Bipolar Disorder in Children

The rate of diagnosis of pediatric bipolar disorder (PBD) in children and adolescents, which includes bipolar I, bipolar II, cyclothymic disorder and bipolar disorder not otherwise specified, has risen to over one million children in the United States, a 40-fold increase over the past decade (Burston 2010). For this study, the definition of PBD is drawn from the Diagnostic and statistical manual fifth edition (DSM-5), and is characterized by the recurring and cyclical presence of manic and depressive symptoms of varying frequency, duration and intensity. Manic episodes are marked by distinct periods of “abnormally and persistently elevated, expansive or irritable mood” (American Psychiatric Association 2013, p. 124) and depressive symptoms meet the diagnostic criteria of major depressive episode (American Psychiatric Association 2013).

The rate of PBD has risen across both inpatient and outpatient settings. Blader and Carlson (2007) reviewed records from the National Hospital Discharge Survey and found that the rate of children with a PBD diagnosis who were admitted to a hospital for psychiatric reasons rose from 1.3 per 10,000 US children in 1996 to 7.3 per 10,000 US children in 2004. Bipolar disorder was the least frequent diagnosis for children in 1996, and it was the most frequent diagnosis in 2004 for children admitted to an inpatient setting for psychiatric reasons (Blader and Carlson 2007).

An increase has also been reported in office visits. Moreno et al. (2007) compared the rates of growth in the bipolar disorder diagnosis in office-based physician visits using the National Ambulatory Medical Care Survey. They found the number of office-based visits of youth, ages 0–19 years, with a PBD diagnosis increased from 25 to 1003 per 100,000 visits in an 8 year period. Also, 90.6 % of these youth received a psychotropic medication prescription during their office visit. The high use of psychotropic medications in children is not uncommon; child and adolescent psychotropic medication use nearly tripled between the late 1980s and 1990s (Olfson et al. 2002; Zito et al. 2003).

One controversy associated with the high rate of bipolar disorder in children is that diagnostic criteria for bipolar disorder as defined in the DSM-IV-TR (American Psychiatric Association 2000) and DSM-5 (American Psychiatric Association 2013) are not consistently used in diagnosing children. Beginning in the mid-1990s, chronic irritability started being used as criteria for the presence of mania in children, rather than euphoria or marked episodic changes in mood (Carlson and Meyer 2006). Faedda et al. (2004) found that the symptoms of children diagnosed with PBD did not match DSM-IV-TR diagnostic criteria for bipolar disorder. Euphoric mania only manifested in 35 % of the children, and depression was observed in only 17 % of the children in their sample of 82 juveniles between ages 7 and 14 years. Further, Pavuluri et al. (2005) reviewed articles from 1992 to 2002 that investigated the epidemiology, clinical characteristics and assessment of PBD. They found no consistent viewpoint among these studies of the clinical presentation of PBD in children. Finally, Carlson and Meyer (2006) did an extensive literature review on the phenomenology of bipolar disorder and concluded that bipolar disorder in children, as defined by DSM-IV-TR criteria, is rare. Elation and grandiosity, for example, are rarely seen in children with a diagnosis of bipolar disorder (Wozniak et al. 2005). What may be labeled as grandiosity in children might actually be a developmental inability to distinguish between reality and fantasy or a child’s reaction to environmental factors (Carlson and Meyer 2006).

Risk Factors

Risk factors contributing to a diagnosis of PBD in a child include socioeconomic status, household status and other family patterns. Financial hardship is a predictor of mental disorders in youth and adults alike (Fan and Eaton 2001; Gilman et al. 2003; McLaughlin et al. 2011; Power and Manor 1992). Certain family factors also are associated with increased risk for a PBD diagnosis. In a 2008 study, Belardinelli et al. compared family environment patterns between 36 families with a child who has PBD and those whose child does not have the diagnosis. The parents of children with PBD reported lower levels of family cohesion and expressiveness and higher levels of conflict when compared with the other parents.

