Bipolar Disorder in Historical Perspective

In order to fully appreciate the conditions that set the pediatric bipolar epidemic in motion, it is useful to being with a brief history of bipolar illness. Originally named manic depressive psychosis, bipolar disorder was the first psychiatric illness to be identified by Emile Kraepelin “ the father of modern psychiatry “ in 1896.

After a century of research on bipolar illness, Kraepelins original description of its symptoms and course have proved to be remarkably robust. [8] The international medical community still believes, as did Kraeplin, that BD is a devastating albeit rare, brain disorder that begins in late adolescence or early adulthood, and is characterized by intense cycles of mania and depression. Outside of the U.S., bipolar disorder is diagnosed less frequently than schizophrenia, which is itself and uncommon disorder.[9]

Symptoms typical of mania include marked euphoria, grandiosity, irritability, racing thoughts, agitation, rapidly shifting mood and sleep disturbance. Paranoia, confusion and psychosis are also typical. Depressive episodes are characterized by fatigue, oversleeping, suicidal thoughts and suicide attempts, and often, psychosis. [T]he crashing lows and manic highs that are the hallmarks of BD can ruin the lives of individuals and families.[10]

[I]n the mid-twentieth century John Cade, an Australian psychiatrist discovered that lithium carbonate not only had a calming effect on manic episodes, but also seemed to prevent future cycles of depression and mania.

Approaches to diagnosis and treatment of BD in the U.S. began to diverge from the rest of the world with the publication of the 1987 edition of the Diagnostic and Statistical Manual of Mental Disorders whose acronym is the DSM and is the preeminent American system of psychiatric diagnosis. This version of the DSM introduced BD subtypes, which both broadened and diluted the criteria for diagnosing it.

After bipolar subtypes were introduced into the DSM classification system, the number of adults in the U.S. meeting these much broader criteria began to soar. It is important to note that the World Health Organization, which published the International System of Classification, now in its 10th edition has much more stringent diagnostic criteria for BD.[11]

In the mid-nineties, two child psychiatry research groups, one at Harvard, another at Washington University - began to train their attention on pediatric bipolar disorder. Both groups contend that until recently, bipolar disorder was under-diagnosed in children because the early symptoms of the illness are typically different from those in the adult phase.

Both groups stress that a majority of bipolar children also suffer from [ADHD], and that many were erroneously diagnosed as depressed. The Washington group, headed by Barbara Geller, claims that children with bipolar illness often cycle through manic episodes that may last anywhere from a few minutes to a few days, as compared to mania in adults that lasts for several weeks or months if left untreated. The Harvard group, led by Joseph Biederman believes that bipolar children may not exhibit cyclical mood disturbances at all, but instead, they may be chronically irritable and explosive, or chronically depressed and angry. His group has run several antipsychotic drug trials with bipolar preschoolers.

As a result of Biederman and Gellers research, the diagnostic criteria for pediatric BD now extend to children who have brief stormy episodes of mania ” lasting only minutes, and extremely moody, irritable, aggressive or emotionally explosive children whose symptoms have almost no continuity with the DSM criteria. [12]

From Theory to Practice

Geller and Biederman claim that bipolar disorder often begins in childhood, but with a different symptom picture, set the stage for the dramatic rise in the diagnosis of pediatric BD. Btu what really accelerated this trend were books on childhood BD, as well as websites, and drug ads targeted to children and parents. In these venues, symptoms are stretched even further to include mildly irritable kids, preschoolers prone to temper tantrums, and creative jubilant, high energy children many of whom have ended up on antipsychotics after a quick visit to the pediatrician.

End Part 1

Bipolar Disorder Overdiagnosed reafirms a recent study by Zimmerman, associate professor of psychiatry at Rhode Island University.

Introduction to Bipolar Disorder and Children by Sharna Olfman - Part 2

The 2007 American Academy of Child and Adolescent psychiatry practice guidelines represent an effort to stem these reckless diagnostic and prescribing practices, by elucidating the differences between tentative research findings and sound clinical practice. However, while the authors' intentions are honorable, their recommendations hardly address the many troubling questions that they themselves raise.

In the preamble to the guidelines, they clearly state that there is no evidence to date that children exhibiting anything other than the classic symptoms of bipolar illness will fact become bipolar adults. Yet they recommend that children with symptoms such as those identified by Biederman, which bare only a remote resemblance to the DSM criteria, should be labeled "bipolar disorder NOT OTHERWISE SPECIFIED." However, adding the term "not otherwise specified" to a diagnosis of BD will have almost no impact in terms of how an ostensibly bipolar child is regarded and treated by her parents, her teachers, and her physician, who is likely to prescribe accordingly.

