Can children get bipolar disorder?It depends who you ask. It's "controversial". Some say that, like schizophrenia, bipolar strikes in adolescence or after, and that pre-pubertal onset is extraordinarily rare. Others say that kids can be, and often are, bipolar, but their symptoms may differ from the ones seen in adults. You know a 20 year old's manic when they stay up for 3 days straight writing a book about how God's chosen them to save the world. A "bipolar" 10 year old, though, is more likely to show irritability and mood swings. Critics say that this isn't evidence of bipolar, it's evidence of... irritability and mood swings. Or, indeed, of being 10.
But what's not always appreciated is how new the concept of pediatric bipolar as a common disorder is, and how specific it is to American psychiatry. Here are a few graphs I put together to illustrate this, based on numbers of scientific publications.
First up, when did people start talking about it? Here's the number of PubMed hits for pediatric bipolar each year. As you can see, it was rarely talked about before the year 2000, after which its popularity shot up rapidly; it seems to have plateaued now, but it's hard to tell.
In fact, the true trend is even more dramatic, because many of the early hits were not about psychiatry at all. For example, in 1999, 5 of the 10 were nothing to do with manic-depression. One was about the growth pattern of a certain kind of bacteria (they're "bipolar", because they have two poles of growth.)Is the post-2000 spike just a reflection of the fact that people are publishing more papers about bipolar in general? No. Here's a graph showing pediatric bipolar hits as a fraction of all "bipolar disorder" hits for that year. It's been rising for a while and it's now 5%.
Where are these publications coming from? America. Taking the first two pages of PubMed hits for pediatric bipolar, and excluding the non-psychiatric ones, 30 are from the USA, and just 4 are from elsewhere. For "bipolar disorder", it's 13 vs. 25. (This is in terms of the affiliation listed for the primary authors of the study.)
What about paediatric bipolar, the British spelling? It's almost unheard of. There are only 53 PubMed hits in total, as against 564 for pediatric bipolar. Of the first 20 hits, 9 are non-psychiatric, and 3 are from an Australian journal, criticizing the American concept of pediatric bipolar!It's remarkable that the monthly British Journal of Psychiatry has never published a paper about "pediatric bipolar" or "paediatric bipolar": if you search their archives you get just 5 hits, and they are all in the references sections, not the papers themselves. The monthly American Journal of Psychiatry has published 37 papers mentioning "pediatric bipolar", of which 25 are not just in the references, and 10 are in the titles.
So, at least in terms of the literature, pediatric bipolar is overwhelmingly a 21st century American phenomenon. It barely existed before 2000, and it barely exists elsewhere. This corresponds to what some non-American psychiatrists have observed. In The Paediatric Bipolar Hypothesis: The View from Australia and New Zealand, Australian psychiatrists Peter Parry, Gareth Furber and Stephen Allison point out that
Traditionally, bipolar affective disorder has been considered rare in children and uncommon in adolescence ... However paediatric bipolar disorder (PBD) has become a topical issue in child and adolescent psychiatry over the last decade, driven by research in the USA. The proponents of PBD are concerned that the traditional approach to bipolar disorder in children and adolescents is missing a large number of distressed children, whose course of bipolar illness could be ameliorated or attenuated by early treatment.
The number of visits to primary care physicians in the under 20 age group where the diagnosis was bipolar disorder increased from 0.01% in 1994/5 to 0.44% in 2002/3
Soutullo et al. reported that none of the 2,500 children 10 years or younger referred to the Royal Manchester Children's Hospital ... had a diagnosis of mania or bipolar disorder ... A more recent German survey revealed German child and adolescent psychiatrists were largely holding to a traditional stance as only 8% claimed to have diagnosed a pre-pubertal child with bipolar disorder.
The majority of participants (53.4%) said they had never seen a case of pre-pubertal bipolar disorder, whilst a further 28.5% estimated they'd seen only 1 or 2 cases. Only 35 participants (18.2%) estimated having seen 3 or more cases of pre-pubertal bipolar disorder. ... Most participants (83.1%) were of the opinion that bipolar disorder in pre-pubertal children was either "very rare (less than 0.01%)", "rare (less than 0.1%)", or "cannot be diagnosed in this age group".