Children in child welfare are especially vulnerable to receiving this diagnosis. While approximately one to one and a half percent of children in the US have this diagnosis, 11 % of a sample of children in the Illinois child welfare system had a PBD diagnosis (Youngstrom et al. 2005). Children who experience abuse, regardless of whether or not they come to the attention of child welfare, are also at risk for receiving this diagnosis. In a study that focused on the presence of sexual and/or physical abuse in a sample of 446 youth diagnosed with PBD, the researchers found that 20 % of their sample had experienced physical and/or sexual abuse (Romero et al. 2009).

There is also evidence to support biological risk factors for children obtaining a PBD diagnosis. In one study of 98 youth, it was found that a PBD diagnosis was 15 times higher in children whose family had a history of bipolar disorder and that the likelihood of diagnosis increased even more when prenatal drug exposure or birth complications were present (Pavuluri et al. 2006).

This literature review shows beginning evidence to support the assertion that children who are vulnerable in terms of poverty, family history and interaction patterns, abuse history, and/or foster care tend to be more likely to receive a PBD diagnosis. These children are further more likely to receive certain psychotropic medications or several medications at once (Belardinelli et al. 2008; Leslie et al. 2011; Longhofer et al. 2011; Mackie et al. 2011; McLaughlin et al. 2011; Romero et al. 2009; Youngstrom et al. 2005).

Treating Pediatric Bipolar Disorder

As more children began receiving this diagnosis, prescription medications approved for their use with bipolar disorder in adults were extended to treat children. Often this took place without any accompanying psychotherapeutic interventions (Littrell and Lyons 2010). Jerrell and Shugart (2004) reviewed medical records of 93 children and adolescents with documented DSM-IV symptoms and concluded that while 90 % of these children were prescribed medications for their symptoms, only 60 % received individual therapy, with an average of 13 units per year. Additionally, Moreno et al. (2007) reported that 90 % of children who go to an office visit with a physician for a mental health issue received a psychotropic medication prescription with no mention of additional services for referrals for outpatient psychosocial interventions. The ongoing scarcity of child psychiatrists in the United State since the 1990 s (Thomas and Holzer 2006) may contribute to other medical professionals diagnosing and treating children’s significant mental health needs.

In 2010, the American Psychiatric Association released a document that acknowledged concerns related to the rise in the use of the PBD diagnosis and current treatment procedures and gave recommendations for changes to the (DSM-5). The Childhood and Adolescent Disorders and the Mood Disorders Work Groups recommended operationalizing the definition of episodicity more precisely by confirming the presence of a hypomanic or manic episode. They also recommended adding a new diagnosis in the mood disorders section of the DSM-5 that more accurately captures the unique features of “psychopathology occurring in children relative to adults” (p. 4) that addresses severe irritability in children. The rationale involves the lack of evidence supporting the claim that non-episodic irritability and not euphoria is how mania manifests itself in children. This new diagnosis in the DSM-5, disruptive mood dysregulation disorder, was added as an aim to have children receive a diagnosis that more accurately reflects their symptomatology (American Psychiatric Association 2013).

The Roles of the Child Psychiatrist and Social Worker

Child psychiatrists are key stakeholders in the field of children’s mental health. They most often assess, diagnose and treat children with a myriad of psychiatric disorders including PBD. Medical professionals, social workers, psychologists and other clinicians refer children with severe emotional and behavioral problems to child psychiatrists for further evaluation and treatment. Such psychiatrists have knowledge and training on the physiological factors that influence symptomatology, and they frequently prescribe psychotropic medications to treat childhood mental illness. It is important for social workers to understand the perceptions of child psychiatrists regarding children’s mental health given their large role in assessing and diagnosing children and psychiatrists’ unique role in prescribing medications. Social workers often provide direct services to these children and their families in school settings, hospitals, mental health clinics, and residential settings among others. Often this work is done as part of a multi-disciplinary team that could include school counselors, psychologists, therapists, and psychiatrists.

