Bipolar Kids: You Read It Here First

By Neuroskeptic | June 17, 2011 7:25 am

Last year, I discussed the controvery over the proposed new childhood syndrome of “Temper Disregulation Disorder with Dysphoria” (TDDD). It may be included in the upcoming revision of the psychiatric bible, DSM-V.

Back then, I said:

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder… many people agree that pediatric bipolar is being over-diagnosed.

So we can all sympathize with the sentiment behind TDDD – but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less “strategic” purposes?

Now, a bunch of psychiatrists have written to the Journal of Clinical Psychiatry to express their concerns over the proposed diagnosis. They make the same point that I did:

We believe that the creation of a new, unsubstantiated diagnosis in order to prevent misapplication of a different diagnosis is misguided and a step backward for the progression of psychiatry as a rational scientific discipline.

Although they go into much more detail in critiquing the evidence held up in favor of the idea of TDDD. They also point out that it is rather optimistic to think, as some people apparantly do, that if we were to diagnose kids with TDDD, as opposed to childhood bipolar, we’d save them from getting nasty bipolar medications.

As they say, the risk is that drug companies would just get their drugs licensed to treat TDDD instead. Same drugs, different label. It would be fairly easy: just for starters, there are plenty of sedative drugs, such as atypical antipsychotics, which would certainly alter or mask the “symptoms” of TDDD, in the short term. Doing a clinical trial and showing that these drugs “work” would be easy. It wouldn’t mean they actually worked, or that TDDD actually existed.

They also point out that the public perception of child psychiatry has already been harmed by the proposal of TDDD, and would suffer further if it were to become official.

Well, of course it would, and quite rightly so. That would be a sign that child psychiatry is so out of control that, literally, the only way it can stop diagnosing children, is to diagnose them with something else!

The same issue of the the same journal features another paper, claiming that “pediatric bipolar disorder” has a prevalence rate of 1.8%, and that rates of diagnosis of childhood bipolar are not higher in the USA than elsewhere, contrary to popular belief based on evidence.

Their data are a bunch of epidemiological studies on bipolar disorder. One of which included children up to the age of…21. The majority included kids of 17 or 18.

So, er, not children at all, then.


The older the “children” in the study, the more bipolar that study found. Everyone knows that bipolar disorder typically starts in late adolescence. That’s the orthodoxy and it has been since Kraepelin. It’s right there at the top of the Wikipedia page. That’s not pediatric bipolar, that’s just normal bipolar.

All the recent controversy is about bipolar in children. As in, like, 8 year olds. Yet this paper is still titled Meta-analysis of epidemiologic studies of pediatric bipolar disorder”. The senior author on this paper also signed the paper criticizing TDDD.

This, then, is the state of the debate over the future of our children.

P.S. I’ve just noticed that in the latest draft of DSM-V, TDDD has been renamed. It’s now called “DMDD“. What’s next? DUDD? DEDD? P-DIDDY ?

ResearchBlogging.orgAxelson DA, Birmaher B, Findling RL, Fristad MA, Kowatch RA, Youngstrom EA, Arnold EL, Goldstein BI, Goldstein TR, Chang KD, Delbello MP, Ryan ND, & Diler RS (2011). Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the DSM-V The Journal of clinical psychiatry PMID: 21672494

Van Meter AR, Moreira AL, & Youngstrom EA (2011). Meta-analysis of epidemiologic studies of pediatric bipolar disorder. The Journal of clinical psychiatry PMID: 21672501

CATEGORIZED UNDER: 1in4, drugs, mental health, papers
  • http://www.blogger.com/profile/05660407099521700995 petrossa

    Job creation. Hey one has to make a buck. The more disorders, the more treatments, the more money. You can't blame them for trying.

    Just as most children diagnosed ADHD are imo just spoiled brats. But go tell that to the incompetent parent. ADHD sounds much better, that way it's not their fault.

    What else is new.

  • http://www.blogger.com/profile/05026223483117357541 usethebrainsgodgiveyou

    I have a son with ADHD. He is not a spoiled brat. He's a little jerk. Ahh…sometimes. I think smart-ass fits him better, though.

    I wouldn't trade him for a sit down and be quiet kid, even if one existed.

    He used ritalin all through 8 grades, when we started homeschooling, like magic, no more ritalin. Before you dis a homeschooler, you've got to realize most of their kids don't fit the mold, and would probably be drugged. Sad state of education, 2 year olds are getting hit.

