Can small children get bipolar disorder?
Posted Friday 19 March 2010
By Zarathustra of the Mental Nurse blog
Recently I heard something via a friend that alarmed me. An American schoolteacher commented on a 5 year old child in his class who was nodding off into his schoolwork due to being prescribed a combination of quetiapine and risperidone - two atypical antipsychotics. This was because a child psychiatrist had diagnosed him with "pediatric bipolar disorder", or PBD.
The idea of of young children having bipolar disorder runs against the traditional view that bipolar disorder emerges in somebody's teens at the very earliest. PBD isn't a recognised category in either the DSM-IV or the ICD-10, the two main classification systems for psychiatric diagnoses. Despite this, recent years have seen rapid growth in the number of children being diagnosed with PBD in the United States. Glossy websites claim that many of the children currently being diagnosed with conditons such as ADHD actually have bipolar.
Among my colleagues in Child and Adolescent Mental Health Services (CAMHS), professionals are taking sides. You know those arguments people have about ADHD? The ones where one side says, "You're drugging up our kids, you sickos!" and the other side exclaims, "These children need help, and we're giving to them!" Well, the pediatric bipolar debate is roughly similar, except with more shouting and the occasional item of hurled furniture. Some of my colleagues reckon it's the new big thing.
Others insist it's a load of cobblers dreamed up by a vocal clique of American shrinks sucking at the teat of Big Pharma. So far, the "load of cobblers" contingent appear to be be gaining ground.
British child psychiatrists tend to have a different outlook to their American counterparts, making more use of psychosocial interventions (counselling, CBT, parent training, family therapy etc) and less use of medication. Antipsychotics are used comparatively rarely, and the use of more than one antipsychotic in a single child is rarer still. For a five year old who is functioning enough to be in a mainstream classroom (as in the ancedote above) to be prescribed multiple antipsychotics is almost unheard of in Britain.
Diagnoses of PBD are also extremely rare over here. Among the kids being seen by CAMHS in my area, I can't think of a single one who was diagnosed with bipolar any younger than 13. We do, however, have a girl on our caseload who was diagnosed with ADHD in Britain and prescribed methylphenidate. The parents then took her to America where she was promptly diagnosed with PBD and prescribed mood stabilisers and antipsychotics. On their return to Britain, she was re-assessed by CAMHS, found not to have signs or symptoms of bipolar, and switched back to methylphenidate.
It's not just Britain where PBD is virtually undiagnosed. PBD diagnoses are almost exclusively an American phenomenon. Almost all of the research comes out of America too. There isn't a single published study of the prevalence of PBD in Britian. That said, I'm aware of a so far unpublished study in which 200 British children with ADHD were assessed for signs and symptoms of bipolar disorder. Of the 200, only one was felt to show evidence of PBD.
Even in America, concerns are being raised about the extent of the diagnoses. The draft of the fifth edition of the DSM contains a proposed diagnostic category of "Temper Dysregulation Disorder with Dysphoria". According to the LA Times, this has been introduced in order to reduce the number of children being diagnosed with PBD, which the authors insist is given too frequently to children who turn out not to have bipolar disorder when they grow into adulthood. It's good that they've recognised these concerns, but it seems odd that they seem to need to slap a medical label onto excessive temper tantrums in order to do so.
So, what's the truth of it? Given the recent explosion in PBD diagnoses in the States, it'll probably be a few years before we have large scale studies tracking how many of them actually develop bipolar disorder as adults. Personally, I'm strongly skeptical that PBD is anything other than a very rare illness, and I suspect that in many cases it will turn out to be a misdiagnosis of other problems. Either way, I'm of the view that we shouldn't be prescribing powerful (and dangerous) antipsychotics to small children without a clear rationale and an evidence base. Right now we don't have either.
Commenting is now closed.