Given the reciprocal and intersecting roles among the two professions, it is important for social workers to understand how child psychiatrists view current issues in children’s mental health, including the diagnosis of bipolar disorder, the underlying reasons for this diagnosis, factors that lead to symptomatology in children and their perspective of this new diagnosis. Child psychiatrists and social workers are instrumental in shaping the landscape of children’s mental health as both are key providers to these children and families. How child psychiatrists view child psychopathology, treatment and the role of other providers is primary to improving the lives of these children and also impacts the social worker’s interaction with these children.

The main goal of this study was to understand child psychiatrists’ perceptions and experiences in children’s mental health practice specifically related to PBD.

A secondary purpose was to get information regarding the psychiatrists’ perspective of disruptive mood dysregulation disorder, a new mood disorder category in the DSM-5.

Methods

This was a qualitative, exploratory study that utilized semi-structured interviews to gather data on child psychiatrists’ experiences and perceptions related to diagnosing bipolar disorder in children. The study was approved by the IRB at Virginia Commonwealth University. The sample was acquired through convenience methods by contacting area agencies and university facilities that employed child psychiatrists. Psychiatrists were eligible if they had successfully completed a child and adolescent psychiatry fellowship and were currently practicing as child and adolescent psychiatrists. Informed consent was obtained from all individuals included in the study.

Interviews with psychiatrists ocurred in their places of employment or by telephone, and were approximately 45 min long. All but one were recorded and transcribed. This participant declined to be recorded, and detailed notes of the interview were used in the analysis instead.

The interview guide was developed by the researchers with goal of learning what child psychiatrists think about the use of the bipolar disorder diagnosis in children, thoughts about the new DMDD diagnosis, factors that influence child symptomatology, and finally, what influences mental health services to children (See Table 1). The questions were reviewed by three social work graduate students and one social work faculty member, whom all have expertise in the area of mental health, for immediate feedback on the focus and wording of the questions and interview guide. This feedback was used to refine the guide. The interview guide broadly consisted of ten questions that focused on the perceptions of child psychiatrists surrounding children’s mental health. Specifically, questions involved the following: the use of the bipolar diagnosis in children; factors that influence child symptomatology and treatment; and the disruptive mood dysregulation diagnosis in the DSM-5.

Table 1 Interview questions
Full size table

Data Analysis

All transcripts and field notes were analyzed using a thematic development approach through a series of iterative readings and codings. Data were analyzed using a conventional approach to content analysis (Hsieh and Shannon 2005). First, the researchers conducted open coding by reading transcripts word by word to derive themes. Next, these themes were used to develop a focused coding scheme which was used to determine which themes, ideas, and issues were repeated often and which represented unusual or particular patterns. The codes were then grouped into a final set of themes and subthemes (Coffey and Atkinson 1996; Patton 2002). The two researchers performed the initial analysis separately and then discussed results to reach inter-subjective agreement on themes and subthemes that transpired from the interviews.

Results

Sample

The sample consisted of ten child psychiatrics from four mid-size cities in one atlantic seaboard state. All participants were certified in psychiatry by the American Board of Psychiatry and Neurology (ABPN). Nine of the ten were also certified in child and adolescent psychiatry by ABPN. Participants varied widely in terms of years of practice, which ranged from 1 to 30 years (mean = 14.35 years; SD = 10.96), and employment setting. Settings included academic inpatient and outpatient clinical settings (n = 4), public and private mental health centers (n = 2), private practice (n = 1) and a private inpatient hospital (n = 1). The two remaining respondents worked in more than one setting; one split time between private practice and a private mental health center, and the other worked both in an academic outpatient clinic and in a community mental health center.

Themes

Data analysis yielded seven overall themes with subthemes. See Table 2. The first theme was the perception that there is overdiagnosis of bipolar disorder in children. While all participants acknowledged that bipolar disorder can be present in children, all also believed bipolar disorder in children was overdiagnosed. One male participant reported, “considerably over half of the kids that come into our clinic have already been diagnosed with bipolar by somebody…and we often have to take that diagnosis away.” Another participant from an inpatient setting stated, “everybody and his brother became diagnosed with bipolar…these kids were highly dysregulated, they were clearly ill, but they did not fit into the criteria for bipolar disorder.”