Peter Parry reports as a conflict-of-interest that he's a member of Healthy Skepticism, who are, in their own words, in the business of "Improving health by reducing harm from misleading drug promotion". I'm sure neither he nor I need to spell out why drug companies might conceivably have an interest in promoting the concept of pediatric bipolar disorder, given the wide range of drugs available for bipolar adults...
Parry, P., Furber, G., & Allison, S. (2009). The Paediatric Bipolar Hypothesis: The View from Australia and New Zealand Child and Adolescent Mental Health, 14 (3), 140-147 DOI: 10.1111/j.1475-3588.2008.00505.x
34 comments:
I don't know the literature in the relevant non-autism areas, so please tell me I'm wrong...
But it seems to me that there is a more general trend towards classifying bipolar and schizophrenia (and possibly depression) as neurodevelopmental disorders, which are present in some form from very early in life, if only they could be spotted.
This creates demands for investigation of very early signs, to allow for very early intervention, on the premise that these conditions can be prevented.
This follows the very established trend in the area of autism, which has now resulted in the funding of autism intervention research targeting young children who are not diagnosable as autistic and may show no currently-known signs of autism at all.
It seems possible that any presumed-to-be undesirable apparent atypicality (and the list can only expand, by leaps and bounds) in young children will become targeted for aggressive intervention on the grounds that this is the only hope to prevent something-or-other.
In 40 years of treating adult patients with bipolar disorder, I do not recall more than a handful with credible onset before age 12.
The acid test for these new diagnoses of childhood bipolar disorder will be follow-up to adulthood. Neuroskeptic, you did not comment on this aspect. What is the evidence to date?
At the same time I should say that when Joacquim Puig-Antich began his seminal biological and drug treatment studies of childhood depression at Columbia in the 1970s
much skepticism was expressed about the diagnoses. These doubts subsided when those patients were followed up by Myrna Weissman. Many had developed clear mood disorder histories, some of them bipolar.
Time will tell.
Michelle: There's certainly a move towards seeing BP and (especially) schizophrenia as neurodevelopmental, and in schizophrenia there is a belief that there are subtle symptoms present - social and emotional difficulties, slightly lower IQ - before the onset of frank psychosis.
However, to my knowledge no-one is saying that such kids actually have schizophrenia, merely that they're showing signs of the developmental problem that will become it one day.
Whereas people are claiming that some kids actually are bipolar - the popular book that you see at the start of the post, "Is your child bipolar?", is by Janet Wozniak who has published dozens of papers on pediatric BP, including the classic Open-label, 8-week trial of olanzapine and risperidone for the treatment of bipolar disorder in preschool-age children. (sic)
It's remarkable that the monthly British Journal of Psychiatry has never published a paper about "pediatric bipolar" or "paediatric bipolar"
Although using those search terms you'd never find one, the BJP has indeed published a study on child bipolar, or at least bipolar symptoms in adolescence, finding that "The participants began to develop major mood episodes in adolescence and not before" and "We did not find evidence of pre-pubertal mania".
In line with your observations about the condition being a phenomenon of American psychiatry, the only paper ever published in the BJP about 'paediatric bipolar' found no evidence for its existence.
Vaugan: Oh yes, I'd read that in fact, I forget it was in the BJP!
BC: I haven't looked in detail at that, I found this study reports that in ADHD kids, "Child Behavior Checklist-Pediatric Bipolar Disorder (CBCL-PBD) score ... > or = 210 (total of attention, aggression, and anxious/depressed subscales)... predicted subsequent diagnoses of bipolar disorder, major depressive disorder, and conduct disorder, as well as impaired psychosocial functioning and higher risk for psychiatric hospitalization."
But if it predicts all those diagnoses equally, that would suggest that "pediatric bipolar" is not a predictor of bipolar, just of psychopathology. (I haven't read the full article.)
