Kids & Bipolar Disorder

A growing trend that is roiling mental health practitioners: the burgeoning number of children diagnosed with bipolar illness, also known as manic depression, that affects about 2.3 million Americans. The illness, which is usually diagnosed in adolescence or early adulthood, is a serious and disabling mood disorder that, if untreated, carries an elevated risk of suicide. Statistics documenting the increase in pediatric bipolar diagnoses are elusive, but a dozen psychiatrists and child psychologists interviewed for a story in Tuesday's Health section say there have been sharp increases in the past decade. As a result, some preschoolers barely out of diapers are being treated for bipolar disorder with powerful drugs, few of which have been tested in childre

Jon McClellan, associate professor of psychiatry at the University of Washington, is dubious and thinks there may be a rush to diagnose kids as a result of bipolar disorder's status as a cultural phenomenon.

McClellan was online Tuesday, Feb. 15, at 3 p.m. ET to discuss the growing number of pre-adolescent children diagnosed with bipolar disorder.

Going to Extremes, (Post, Feb. 15)

An offer has been made to a doctor representing the opposing viewpoint. Stay tuned for details.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

_____________

Washington, D.C.: I am a child psychologist and have been alarmed at the number coming into my office with the diagnosis of bipolar disorder who, in my opinion, really don't have it. It almost seems like a plot created by managed-care child psychiatrists to make a diagnosis that needs long-term treatment (so that they have ongoing clients and, therefore, make money). One local psychiatrist diagnoses almost every kid he sees with bipolar disorder (and, indeed, he has a very busy practice). The medications used to treat this disorder are poisoning with numerous side-effects and in-and-of themselves look like a disorder (i.e., the side effects). The real question is: Which came first, the diagnosis or the side-effects of the medications (that look like psychiatric disturbance)?

Jon McClellan: I think this is mostly the outcome of physicians trying to treat very complicated kids that do not fit neatly into existing diagnostic categories. It is easier to conceptualize problems as being a single thing, such as bipolar disorder, even if that turns out not to be true. I don't think this issue is the result of medication side effects, although obviously some kids get more activated on certain agents, making it even more complicated. The problem is that although medications offer potential easy solutions, but have not been well studied, nor are they necessarily addressing the underlieing issues involved.

_______________________

Arlington, Va.: Good afternoon -- I read the column on bipolar kids with interest -- while it appeared to show that many parents are grasping at the bipolar diagnosis as a reason for their childrens' misbehavior, the article did not show that, in fact, there are many valid diagnoses of children with bipolar disorder.

My son has been diagnosed with bipolar disorder since the age of 9. He has had true manic states (not just rages) with delusions and hallucinations. In addition, in his depressive state, he has been extremely suicidal.

I believe that writing a story in which both sides of the issue are not fully vetted does the reader great injustice --

While there may be controversy as to the latest "in" diagnosis, this type of article does not do service to the children who truly do suffer from this disorder nor to the parents of the children. Some parents may in fact be grabbing at the lastest fad diagnosis for their child, but there are those parents who struggle to help their child live as normal and productive a life as possible and unfortunately this article does them and their children no service.

Jon McClellan: Hello

Your points are well said. I certainly agree it is very important to identify the disorder when it is present, and initiate appropriate treatment. Part of the dilemma now is that the very definition of how the disorder is being used varies greatly across communities and providers. This is all enormously confusing and frustrating to families, who for the most part do not care as much about what to call it as they do about what to do to make it better.

_______________________

Woodbridge, Va.: I am tremendously frightened for the future of our society, when behavior problems are labeled as one disorder or another, and accountability is lost. Regardless of how real any perceived mental disorder appears to psychiatric practioners, the long-term effect on society as a whole will be a dysfunctional community. Clockwork Orange, perhaps?

Jon McClellan: I certainly hope not. Most clinicians are very well meaning, and trying to do what is best for the child and family. Part of the problem is that psychiatric illnesses are very complicated, we do not have biological markers to define disorders, so the field is vulnerable to subjective opinions about what is a disorder, and what is the best treatment for it. As science moves ahead, some of this will improve.

_______________________

Washington, D.C.: Dr. McClellan,

What do you believe to be the reason for the spike in diagnoses of bipolar illness in young people?

Jon McClellan: I believe the definition has changed. There is little debate that some young children have significant problems with controlling their moods and behavior, the issue is whether that is the same thing called bipolar disorder in adults. Its an important question, since calling it the same thing implies that the same medications work to treat the problems. Why this occurred is complicated, but probably in part because the categories often used to characterize problems in kids do not necessarily capture all the difficulties some kids have. Plus bipolar disorder has well defined treatments, so the diagnosis offers hope to providers and families.

