Diagnosis of bipolar disorder in children continues to be controversial. In an article in The New Yorker (April 4, 2007) Jerome Groopman MD, a respected medical writer, raises questions about the over diagnosis of the disorder. He notes that according to one study the diagnosis of bipolar disorder in children under 18 increased fourfold between 1990 and 2000. He quotes former director of The National Institutes of Mental Health (NIMH) Steven Hyman as cautioning: “The diagnosis has spread too broadly, so that powerful drugs are prescribed too widely… We are going to have hell to pay in terms of side effects… You can do more harm than good if you treat the wrong kid.” Hyman goes way too far, however, when he remarks, “Bipolar disorder in children represents the intersection of two great extremes of ignorance: how to best treat bipolar disorder and how to treat children for anything.” [Click here to read "What's Normal? The difficulty of diagnosing bipolar disorder in children" on Dr. Groopman's website.] Psychiatry is not ignorant about treating bipolar disorder, in either children or adults, although the appropriate treatment can vary widely from one person to another. What is more, enormous progress has been made in the diagnosis and treatment of bipolar disorder in children. Progress has also been made in understanding the neurological basis of the disorder.
An editorial in the American Journal of Psychiatry, also in April of 2007, observes that “pediatric bipolar disorder significantly affects the normal psychosocial development of the child and increases the risk for suicide and substance abuse as well as for behavioral, academic, social, and legal problems….” Although estimates of the incidence of bipolar disorder in children are controversial, the editorial observes that “…up to 60% of adults with bipolar disorder report the onset of their mood symptoms before age 20.” What is more, “An average of 10 years elapse before bipolar disorder is diagnosed and treatment begins….” Even more disturbing is the observation that: “For each year of illness, bipolar disorder youths have a 10% lower likelihood of recovery.” In other words, substantial harm can occur if the diagnosis of bipolar disorder is missed in a child , and that is more often the case than not—with an average of 10 years going by before diagnosis and treatment begin. [Click here to read the editorial.]
Nonetheless, Dr. Groopman warns, “the consequences of… treatment can be dire, particularly when parents are unaware of or ignore the dangerous side effects of the medications.” He goes on to cite the dangers of Depakote, Risperdal, and Lithium. But Groopman does not observe that there are alternatives to each of these medications that can avoid these side effects. It is also true that both lithium and depakote have been shown to promote proliferation of stem cells in the central nervous system resulting in neuroregeneration. These medicines have long term positive effects. More importantly, Groopman does not consider the effects of the untreated illness on a child’s developing brain.
[Click here to read "The Mood-Stabilizing Agents Lithium and Valproate Robustly Increase the Levels of the Neuroprotective Protein bcl-2 in the CNS" (1999) by G. Chen, W. Zeng, P. Yuan, L. Huang, Y. Jiang, Z. Zhao, and H. Manji in the Journal of Neurochemistry 72 (2), 879–882; click here to read abstract of "Lithium-induced increase in human brain grey matter" (2000) by G. Moore, J. Bebchuk, I. Wilds, G. Chen, H. Menji in The Lancet, Volume 356, Issue 9237, Pages 1241-1242.]
An article published in June of 2006 in the Proceedings of the National Academy of Sciences (PNAS | June 6, 2006 | vol. 103 | no. 23 | 8900-8905), “Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder,” gives evidence—based on localized images of brain activity—that children with bipolar disorder have a heightened response in areas of the deep brain linked to rage and fear. Moreover, this over activity affects the child’s cognitive function in recognizing and articulating facial expressions. Put more directly, a bipolar child’s increased emotional sensitivity can cause misinterpretation of social circumstances and a decreased ability to talk about their perceptions. The article concludes that in bipolar children an over activity of the limbic system compromises cortical function. Feelings overwhelm perception, judgment, and language. It is just this over activity of the limbic system that is limited by many of the medications used to treat bipolar disorder. [Click here to read the article.]
An earlier study (1998), “A “sticky” interhemispheric switch in bipolar disorder?,” by John D. Pettigrew and Stephen M. Miller, offers evidence that individuals with bipolar disorder may have greater difficulty switching from one brain hemisphere to the other. This difficulty in coordinating the activity of one hemisphere with the other may contribute not only to abnormal alternations of mood but also to problems with visual and motor integration commonly seen in children with bipolar disorder and also to abnormal sensitivity to circadian and seasonal cycles. [Click here to read the article; click here to read an update.]
Overwhelming evidence that bipolar disorder is both neurologically and genetically based makes it more likely than not that biological predisposition exists at birth and that children will exhibit signs and symptoms of the disorder. It is already agreed that those signs and symptoms are different than those appearing in adults and that they appear differently at different ages. The increased diagnosis of bipolar disorder in children takes place within a context of increasing rates of mood disorders at all ages together with an earlier onset of these disorders. This increase has been observed for over ten years. [See "Increased prevalence and earlier onset of mood isorders among relatives of prepubertal versus adult probands,"Journal of the American Academy of Child and Adolescent Psychiatry, April, 1997 by Todd, Richard D.] Although both the appearance and the treatment of bipolar disorder in children can vary widely, diagnosis is not arbitrary and appropriate treatment protects a child’s brain and development.
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