Children and bipolar disorder

Thanks to the e-mailers who've forwarded this Washington Post story about the rise in pediatric bipolar diagnosis. I'm not a child psychiatrist, so I turn to colleagues for opinions about this. Most believe that too few mentally ill children are receiving psychiatric help of any kind, and that the incidence of pediatric bipolar disorder is still unknown; furthermore, that children who are diagnosed bipolar are among the most challenging patients in their practices. At the Washington Post online Discussion site, Dr. John McClellan shares his thoughts:

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...

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.

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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.

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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.
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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.

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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.

For more of this online discussion, see
"Kids and Bipolar Disorder." WaPo says they're trying to arrange an online chat with an opposing view. To be continued...