_______________________

Alexandria, Va.: Not only has there been a rise in children diagnosed with Bipolar but also with ADHD. I'm not sure I understand why there has been an increase? Were these same behaviors not present 30 years ago and now are all of a sudden rearing its ugly head and if so, what type of environmental, social, emotional changes are causing such behavior? I believe the majority of the children are misdiagnosed and it is really just big pharmacutical businesses getting big bucks at the expense of our children.

Jon McClellan: This is a very good question, but complicated. In part I think our culture has changed about how we view mental illness, and in some ways the definition of what is normal has narrowed. Expectations for kids has increased. In a world dominated by technology and computers, being able to pay attention and focus is a much more necessary trait. Some of this shift is not necessarily bad. For example, it used to be more acceptable for kids to be physically aggressive, bullies were considered part of life, etc. What used to be "boys will be boys", in many ways is now recognized as a problem because of the impact such behaviors might have on others. However, that doesn't mean such behaviors are the same as having a mental illness.
I don't think this is an organized plot by the drug companies, yet they clearly benefit. Their marketing reflects what we want as a society; better moods, better sex, better social functioning, etc. The difference between treating an illness versus enhancing skills or quality of life has become blurry.

_______________________

Oxford, Miss.: Speaking of "biological markers," what is your opinion of the new emphasis on brain scans to diagnose various types of mental disorders? Are these scans a valid measure in and of themselves, can they be used as part of the overall diagnostic picture, or are they basically useless?

Jon McClellan: They are neither useless, nor do they yet represent standard clinical practice. They are research tools. There is no evidence yet that imagining tools can be reliably used in clinical settings to make diagnoses. There are however, very important research tools to try and learn how the brain works.

_______________________

Crescent City, Calif.: Would you comment on the work of Dr. Fuller Torrey, who sees a significant rise overall in the incidence of mental illness, and the increase in child onset bipolar diagnoses?

Jon McClellan: I only know of Dr. Torrey's writings regarding schizophrenia in adults, so I cannot comment on this.

_______________________

Minneapolis, Minn.: Can you state clearly, whether or not you believe that it is possible that children can suffer from mental illness? What could the "underlying" issues of a child be besides biological? Isn't the argument then merely over how to treat these illnesses and not whether to treat them?

Jon McClellan: Yes, I agree with your statement. Children can clearly have mental illnesses. However, how we define mental illness is part of the issue, since without biological markers we are left with subjective symptom criteria, leaving room for debate. A child with classic autism clearly has a neurological problem, yet a child with mild ADHD symptoms may only look as though they have a mental illness in certain settings. Ultimately all behavior relates to our underlying biology, but the notion of illness often translates into assumptions that there must be some specific error in a biological process that is the same across all individuals with that diagnosis, and that probably is not true of the vast majority of mental health problems in kids, even those where there is no dispute it is a mental disorder.

_______________________

Morgantown, W. Va.: While I cant disagree with you regarding the misdiagnoses, I am concerned and do have experience with bipolar disorder not being diagnosed. My child, after having been diagnosed with severe ADHD, and PTSD experienced a full manic episode triggered by use of stimulants, meeting all the criteria of Bipolar I -- there really is no question in this case. However, earlier diagnosis and treatment would have saved all of us from trauma, and would have saved this child from further damage to his brain, and psyche. While I certainly dont want children to be diagnosed and treated with medication they need, I think there is as real a problem with not diagnosing and treating EOBP.

Jon McClellan: Certainly, and I am not trying to say it should be never diagnosed. My point is that what is now being called bipolar disorder in children, especially younger children, may not be the same thing as what we classically considered bipolar disorder in adults. That being the case, research is needed as to how best to treat these kinds of problems.

_______________________

Manassas, Va.: Can children as young as two years old have bipolar disorder?

Jon McClellan: That is the debate. I personally have never seen a child that young where I would make the diagnosis. If a child that young presented with severe moodiness and aggression, I would certainly recommend treatment. But I probably would not label it as bipolar disorder until following the child over time, and I certainly would focus on behavioral interventions before starting medications.

Others in our field obviously disagree with me, and only ongoing research will sort it out.

_______________________

Livermore, Calif.: Insinuating that accountability is lost when parents recognize that their child has a problem and do everything they can to get their child help, even so far as something associated with such stigma as seeking help from the mental health field, really does a disservice to the families that are forced to live through the pain of the sympomatic syndrome associated with bipolar (or any other the other alphabet soup of diagnoses that mimic bipolar)... are are doing their best to tread water.

I am one of those moms, and my daughter tries so unbelievably hard to "be good" - she has spent most of her childhood just coping wiuth this illness rather than being a kid.

I found the article and comments like the above to be tremendously insulting.

