Bipolar Disorder in Children: Is it being Over-diagnosed?

Is Bipolar Disorder being over-diagnosed in children?

Many people erroneously argue that it is, so let's take a look at the evidence. First, I am talking about children aged five years into adolescence who actually meet the full DSM-IV criteria for Bipolar Disorder. I am not discussing children who only have irritability or aggression without any other manic criteria.

FACTS:
In 1994/1995 the frequency of the Bipolar Diagnosis was 25 cases per 100,000. In 2002/03 the frequecny increaed over forty-fold to 1003 cases per 100,000. (See: National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth, Carmen Moreno, MD; Gonzalo Laje, MD; Carlos Blanco, MD, PhD; Huiping Jiang, PhD; Andrew B. Schmidt, CSW; Mark Olfson, MD, MPH, Arch Gen Psychiatry. 2007;64(9):1032-1039.)

Put another way, the diagnosis of Bipolar Disorder rose from 0.01% in 1994 to 0.44% in 2002. That is certainly a 40X increase, but is it really over-diagnosis?

The standard method to estimate the actual prevalence of psychiatric conditions is to conduct an epidemiological study, where trained researchers study large representative samples of the general population (not preselected clinical samples) with standardized, validated instruments (like the SCID or MINI or CIDI) to assess and diagnose the general population using DSM-IV criteria (not just irritability or aggression in children as bipolar disorder, for instance). Using those methods in over 5000 persons, the most recent analysis (see: Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication
Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS, Arch Gen Psychiatry. 2005;62:593-602.) reports a one year adult prevalence of bipolar disorder (types I and II) of 3.9%. In an analysis of age of onset in the same citation above, the study found that bipolar disorder began before adulthood in a substantial minority of persons: in 25% of persons, it began by age 17, in 10% it began by age 13.

Let's do the math now and see what results. Excluding the adolescents up to age 17, and using the lower range of the NCS data:
If 10% of bipolar disorder begins by age 13, and 3.9% of the total population is diagnosable with the condition using DSM-IV criteria in a community-based epidemiological study of actual prevalence, then how many children should that clinical study have diagnosed with bipolar disorder? 0.10 multiplied by 0.39 is 0.039, or 0.39%. If we round to 0.4%, then we have the actual prevalence of bipolar disorder in children. The vaunted 40-fold increase from near zero led to the diagnosis being made in 0.4% of children based on percentage of office visits.

0.39% is about the same as 0.44%, so the purported evidence for over-diagnosis seems underwhelming, to say the least.

Notes from ATTACh

The Association for the Treatment and Training in the Attachment of Children has achieved a number of major accomplishments recently. In addition to preparing and publishing a Therapeutic Parenting Manual, A Clinical Practice Manual, and a wonderful DVD, it wrote an influential letter to the DSM V committee advocating for the inclusion of a diagnosis of Developmental Trauma Disorder. This is exciting work. This international association, with members from across the US, Canada, Europe and Asia is quite influential. Parents and professionals should visit the website of Association for the Treatment and Training in the Attachment of Children.

The organization is now working on a number of projects that will benefit therapists and parents.

Anticonvulsant medications and potential risks

Certain anticonvulsant drugs could be associated with an increased risk of suicide, attempted suicide or violent death. Anticonvulsants are used to help people with epilepsy but can also be prescribed for bipolar disorder, mania, neuralgia, migraine and neuropathic pain. Researchers from Harvard Medical School analyzed data from 14 states about patients fifteen-years old and over who started taking anticonvulsants between July 2001 and December 2006. They found that the risk of suicidal acts was increased for gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazapine (Trileptal), tiagabine (Gabitril) and valproate (Depakote).

You can find out more about this research at

http://psychcentral.com/news/2010/04/15/broadly-used-seizure-meds-may-increase-suicide-risk/12858.html

Artyom Savelyev

In today's New York Times there is an excellent editorial about the story of Artyom Savelyev (Sunday April 18, 2010, pg9) titled "A Safe, Loving Home."

As the editorial states, while we don't know all the facts and details, returning a child is "profoundly wrong." The response of the Russian Foreign Ministry, while understandable, is, in my opinion, also wrong. Since 1991 over 50,000 Russian children have been adopted by US families. Currently there are 250 adoptions nearly completed and 3,500 pending. Children do better in families than in orphanages. That being said, many children who come from orphanages, which are frequently over-crowded and understaffed, have a variety of difficulties that sometimes require very specialized care, such as Alcohol Related Neurological Dysfunction, Sensory-Integration Dysfunction, and various psychological and emotional problems caused by chronic early maltreatment.

The inadequacy of post-placement services for families is a problem that we can fix by requiring agencies to provide those services. The problem of inadequate information from the orphanages, under staffing, and over crowding is something the other government can and must fix.

Artyom Savelyev & Torry Hansen’s Case

This is a very sad case for the child, first and foremost, for the family, and for the adoption and child welfare systems. It speaks to a gross failure on many levels.

The Case:
A few days ago Artyom's adoptive mother, Torry Hansen, sent Artyom Savelyev back to his native Russia. Seven year old Artyom had been adopted from a Russian orphanage about one year ago, around the age of six. The story has been featured in every major news outlet in the US and is the subject of great attention and outrage in Russia and throughout the world. Russia has suspended the license of WACAP, the adoption agency.

While the facts we do know, sending the child back to Russia on a plane, are unacceptable, a rush to judgment is also not called for. There is too much we don't know. For example:

What was the nature and quality of the homestudy and what were the qualifications of the provider?

What were Ms. Hansen's expectations and motivations regarding adoption.

What was the content and scope of education Ms. Hansen received regarding adopting an older child, and the potential for various psychological, emotional, and behavioral problems?

Who provided post-placement supervision?

What help did Ms. Hansen seek and from whom?

We do know that Ms. Hansen never brought Artyom to a Psychologist or other mental health professional (This from Ms. Hansen's mother as quoted in an Associate Press article, see for example, page A4 of the Buffalo News or similar material in the April 11, 2010 New York Times). "Hansen said her daughter sought advice from psychologists but never had her adoptive son meet with one." What advice was given?

Did the family seek help from the TN child welfare system, if so what was their response, if not, why not?


This case calls for a thorough and detailed gathering of all the relevant facts, followed by a thorough critical review of what happened and why.