    It's the demonization of childhood. Children will be seen and not heard. And the G.d. schools still fail…

    Go figure.

  • Anonymous

    Child psychiatry is out of control… you would have to be nuts to entrust your child's mind to a psychiatrist.

  • Anonymous

    The new manual will be called DSM-5, not DSM-V

    http://thoughtbroadcast.com/2011/06/08/i-want-a-dsm-wiki/

  • http://www.blogger.com/profile/05026223483117357541 usethebrainsgodgiveyou

    Thanks for this article. Our kids need help to just be kids.

  • http://www.blogger.com/profile/00881456420133111695 Healing

    People like using huge theoretical terms and make the things complicated. Children do suffer due to such wars of words. I agree that child psychiatry is somewhat out of control. Can someone propose a way to bring it under control?

  • http://www.blogger.com/profile/05660407099521700995 petrossa

    I offer my sincerest apologies to all parents whose spoiled brats aren't spoiled brats but just smartasses ;)

  • http://www.blogger.com/profile/05026223483117357541 usethebrainsgodgiveyou

    Damn straight, petrossa…damn straight!!

  • http://www.blogger.com/profile/06832177812057826894 pj

    You get the same pressures in general adult psychiatry – people present with a problem, grumpy adult with shit life, moody kid, its quite similar. And we're now seeing a hell of a lot of people referred with '?bipolar disorder (not currently hypomanic or depressed)' who are either just plain depressed (probably a reasonable referral if the GP wasn't sure), have an emotionally unstable type personality, or are just plain normal with the usual ups-and-downs that goes with that.

    I've always tried (including with the people with emotionally unstable traits) to emphasise that there is nothing wrong with them, these are just the normal fluctuations of mood that come with being alive. But I've equally seen a lot of people labelled as bipolar or whatever – it is very easy to do because they (or their family) are looking for a label to 'explain' their problems and sometimes to justify them or access help with them – and this is even more pronounced with children.

    In adult psychiatry we get a similar story with ?Aspergers and ?Adult ADHD.

  • Anonymous

    Isn't the label often times just a the 'ticket' to get some sort of treatment? Unfortunately, developmental diagnoses, or non-medicalized assessments aren't typically eligible for payment.

    The counseling codes weren't getting reimbursed, so they died on the vine. Overly simplistic, often overly medicalized labels–particularly the lables the HMO's will pay for, ends up winning out.

    I could write a much better narrative than ADHD, to respond to the specific needs/unique aspects of a child, but if I put ADD instead of ADHD–most insurers won't pay. So if a child is depressed but presenting as ADHD because his family is in shambles and he has no confidence and has taken on the mantle of victimhood–you don't get paid for that.

    Mental health still isn't taken seriously, until people become violent, or suicidal etc by most. I still see kids medicated on Anti-depressants for mild-depression even though the data shows no efficacy. I still see kids on amphetamines, given anti-anxiety meds after a couple years–because their dopamine levels are likely so high–that serotonin isn't working effectively.

    I saw one Child psychiatrist who was prescribing ambien as a “mood stabilizer”. Sure, its pretty hard for a kid to act up when they are unconscious!

  • http://www.blogger.com/profile/05660407099521700995 petrossa

    @pj

    Don't you dare critize my Aspergers! :) Best diagnosis ever.

    But i agree it's becoming a bit of a fashion to diagnose AS/autism all over the place for any socially inept person.

    Fault of tv i guess. So many series now include an AS person.

    In my homecountry Shell proudly introduced an AS program for it's personnel.
    ‘Autisten kunnen bedrijven als Shell een degelijke basis geven’
    which means:
    'Autists can give companies like Shell a solid base'

    It describes actually Aspergers so the title is somewhat misleading.

    It's a trend.

  • http://www.blogger.com/profile/17833815088739473896 Mona Trixa

    What a horror…
    In the not-so-distant future when the monetary system will have been rendered obsolete and replaced by a more solid system, the historians of that time will surely write wonders about the “moden psychiatry” practises of the 20th and early 21th century.

    We started with lobotomy and ended up with virtually all of the psychiatrists being “sponsored” by the likes of Novartis and Eli Lilly. The incentive is there, and they don't hesitate to use it : more prescriptions, more $. Psychiatry and its pharmacology are strictly a money making business; these companies already interfere with the (future) psychiatrists at the universities, so every last bit of objectivity is lost.

