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frequently asked questions

... about the use of psychiatric medications in children and the steep rise in the diagnosis of bipolar disorder. The number of American children identified as bipolar is now over a million and rising.

What is classic bipolar like in children? Is there a consensus on what it is?

Unlike the well-studied bipolar illness in adults, there is strong academic debate about the key symptoms that indicate bipolar disorder in children. Part of what makes diagnosing bipolar difficult and even controversial is that it is not a single illness but a spectrum disorder with a constellation of symptoms which occur in varying combinations and to differing degrees of severity. For the purposes of diagnosis, clinicians often group patients into one of three sub-categories.

Bipolar I
Bipolar I, or classic bipolar, is the well-studied version of the illness that long has been recognized in adults and known for its mood swings between dramatic highs and lows. The highs, or manic episodes, are marked by one or more of a list of debilitating behaviors, namely euphoric or expansive mood, irritability, decreased need for sleep, increased goal-directed activity, pressured speech, rapid thoughts, distractibility, risky or hypersexual behavior, psychosis and suicidality.

Bipolar I also involves prolonged periods of depression. The most common symptoms include pervasive sadness and crying spells, sleeping too much or inability to sleep, agitation and irritability, withdrawal from activities formerly enjoyed, inability to concentrate, thoughts of death and suicide, low energy and significant change in appetite.

The DSM-IV, the manual used to diagnose psychiatric illness, does not specify particular criteria for diagnosing bipolar in children. And there is debate among child psychiatrists over which behaviors are most important, particularly when diagnosing mania in children. Some hold that grandiosity is the hallmark symptom in children -- an emphasis that hews closer to the pattern recognized in adults with the disorder. But another camp argues that, in children, the key symptom is extreme irritability, often resulting in raging tantrums. Which criteria to emphasize remains an open question in the field.

Bipolar II
Bipolar II disorder (BPD-II) is a less extreme version of classic bipolar. The symptoms are similar but less pronounced. It often comes to clinical attention when the child or adolescent experiences a major depressive episode. In this form of the disorder, the patient experiences episodes of hypomania between recurrent periods of depression. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy.

Bipolar NOS
Bipolar Not Otherwise Specified is the third category and the least well-defined. It represents the largest group of patients with bipolar symptoms and it is mostly made up of children with only a few manic symptoms, or without clearly defined episodes. Kids who receive the bipolar NOS label might be explosive and irritable and have a couple of symptoms, but otherwise show no clear signs of the bipolar pattern. Top researchers are concerned that the NOS label has become a catch-all, lumping together kids with a variety of symptoms, some of whom may develop full-blown bipolar and others who may not.

These are the cases that pose the greatest challenge to clinicians. On the one hand, there is a strong belief that catching a disorder at an early phase gives a better chance of success with treatment. On the other hand, because it's not clear what these kids have, it may well be premature to start them on medication. This is the dilemma that doctors -- and their patients -- face every day.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Dr. David Axelson, director of the Child and Adolescent Bipolar Services Clinic at the University of Pittsburgh Medical Center, discusses the debate over how to identify childhood bipolar ... Dr. Kiki Chang, a child psychiatrist and academic researcher in childhood bipolar at Stanford University, discusses the confusion over which symptoms are key for bipolar and how it first started with one researcher's focus on irritability as a hallmark symptom for bipolar. Chang thinks the most common diagnosis, bipolar NOS, "doesn't really mean anything," and he outlines what classic bipolar looks like in kids and how it can vary ... And Dr. Thomas Insel, director of the National Institute of Mental Health (NIMH), talks generally about the controversy in diagnosing psychiatric disorders and the limitations of the DSM-IV, the manual for diagnosing mental illness.


Does a child diagnosed with bipolar disorder grow up to have it as an adult?

Scientists don't know whether a child can outgrow this mental disorder. The University of Pittsburgh's Dr. David Axelson talks about the unpredictability of the illness and says that by treating a child early "we're hoping that we're interrupting the progression of the illness, but we don't have proof of that." Stanford's Dr. Kiki Chang also addresses the question of long-term outcomes.


Why has there been a 4,000 percent increase over the past 10 years in the number of children diagnosed with bipolar?

Top experts offer a range of reasons. They acknowledge some of the increase is likely due to bipolar being mislabeled; some think "bipolar disorder" has become a catch-all diagnosis for kids with a range of problems. But many experts say the increase is simply because doctors are better at identifying bipolar in children today than they were 10 years ago. They believe these kids have always existed, but that doctors failed to recognize the symptoms of bipolar and called these children oppositional or diagnosed them with ADHD. Some experts also cite evidence of a genetic link behind the rise in childhood bipolar, and some even speculate that environmental factors are playing a role in triggering childhood bipolar.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Dr. Thomas Insel, head of NIMH, explains why "it's not really clear whether many of the kids who are called bipolar have anything that's related to [the] ... disorder in adults." ... Child psychiatrist Dr. David Axelson offers his views on whether bipolar is today's fashionable diagnosis, and Dr. David Shaffer, chief of Child Psychiatry at Columbia University Medical Center, states that bipolar is indeed a fad ... Stanford University researcher Dr. Kiki Chang talks about bipolar's genetic link and the phenomena of genetic loading and genetic anticipation: In each new generation of families with bipolar there can be ever-increasing strength and earlier onset of the illness ... Chang also talks about why bipolar in kids seems to be a problem mainly in the United States.