Table 2 Respondent responses by theme and subtheme
Full size table

The second theme was perceived reasons for overdiagnosis. These varied somewhat among participants but two main subthemes emerged. First, all participants believed the children ultimately receiving a bipolar diagnosis needed treatment, but the symptoms that some displayed did not fit particularly into any diagnostic category. As one respondent put it, “kids need treatment and the best treatment guides diagnosis…but there is a lack of clarity in the diagnosis.” This idea of a lack of clarity was discussed by seven respondents. Two referred to it as “two schools of thought” about what qualifies as a bipolar diagnosis in children, and one reported that providers diagnosing children “have not been using strict criteria for manic episodes.” Second, seven participants reported that medical professionals not trained in child psychiatry were assessing and diagnosing children. One participant reported that because of mental health policies, “what ended up happening was there was this huge [group] of poorly trained, or not adequately trained professionals diagnosing and treating children.” Additionally, four child psychiatrists noted that the inadequate number of child psychiatrists in the state contributed to the problem of less qualified professionals diagnosing children.

The third theme consisted of a general consensus that while the treatment tool for child psychiatrists was primarily psychotropic medication, environmental issues often had as large an impact on children, if not more so, than biological factors in child symptomatology. Specifically, all ten participants discussed family stress as playing a major role in children’s mental health. One respondent who worked in an academic clinical outpatient setting reported, “The kids we see are under very significant amounts of stress and sometimes repeated or chronic stressors…I think the amount of psychosocial stressors that these children and families are embedded in is significant.” Trauma or abuse was specifically mentioned by five participants as environmental issues impacting children; bullying was discussed by two; and social media and technology was discussed by three. One participant said, “My concern is that we are seeing either a delay or impariment in children’s ability to connect with others because they spend so much time connecting with the screen.” Additionally, five participants specifically talked about stress in the home from marital instability, mental health issues, and domestic violence. As one participant stated, “environmental factors are huge and they are just as prominent if not more so than any underlying biology. [They come from] high risk situations such as foster care, abject poverty or family situations being very traumatizing; those social contexts themselves are the biggest problem.”

The parents’ role in the diagnostic process and medication treatment and the commensurate need to educate the child and parents was the fourth theme that emerged through data analysis with nine participants reporting this theme. Psychiatrists in this study reported parents sometimes will cling to a bipolar diagnosis, for example because “parents are more familiar with bipolar disorder than mood disorder NOS,” and it is seen as a genetic disorder, which may reduce feelings of blame in the parents. Respondents also believed parents come in with specific ideas about medicating their children and sometimes about specific medications that they think might be helpful.

Participants also reported differing views by parents. As one participant said, “Sometimes parents do not want medications when I think they are warranted and sometimes parents want medications when not warranted. I try to educate them.” One respondent noted that the parents are often armed with information from the Internet or from friends or family members whose children are on similar medications; yet other parents do not want their children on medications and there is a need to educate them on the disorders and treatments. “Sometimes I feel pressure from parents asking me to put their child on medications, but sometimes it’s the opposite. The kids need medication but the parents refuse it.”

The fifth theme regarded insurance as a treatment barrier. All participants agreed insurance was a factor that negatively influenced a child psychiatrist’s ability to help children. It was called “a system of failure” by one participant and described as such by six of the ten participants. “Medications I think are clinically most appropriate—getting approval from insurance companies [for them] becomes exponentially harder every year. Certainly this negatively impacts treatment at times, and almost makes treatment inhibitive.” Another respondent said, “these lists [of insurance company approved medications] are very poorly thought out and are based upon the economics of the pharmaceutical institutions which have really altered the way we practice medicine. Sometimes this leads to making decisions which are absolutely crazy, such as putting an overweight child on risperidone which is known to cause significant weight gain.”

