.

Some psychiatrists argue that many of these children are being misdiagnosed. They worry that the medications the kids are prescribed could affect developing nervous systems and say that the symptoms generally do not fit the traditional guidelines for diagnosing bipolar disorder. Rather than having episodic mood swings, these children tend to have temper outbursts that involve yelling and physical aggression and are rarely in a positive mood for more than a day. Doctors also note that many kids tend to grow out of these behaviors with time.

In a draft of the next edition of the Diagnostic and Statistical Manual of Mental Disorders — the American Psychiatric Assn.'s bible — a new label, temper dysregulation disorder with dysphoria, is proposed for these behaviors instead. Unlike bipolar disorder, the new label doesn’t specify that the disorder is a lifelong condition.

But not all doctors are pleased with the proposed moniker. Some feel it may only make the treatment issues more challenging. Treatment for bipolar disorder in adults may not always work, but at least there were some generally accepted guidelines, they say — whereas temper dysregulation disorder brings in a whole new realm of uncertainty.

Read on for two competing views on the topic:

The new diagnosis will reduce inappropriate use of the bipolar label

Dr. Gabrielle Carlson is the director of Child and Adolescent Psychiatry at Stony Brook University School of Medicine in New York.

Bipolar disorder has been over-diagnosed in children. One study suggests that the diagnosis of bipolar disorder has gone up fortyfold since the mid-1990s, and an analysis I did says it has gone up sevenfold in psychiatrically hospitalized children. We simply can’t have that much bipolar disorder out there. Re-labeling children with explosive behaviors is accounting for this rise.

The reason I’d like to see a new label applied to these explosive behaviors is that it will give doctors a diagnostic option. Some of the treatments may be different, and the outcome is likely to be different. Bipolar disorder is a lifelong disorder, and we need to be sure before calling something “lifelong.” My view is that calling explosive children a special kind of bipolar muddies the water.

Basically, around 10% kids come into our clinic with very explosive behavior, and of those less than 2% of them actually have classic bipolar disorder. On our inpatient unit, up to 90% of kids are admitted for explosive behavior and 14% have observable mania — the key condition for bipolar disorder.

It’s important to recognize that this controversy is about kids who are very difficult to treat. However, kids with explosive disorders can have a lot of things wrong with them; sometimes they are psychotic or autistic. The most frequent alternate diagnosis is severe attention deficit hyperactivity disorder with oppositional defiant disorder. We need a way to identify, reliably label and study explosive children. Without that, nobody will fund research and nobody will approve treatments for them.

In our current climate of insurance reimbursement, doctors cannot spend the time they need to fully diagnose these kids. The problem is that kids are being labeled with something we think we know, and which is lifelong. Even with the new diagnosis, very often they may receive the same medication anyway — because the medications are not that specific — but treatment may be more short-term. It’s like the difference between telling someone their high fever is a symptom of the flu or it’s the first sign of leukemia.

A new diagnosis is only going to confuse the field

Dr. David Axelson is the director of the Child and Adolescent Bipolar Services Clinic at the University of Pittsburgh Medical Center.

I agree that bipolar disorder has been over-diagnosed at times, but I don’t think it’s the disaster some people have been talking about. These are very sick children we are trying to diagnose, who are failing out of school, assaulting peers, attempting suicide and frequently getting hospitalized. It’s appropriate to say we don’t want to lump all those kids into a bipolar disorder category, but I am against creating a new label like temper dysregulation disorder.

Bipolar disorder clearly exists in adults. That’s without question. And if you look at adults who have bipolar disorder in the U.S., nearly 50% recall having significant mood symptoms in childhood and adolescence. This isn’t an illness that started at age 25 to 30; it started when they were much younger.

I agree that it can be more difficult to assess manic symptoms in children than in adults. One of the criteria in adults is episodes of recklessness: doing pleasurable things that have a high chance of painful consequences — driving a car fast, having sex with lots of people, shoplifting or spending money you don’t have. Scale that down to a 7-year-old and it’s a lot harder to think about what the equivalent symptoms would be: Doing wild things on a bike? Giving away their possessions? Inappropriately exposing themselves?

Different disorders often require different treatments. If some of these kids being diagnosed with bipolar actually have post-traumatic stress disorder, they might respond to psychotherapy and an antidepressant. Others might do better on a stimulant. The point is, I don’t think we should be adding a new disorder unless it is likely to have treatment relevance and have a unique neurobiological basis. Bipolar disorder does respond to antipsychotic medications, and the diagnosis has some treatment relevance. We don’t know if the same is true for temper dysregulation disorder.

People fear that a bipolar diagnosis will lead to doctors ignoring a child’s home and school environment. In our program, we take a holistic approach with the kids, and a good part of the treatment and research we engage in is to help improve communication between the child and family, or intervene in the school. For instance, we may recommend that a child diagnosed with bipolar disorder adjust their regular class schedule during periods of mood instability or go to emotional support classes. In short, I think we need to be careful about bipolar diagnosis, but I don’t see the need for a new label.