Also, if you search for "childhood bipolar" and "childhood-onset bipolar" in the BJP you get three more hits: two case reports (1,2) from the 80s (and you don't write case reports about things you think are common), and one study, from American authors, finding that early onset bipolar is more common in the US!
The trends you plot look rather like that for atmospheric CO2. There's obviously the opportunity for a research grant application there.
Is there any research on whether antipsychotics or mood stabilizers medications are helpful in young children?
Just read a story, Link, that is really scary. These medications are being prescribed to 2 year olds. Depakote was given to a 30 month girl, who died from an overdose. The parents are on trial for first-degree murder.
Why is it considered ethical to prescribe untested (assuming there are no clinical trials of depakote in young children) and potentially dangerous medications to children? At least adults can be assumed to be able to give informed consent.
The recent NY Times Sunday magazine article, "The Americanization of Mental Illness" may be relevant to this discussion.
Ooooh, I have inside gossip on this subject!
A group of child psychiatrists at Cardiff University are in the process of submitting a paper to the British Journal of Psychiatry on this very subject.
They took a sample of 200 kids with ADHD and assessed them for symptoms of pediatric bipolar disorder - one of the claims coming out of America is that the reason us silly foreigners aren't diagnosing PBD is because we're supposedly misdiagnosing them as having ADHD.
Of the 200 kids they found one who showed symptoms of bipolar disorder. And this was a kid who's mother has bipolar.
Not sure when this is being published though.
Anonymous: Indeed it is, I'll be posting about that (and the book that article is based on) soon.
Z: Ooh, nice. I'll keep an eye out for that. Still, pediatric BP proponents could always say that they didn't find any bipolar because they were using unnecessarily narrow criteria... the crux of the debate seems to be whether you can apply DSM-IV criteria for adult bipolar to kids (in which case, it's incredibly rare in kids), or whether you should use broader criteria...
nice post.the site is gives an idea about,"A Brief History of Bipolar Kids".
One of the issues here is that we already know our syndromal labels are actually covering heterogeneous conditions - and it is certainly the case that different age groups can present with similar symptoms that seem to originate from different pathological processes (I'm thinking particularly here of schizophrenia and late-onset variants).
So it could well be the case that what American psychiatrists have decided to label as 'bipolar' is not really connected to adult bipolar disorder anyway. As Bernard says, the acid test is whether these diagnoses predict adult diagnoses of bipolar (although, as we all know, once a diagnosis has been applied it is very difficult to shake it).
Pediatric Bipolar Disorder (PBD) is fraud imposed on american public by unholy alliance btwn pharmaceutical industry and pediatric psychiatric department of MGH in Boston (J. Biederman and Co)
Singlehandedly Dr. Biedrman increased dx of PBD 40-fold! earning more than a million $$ in the process.
Other culprits are Demitri Papolos, MD - the author of Bipolar Child and several "patients/parent" organizations that pushed the cause.
As a result we have an industry of bipolar-ologists and no relief in sight.
Fighting this travesty is tiresome and unrewarding because well financed pro-BPD crowd outscreams any sensible commentary.
It's so disheartening to see the statistics on who is pushing the BP diagnosis and for what not-so-noble reasons. As a parent who has been desperately seeking a diagnosis and treatment for a child with significant emotional and behavioral issues for 5 years, I just want someone to figure out what's going on. The apparent over-diagnosis of BP in kids has gotten so bad that now one of the first things a new specialist tells us is, "I'm very reluctant to say it's bipolar"--when we haven't even mentioned it as a possibility. I think the perception among many doctors is that every parent with a challenging child is looking to label the child as BP and then medicate him/her into submission. Unfortunately, this perception often seems to translate into not taking the extent of the child's true problems very seriously. We have been to 2 major research hospitals and are waiting to get into a third--and no help yet. We've started videotaping some of the typical behaviors, in hopes that this will constitute better "evidence" of what we've been describing. Any thoughts--especially from drs.?
Neuroskeptic,
Re criteria. There are no agreed upon criteria for PBD and the original study that started the whole mess used "two board certified child psychiatrists from MGH" for diagnosis.
besides, there couldn't be any valid clinical diagnosis for pediatric mania because mild emotional fluctuations in children would manifest as full-blown affective disorder in absence of fully developed executive function.