Another subtheme regarding insurance as a barrier that emerged was the need for more time with patients in order to conduct a thorough assessment, as described by eight participants, but insurance companies and payment scales that kept time limits low. One respondent who is a psychiatrist in an academic facility, said, “It is a commodity that we are least in the position to offer our children and families and that is time. With time, we can make a better diagnostic assessment, you are going to understand the family better, connect with the children and family better, so that any treatment recommendation you make in any direction is going to be taken better. And you will have the opportunity to provide some corrective experience not just with the child, but with the family.” Another respondent lamented that children are often in the [psychiatric] hospital for no more than 3 to 7 days. “Fifteen years ago, it was probably three-to-four times as long and there were residential sites- in other words- safe, secure sites where a doctor could determine what a kid’s behavior is like away from home and off medication.”

A sixth theme emerged from the question that was asked about disruptive mood dysregulation disorder. The new diagnosis was seen primarily as a positive step in child mental health diagnoses by eight of the participants. One respondent claimed, “It describes pretty well these kids with temper tantrums and chronic irritability… so a lot of kids that are currently diagnosed with bipolar disorder or something like that clearly fulfill this particular criteria.” However, eight psychiatrists were also not convinced it would change psychiatric treatment for these children.

A final theme that emerged involved recommendations on how to help children with psychiatric disorders. All pointed to a need for a family approach to treatment in addition to child services. “I think the best we can do is help parents be better parents, especially when the kids are young” reported one participant. Another said, “I really believe in family therapy because otherwise there is no resolution.” Nine specifically discussed a need for an interdisciplinary approach to treatment in order to help children improve. “It is more of a global team effort. We have to be all encompassing.” Others stated, “child psychiatry is absolutely multidisciplinary” and “a mulitdisciplinary approach is extremely important.”

Discussion

There were several limitations in this study. This was a small sample taken from mid-size cities in one state in the US and is not generalizable to other areas. It was also a convenience sampling approach given the difficulty in finding child psychiatrists to participate in the study. Also, most child psychiatrists were from similar types of agencies—primarily child clinics associated with universities or public community mental health centers who serve a similar clientele. Finally, one of the psychiatrists interviewed was not certified in child and adolescent psychiatry by the ABPN.

This study supported several findings from the literature but also brought up new information. The results support the ongoing controversy about a lack of clarity in terms of what constitutes a diagnosis of bipolar disorder in children (Faedda et al. 2004; Pavuluri et al. 2005) and its increased use in children in the past two decades (American Psychiatric Association 2010). Three specifically mentioned “two schools of thought” that existed in their discipline regarding when to use the bipolar diagnosis in children. One school views bipolar disorder in children as rare, and uses the DSM criteria to diagnose children with bipolar disorder. The other school, which participants mostly viewed as faulty, uses a broader phenotype of symptomatology in diagnosing children with bipolar disorder (Kowatch et al. 2005). Participants in this study agreed it was difficult to diagnose and treat children with severe and chronic irritability, explosiveness and affective dysregulation under the current DSM guidelines as these children do not “fit” a diagnostic category. This is similar to the findings of Carlson et al. (2006) and Kowatch et al. (2005), which point to the heterogeneity of symptomatology in children diagnosed with bipolar disorder.

Results of this study also support the risk factors identified in the literature that make children more vulnerable to receiving a PBD diagnosis (Belardinelli et al. 2008; Fan and Eaton 2001; Gilman et al. 2003; McLaughlin et al. 2011; Power and Manor 1992; Romero et al. 2009; Youngstrom et al. 2005). Childhood environmental stressors related to family functioning, chronic stress and abuse or neglect were all seen as factors that contribute to child mental health disorder symptomotology. Specifically, the idea of family was seen as an overarching force in symptomatology, diagnosis and treatment of children. Chronic family stressors such as poverty, domestic violence, trauma, parental separation, and family conflict, were seen as influencing a child’s functioning. The necessity of involving parents in the treatment process was mentioned as critical when working with children with diagnoses of PBD or DMDD. All psychiatrists in this study understood the importance of the family role in child functioning and child improvement. This highlights the need for social workers, who work within the ecological realm of the child, to collaborate with the psychiatrists in providing a thorough assessment and treatment plan for the child and family. Social workers are ideally situated to work with the child and family in addressing these familial risk factors.

