Bipolar diagnosis in children: another epidemic?
By Dov Michaeli , MD, Ph.D
One of the plays we saw last Sunday in Ashland was “Distracted”, describing a mother whose nine year old child was diagnosed with Attention Deficit Hyperactivity disorder, or ADHD. The kid was a lively, curious, imaginative, highly intelligent child who was bored with his school, couldn’t keep his mind concentrated on the dumb and further dumbed down assignments-and was labeled by his teacher as “challenged”. It was all downhill from there. The child was seen by all kinds of healers (school nurse, psychologist, neuropsychologist, homeopathic psychiatrist), loaded up with drugs designed to “control” his behavior which in turn led to a new diagnosis: bipolar disorder. I had been vaguely aware of the problems of over- diagnosis and misdiagnosis in child psychiatry, but no idea of its alarming extent.
The problem quantified
In a study published in the September 2007 issue of the "Archives of General Psychiatry" the researchers examined 10 years of data from the National Ambulatory Medical Care Survey (NAMCS), an annual, nationwide survey of visits to doctors' offices over a one-week period, conducted by the National Center for Health Statistics. Their finding was astounding.
· The researchers estimated that in the United States from 1994-1995, the number of office visits resulting in a diagnosis of bipolar disorder for youths ages 19 and younger was 25 out of every 100,000 people. By 2002-2003, the number had jumped to 1,003 office visits resulting in bipolar diagnoses per 100,000 people. This is a 40 fold increase in 8 years! In contrast, for adults ages 20 and older, 905 office visits per 100,000 people resulted in a bipolar disorder diagnosis in 1994-1995; a decade later the number had risen to 1,679 per 100,000 people, a “mere” two fold increase.
· About half of all children and adolescents who received a diagnosis of bipolar disorder also received a diagnosis of ADHD.
What could account for this increase?
There could be several factors accounting for this “epidemic”.
· Increased awareness of the disorder. This may be true to a limited extent, but a sudden awareness by child psychiatrists (90% of the diagnoses were made by them, only 10% by pediatricians)is simply not credible. What were they teaching in medical schools and psychiatry training programs in the decades up to 1995?
· Was there a sea change in our knowledge of childhood bipolar disorder since 1995? There has been great progress made in understanding the neurobiology and genetics of the disease. Great progress has been made in drug treatments of psychiatric disorders. But such advances do not affect the diagnosis. The latter is based on observation of behavior, not on objective criteria such as fMRI scans of the brain, or biochemical markers of the disease.
· The classical manifestation of bipolar disorder is a period of euphoria alternating with deep depression. Yet in children and adolescents euphoria is almost never present. The children are depressed, angry and given to tantrums. But isn’t it reasonable to expect a child who is more or less ignored by his harried parents, or is chauffeured from one activity to another, or is subjected to the constant anxiety of Little League and pressure to get the top grades in school, will be angry and depressed? Animal experiments have demonstrated that chronic anxiety, or lack of parental attention, lead to profound depression and aggressive behavior. What makes us think that we are somehow different?
· I think that the most credible, and most cynical reason for the huge increase in the diagnoses of bipolar disorder and ADHD is money. The diagnosis is made on subjective criteria, and this is an invitation to abuse. I suspect that when this issue will get investigated in depth, it will turn out that psychiatric overdiagnoses are first cousins of excessive cardiac caths, excessive imaging studies, excessive bypass surgeries, excessive prescription of medications, and so on and so on.
I am not a policy wonk, but I sense that this corruption of medicine cannot continue without dire consequences for our society.
Dov Michaeli MD, Ph.D is in the biotech industry, researching the development of new drugs.
The Doctor Weighs In
in ADHD, Adolescents/teens, Adverse childhood experiences, Aggression, Dov Michaeli, MRI, attention deficit hyperactivity disorder, misdiagnosis, overdiagnosis
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Response: More on the Bipolar EpidemicBy Dov Michaeli MD, Ph.D
Reader Comments (7)
You've no need to be a policy wonk. The fact that you are an MD/PhD is enough. The "solution" to this has to come from within the culture of your "profession."
The fact of the matter is that physicians need to realize that this refelcts poorly upon your entire profession and then perhaps take some ownership of that profession.
Whether you actively engage in this corruption of medicine or not, this is not somehow external to you. I know countless doctors that shrug there shoulders, but then do nothing else about this nonsense. I am not accusing you of the same indifference, but rather I am urging . . . prodding . . . pleading:
"Medicine" is your house not ours (the patients). Please try to clean it up.
