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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.
Zarathustra
10 Comments
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It is a fascinating debate.
I have no medical background but I am a 25 year old Bipolar sufferer. With hindsight there are certainly some traits that I displayed at a young age which can be seen post-diagnosis as indicative. At about 10 my doctor thought I may have been depressed but it was something that she discussed with my mum and they just agreed that it was something to keep an eye on.
I do think that learning difficulties and some mental health problems such as ADHD and Autism are apparent in children from a very young age. However, when it comes to personality and behavioural disorders, I don't believe it is of benefit to a child to label them that young. The personality of an individual is certainly not developed until after adolescance and even the physical formation of the brain goes through huge change at that age. To prescribe medications that will interfere is potentially dangerous and where does it end?? Children can misbehave or behave 'oddly' because of their diet, their environment, how much sleep they have had, the list goes on. By the same token, a childs mood and behaviour can be altered with these things.
America seem to have been overtaking the UK for years in the prescribing of such drugs and I have to say, I don't think it is a route I would like to see us go down.
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In America there trend is quite frightening and there are cases of children under the age of 5 being treated with antipsychotics. Antipsychotics create illness and reduce life expectancy. That's well established. They also interfere with the development of the brain so using this strong chemicals may change the way a child's brain develops.
Its unethical to treat behaviour in children in such a way. Psychosocial interventions offer the chance to save children from illness caused by antipsychotics, dependence on drugs and creating organic and psychosocial problems in adulthood through
the use of these drugs during a vitally important stage of development.Its important to remember that antipsychotics are also know as the "chemical cosh" and they are a tool misused for behavioural control when a society can't accept that some kids can be loud, obnoxious and challenging so they call normal childhood growing experiences an "illness" when it isn't really an illness. Its just being a kid.
The nuance of temper dysregulation syndrome versus paediatric bipolar disorder versus "just being a kid growing up in an unaccepting society disorder" is of little importance weighed against the treatment options. If all three end up with the prescription of antipsychotics instead of safer alternatives then it really doesn't matter what its called. There are psychosocial alternatives but they don't have multibillion dollar research and marketing budgets. They're the safer alternative but they're not as easy to use or as convenient as popping a pill. Psychiatry is happier to have the quick fix irrespective of the ethical and moral reasons to use psychosocial interventions as is seen time and again in practice in the UK and the US.
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I have an 8 year old who has diagnoses of Asperger's, ADHD, OCD, hears voices and now also PBD. He is on methylphenedate and Atomoxetine at maximum doses and is still displaying HUGE mood swings which everyone (including him) is really struggling to deal with. The psychiatrist says there are no other options available really other than a trial of risperidone which we are reluctant to try. A recent withdrawal of the atomoxetine really did seem to trigger a HUGE mood shift and whereas he was previously stable he is no richoceting off the walls emotionally all day long, running away and threatening to kill himself. I hear what the Blog is saying here but what else IS there? :(
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I felt sick when I read that a 4 year old in the US was killed by an overdose of antipsychotics after being diagnosed with 'juvenile bipolar disorder'. Her mother is on trial for murder. (See New Scientist www site).
These are powerful, dangerous drugs - which cause dangerous sideeffects. They should not be prescribed to children.
Twins plus two above - please please be careful. The withdrawal symptoms can be huge, -
You asked the question
Can small children get Bipolar disorder ?
the answer is yes
for small children grow into adults.
I once was a small child who had more problems than I would have liked , but those were the days when i just was a bad boy I do not believe in giving drugs to children for the sake of it , but i do believe in naming a condition and try to understand it. If a child is diagnosed at 5 as bipolar at least the child can have counseling rather than blamed as many are.A illness does not go away because your scared to name it, mental illness needs to be undestood. 5 or 55 -
TwinsPlusTwo , was the atomoxetine withdrawn slowly over a long time or stopped suddenly/ over a very short period of time? It may be 'withdrawal' if your child has been on it a long time, and a very gradual tapering down of the dose over a long time is the safest way to go.
[this is just my opinion and although I am a medically qualified doctor training in psychiatry in the UK, I am relatively junior and you should discuss this with your child's doctor of course]
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I think there are many different issues here:
- can a child have bipolar disorder?
- are children with other conditions misdiagnosed as bipolar?
- are healthy children diagnosed as bipolar?
- what medications should be used in children and when?As for the first of my points, to some extent we have the opposite problem here. Doctors seem to believe that your brain suddenly changes once you turn 18 and before that any signs of mental health problems are not serious. I've even heard a psychologist say a girl who tried to kill herself was not mentally ill because she was a teenager. While some chaos is anticipated in adolescence, we would not survive as a species if we regularly killed ourselves in our teenage years! Child and adolescent mental health does need to be taken seriously. The suffering is just as real. I have seen cases in the UK where it was taken seriously, and I have also seen this mad overdiagnosis over here.
It's the medication thing that scares me. These drugs are not designed for young children. I realise sometimes medication is indeed necessary, as I've tried to say above, but I'm very sceptical that it's that necessary to prescribe it so often, so young, and in such high dose or use multiple drugs, like is done in the US. I don't really see any signs of the same thing happening here in the UK, as we all seem horrified by it!
I've noticed from forums for autistic people that a lot of American autistic kids are labelled 'bipolar'. Autistics (like myself) have trouble understanding their mood and therefore regulating it. There's some overlap between many conditions - that doesn't mean we need to be labelled with all of them!
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I'm that friend of Z's. Yes, this child was 5 and in the teacher's opinion was that the kid was acting out because his parents were going through a messy divorce. So they brought the kid to the doctor and were told he was bipolar, take these meds.
I don't like the sound of that.
I too am bipolar and my depression started at age 10. So I'm not one of these people who think children can't be mentally ill. However, the characteristic mood swings and mania didn't hit til puberty 3 years later. While I know a very small number of young children DO suffer psychotic symptoms pre-puberty, but they seem to be a lot rarer in the UK than in the US if you look at diagnostic and prescribing habits, for example. Funny, eh?
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I have no medical training, but the thought of a young child of five or so being placed on anti-psychotic drugs disturbs me very much.
I have worked with children diagnosed with ADHD, and noticed that those children were invariably of a high level of intelligence,aware of the drugs they were taking, and given the choice, wouldnt take them.
I'm very sceptical of the whole thing.
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There are obviously certain brain conditions that require medication, such Parkinsons, Alzheimers, Epilepsy , etc, but the huge number of spurious disorders emanating from the psychiatrists reference manual, the DSM, is big pharma's cash cow. That would be the same DSM compiled by an APA team with drug industry connections/enrichment/corruption. While marketing propaganda is taken to extraordinary new heights through disease mongering advertising, ghost written articles, 'inducements' for healthcare professionals, patient group funding and the 'burrying' of adverse clinical trials. Drug regulating is inadequate at best, with both american (FDA) and Uk (MHRA) regulators blighted by political interference, inspired by big pharma lobbying and the wholesale reliance of bias trial data supplied by the industry. The US healthcare system is a puppet to big pharma's profit driven strategy, while the UK is only partially immune because of NHS fiscal caps. Parenting is tremendously rewarding but nobody said it was easy, so don't buy into this 'pop a pill' mentallity; chemicals belong in the laboratory not in the brain.
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