Doctors for years believed that the onset of a mental illness called bipolar disorder could only begin in early adulthood. But in 1995 two psychiatrists observing children in a psychiatric clinic found that children could exhibit symptoms of the disorder, and doctors began prescribing medications approved for adult use to young children.
According to “The Diagnostic and Statistical Manual of Mental Disorders,” which professional psychiatrists use in order to look at their patient’s symptoms and diagnose their illnesses, bipolar disorder, also known as “manic depression,” is characterized by mood swings between two different, intense states — a “manic” phase in which the patient is hyperactive, shows reckless behavior, acts grandiose, and has racing thoughts, and a “depression” in which the patient is sad, lacks energy, has difficulty concentrating, and can even be suicidal. The length of time that a manic or depressive episode usually lasts is at least one or two weeks.
New findings
In 1995 psychiatrists Dr. Joseph Biederman and Dr. Janet Wozniak were observing children with attention deficit hyperactivity disorder in a psychiatric clinic at Massachusetts General Hospital, the primary teaching hospital of Harvard Medical School. Attention deficit hyperactivity disorder — the most commonly diagnosed childhood behavior disorder, which affects three to five percent of school-aged children — is when kids have problems with inattentiveness, over-activity, and impulsivity.
Doctors Biederman and Wozniak found, however, that some children were having periods of extreme aggressiveness, depression, or anger, and were not getting better by taking stimulants, which are psychoactive drugs that improve concentration and focus for sufferers of the disorder.
Dr. Biederman felt that there was a portion of the kids in his clinic whose problems with anger seemed to go way beyond normal attention deficit hyperactivity disorder. He and Dr. Wozniak observed these children more closely and saw kids who continued to struggle with intense, uncontrollable outbursts of anger — violent hitting, screaming, and kicking — even after they passed through their preschool years.
While Dr. Wozniak believed children suffering from attention deficit hyperactivity disorder had difficulty with impulse control, she thought that the other kids dealing with difficult-to-treat attention deficit hyperactivity disorder had serious mood problems, which could be defined as bipolar. She wrote up her observations in 1995, in a now-famous paper in which she proposed that some of the kids originally diagnosed with attention deficit hyperactivity disorder were actually bipolar. Her paper won awards and many physicians believed her insights helped transform their practices.
Dr. David Shaffer, professor of Psychiatry and Pediatrics at Columbia University Medical Center, explained the findings.
“The defining feature of [adult] manic-depression was that it was episodic. You had episodes of depression and episodes of mania and episodes of normal mood, and that was really [bipolar disorder’s] defining characteristic,” he says.
According to Dr. Shaffer, the kids Dr. Wozniak described rarely, if ever, had these kinds of week-long or month-long episodes. In order to make these children fit the traditional concept of bipolar disorder, Dr. Wozniak and Dr. Biederman made the argument that the children experienced these episodes in a different context.
“They said, maybe in childhood the episodes would be very brief and very frequent,” says Dr. Shaffer. “These are called ‘ultra diem,’ you know, ‘many times a day.’ If you regarded every time children changed their mood, every time they lost their temper or became over excited, as a mood episode, then they were really being misdiagnosed and were really cases of bipolar disorder.”
Critics countered that bipolar disorder should look the same in kids as in adults, and that there were bipolar adults who did not suffer uncontrollable anger issues when they were younger. Nevertheless, the pediatric bipolar disorder diagnosis took off.
Controversial prescriptions
Once psychiatrists learned they could diagnose children as bipolar, the number of cases of children with the illness exploded. Based on a study published in the Archives of General Psychiatry that measured national trends in outpatient visits that resulted in a diagnosis of bipolar disorder, there was a 4,000-percent increase in the number of children diagnosed with bipolar disorder from 1995 through 2010. Suddenly, children with attention deficit hyperactivity disorder, who were becoming more agitated by taking stimulants, were being treated with antipsychotic medicines, which adults took for bipolar disorder.
“The initial reports from Joseph Biederman and Janet Wozniak started a very controversial period when kids started getting antipsychotics all over the country for disruptive behavior,” stated Dr. Jess Shatkin, an associate professor and director at New York University’s Child Study Center.
Consequently, some doctors began prescribing to children a new breed of antipsychotic medicines that had just come onto the market in 1993 — Geodon, Zyprexa, Abilify, Seroquel, and Risperdal.
