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."
Insurers stepped in as gatekeepers because access to psychiatrists had to be limited. Why? For every 11,000 American children—of whom at least 1,000 to 2,000develop a mental health disorder—we have only a single pediatric psychiatrist. There simply aren't enough doctors around to provide the key treatment for explosive behavior: face-to-face time for cognitive and behavioral therapy. Just getting an appointment with a good child psychiatric expert in many parts of the country can take six to eight months.
To get attention from the dysfunctional and overburdened mental health care system, some embarked on an arms race for more dramatic-sounding diagnoses. (Many insurers, for example, won't cover old-fashioned diagnoses like "conduct disorder," but will cover the more serious-sounding bipolar disorder.) In addition, there was a strong incentive to expand drug therapy because giving pills is less labor-intensive than cognitive and behavioral therapy. The perverse result: Kids get more and more disturbing labels and medications.
In June, the American Academy of Pediatrics suggested various ways to improve mental health care for kids, such as increasing the number of child psychiatrists and constructing a more comprehensive care system. How might the landscape look if parents weren't forced into labeling kids as bipolar, and instead those kids were treated by competent, accessible therapists with the necessary time and compensation to deliver high quality care?
Ross Greene, the author of The Explosive Child, outlines one sensible model. He shies away from labels and instead focuses on what he calls "lagging skills." Outbursts, he argues, arise from developmental delays in three areas: flexibility, frustration tolerance, and problem solving. "Kids," he told me, "do well if they can." He spends a lot of time weaning his patients off multiple medications—some are taking almost a dozen of them when they show up in his office—and teaches them behavioral strategies instead. (Every now and then, he does recommend medications but only for very specific issues.)
Several child psychiatrists with whom I spoke endorsed variations of this theme: Much of the debate around bipolar disorder in kids is fixated on quixotic attempts to shoehorn complex behaviors into neat labels instead of studying and treating the various complex symptoms themselves, like inflexibility, irritability, and anxiety. We now have great behavioral tools for relieving those symptoms. But so long as the right resources are only deployed for those children who can score a label like "bipolar disorder," we're doomed to an endless cycle of coming up with new names for old problems.