Jon McClellan: Sorry, I of course didn't write the article; however, what my comments about accountability were referring to was that I unfortunately have seen cases where labeling behavioral problems as bipolar disorder somehow translated into the child shouldn't be held accountable for his actions since he/she couldn't help them. Thats a potential problem, and can serve to make the behaviors worse. In children with complicated behavioral disorders, it is very important to examine whether circumstances or responses by others are actually reinforcing the behaviors. Its actually easy to reinforce certain behaviors. For example, intimidating people unfortunately often do get their own way. So by focusing on these dynamics, it doesn't mean the parents are bad or purposely trying to create problems; the goal is to identify strategies that reduce the problems, which is why families come for treatment in the first place.

You also raise an important point, it is very hard to find quality mental health services for children, families are blamed, the system is confusing and fragmented, it definitely adds to the dilemma.

_______________________

Crescent City, Calif.: If you could set the research agenda that would solve the problem of misdiagnosis of bipolar disorder in children, what would the top three or four issues on your list be?

Jon McClellan: I think we need to step back from the diagnostic categories, and focus on learning more about how the brain works, and what systems of the brain are involving with organizing and initiating complex behaviors. There is lots of research going on in this area, but most is not necessarily connected with clinicians or clinical research.

I would also greatly expand treatment research. Regardless as to what we call it, what helps the problems and how safe are the treatments remains largely unanswered questions for kids with complicated presentations.

_______________________

Livermore, Calif.: Could it be instead, that the classical definition is in need of revision to account for new data. Specifically, with the criteria to allow for ultra-rapid cycling and mixed states that our children frequently suffer though? This is one problem with the current DSM, which only specifically accounts for length of cycling typically seen in adults.

Jon McClellan: Possibly, although it leads to a circular argument. Bipolar disorder in kids doesn't present the way it does in adults, so we change the definition to fit the way children present, yet how do we know they have it in the first place?

_______________________

Reston, Va.: Isn't it possible that these "symptoms" that don't fit into any other diagnosis could be "symptoms" of something else... like poor parenting? It seems to me that as society is becoming more complicated and increasingly focused on materialistic values, children are misbehaving out of the need for more attention.

Jon McClellan: I do think its unfair, and usually inaccurate, to say it simply or solely due to poor parenting. It is fair to say its usually complicated, and that helping parents develop effective strategies to help their children needs to be an important goal. I assume parents are doing the best they can, and some of this kids are very difficult to manage.

_______________________

USA: At some level, this issue has clear political/cultural undertones. A southern, rural, Christian fundamentalist parent would almost certainly see the whole issue of children with behavorial issues very differently from an an urban, liberal secular one.

While I realize that you are not a political commentator, you must surely have thought about this as you ask these questions in a public forum.

Any comments?

Jon McClellan: I don't think the issue sorts across political lines. While its true that different cultural groups interpret behaviors differently, for the most part all cultures have in the majority good parents that care about their kids and use common sense to raise them. The issue does have cultural overtones, such as what do we expect from our children, and what kinds of interpretations/explanations/treatment options do we feel comfortable with; but those are large issues, and are not isolated to single groups.

_______________________

Oxford, Miss.: How would you yourself go about the process of diagnosing a young child who is displaying the most common symptoms attributed to bipolar disorder? While my own daughter was diagnosed after a prolonged hospitalization and detailed evaluation, I know of a few other children who were diagnosed after a 1 hour appointment with a psychiatrist. What are the appropriate steps that should be taken before giving this diagnosis?

Jon McClellan: I would ask your family doctor, as well as friends/other providers, as to who the best child psychiatrists (or other mental health clinicians) are, and go to those individuals. I know it seems simplistic, but the best providers do a good job, regardless as to the diagnosis.

_______________________

Washington, D.C.: Why can drugs be prescribed to children when they are not approved for them and not tested if and how they work in children? Isn't this dangerous and a form of "Russian roulette?"

Jon McClellan: In the questions you can see the argument on both sides. On one hand you do want the most information possible about a treatment before using it in children. On the other hand, there are a large number of children with significant problems that need help, and to deny them treatment where there is some information and clinical experience to suggest that treatment may be helpful, also creates ethical concerns. Good clinicians try to sort thru both sides of the issue, talk over the various points with families, and help the family make the best decision.

_______________________

Seattle, Wwash.: I'm concerned about everything I've been hearing in the news about the potentially harmful side effects of psychiatric medications, like antidepressants and now adhd medications, in kids. What is known about the longterm effects of lithium, anticonvulsants, and antipsychotic medications that are typically used to treat bipolar disorder?

Jon McClellan: Unfortunately, there are not a lot of long term studies with mood stabilizers or antipsychotic agents in children. I am involved in conducting such studies, but more work is clearly needed.

_______________________

Jon McClellan: Thank you all for your thoughtful questions and comments. This is a complicated area, so the best advice I have is to stay informed, and be good consumers when finding help for your family. I appreciate having the chance to talk with you.

_______________________