    The doctors are trained to use their largely useless drugs, to the point that when they start practising they feel it is the most natural thing to prescribe tons of meds to just about everyone.
    And of course bodies like the American Psychiatric Association make sure they stay that way and progressively become more and more greedy.

    Lowering the age limit and inventing new labels is an exact effect of that : greed.
    They can only make so much money from adults so their goal is obviously to broaden the age span if possible from infancy to advanced third age.
    The problem is that adults are in the position to say no and legally are not obliged to take the meds if they are not a threat to themselves or to others – which should be the only justified prescription cases, but how many drugs can you sell on them alone?

    Still, in the legal sense you essentially own your children up to the age of 18 and you can do just about anything with them, except physically harm them.
    Please, don't let them use your kids as guinea pigs and make money on them.

  • Anonymous

    “Still, in the legal sense you essentially own your children up to the age of 18 and you can do just about anything with them, except physically harm them.”

    Circumcision is legal.

  • http://www.blogger.com/profile/02537151821869153861 Andrew Oh-Willeke

    Given that the de facto result under the DSM-IV is that children who fit the proposed TDDD diagnosis are being diagnosed with pediatric bipolar, and the serious concern that TDDD is either far less serious than TDDD and likely to go away in adulthood, or isn't a psychiatric disorder at all, it would be a shame if the DSM-5 simply kept the DSM-IV diagnostic criteria for pediatric bipolar unchanged.

    One can dispute the “fight fire with fire” attitude, but both sides of the debate seem to agree that the DSM-IV criteria for pediatric bipolar diagnosis are broken, yet the likely outcome of their scuffle, if the anti-TDDD faction prevails, is that the DSM-IV pediatric bipolar diagnostic criteria will remain unchanged.

    I'm increasingly coming around to thinking that rather than its current form, the DSM-5 should be structured like pattern jury instructions are – a presumptive standard is set forth, but that standard is only presumptive and the evidence (studies in the case of DSM-5, but court cases in pattern jury instructions) supporting the presumptive standard follow immediately in a long multiple issue annotation for each one.

  • Anonymous

    “That's not pediatric bipolar, that's just normal bipolar.

    I'm a Brit living in the US, and here are my thoughts.

    The rates of manic-depression seem to be roughly the same around the world but the stats differ because of cultural issues. Some countries (Germany) don't like the term bipolar, because there's still a cultural stigma, so use ADHD for cases what would be called BP in the US.

    And, you are correct above that this would be “normal bipolar” BUT in the US a young person would be seen by a child/adolescent psychiatrist.

    This is the same for all aspects of medical care here — we don't all go to a GP like in the UK. The young 'uns go to a pediatrician, most of the rest go to a primary care provider or internist, and some old folks go to a gerontologist.

    It's the same with medical specialities — there are pediatric oncologists, pediatric endocrinologists, and so on. A “regular” endocrinologist might not accept patients under 18 — it's just how it's done here.

    So the term “pediatric bipolar” in the US is more about the demarcation in the practice of medicine along age lines, than any difference from “normal bipolar” in the UK .

    Now, how old do you have to be to “age out”? Usually 18 — but my own kid's psychiatrist saw her through the college years.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Anonymous: Thanks for the comment, that's helpful.

    In the UK we have “Child And Adolescent” psychiatry – at least that term recognises that there is a difference between children and adolescents.

    If we define everyone 18 or under as “pediatric”, in the American sense, there is a risk – and this is indeed what seems to have happened – that we'd wrongly start thinking of 8 year olds and 18 year olds as part of the same group.

    You might as well say that 8 year olds and 80 year olds are part of the same group because they're both multiples of 8.

  • http://www.1boringoldman.com John M. Nardo MD

    How about something honest like Idiopathic Behavior Disorder?

  • Anonymous

    I have a couple of questions for Dr Nardo:

    Say you have a young person with chronic, recurring depression who has experienced mania or hypomania — all for the durations listed in the DSM -IV for a diagnosis of bipolar.

    Would you use the term “Ideopathic Behavior Disorder” for that young person if s/he was under 18 years of age?

    Or is “Ideopathic Behavior Disorder” a substitute term for the proposed new syndrome of TDDD only?

    Brit in U.S.

  • Anonymous

    Well, basically whatever the diagnosis, my kid is the child from you-know-where. Out of the 21 foster kids, this one takes the cake. Yikes.

  • Anonymous

    Whatever the diagnosis, mine is the kid from you-know-where. Is going to put me in my grave before she's 9. And we've had a lot of special needs kind of kids, but this one takes the cake.

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About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.

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