Diagnosing mental illness is a tricky and convoluted business, particularly in children. A psychiatrist cannot draw blood or perform EKG’s to determine what mental malady plagues his or her patient. It is this inherently labyrinthine nature of psychiatric diagnosis that has led to the alleged explosion of pediatric bipolar disorder. Researchers estimate that “the number of visits to a doctor’s office that resulted in a diagnosis of bipolar disorder in children and adolescents has increased by 40 times over the last decade.”
Symptoms of bipolar disorder oscillate between episodes of mania, in which a person is some combination of restless, hyperactive, impulsive, and/or angry, and depressive periods. However, the symptoms seem to differ in children, and are often classified under the broad category of “Bipolar Disorder, Not Otherwise Specified.” Dr. Allen Francis, chair of the DSM-IV task force, observes that, “Most kids who now get the diagnosis have non-episodic temper outbursts and irritability–not the classic mood swings between mania and depression.”
So what does all this mean? Have some virulent genetic or environmental factors caused a substantial increase of bipolar disorder in vulnerable children? Or is it simply being misdiagnosed? Research points to the latter. For instance, one important fact to consider is that, “the diagnosing and medicating of infants, toddlers, pre-schoolers and thousands of primary schoolers with bipolar disorder is a phenomenon virtually confined to the USA.” It seems far more likely that social and cultural factors have played into the over-diagnosis of this disorder in the United States, as opposed to the unique existence of many legitimately bipolar children in one country alone.
In the past several years, some of these social and cultural factors have been identified.
It began with “’thought leading’ researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way.” The pharmaceutical industry only exacerbated the phenomenon by encouraging and advertising the use of drugs usually used to treat bipolar disorder in adults – namely lithium and anticonvulsants – to be prescribed “off-label” to treat symptoms in children.
A final compounding factor are the circumstances under which most doctors work: “Many doctors, especially in primary care, practice under extremely difficult conditions… that don’t really allow for careful evaluation. They may also have little training or interest in the fine points of psychiatric diagnosis and get more of their ‘continuing medical education’ from drug company hype…” Indeed, Dr. Mark Zimmerman conducted a study in which 700 volunteers filled out questionnaires indicating if they had ever been diagnosed with bipolar disorder. 20% apparently were diagnosed at some point. They then interviewed the subjects using the Structured Clinical Interview for DSM-IV. What they found was that fewer than half of those who were previously diagnosed met the actual DSM criteria for any variation of bipolar disorder.
The consequences of the over-diagnosis of pediatric bipolar disorder can be felt for a lifetime. The long-term effects of heavy duty mood stabilizers and anticonvulsants on a child’s developing brain are not well-documented. Further, once labeled as bipolar, a child will inevitably face the stigma attached to this currently incurable disorder.
The creators of the DSM-V addressed this issue by creating a new diagnosis, known as Disruptive Mood Dysregulation Disorder (DMDD). The diagnostic criteria are as follows: The child must exhibit severe outbursts of anger 3+ times a week for at least a year. Their mood must be noticeably irritable on a daily basis for at least a year. The onset must occur before the child is 10. In the DSM-V fact sheet for DMDD, available for free online, they explain that the research “pointed to the need for a new diagnosis for children suffering from constant, debilitating irritability. The hope is that by defining this condition more accurately, clinicians will be able to improve diagnosis and care.” A hope that we, too, share.