Bipolar in Children: Upcoming Changes
The most valuable thing I learned in graduate school was from my professor Marvin Bloom. Health Care Policy has unintended consequences. When crafting policies you must pay attention to what those consequences might be! This is what I think we must do when examining the new proposed changes in the DSM related to bipolar in children.
Dr Bloom was someone I respected and admired. He had been involved in social work in New York when it was really about social change and fighting for injustice. He went to Columbia. He would come to class completely unprepared, with a general topic to discuss that was somehow related to what we were supposed to be learning. Other students did not like his class because of the obvious lack of structure. I loved it because I knew if I just paid attention, I would come away with jewels.
The bible for mental health professionals, The Diagnostic and Statistical Manual of Mental Disorders (DSM) is in the process of being revised. The American Psychiatric Association has recently published the revisions online here..
Although all the proposed changes intrigue me, the one of most interest to me is related to the diagnosis of Bipolar in children. I have worked with this population for years. These are children and families who have suffered great injustices at the hands of the medical professionals who should be helping them.
My hope was that the upcoming DSM would make some changes that would help these families to be treated with more compassionate and quality care. I'm not sure that this will happen. Maybe its unfair to expect the DSM to impact that kind of change. Clearly the DSM is not responsible for all of the problems in mental health care!
Differences between Adult and Child Bipolar
Bipolar in children looks different from Bipolar Disorder in adults. Specifically, children have shorter cycles that don't meet the DSM definition. Symptoms of mania and depression also look very different in children than they do in adults. Most of us will use a diagnosis of Bipolar Disorder NOS or Mood Disorder NOS to categorize children who we feel have the disorder.
Additionally Bipolar in children is really poorly understood. It overlaps with ADD, Depression, and Anxiety. The medications that treat these illnesses make Bipolar in children worse. Kids are frequently misdiagnosed, improperly medicated and inadequately treated.
The solution in this new version is to add the diagnosis of Temper Dysregulation Disorder with Dysphoria( TDD).
I think the intention here is to address a group of children who are falsely diagnosed with Bipolar Disorder and placed on very powerful medications. Maybe not. Maybe the intention is to create a new category of kids to medicate. I don't know for sure.
Misdiagnosis of bipolar in children is a problem. I do see children diagnosed as having bipolar disorder when they really are just having tantrums. This is a disturbing trend that these changes could reverse. However, there are also many possible unintended consequences.
I am fearful that this new diagnosis will lead to funneling of children with different diagnoses into one ambiguous category. Yes, that already happens, but it might get worse.
A child who has been exposed to domestic violence or who is physically abused, for example, will most certainly have difficulty regulating their temper, and will also most likely have dysphoria ( which is actually vaguely defined) and dysregulation. A child who has early onset bipolar disorder has a biologically based brain disorder and may present with these same symptoms. I am fearful that these two could potentially get lumped together. Part of this is because of shoddy work on the part of the clinician, and not necessarily in the DSM itself.
The children and families I work with are often treated badly by mental health professionals. They are told they are bad parents and that the children misbehave. They are shunned socially by churches and by family because of being labeled in this way. The are prescribed medicines that make them worse. They require a very sensitive and informed level of treatment that educates them about the illness first, with a focus on the behavior second. The behavior must be understood as separate from the child and part of the illness and the mood. At least until the child's mood is stable. I am fearful that with this new definition, kids with Bipolar Disorder may be lumped in here. I worry that they will be treated as if they have a behavioral problem.
To be fair, the proposed changes have a section that attempts to rule out children who have bipolar disorder from this category. However, the basic problems with the diagnosis have not been fixed. The new definition does not adequately address the shorter cycles of mania in children. Children who do not meet the duration criteria for mania, and many don't, would be lumped into this category.
I would like to see revisions to the DSM that focus on better articulating what we know about Bipolar in children. I feel this is an attempt to address the problem of over diagnosis, and I am happy to see some attempt. Over-diagnosis, however, is not the issue. Misdiagnosis is the issue. Every day I see children who are just improperly diagnosed. I wonder what the result of this change, if it is made, will be?
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