Diagnosis of pediatric bipolar disorder might be entertained to some degree if one or both parents have major affective disorder. Alternatively, given hereditary nature of bipolarity, absence of close relatives with BD cast doubt on disorder in progeny.
Anonymous,
I would not focus on specific diagnosis, bipolar or otherwise, because we don't have treatment for it anyway. Psychotherapeutic treatment exists outside specific diagnoses and pharmacological treatments targets symptoms of systems(circuits) failures, not the diseases (nosological entities)
Systems (circuits) breakage is not specific for a particular diagnosis. In other words, labile/unstable mood can accompany either bipolar disorder, or Tourette's, or schizophrenia, or Autism, etc.
If the system responsible for mood stabilization is faulty then medications should "stabilize" it, they can also enhance inhibitory system (executive function/PFC)regardless of the label or block the influence of destabilizing/activating system (arousal- amygdala). It's a bit more complex than that, but not too complex.
Don't be confused about the labels and FDA approved indications (USA)for meds but together with your smart MD try to deconstruct your son's disorder into components and address these components individually.
I do think bipolar is currently over-diagnosed in pediatric populations in the US, but at the same time, I have personal, anecdotal experience which makes me believe that there are kids with bipolar.
My family has a huge history of bipolar. My grandfather was bipolar, as was his brother. My father has 3 of 9 siblings who are bipolar. My brother is bipolar.
The kids in my family that grow up to have bipolar as adults do seem to be different as kids.
In the people with bipolar that I knew personally as children (my dad's the oldest by a lot) -- 3 out of 4 had symptoms as kids that I would call bipolar.
Those kids had "temper-tantrums" that would go on for hours. These kids would lay in the floor and tantrum for hours. Nothing could stop them and they couldn't stop. They banged their heads into the floor. They broke furniture and windows and ran into traffic. They ran away from school in the middle of the day and would run for ten miles for more.
The kids were normal, most of the time, with the exception of these episodes. IQ scores were normal. Speech was normal. They weren't ADHD. There were other siblings with similar parenting who didn't display that kind of temper.
I STILL wouldn't put any of those kids on a psych drug, if it were my kid. (And with our family history, it might be my kid one day.) I would keep a careful eye on them in their teens and twenties and intervene as soon as they showed signs of bipolar.
Anonymous,
why wouldn't you put a kid on a "psych drug" while clearly realizing that they are danger to self (10-20% suicide rate untreated and more than 50% of substance abuse) and to others (ruining marriages, families, work, driving, etc.)?
Suicide rate alone outweighs all possible side effects of medications.
ML, MD: Hang on, you earlier said that "Pediatric Bipolar Disorder (PBD) is fraud imposed on american public by unholy alliance btwn pharmaceutical industry and pediatric psychiatric department of MGH in Boston" - a not unreasonable conclusion.
But then you say that "why wouldn't you put a kid on a "psych drug" while clearly realizing that they are danger to self (10-20% suicide rate untreated and more than 50% of substance abuse) and to others (ruining marriages, families, work, driving, etc.)?"
Those are reasons to treat bipolar disorder, but if as you say kids don't get bipolar, we shouldn't be treating them for it, surely?
Since when does the amount of published studies determine the actual incidence?
Is PBD hard to diagnose, of course. Distinguishing it from normal adolescence alone is difficult.
Now follow the rise and fall of KCC2 after the initial post natal up-regulation, and you will find at least 2 periods of downregulation. The first coinciding with early childhood amnesia (and terrible twos) and the second with the onset of puberty. Both periods are during grey matter growth spurts. Both have behavioral symptoms.
If PBD is conceptualized as as one of neuronal instability, such waves of neurogenesis will occur more frequently. Along with the behavioral consequences.
See the works of Ei Terasawa, Paul Thompson, Gal Checik and Fred Gauge.
