Children With Bipolar Disorder: Medical Fact or Dangerous Fad?

Oct. 27, 2000 -- A dangerous new trend is on the rise, noted child psychiatrists tell WebMD. Egged on by a batch of popular self-help books, more and more parents are becoming convinced that their children have bipolar disorder -- and even scarier, their doctors are agreeing.

Patients with bipolar disorder, or manic depression, typically exhibit dramatic swings between bouts of debilitating depression and euphoric mania. The lows can be so devastating as to prompt suicide. But even the pleasurable highs -- when no plan seems impossible and no goal unattainable -- can lead to serious trouble when patients cannot keep their often irrational enthusiasm in check.

"Suddenly it's like there's an epidemic of bipolar disorder," Elizabeth B. Weller, MD, tells WebMD. "A lot of children who have behavioral problems such as hyperactivity and conduct disorder are being called bipolar and being given all kinds of medications for bipolarity, without the evidence being there."

Weller, who is professor of psychiatry and pediatrics and vice-chair of the psychiatry department at University of Pennsylvania and Children's Hospital of Philadelphia, presented her research on differentiating pediatric bipolar disorder from attention deficit hyperactivity disorder (ADHD) at the American Academy of Child and Adolescent Psychiatry meeting on Thursday in New York.

In the study, conducted while she was at Ohio State University, Weller's team followed more than 300 prepubertal children hospitalized for psychiatric reasons between 1989 and 1995. They compared those children who had been diagnosed with bipolar disorder and those who had been diagnosed with ADHD.

The team determined that "the bipolar kids were a lot sicker than the ADHD kids. They were really not functioning well -- at school, at home, in the social environment. And they had a lot more family history of [bipolar disorder] than did the kids with ADHD," Weller says. Children with bipolar disorder also displayed more inappropriate emotional responses than did those with ADHD.

Noted child psychiatrist Alvin Rosenfeld, MD, tells WebMD that he doesn't quite know "what to make of the study" because he's "not so sure we know what prepubertal bipolar disorder looks like. How exactly they [made] the diagnoses is not clear because I'm not sure how to diagnose a prepubertal bipolar child." Rosenfeld is the former director of child psychiatry training at Stanford University. Now in private practice in New York and Connecticut, he is the author of four books on child psychiatry, including the current best-seller Hyper-Parenting: Are You Hurting Your Child by Trying too Hard?

Despite his critique of the study, Rosenfeld "agrees completely" with Weller's conclusion that overdiagnosis and treatment of pediatric bipolar disorder is an immediate and growing threat to children.

"If you look at Amazon.com's best-seller list on parenting, there are two or three books on 'the bipolar child'," he says. "I've had five-year-olds referred to me who were supposedly ... diagnosed with [bipolar disorder], and I have colleagues who've seen up to 10 of these kids in a month. It's a scandal." Rosenfeld tells WebMD that the authors of the extremely popular books are "not child psychiatrists and the kids they're describing are not bipolar." Even so, "parents are jumping to conclusions, and the kids are being put on medications they don't need. That's really the issue."

Exactly, says Weller. To date, according to her, none of the drugs being used to treat bipolar disorder has been tested and proven superior to a placebo in good clinical trials. "Why would you expose children to medications for which you don't even know the long-term effects on the developing central nervous system?" she asks. Caution should be the operative word.

Yes, say both experts, the bipolar disorder is real. And yes, it's important to catch it early, as delayed diagnosis and treatment can mean a worse long-term outcome. But there is certainly no pediatric bipolar disorder epidemic. "[Bipolar disorder] affects 1% of the adult population, 1% of the adolescent population, and we don't know, but we guess that it's also 1% of the prepubescent population," says Weller. "So it's there, but the chance of an average doctor seeing a lot of cases is very low."

So why the sudden hysteria? Weller tells WebMD that it's a combination of factors. "Twenty years ago when we first described pediatric [bipolar disorder], no one believed that these kids existed. Now any child throwing a severe tantrum is shipped to the doctor to see if they are bipolar. Parents are desperate to get help, and clinicians are willing to do whatever it takes to get these kids to settle down."

And the current system isn't helping, she says. "With managed care, doctors can't possibly take the time they need to get to the bottom of a child's behavioral problems, and you can't make the proper diagnosis in the allotted one or two hours." Furthermore, some doctors may be stepping outside the bounds of their expertise. "There are really very few experts in this field," Weller says. While "follow-up can be done by a less-experienced doctor," a pediatric bipolar diagnosis should always be made by a specialist.

"My recommendation is that we be very careful," says Rosenfeld. "There are young kids that carry a biological vulnerability for bipolar disorder, and hopefully in the future we'll be better able to distinguish them. What we need right now is public calm, so we don't overdiagnose this and put kids on medications that are really contrary to their best interests."