How does a doctor sort out whether a child has bipolar disorder?

Making an accurate diagnosis is difficult and requires careful evaluation, which in some cases can take years. That's because bipolar disorder overlays with other disorders in a spectrum of symptoms. Reported symptoms like impulsivity, hyperactivity, depression or irritability may suggest a range of possible diagnoses. In addition, reports from parents, teachers and friends about a child's behavior are not always totally reliable. And a doctor also needs to figure out what are normal childhood stresses and anxieties and what are the actual sympoms that need treatment. There is no clear scientific answer on what to do.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Dr. David Axelson of the University of Pittsburgh explains the steps and time required to determine whether a child has bipolar disorder. ... Child psychiatrists/researchers Dr. Kiki Chang and Dr. David Shaffer also talk about the challenges in diagnosing. Chang notes that irritability is an important symptom, but must be evaluated in context with other observed mood disorders.

[Note: Most of the top clinics use the K-SADS methodology to determine the illness. It is a semi-structured diagnostic interview designed to assess current and past episodes of psychopathology in children and adolescents according to DSM-III-R and DSM-IV criteria. To read the K-SADS, download the PDF file here.]


With a mental illness like bipolar, what is going on in the brain?

Child psychiatrist Dr. David Axelson outlines here what's involved and talks about what scientists still don't understand about the brain and its extraordinary complexity.


How much is known about the medications and how they work in the child's brain?

Very little is known about the effects of medications being used in the treatment of a complicated illness like bipolar. Do antipsychotic drugs that work in adults with bipolar work in children and are they safe? Which combinations are least successful? What are their long-term effects on the child's developing mind and body? So far, no antipsychotic drugs have been approved for treating children who have schizophrenia or bipolar illness; these drugs are used "off-label," meaning for purposes others than for what they were tested or approved by the FDA. Nonetheless, they are being used in children.

MORE: Comments from experts interviewed for FRONTLINE's report --
... Dr. Robert Temple, director of the Office of Medical Policy of the FDA's Center for Drug Evaluation and Research, talks here about weighing the risk in using off-label antipsychotics. He also explains the ambiguity of the term "off-label" ... And Stanford's Dr. Kiki Chang explains how researchers are "at the forefront" in understanding how the medications work, but the field is not there yet.


Why is there so little data on which medications are safe and work in children? Why aren't there more studies?

A decade ago, the U.S. government began trying to ensure that prescription drugs used to treat children are effective and safe. But doctors still have scant information to guide them when they administer many medications to children. Conducting trials in children involves addressing ethical issues and assessing the risk threshold. More funding is also needed to do many more studies.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Dr. David Axelson of the University of Pittsburgh talks about the risks and ethical issues in research trials involving kids ... as do the head of the National Institute of Mental Health, Dr. Thomas Insel and the FDA's Dr. Robert Temple.

[Note: The FDA offers online information on dosing changes for a range of medications used in children and the safety signals for them. This information reflects the FDA's efforts to encourage more studies on children about drugs' safety and efficacy.

  1. See the Pediatric Exclusivity Labeling Changes;
  2. See the list of PREA Labeling Changes;
  3. See the Summaries of Medical and Clinical Pharmacology Reviews of Pediatric Studies.


What are the pros and cons of treating children with antipsychotic medications?

Medications can make a positive difference in successful cases, acting on symptoms right away to help the child reach key developmental phases and milestones such as learning in school, developing tentative independence from parents, being comfortable with peers, etc. However, these medications also can have serious side effects or they can stop working, in which case a doctor is pushed to increase the dose or add a second medication. And scientists don't know what the consequences are with long-term use of these drugs. The concern is that psychiatric medications can have a very different impact in children than they have in adults.

MORE: Comments from experts interviewed for FRONTLINE's report --
... Dr. David Axelson, head of Pittsburgh University's bipolar clinic, discusses the complexities in treating a child with medications ... Dr. Robert Temple of the FDA talks about some of the drugs' serious side effects ... Stanford University's Dr. Kiki Chang explains the risks and benefits of medications, pointing out there are indications the drugs may offer a "neuroprotective effect" to the brain, and that with early intervention in an at-risk child, medication possibly might even prevent the progression of bipolar illness ... And Dr. Thomas Insel, director of the NIMH, addresses whether children will outgrow mood disorders if they're not given treatment.