Neuroskeptic,
Thare are no inconsistensies in my reasoning and I would direct you to my other post on this thread where I suggested not to "focus on specific diagnosis, bipolar or otherwise, because we don't have treatment for it anyway." And also "Psychotherapeutic treatment exists outside specific diagnoses, and pharmacological treatments target symptoms of systems(circuits) failures, not the diseases (nosological entities)"
My doubt about pediatric bipolar "epidemic" doesn't mean that the child described by the Anonymus doesn't have the disease. I didn't question the child's diagnosis, but offered suggestions on course of treatment.
Lastly, learning that oil and car companies conspired to keep low MPG cars on the road to jack up their profits won't stop me (and you (I hope) from driving gasoline powered vehicles.
Anonymous,
Fundamental problem with quoted research is lack of objective criteria for pediatric bipolar disorder. Without agreement on diagnostic standards, it's impossible to reconcile different studies.
Some of Paul Thompson's work appear to be closest to clinical experience, but even his studies leave diagnostic criteria for PBD in hands of subjective diagnosticians.
A good post, though.
ML, MD,
I disagree somewhat that we don't have a treatment for it. Yes we do. Lithium. IMO, a self limiting (via transport that does not disrupt the potassium gradient) AD. Yes the clinical management takes more time, but it works better than all the rest. This agent is far to underutilized. See: Effect of abrupt change from standard to low serum levels of lithium: A reanalysis of double-blind lithium maintenance data, as to make it more palatable.
Back to the diagnosis issue. PBD, just like BD suffers from the fact that it we are defining it. A good analogy is one of a car engine that is running roughly. Is the ignition system wet? Is the fuel supply restricted or plugged? There are hundreds of reasons an engine may by running ruff. Yet no mechanic would dare define 'rough running' as a problem. It is, like BD, a cluster of symptoms. The manifestations of the underlying causes will, predictably, be different in a brain that itself is different.
Anonymous,
Lithium doesn't treat PBD but helps stabilizing mood - not the same thing. In psychopharmacology we don't treat the diagnoses, only symptoms (not specific for any particular nosological entity). By analogy, aspirin doesn't treat strep throat but lowers temperature in patients with that disorder.
About your car mechanic analogy:
Disease is a harmful dysfunction , not a symptom. "Engine running roughly" is meaningless until car stops running. PBD is the label broadly applied to all car malfunctions as if a mechanic proclaims that all car problems come from bad transmission (particularly if he only knows how to fix it) without opening the hood.
As I said, we need to educate our public and "mechanics" and not attack power tool industry, even if it tries very hard to sell their products.
it doesn't apply to psychopharmacology that treats dsieases
It's both refreshing and bitter that the medical profession in general and to a lesser extent the field of psychiatry is finally putting an end to this bullshit, to be frank.
Dr. Carroll? Follow-up? I'll give you follow-up.
I was diagnosed and treated by highly-conflicted and incompetent staff with a partners affiliated hospital in MA starting at age 12. I'll spare the dickwads' name as he is a well-knoww child psichiatrist who also works at MGH.
This awful disaster that has become my life actually began in 2000 at the time the diagnosis exploded in the very geographical area where it was invented out of thin air... or possibly in the Johnson and JOhnson Center for the Study of Child Psychopathology, such a bastion of productivity and timeless medical advances.
Anyway, I was put on an SSRI to treat bad OCD symptoms that eventually went away on their own, but it made me maniac, so I got a BP diagnosis and was on 7 meds within a few weeks and then for the rest of my developing years until I said enough.
I've been abused in my home by a sibling, my house was chaotic and my mother has severe psychopathology.
Before becoming a fat, depressed zombie of a child on these cocktails I was a national YMCA swimmer and a straight A student.
Needless to say I do not have Bipolar disorder, I have had many many hospitalizations, a chrnnoic depression on and off for the last 10 years.
I went to college for a year and did well academically, had to drop out for emotional reasons.
If the dickwad psychiatrist had actually assessed my family sistuation and applied appropriate treatments like extensive family therapy, my trajectory might be a lot different.
In addition my body has been a dumpster for dozens of untested drugs that likely have develomental, reproductive, and lasting neurocognitive effects.