Antipsychotic medications are primarily used to manage psychosis, which is when a patient loses touch with reality by having delusions or hallucinations that are often caused by schizophrenia or bipolar disorder. Some physicians, on the other hand, found that when the kids with difficult-to-treat attention deficit hyperactivity disorder took these medications, they seemed to settle down and had fewer aggressive outbreaks.
The U.S. Food and Drug Administration approved the use of antipsychotics in youth for treating bipolar disorder, schizophrenia, Tourette’s syndrome, and irritability stemming from autism. Other physicians, nevertheless, began in the mid-1990s to prescribe these powerful drugs to young children and adolescents to treat conditions such as attention deficit hyperactivity disorder, anxiety, and insomnia.
In a 2008 study conducted at the University of North Carolina-Chapel Hill’s School of Public Health, two doctors found that patients under 19 years old accounted for 15 percent of antipsychotic drug use in the U.S. in 2005, compared with seven percent in 1996.
According to Stephen Crystal, a Rutgers University professor who studies the drugs, more than 70 percent of the antipsychotic use in young children and teenagers has been for off-label mental disorders, like attention deficit hyperactivity disorder, a nonpsychotic condition. In other words, the doctors were prescribing these drugs to treat illnesses that the Food and Drug Administration did not approve the medications to be used for.
“In 2010 antipsychotics were one of the most prescribed classes of drugs in the United States. That’s remarkable. If you had told us 10 years ago that antipsychotics would soon be one of the most prescribed medications in the U.S., we [psychiatrists] wouldn’t have believed you,” Dr. Shatkin explained. “Antipsychotics are being increasingly used because so many doctors, most often non-psychiatrists, are prescribing them for sleep, anxiety, agitation, irritability, and to augment an anti-depressant. These medicines are expensive and have great promise, and they also have significant side effects and should be used with great caution.”
Unfortunately, the children who have benefited from taking the drugs have also often suffered many documented side effects. In 2009 the Journal of the American Medical Association conducted a study of young children and adolescents from ages 4 to 19. These patients took four different antipsychotic medications.
In less than 12 weeks the young patients added eight to 15 percent to their body weight after taking the pills. The study concluded that when children and adolescents took certain antipsychotic medications, they risked rapid weight gain and metabolic changes that could lead to diabetes, hypertension, and other illnesses.
The two most severe side effects from taking antipsychotic drugs are a life-threatening nervous system problem called neuroleptic malignant syndrome, and an uncontrollable movement problem called tardive dyskinesia. One mother recounted that her son had taken an antipsychotic medicine for three months before he experienced tardive dyskinesia.
“The muscles in his face were contorted and he looked like a different kid, like frozen in a way,” she said. She complained that the doctor who prescribed the medication had never even mentioned the side effects to her.
There is also a decade-long history of lawsuits against pharmaceutical companies that manufacture antipsychotic medications by the patients who use them and experience unreasonably dangerous side effects. Patients also sue the pharmaceutical companies, pharmacies, and physicians for not providing sufficient warnings or instructions regarding the use of these drugs.
Future of disorders
“The Diagnostic and Statistical Manual of Mental Disorders” does not address pediatric or adolescent bipolar disorder in children, since it was published in 1994, one year before the controversial Massachusetts General Hospital study. An updated manual to be published in May 2013 will define bipolar disorder in children, but psychiatrists have insisted on including a new term for children who do not classify as bipolar.
The newly proposed category is called temper dysregulation disorder, which is seen as a brain or biological dysfunction but not necessarily a lifelong condition. Kids who can be diagnosed with the condition are between the ages of 6 and 18 and have temper outbursts three or more times a week that are grossly out of proportion in intensity or duration to the situation.
By adding this new entry, the American Psychiatric Association is trying to help curb the use of the pediatric bipolar label, which is a lifelong label that some physicians seem hesitant to diagnose in young children.
However, critics think temper dysregulation disorder, also referred to as disruptive mood dysregulation disorder, is too vague a diagnosis and will turn temper tantrums into mental disorders. Its defenders, though, believe there are irritable kids who get excited and overreact, most likely by having tantrums, and whose parents and teachers have trouble dealing with them. If these children are diagnosed with disruptive mood dysregulation disorder, they won’t be labeled bipolar, which, according to proponents of the use of the term, can often lead to stigma and the likelihood of taking powerful drugs.
Allison Plitt is a freelance writer who lives in Queens with her husband and daughter. She is a frequent contributor to NY Parenting Media.
