That's 20 times faster than the growth in diagnoses of adult bipolar disorder over the same decade. Are we only now discovering a huge reservoir of untreated psychiatric illness? Or is there an epidemic not of disease, but of misdiagnosis and overtreatment?
The study that provides this alarming data doesn't answer this crucial question, says study researcher Mark Olfson, MD, MPH, professor of clinical psychiatry at Columbia University Medical Center and New York State Psychiatric Institute.
"We found a striking national increase in the treatment of young people for bipolar disorder: from 20,000 youths in 1994 to 800,000 youths in 2003," Olfson tells WebMD. "The study does not tell us why so many more kids are being diagnosed and treated for bipolar disorder. But it gives us clues."
- Bipolar disorder is often a lifelong condition. More bipolar disorder in children should mean a corresponding increase in adults with bipolar disorder. Olfson says that isn't happening. This means we're either discovering previously unrecognized bipolar disorder in children, or that we're misdiagnosing children.
- Youths diagnosed with bipolar disorder are more likely than adults to also be diagnosed with ADHD (attention deficit hyperactivity disorder).
- Most adults diagnosed with bipolar disorder are female. Most children and teens diagnosed with bipolar disorder are male. "It is my sense that most of these people are boys around age 12, and many have ADHD or at least are treated for that with stimulants," Olfson says.
- During the 10 years covered by the study, the diagnostic criteria for bipolar disorder have broadened. "Many adults and young people who would not have been considered to have bipolar disorder now are," Olfson says.
Definition of Childhood Bipolar Disorder Controversial
What, exactly, is childhood bipolar disorder? It's controversial. Bipolar disorder used to be called manic depression because it is characterized by bouts of depression and bouts of mania.
Mania in adults is characterized by euphoria, grandiosity, irritability, racing thoughts, and frenetic activity. While some experts argue that childhood mania must also exhibit signs of euphoria and grandiose behavior, others say irritability may be the only sign.
"In children, the symptoms of bipolar disorder are very different from the symptoms in adults," Julio Licinio, MD, chairman of the department of psychiatry at the University of Miami, tells WebMD.
In January 2007, the American Academy of Child and Adolescent Psychiatry (AACAP) set out a "practice parameter" acknowledging the controversy. The AACAP's expert panel noted that for both children and adults, doctors are much more often diagnosing bipolar disorder based on individual symptoms rather than characteristic patterns of symptoms.
The AACAP panel noted that there's also debate over whether bipolar disorder in children is even the same illness as bipolar disease in adults. What is agreed on is that bipolar disorder is an increasingly common diagnosis in children -- including preschool children.
"There was a real underdiagnosis of bipolar disorder in children. We've gone to the other situation now," Licinio says. "Some of these children are just irritable and cranky and negative. They get more brittle than manic. And people can mistake juvenile delinquency for bipolar disorder. So there is a potential for this to be really missed."
Treatment of Children With Bipolar Disorder
Olfson and colleagues used data collected annually by the National Center for Health Statistics. The data come from questionnaires given to office-based doctors who directly treat patients. The study compared reports on treatment of bipolar disorder in adults with reports of bipolar disorder treatment of children/teens aged 0 to 19 years.
The Olfson team's report, in the September issue of Archives of General Psychiatry, shows that doctors treat bipolar disorder in youths the same way they treat it in adults: with powerful psychiatric drugs.
In two-thirds of visits, youths diagnosed with bipolar disorder receive mood stabilizers -- most often anticonvulsants such as Depakote. Children are just as likely as adults to be treated with antipsychotic drugs, although children are more likely to receive the newer "atypical" antipsychotics. In six out of 10 visits, patients regardless of age receive a combination of at least two drugs.
"The types of medications they receive resemble those received by adults," Olfson says. "There are real risks associated with misdiagnosis of children with bipolar disorder. These drugs have powerful side effects and their long-term safety has not been established for children."
Worrisome as they are, drug side effects are not the only problem facing children diagnosed with bipolar disorder. There's also the stigmatization of having a serious, possibly lifelong mental illness.
"School personnel may treat the child differently, the options for things like after-school programs and summer camp may be limited, and there may be problems with getting health insurance," Olfson says. "And the children may give up on themselves if they think they have a brain disorder that has no cure. So there is the potential for serious risks."
So what should parents do if their doctor suspects their child has bipolar disorder?
"It can be a devastating thing for a parent to hear," Olfson says. "Rather than overreact, parents should ask how the diagnosis was made. Did the provider talk with the child's teachers? Did the psychiatrist or another doctor look at the child over time? How much information went into this decision?"
Before deciding on treatment, Olfson recommends that parents consult an expert in child and adolescent psychiatry.
Licinio says that while there may be a trend to overdiagnose bipolar disorder in children, there are still many children who would benefit from having their bipolar disorder recognized and treated.