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Linda Biggs

What's In a Name? Mental Illnesses in Children and Adolescents

Pediatric bipolar disorder, like its adult form, involves episodes of mania and depression. Unlike its adult counterpart, however, rates of diagnosis of PBD have risen greatly over the past decade, and its current diagnosis is attended by a great deal of controversy, even among experts in the field. Below I briefly summarize what the diagnosis is, according to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 1994), and describe current controversies in the field about PBD's diagnosis and treatment.

Formal studies have shown that PBD, as diagnosed by the traditional diagnostic criteria, compromises normal functioning and can produce extreme shifts in mood and energy, risky behavior, and interpersonal problems. Historically, it has been believed to be relatively rare in youth, with rates ranging from 0 percent to 1.2 percent (Carlson & Kashani,1988; Lewinsohn, Klein, & Seeley, 1995; Shafferet al., 1996). Investigators using looser criteria, however, describe rates as high as 7% (Carlson & Kashani, 1988). PBD often demonstrates a great deal of co-morbidity and symptom overlap with other psychiatric disorders, such as attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, anxiety, and depression, making it a challenging diagnosis.

According to the DSM-IV-TR, a manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting for at least 1 week. To be diagnosed with bipolar disorder, a youth must experience three of the following symptoms (with expansive mood) or four of the following symptoms (with irritable mood):

>> Inflated self-esteem or grandiosity
>> Decreased need for sleep
>> Pressured speech
>> Flight of ideas or racing thoughts
>> Distractibility
>> Psychomotor agitation
>> Excessive involvement in pleasurable activities that have a high potential for painful consequences

Child and youth with bipolar disorder may also experience formal episodes of depression. Sometimes, symptoms of mania and depression occur together, creating a mixed state that can also be characterized by agitation. Depression is diagnosed when a person experiences five or more of the following symptoms for a period of 2 weeks or longer:

>> Feeling sad or losing interest in activities that were once enjoyable
>> Feeling hopeless and worthless
>> Having decreased energy
>> Having changes in sleep and eating patterns
>> Having psychomotor agitation or retardation
>> Having thoughts of death or suicide

All of these criteria were developed for use in adults and may not adequately represent bipolar disorder in children, and this is where the controversy begins. For example, some investigators maintain that juvenile bipolar disorder is characterized by severe irritability (Biederman et al., 2000), rapid cycling (Geller et al., 1998), and chronicity (Geller et al., 1998), more so than its adult counterpart. Aiming to operationalize the variety of clinical presentations diagnosed or misdiagnosed as bipolar disorder, investigators have developed a system of classifying mania into narrow, intermediate, and broad phenotypes (Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). Standardized rating scales, such as the Young Mania Rating Scale (YMRS; Young, Biggs, Ziegler, & Meyer, 1978; Youngstrom, Danielson, Findling, Gracious, & Calabrese, 2002), may be useful in clinical practice to support diagnostic decisions as well as to monitor treatment response. Although the controversy is still very much with us, a conservative approach (which I believe is most sensible until we have more data) for describing and diagnosing children with bipolar disorder is to carefully understand a patient's psychopathology and to consider a child's developmental level as well as environmental and psychosocial factors.

Families, clinicians, and administrators sometimes find themselves frustrated by the current uncertainty surrounding the diagnosis of bipolar disorder in children and adolescents. For parents, it can be disheartening, especially after one has sought and obtained a diagnosis from one expert, to find that another expert comes to a different diagnostic conclusion. For administrators, the possibility of missed diagnosis or misdiagnosis raises the specter of medical and legal risk if a child is inappropriately diagnosed or treated and a bad outcome ensues.

As in other areas of psychiatric diagnosis, the diagnosis of PBD is not an exact science, and there are, as yet, no firm diagnostic tests, biological indicators, or genetic markers that can be applied to assist doctors in making a diagnosis. Even a family history of bipolar disorder cannot lead one to conclude that a given child has the disorder, if all the DSM-IV criteria are not met. In fact, statistically speaking, a child with severe behavioral disturbances in the presence of a family history of bipolar disorder is more likely to have ADHD, major depression, conduct disorder, or conditions other than PBD. As with psychiatric diagnoses, clinicians must rely on the careful determination of whether a particular pattern of behaviors, emotions, or thoughts is present, and then determine whether the symptoms fit the diagnostic criteria for bipolar disorder or other DSM-IV conditions. These already complex challenges are further compounded in children whose behavior, emotions, and thoughts are continuously changing.

