Why are more and more children being diagnosed with bipolar disorder?
Ross Greene's parenting book The Explosive Child begins with a particularly vivid example of inflexible behavior. One morning, 11-year-old Jennifer finds six waffles in her family's freezer and decides to toast three for breakfast and save the rest for another day. When her 5-year-old brother enters the kitchen and also wants waffles, Jennifer refuses to relinquish the ones left in the freezer and flies into a screaming rage. Their mother is unable to calm her. Jennifer shoves her out of the way, grabs the waffles from the freezer, and stalks off to her room.
Various best-selling advice books give their own labels to children like Jennifer. Rex Forehand and Nicholas Long go over strategies for dealing with tantrum-prone tots in a book called Parenting the Strong-Willed Child. Michael Bradley delivers a less nuanced diagnosis in his book's title: Yes, Your Teen Is Crazy!Stanley Turecki called his classic work The Difficult Child, while Perri Klass and Eileen Costello named their book and its subjects Quirky Kids. And psychiatrists have their own set of terms: opposition-defiant disorder, intermittent explosive disorder, conduct disorder, and so on.
About a decade ago, one more label found its way into the diagnostic basket. Some doctors began to point out that episodic outbursts like Jennifer's waffle meltdown reminded them of the periodic highs and lows of manic depression, now known as bipolar disorder. A psychiatrist named Demitri Papolos and his wife, Janice, published a book called The Bipolar Child in 1999, the same year that a group of parents who had met on the increasingly-popular "BPParents listserv" formed the Child and Adolescent Bipolar Foundation. Pretty soon, many easily frustrated and chronically inflexible children were receiving a label previously reserved for adults. From 1994 to 2002, the number of children with the diagnosis increased 40-fold.
With pediatric bipolar on the rise, the mainstream research establishment decided to investigate. In 2000, the National Institutes of Mental Health director Steven Hyman (now Harvard University's provost) convened a "roundtable" of 19 psychiatrists to determine whether the use of "bipolar disorder" for young children was appropriate. The group opined that the disorder exists in children but offered no practical advice on how to diagnose or treat it.
This vague but ominous report encouraged a mini-industry in ways to identify the condition. "Life with your child is chaotic," begins the Harvard psychiatrist Janet Wozniak in her 2008 book, Is Your Child Bipolar? "A simple request might trigger a violent outburst, like the time she heaved a rock through a window when you asked her to set the table for supper," she explains, describing the first of many cases in which the answer to her titular question is yes. The Juvenile Bipolar Research Foundation provides a 65-item online test with questions like, is your child "very intuitive and/or very creative"? Is he "intolerant of delays"? According to the survey, these characteristics could suggest bipolar disorder. (Or it could be "temper dysregulation disorder with dysphoria," yet another label that might soon be added to the list, suggesting a sort of bipolar lite.)
All this has led to even more diagnoses, a putative epidemic of bipolar among the nation's children, and a corresponding increase in the pediatric use of antipsychotics, mood stabilizers, and other drugs often used to treat bipolar adults. More than 8,000 children in Massachusetts are prescribed antipsychotic medications like Zyprexa, for example, and the figure doesn't include stimulant drugs like Ritalin or Adderall. That's worrisome since, according to a British government review, the evidence behind drug treatment for the condition in kids is "extremely limited," and several drugs cause major weight gain (roughly 20 pounds in two months on average), hormone problems, and other side effects.
But criticizing widespread proliferation and drug treatment of pediatric bipolar disorder misses the important underlying problem. Normal families don't seek out stigmatizing labels and give their kids scary drugs for the hell of it. They do these things because they are at wit's end. Kids like Jennifer who violently melt down over the allocation of waffles have a problem that's every bit as disabling and damaging to families as a heart defect or blood disorder. A serious diagnosis like "bipolar" validates their extraordinary pain in a way that "difficult" or "strong-willed" or "quirky" just doesn't. Bipolar disorder is the big tent that brings people together—and allows some to access expert help.
In her recent book We've Got Issues, Judith Warner explains how we reached this desperate situation in child psychiatry. On the one hand, she argues, science has made solid advances in treating attention problems, dyslexia, autism, and many behavior problems in children. And yet the mental health system is so fragmented, variable in quality, and frankly unfair to those without money that "there are virtually no guidelines, no gatekeepers—other than the insurance companies, who essentially create protocols for care according to what they will pay for."
Darshak Sanghavi is Slate's health care columnist. He is chief of pediatric cardiology and associate professor of pediatrics at the University of Massachusetts Medical School as well as the author of A Map of the Child: A Pediatrician's Tour of the Body. Follow him on Twitter.