Again, the dickwad who f'ed up my care this whole time is still a paid consultant for about a half dozen drug firms, honoraria, "speaker's bureau", especially for Jansenn which is what MGH of course pushed on kids bc of their gross financial arrangment with the company.
Basically, if I had gotten enough therapy early, with additonal family intervention, instead of psychopharmacology, I would probably have a much diff'nt life and probably would be the very successful joyful person Ive always had the potential to be.
And Dr. Carroll, through my numerous travails in hospitals Ive met many former bipolar children my age so I think that should answer your question. These people should be shut down. I hate the entire MGH establishment for this reason. The arrogance and abuse of their patients for money and prestige. Of course thats not everyone but their is a definite culture of that there.
Oh it is so awful for people to tell you you have bipolar disorder when you know you dont, i imagine its like when black people get called the n word or something and you have all that righteous frustration but you may not be in an environment where the validity of your beliefs can be acknowledged. It requires a lot of self-restraint.
My mother had full blown factitious disorder by proxy and now 10 years later she doing it to herself.
So, the incompetent dickwad who poisoned my body and violently and irreprably alterd the trajectory of my life, a child psychiatrist at MGH, a man who is a paid consultant to at least 6 pharmaceutical firms, the dickwad, oh gosh, i dont care, his name is Jefferson Prince,director of "child psychopharmacology" at Northshore medical Center Salem and staff at MGH.
MGH Bipolar Children don't turn out Bipolar. Case Closed.
JC, thanks for your comments. It looks like time did tell in your case. Stories like yours underline why it's important to get the diagnoses right at the front end. Managed care pressures and regimented treatment algorithms don't always promote that.
Cindy-Concerned MOM
I have a 13yr old daughter who seems to be very immature. Developmentally I believe she lags. She lacks common sense most of the time. She doesn't correlate cause and effect well. She can't properly associate wrong choices with consequences. She is weak academically and repeated 3rd grade. Always seems to be barely getting by. I feel her basic skills are hindered or were hindered by what seems like this developmental delay. She looks fine on the outside and is very charming and pleasant but can be very moody at time alternating with elation/manic like behavior. I took her to 3 different Psychiatrists that diagnosed her with Bipolar Disorder and ADHD. I'm concerned about giving her medications for bipolar due to my denial of her being a true bipolar. This doesn't run in my family at all nor does it run on her fathers side. Are there any definitive test to better diagnose Bipolar disorder?
nice blog!
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The information that this article has spurred is wonderful. While I understand that from a medical standpoint many do not feel that children can be bipolar... I would have to disagree. Let me start by stating that my husband, the father of my children, is bipolar. He showed all of the classic signs as a child, was medicated for ADHD which just enhanced the manic episodes. He had a terrible childhood with no real help. No one knew how to help him because he clearly was not a child with ADHD. In his early adult years he went to a psychiatrist to get help in dealing with adult ADHD. The psychiatrist laughed at him and explained that he is so textbook bipolar that he was shocked it took so long for someone to diagnose it.
Our daughter also shows all of the classic signs. She has jumped out of moving vehicles, second story windows, tries to hurt her siblings and does not sleep when not medicated! I believe that children can be bipolar. I knew in my head for years that she was struggling with this disorder. I did not get her help until she cried telling me she wanted to die because she just could not do it anymore. She struggles so hard to keep it together. I believe that she is in fact bipolar. The medication, although it has been difficult to regulate, have made her feel a little more like the other kids. They have reduced raging from 6-8 hours to a mere hour or so. I am not saying that it has been a perfect fix but it has allowed her the opportunity to be like other kids, she has been able to enjoy things other kids enjoy.
It cannot have effect in actual fact, that is exactly what I think.
I'm currently doing a systematic review on the early onset of bipolar disorder in children. I was wondering if there has been any change in your stances over the past 2 years? I know personally I have seen a very real case of bipolar disorder in an 11 year old.
Caitlyn: Well bipolar certainly can have a pre-pubescent onset, but I believe most child psychiatrists outside of the USA think that it's very rare (<5% of cases of bipolar). See my posts on some recent research: 1,2
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