Also, the authors of the guidelines state that the safety of atypical antipsychotic and anticonvulsant drugs has not been established with children, and yet these very drugs are listed as first line treatments for children diagnosed with bipolar disorder. Finally, although they assert that there is no reliable method for diagnosing BD in preschool children, they do not recommend a moratorium on this practice.

Of even greater concern is the way in which these guidelines are filtering down from clinicians working in university affiliated clinics to psychiatrists in private practice, to pediatricians with no training in psychiatry or psychology, and to harried, sleep deprived residents and interns who treat the majority of disadvantaged children.

As a consequence, there has been up to a forty-fold increase in the number of children being diagnosed with BD in the span of a decade, a trend that is exclusive to the U.S., the majority of whom are being prescribed antipsychotic drugs often in combination with anticonvulsant drugs. These classes of drugs have dangerous side effects, such as a doubling of mortality rate, shortened lifespan, extreme weight gain and type II diabetes. [13]

At the end of the American Academy of Child and Adolescent Psychiatry's write-up of the guidelines, it was disclosed that two of the three authors had ties to the pharmaceutical industry. The lead author, Robert McClellan, received a research grant from Pfizer..........has received research support, acted as a consultant, or served on the speakers' bureaus of no fewer than 16 different pharmaceutical companies. I believe that the disconnect between their research and their recommendations reflects the conflict of interest that invariably ensues when profit driven drug companies fund medical research. In light of the dire consequences for millions of children affected by reckless polypharmacy, these conflicts of interest are not just misguided. They are immoral, and should be illegal.

The Pediatric Bipolar Epidemic in Cultural Context

Questionable diagnostic and prescribing practices, fueled in large part by unethical partnerships between the medical profession and the pharmaceutical industry, are the direct cause of the American pediatric bipolar epidemic, but broad cultural trends have acted as enablers. These include the glaring absence of support for families in this nation, and our faith in the technological fix.

Bipolar Disorder and Children - Families Under Siege

A cultural condition that has set the stage for the steep rise in child psychiatric diagnoses in general, and bipolar disorder in particular, is the dearth of public policies that support the welfare of children and families in the U.S. As Urie Bronfenbrenner, on of the finest developmental psychologists of the 20th century expressed:

"The heart of our social system is the family. If we are to maintain the health of our society, we must discover the best means of nurturing that heart." [14] Tragically though, as Bronfenbrenner noted towards the end of his career. "the comparative lack of family support systems in the United States is so extreme as to make it unique among modern nations." [15]

How can a mother who must return to work only days after giving brith, while placing her newborn in substandard care, establish a secure attachment with her infant? If a single mother must work two or three low wage jobs to make ends meet, while her children return to an empty home, how can she scaffold their arduous journey towards adulthood?

And how can she protect them from the tidal wave of violence, hatred, racism, sexism and pornography that pervade the media? And if this mother is the second or third generation to have raised children under these compromised circumstances, how will she herself have acquired the psychological maturity and wisdom to related lovingly and responsibly towards her children? But these are precisely the conditions under which millions of American parents are obligated to raised their children. And when parents are overwhelmed, their children are more likely to be overwhelmed and overwhelming. Parents in turn become more reliant on and more vulnerable to the current climate in child psychiatry which views virtually all forms of psychological distress as a medical illness to be treated with drugs.

The Medical Model - Mind as Machine Medicine

The medical model of mental illness conceptualizes psychological distress as symptomatic of an underlying medical condition. So for example, just as fever may signify the presence of a virus, depression and mania are assumed to point to the presence of a genetically influenced brain disorder. This model makes an important contribution to the mental health field, because it recognizes that genetic predisposition, and brain anomalies can play a role in psychological disturbance.

However, other models are equally essential to our understanding of the cause and cure of mental illness because they explain the role of social and cultural forces, and the human condition in all of its rich complexity. The field of developmental psychology also offers vital insights, because it provides a yardstick of healthy development against which to measure disturbance.

But the medical model of mental disorders has monopolized the mental health field in recent decades, effectively 'muscling out' other approaches, and this has led to a biased and distorted understanding of the cause and cure of psychological disturbance. The medical model lends itself to a conceptualization of the human mind as a machine, whose software is a set of genes that we are learning to decode and recode, and whose hardware can be corrected or enhanced pharmacologically.

We have bought into the 'mind as a machine' metaphor to such an extent, that even children's expressions of emotion are being translated into the language of symptoms in need of a pharmacological overhaul as opposed to meaningful communications. So for example, a child's jubilant elation is reframed as 'hypomania' and her sadness is termed 'depression'.