So what's in a "name," or a diagnosis? Strictly speaking, scientifically based medical practice would be impossible without rigorous diagnosis. By putting a name on a common set of medical signs and symptoms, diagnoses offer an efficient means of communication among scientists, healthcare providers, consumers, and policymakers. But this is more than just a simple naming or labeling process. Accompanied by a vigorous program of research diagnoses can be used by doctors to make important predictions about the child's (or adult's) likely response to a particular treatment, the course of the condition, and its eventual outcome.

Thus, careful diagnosis is the backbone of clinical research and the cornerstone of clinical practice. But if a diagnostic term such as bipolar disorder is loosely or inexpertly applied, all the research relevant to that diagnosis may not be applicable to the person for whom that diagnosis has been misapplied, and that clinician (and the family too) may be operating in the dark. And even if a diagnosis is expertly applied, if it is not accompanied by rigorous research to demonstrate its meaning and value, it is essentially a hollow victory for the clinician, child, and family, although short-term relief sometimes comes by having a name for the problem. But a name not accompanied by scientifically grounded understanding of prognosis, treatment choices, or anticipated outcomes is merely a name-nothing more. With a name appropriately applied and a rigorous program of research, we can offer children and families information about outcomes, and treatments that are safe and effective.

Currently, for DSM-IV-diagnosed PBD, research has demonstrated that several treatment options are useful. Typical medications include mood stabilizers and antipsychotics. Children and adolescents usually require medication to control the symptoms of bipolar disorder. Mood stabilizers and atypical antipsychotics can help control mania and prevent recurrences of manic and depressive episodes. Because children and adolescents with bipolar disorder typically present with chronic and complicated symptoms and do not respond sufficiently to treatment with one mood stabilizer, they often require long-term, combination treatment (Carlson & Kashani, 2002; Findling et al., 2005; Geller et al., 2002; Kowatch, Sethuraman, Hume, Kromelis, & Weinberg, 2003). Many of the medications used to treat children with bipolar disorder have Food and Drug Administration indications for adults with bipolar disorder but not for children. However, the FDA has recently approved two typical agents (aripiprazole and risperdal) for the treatment of bipolar disorder.

Also of great value is psycho-education that teaches families about bipolar disorder and its course, prognosis, medication, and management (Fristad, Gavazzi, & Mackinaw-Koons, 2003; Keller, 2004). In this area, several manualized treatments that use a psycho-education-based approach have shown promising results in controlled pilot studies using multifamily psycho-education groups (Fristad, Goldberg-Arnold, & Gavazzi, 2002) and family focused psycho-educational treatment (Miklowitz et al., 2004).

Although a growing amount of research is available to guide clinicians' treatment choices, a good deal of uncertainty remains in the absence of a large body of evidence. To address this problem, experts have worked with family advocacy organizations to develop consensus-based treatment guidelines, which may be helpful in supporting clinical decision making (Kowatch et al., 2005).

So what's in a name? Let the buyer beware! As a field, we must remember that all diagnoses and diagnostic systems are shaped by current norms and values, medical fashions (yes, unfortunately, even diagnoses are suspect, if loosely applied or not based on solid research). Remember, just 40 years ago, almost all severe psychiatric disorders in adults were characterized as "schizophrenia;" our understanding today is much more refined vis-?-vis major depressive disorder, bipolar disorder, and a range of schizophrenia-type disorders. Even conditions such as peptic ulcer, long thought to be a result of excess stomach acid or stress, have been recently re-conceptualized and better understood as principally due to the presence of a particular bacterium, Helicobacter pylori.

This situation is not a cause for despair; rather, it is merely a cause for caution. Yes, investigators are not in total agreement about how to best diagnose PBD, but the arguments are about scientific uncertainties, not about whether such children have severe conditions or not. And when investigators quarrel, almost one thing is invariably certain: The research is not yet definitive, and we must insist on more high-quality research. From this perspective, current issues, such as controversies about whether bipolar disorder is under-, over-, or misdiagnosed in children, should be re-conceptualized as not whether bipolar disorder exists but how it should be diagnosed, how it should be treated, and how it turns out! To get answers to those questions, we need high-quality scientific findings targeted at improving the predictability of our knowledge.

Likewise, we must understand the temporary nature of our current diagnostic systems: Look for-and insist upon-further advances. As one wise child psychiatrist once said to me, "In God we trust . . . but from all others, demand data!" As clinicians and administrators, we can do our part in this process by ensuring the careful use of established diagnostic criteria and monitoring our diagnostic and treatment practices for consistency, predictability, and understandability while avoiding the potential pitfalls of diagnostic fashions or treatment trends in the absence of evidence.

About the Author

Linda Rosenberg is the president and CEO of the National Council for Community Behavioral Healthcare. TNC specializes in lobbying for research toward the diagnosis and treatment of mental illness, including bipolar disorder, in children. Lean more at www.thenationalcouncil.org.

Linda Biggs Interview 11-12-08

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