Broad application of bipolar diagnosis in children may do more harm than good

The researchers support an emerging approach, which gives many of those children a new diagnosis called Severe Mood Dysregulation (SMD) or Temper Dysregulation Disorder with Dysphoria (TDD).

The findings come soon after proposed revisions to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) were opened to public comment.

In a paper published in Child and Adolescent Psychiatry and Mental Health,Erik Parens and Josephine Johnston examine the evolution of the diagnosis of bipolar disorder in children and its dramatic increase since the mid 1990s, after the criteria for diagnosis broadened. They emphasize that there is vigorous debate in pediatric psychiatry about whether symptoms in children accurately reflect the criteria for bipolar disorder, particularly for mania.

The increase in cases has led to concerns about accurately defining psychiatric disorders in children as well as the safety and efficacy of resulting pharmacological treatment.

It is difficult to diagnose psychiatric disorders in children, Parens and Johnston write, and many children receiving bipolar diagnoses exhibit behaviors that do not closely fit the disease's criteria. "Using new labels such as SMD or TDD reflects that physicians do not yet know exactly what is wrong with these children or how to treat it," said Johnston. "Facing up to this uncertainty could lead to better treatment recommendations and more accurate long-term prognosis." A new diagnostic category would also help reframe the research agenda.

Their findings come from an interdisciplinary series of workshops funded by a grant from the National Institute of Mental Health. Participants included psychiatrists, pediatricians, educators, bioethicists, parents, and social scientists. Erik Parens is a senior research scholar and Josephine Johnston a research scholar at The Hastings Center, a bioethics research institution.

Among the workshop conclusions:

• The bipolar label may fit poorly many of the children who have received it over the last decade.
• There is debate about what children's symptoms represent. For example, what is characterized as mania in children is very different from its features in adults. Mania is a hallmark feature of bipolar disorder, formerly known as manic-depressive disorder.
• The bipolar label, which has a strong genetic component, can distract from addressing the family or social context.
• Physicians must be forthcoming with families about uncertainties and complexities in the diagnosis and treatment of bipolar disorder in children.
• Current training practices and reimbursement policies may leave some psychiatrists and pediatricians unable to deliver the comprehensive care that these children need.

The authors also note that, while experts sometimes disagree about labels, the workshop group universally agreed that "children and families can suffer terribly as a result of serious disturbances in children's moods and behaviors," and that these troubled children desperately need help. They also write, "It is a deeply regrettable feature of our current mental health and educational systems that some DSM diagnoses are better than others at getting children and families access to [needed] care and services."