One finding from this study that has not been fully addressed in previous literature is the perception from many participants that both a lack of child psychiatrists and insurance restrictions that limit time with a child affect the ability to do an adequate assessment and make a proper diagnosis. Specifically, the dearth of child psychiatrists in the state, also endemic of the country (Thomas and Holzer 2006), was seen as contributing to children being assessed and diagnosed by other medical professionals who are not trained in child psychiatry. These could be contributing factors to the rise of PBD diagnoses in office care visits and the prescribing of psychotropic medications from those visits (Moreno et al. 2007).

The role of insurance in children’s mental health is a large source of frustration for the respondents. According to the participants, in order for a child to get needed treatment at least from a managed care payment standpoint, a child needs a diagnosis that corresponds to the treatment regimen mandated by the insurance companies for payment. Respondents saw this as a potential contributor to the misuse of the bipolar diagnosis in children as a bipolar or other mood disorder diagnosis is needed in order to prescribe a particular medication that might be helpful for that child.

This study lends support to the understudied, yet widely held belief that the system of payment set up by insurance companies negatively influences the helping process with children. Specifically, it was seen as a road block to accessing the most clinically appropriate treatment. Current insurance practices identified by respondents point to the fact that the medical system is bound to practice within the constraints of third party payment sources. While certainly there are reasons behind these constraints, it appears they do not always function as a means to providing optimal care for children.

At this point, there is little research on the diagnosis of disruptive mood dysregulation disorder that has recently been introduced in the DSM-5 (American Psychiatric Association 2013). Child psychiatrists in this study primarily saw it as a positive step in child psychiatry as it gives children who previously did not fit in a category a diagnostic home. Those children with mood disorder NOS or one of the bipolar diagnoses may better fit in this category, thus reducing the overdiagnosis or misdiagnosis in those categories. Some psychiatrists in the study had begun using this diagnosis and others had not, pointing to the need for further research on this diagnositic category, especially in terms of presentation of symptoms and treatment protocols. However, most of the psychiatrists in this study did not see treatment changing for the children who now met this diagnostic criteria, seeing at it as a similar treatment protocol as that of the bipolar disorder or mood disorder NOS in children.

One key finding of the study was the overwhelming consensus that psychotropic medication use is only one piece, and often not the most important piece, of treating children with psychiatric disorders. The environmental stressors in a child’s life are seen as contributing factors to child symptomatology and need to be addressed in child treatment.

This study has helped elucidate ten child psychiatrists’ perspectives on the diagnosis of bipolar disorder in children, the new disruptive mood dysregulation disorder diagnosis and barriers to treatment which can assist social workers in their direct service with children. Taking an interdisciplinary approach to helping children, within the context of their family and environment, may be critical to improving a child’s well-being. The child psychiatrists in this exploratory study want to work as part of an multidisciplinary team that takes the child’s environment into account. Social workers are poised to collaborate with psychiatrists during the assessment and treatment process such that services can address the scope of biopsychosocial factors that influence child functioning. Social workers could partner with the psychiatrist to provide the needed assessment information and jointly develop a treatment plan that includes services beyond what the psychiatrist is currently able to provide.

The constraints by insurance companies that were discussed by these respondents may also be a hindrance to effective and multidisciplinary practice. Eligibility criteria and restrictive, inflexible funding streams are two examples. The current payment system discourages team-based and integrated approaches to service delivery through its payment structure (Grimes et al. 2006). Also, under the current system a child needs to have a diagnosable “mental illness”, as recognized by the DSM-5 (American Psychiatric Association 2013), and often a biologically-based mental illness, which ignores the complexity of mental health problems in youth (Kapphahn et al. 2006). Further changes to policies that address the constraints of the managed care system are needed.

The results of this study are certainly preliminary. The themes derived from this study could be used, however, to develop a survey for future research studies that use a larger, more representative sample of board-certified child and adolescent psychiatrists to determine if these themes are supported. Finally, additional research is clearly needed in the study of the DMDD diagnosis and its effect on the rates of other diagnoses. What the new diagnosis will mean for assessment and treatment is not yet understood.