Monday, May 21, 2012

Shrink Rap Radio #305 – The Dangers of Diagnosing Children as Bipolar with Stuart Kaplan, MD

Ethically, diagnosing children with bipolar is way out of bounds. Even so, since the mid-1990s, the number of children diagnosed with bipolar disorder has increased a staggering 4,000 percent. The only problem is the the children do not have the behaviors outlined in the DSM as to how bipolar manifests.

This story from NPR gives a little history of the bipolar diagnosis in children:

The Beginning Of 'Bipolar' Children
The notion that children might suffer from bipolar disorder in large numbers is new, dating back only to the mid-1990s.

Dr. Janet Wozniak, an assistant professor of psychiatry at Harvard Medical School, was one of the people who first popularized this idea.

Wozniak says that when she was starting out, most psychiatrists placed the prevalence of bipolar disorder in children somewhere between "never" and "vanishingly rare."

"Papers about bipolar disorder in children would usually start out with the phrase, 'Here's a disorder that's so rare maybe you'll see one or two in your entire lifetime in practice,' " Wozniak says.

Wozniak herself only started thinking about pediatric bipolar disorder when she got a job as a researcher in the clinic of a famous Harvard child psychiatrist named Dr. Joseph Biederman. Biederman was studying kids with attention deficit hyperactivity disorder and felt that there was a portion of the kids in his clinic whose problems with anger seemed to go way beyond normal ADHD. So he asked Wozniak to look into it.

She did. And what she found were kids who continued to struggle with intense, uncontrollable outbursts of anger — violent hitting and screaming and kicking — even after they passed through the preschool years.

She felt these outbursts were substantively different from the kind of outbursts you saw among ADHD kids, who often had problems regulating their impulses. Then one day, she says she had an insight.

"This child that I was thinking of as having really difficult-to-treat ADHD and a lot of parent-child interaction problems, I really was ignoring the serious mood component of their problem." In other words, it wasn't that the kids just had problems with their impulse control; there was a more serious problem of mood. These kids were bipolar.

Redefining A Defining Characteristic
Wozniak wrote all this up in a now famous paper proposing that some of the kids characterized as having ADHD were actually bipolar.

The paper won awards. Clinicians began to approach Wozniak at meetings saying her insights made intuitive sense. She had helped transformed their practice.

But Shaffer says that to see these children as bipolar, Wozniak and her co-author, Joseph Biederman, had to change one critical component of the traditional definition of bipolar disorder. "The defining feature of manic-depression was that it was episodic," says Shaffer. "You had episodes of depression and episodes of mania and episodes of normal mood, and that was really, its defining characteristic."

But the kids Wozniak described rarely, if ever, had these kind of discrete weeklong or month-long episodes. So to make them fit the traditional concept of bipolar disorder, Shaffer says, she and Biederman made the argument that in children, episodes presented themselves in a radically different way.

"They said maybe in childhood the episodes would be very brief and very frequent," says Shaffer. "These are called 'ultra diem,' you know, 'many times a day.' If you regarded every time children changed their mood, every time they lost their temper or became overexcited, as a mood episode, then they were really being misdiagnosed and were really cases of bipolar disorder."

Critics countered that bipolar should look the same in kids and adults, that there wasn't good evidence that these kids grew up to be bipolar, and that if you looked backward at bipolar adults, they didn't necessarily have these uncontrolled anger issues when they were young, Shaffer says.

Nevertheless, pediatric bipolar disorder took off. Today, it's estimated that at least 1 million children in the United States have been diagnosed with the disease. Wozniak is convinced that she knows why. "The diagnosis took off because it made clinical sense," she says. "Because we opened our eyes."
There is a proposal to add a new listing for the DSM-5, one which removes the lifelong stigma of bipolar diagnoses, and one which more accurately describes the behaviors.

Temper Dysregulation Disorder: This proposed new disorder is seen as a brain or biological dysfunction, but not necessarily a lifelong condition. It can only be diagnosed in children over the age of 6, and onset must begin before a child is 10. 

The disorder is characterized by severe recurrent temper outbursts in response to common stressors. To have the disorder, the person has to have had these symptoms for at least 12 months, and cannot have been free of symptoms for more than three months at a time.
  • temper outbursts involving yelling or physical aggression
  • overreacting to common stressors
  • temper outbursts occurring on average three or more times a week
  • nearly everyday the mood between temper outbursts is persistently negative.
  • in the past year the patient has not had a period longer than a day of elevated or euphoric mood.
Personally, I think this is a much more complex issue that has a lot to do with parenting (or the lack of it), environmental over-stimulation (video games, electronic education devices, television, etc.), chemical dysregulation of affective systems from environmental toxins and food additives, lack of boundaries and consequences, and a whole host of other issues. But parents and physicians want the quick fix, not the real solution.

Shrink Rap Radio #305 – The Dangers of Diagnosing Children as Bipolar with Stuart Kaplan, MD

According to Stuart L. Kaplan MD, there are six things you should know about him:

• He is a Distinguished Life Fellow of the American Academy of Child and Adolescent Psychiatry.
• He is a Clinical Professor of Psychiatry at Penn State College of Medicine.
• He was awarded the Outstanding Mental Health Professional of the Year by the National Alliance of the Mentally Ill, Saint Louis Chapter, in 1998.
• He has served as the Director of Child and Adolescent Psychiatry at three major institutions, two of which were University medical schools.
• He is Board Certified in Child Psychiatry and Adult Psychiatry and served as an examiner for the American Board of Psychiatry and Neurology 14 times.
• Dr. Kaplan has authored over 100 scientific papers, book chapters, abstracts and national and international scientific presentations.
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