If your "M.D." is to actually mean something noble, worthy of respect, then you - as a "profession" - must be willing to do something to address it internally. The public is already to starting to lose some of that hard-earned trust, and at it does not take a wonk to see that at the end of the day: no one will distinguish between the "good" MDs and the "bad" MDs when all of your integrity has been sold.
You have a lot of nerve.
Early Onset Bipolar Disorder, which is how we discuss children hit with this disease, has only recently been understood as something related to, but distinguishably different from, adult BP. Importantly, pediatric specialists have recognized "rapid cycling" as the leading characteristic that separates Early Onset Bipolar Disorder from adult BP. "Rapid cycling" describes a brief period of time, often lasting about 20 to 40 minutes or so, during which a child "cycles" or moves fully and fast through many extreme emotions. Children can cycle several times in a day. Adults with BP will more typically experience these mood swings over months, at times with months in between.
I am a parent of a wonderful boy, currently in middle school, who lives with Bipolar Disorder, Type One. You are wrong to say that children "almost never" experience euphoria. My child and thousands like him absolutely do regularly hit that extreme high before crashing into a dysphoric state. It does not look the same in children as it looks in adults, just as depression doesn't look the same in children.
You take pot shots at parents, who, you say, ignore their children and insensitively push them into sports they don't want and levels of academic readiness they can't handle. I hope you are not speaking from personal experience. A brighter possibility would be that you simply have no experience in parenting at all. Well, you could learn.
In my experience, the most hard-working, 24/7 parents I know are tirelessly creating new inroads and opportunities to promote their children's wellness, children who live with exceptional emotional disturbances, like Bipolar Disorder. For our part, my spouse and I adore, honor and respect our child, even while we recognize that he is painfully difficult to raise due to this disease and other co-morbid factors. In your article, you go looking for blame. Well, it isn't our son's fault, nor ours. No more than Lupus is the fault of those who get it, those who pass it on genetically or those who diagnose their patients with it. Bipolar Disorder is likewise strongly genetically linked. But you can't see it on an image.
You suggest in your article that because our son's physicians can't use an fMRI to see his disease, that it cannot be truly and accurately diagnosed. That’s hogwash. To begin with, no doctor, if he or she is any good, makes such a serious diagnosis alone, or quickly. Our team has watched meticulously the details of our son for years, and remediated in various trials before concluding with this diagnosis. Even then, my spouse and I got an independent second opinion, which resulted in a ten-page, comprehensive report.
Another thing: I have been a dedicated elementary school teacher for over a decade, and there is no question that among experienced, good teachers, children who are exceptional due to mood lability sorely stand out. The majority of children in classrooms — even the many who may grow up in the awful scenarios you proposed — the majority do not cycle rapidly through emotions beyond their immediate control, flitting self-agrandizingly around in euphoric, silly and infantile behavior; suddenly misperceiving that everyone hates them; then, crying in extreme wails of sadness, only to shift and fly into a rage and become dangerous to others and to themselves, throwing desks, screaming suicidal threats, before turning sullen, exhausted. Most children do not, no matter how poorly they respond to Little League or AP English, resemble anything like the rapid cycling seen in Early Onset Bipolar kids.
Teachers, psychotherapists, tutors, primary care doctors; psycho pharmacologists, special education professionals, specially-trained home aids, who can safely handle the possible need for a child's temporary restraint, massage therapists and other legitimate service providers must very often all work exceedingly carefully as a team, led by severely pressed and inspiringly dedicated parents — awesome, in point of fact — to help stabilize their well-loved children, encourage their fragile self-esteem, keep schooling and friendships from disintegrating — and the list goes on.
If you and your readers really want to learn something about this terrible disease, start by going to bpkids.org, the website of Child and Adolescent Bipolar Foundation (CABF), a national non-profit organization that has thrown a lifeline of help and education to families like mine across the country. From there, you will find a rich bounty of resources. Read The Bipolar Child, by Janice and Demitri Papolos, and visit their website, bipolarchild.com.
Early Onset Bipolar Disorder is a lifelong, medical disease. It is not, as you insinuate, a social disease. Educate yourself, doctor, before you publish to the public because, in my view, you do harm writing misguidedly. You say you have a cynical point of view, referring to your theory that doctors give this diagnosis for the income? Here's another cynical view for you: you were under deadline to get an article in on this "hot" topic getting a lot of spin lately, and threw something together last minute.
You claim that Bipolar Disorder in children is willy-nilly over diagnosed, and that that explains the jump in numbers over the last ten years. Try this instead, although it is hardly cynical: Bipolar Disorder in children is finally accurately diagnosed, and my son and we are grateful beneficiaries of this past decade’s arduous and serious science.
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