What can parents do to be better informed about the risks and benefits of medication?

Parents need to realize that the field of child psychiatry is in its infancy. That doesn't mean that it's not advancing nor that the medications don't work, but there is a long way to go before the field catches up with the rest of mainstream medicine. Parents need to ask hard questions of the doctors they see. And as often as possible, they should try to see specialists in a given field.

The most comprehensive document on the bipolar diagnosis are the diagnostic and treatment guidelines written by the foremost experts in childhood bipolar. You can download and read it by clicking on the link at the very bottom of this page on the Child and Adolescent Bipolar Foundation's Web site.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Stanford's Dr. Kiki Chang points out how doctors can be confused about the medications and how to use them.


Is behavior therapy also a part of the treatment for bipolar disorder?

Yes, behavior therapy for the child can make a real difference. However, many doctors say they don't think young kids respond to behavior therapy as well as they do to medication -- they don't have the language skills to really make use of it. Others point out that some kids are so sick, they simply can't benefit from therapy unless they are already on some medication to bring their symptoms under control. It's important to note that top studies sponsored by the National Institue of Mental Health suggest that medication alone is less effective than the combination of medication and behavior therapy.

In addition, counseling and a therapeutic approach including family and teachers plays an important role in eliminating home, school and social stressors that can aggravate a mental disorder. However, experts point out that health insurance more readily reimburses for medications than for therapy, and some wonder whether the system isn't being set up to favor medication over other forms of treatment.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Child psychiatrist Dr. David Axelson talks about the home environment and the need to help families, but says a therapeutic approach alone isn't enough for a child who already shows bipolar symptoms ... Dr. Thomas Insel, director of the NIMH, explains here what's being learned about why medications are only part of the answer in treating psychiatric illnesses.

[Note: There's growing recognition that families need support and services when they have a child with a mental illness. For example, families needing help may have access to one of the 800 "wraparound" programs active across the United States at the local or state level. There's at least one of these programs in 90 percent of states -- here's a look at Mississippi's statewide program. The wraparound approach combines the efforts of a child's teachers, doctors and family members into an individualized therapeutic program. Parents should contact the Federation of Families for Children's Mental Health to learn if a local program is available and appropriate.]


What are the issues surrounding drug companies' funding of research studies for medications?

Critics point out that researchers who advocate the use of psychiatric medications receive enormous support from drug companies. The critics believe that these industry-funded studies unduly influence doctors' decisions.

MORE: Comments from experts interviewed for this FRONTLINE report --
... Stanford University's Dr. Kiki Chang, a top researcher on bipolar in children who has consulted for several pharmaceutical companies, discusses the need to find money for more research and the "uneasy partnership" that arises when that money comes from pharmaceutical companies ... Dr. David Axelson of the University of Pittsburgh explains why he doesn't accept money from the drug industry ... and Merrill Goozner, a critic of the pharmaceutical industry, lays out in his interview the conflicts of interest he sees among the medical community, the pharmaceutical industry and the FDA.


What are the trends and the future for mental health care for America's children?

On the scientific front, there is a lot of optimism among child psychiatrists. Producer Marcela Gaviria reports that the field is excited by the advances made in the last 20 years, and many experts believe they are probably 15 years away from finding a biological marker for mental illness. But funding research studies to see what therapies and medications work and are safe for kids is a challenge. Increasingly, researchers and the government are turning to the pharmaceutical industry for support.

Another problem: There are very few child psychiatrists in the U.S. -- only some 8,500 for the whole country, with most of them clustered in the big cities. Consequently, most children are being diagnosed and treated by family doctors or pediatricians who are less experienced at applying the diagnostic criteria and less prepared to do careful monitoring of the medications. For example, there are standard procedures that can ensure a child's medications are properly monitored, such as checking blood levels if a child is on lithium, taking a child's blood pressure if a child is on clonidine, and monitoring muscle stiffness if a child is on an antipsychotic.

MORE: Comments from experts interviewed for FRONTLINE's report --
... The NIMH's Dr. Thomas Insel talks about the "decade of discovery" that science has recently entered, but cites the challenges too, including the troubling shortage of child psychiatrists ... Child psychiatrist Dr. Thomas Axelson talks about overall trends in the mental health for U.S. children, and why he feels far more investment is needed in the mental health care system and "a whole lot of change" is required for the insurance reimbursement system.


Are American children overmedicated?

There's no clear-cut yes or no answer to this question. NIMH Director Dr. Thomas Insel says the U.S. is both overusing and underusing medications in kids and explains why "we haven't found quite the right balance" ... And Stanford University's Dr. Kiki Chang discusses the possible reasons why bipolar seems to be a problem mainly in the United States.

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posted january 8, 2008

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