Child Psychology: Emotions and Children - Learning to Feel

Emotions are not simple reflexes or instincts that are present in their mature form at birth, that are either in working order or in need of an 'adjustment'. Like other lines of development such as intellectual, language, personality and social development, they follow a trajectory that is powerfully shaped by experience. In the early months and years, healthy emotional development is dependant on loving and consistent 'attachments' to parents and other caregivers.

When a child is deprived of loving care in the first months and years of life, her emotional development will be stunted. For such a child, everything from mild disappointment to profound loss may engender rage, and everything from a simple courtesy to passionate love may elicit elation. Conversely an emotionally deprived child might defensively blunt all emotionally loaded experiences. We can imagine how in the current climate, derailed emotional development might be recast as early onset bipolar disorder.

Child Psychology: Emotions and the Human Condition

When children's emotions, their highs and lows, anger and frustration, humiliation, irritation, giddiness, joy, enthusiasm are stripped of meaning and read exclusively as symptoms, the consequences are profound. When a form of experience and expression that is integral to our humanity, and essential to our fulll engagement with life is reduced to a symptom, then we risk dehumanizing our children; treating them like machines to be programmed rather than children to be loved, taught, mentored and disciplined.

Stemming the Tide of the Pediatric Bipolar Tsunami

Many of the children and adolescents who have been labeled with BD, now numbering into the millions, are in great emotional pain, and in some cases they are an overwhelming challenge to their families. but in the vast majority of cases, they are not suffering with BD.

A child who is misdiagnosed with a bipolar illness is effectively denied treatment for the real source of her suffering. And when we expand and distort the diagnostic criteria for BD beyond recognition, we risk making a mockery of a grave illness, and denying those who do suffer from it, access to effective research and treatment. When a child is unnecessarily prescribed antipsychotic and anticonvulsant drugs, her mental and physical health may be irrevocably compromised. With as many as two and a half million children from across the socioeconomic spectrum not taking antipsychotics we have set the stage for [a form of] wide scale child abuse.

In June of 2007, a nationally known group of mental health specialists convened at Point Park University in Pittsburgh to identify the factors that have set the stage for pediatric bipolar epidemic in the absence of any compelling evidence for either the validity of the diagnostic criteria currently used, or the safety and efficacy of the drugs being prescribed to treat it, and to insist that rigorous scientific standards which do not imperil children's safety be reinstated in the research and treatment arenas.

ENDNOTES for Bipolar Children

1. Roberts E. (2007). The Childhood Bipolar Epidemic: Brat or Bipolar? In Sharna Olfman, Ed., Bipolar Children: Cutting Edge Controversy, Insight, and Research. Praeger Press, Westport CT.

2. Healy, D. (2007). Bipolar Syndrome by Proxy? The Case of Pediatric Bipolar Disorder In Sharna Olfman, ED., Bipolar Children Cutting Edge Controversy, Insight, and Research. Praeger Press, Westport CT.

3. J of AACAP, 46:1, January 2007, p.107

4. J of AACAP, 46:1, January 2007, p.114

5. J of AACAP, 46:1, January 2007, p.114

6. J of AACAP, 46:1, January 2007, p.116

7. J of AACAP, 46:1, January 2007, p.115

8. Burston, D. (2007). An Invisible Plague: Pediatric Bipolar Disorder and the Chemical Colonization of Childhood. In In Sharna Olfman, Ed., bipolar Children: Cutting Edge Controversy, Insight, and Research, Praeger Press, Westport CT.

9. Healy, D. (2007). Bipolar Syndrome by Proxy? The Case of Pediatric Bipolar Disorder In Sharna Olfman, ED., Bipolar Children Cutting Edge Controversy, Insight, and Research. Praeger Press, Westport CT.

10. Healy, D. (2007). Bipolar Syndrome by Proxy? The Case of Pediatric Bipolar Disorder In Sharna Olfman, ED., Bipolar Children Cutting Edge Controversy, Insight, and Research. Praeger Press, Westport CT.

11. Healy, D. (2007). Bipolar Syndrome by Proxy? The Case of Pediatric Bipolar Disorder In Sharna Olfman, ED., Bipolar Children Cutting Edge Controversy, Insight, and Research. Praeger Press, Westport CT.

12. See chapters by Diller, Healy and Roberts.

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Bipolar Disorder Overdiagnosed reaffirms a recent study by Zimmerman, associate professor of psychiatry at Rhode Island University.

The Ethics and Science of Medicating Children, Jacqueline A. Sparks, The University of Rhode Island; Duncan, B., (Spring, 2004). Ethical Human Psychology and Psychiatry, Volume 6, Number 1.

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