Treatment for the extreme emotional outbursts seen in some children may benefit more from family therapy than from psychopharmacology.

The statistical rise in diagnoses of pediatric bipolar disorder over the last several years has stirred debate among child psychiatrists, and there’s no lack of argument about its implications, said Allan Josephson, M.D.

“Office-based visits with a diagnosis of bipolar disorder for youth have risen 40 times in 10 years, from 25 per 100,000 in 1994-95 to 1,003 per 100,000 in 2002-03,” he said at the annual meeting of the American Academy of Child and Adolescent Psychiatry in New York in October.

There are good and bad outcomes of this development, said Josephson, a professor and vice chair for child and adolescent psychiatry services and CEO of the Bingham Child Guidance Center at the University of Louisville.

Bipolar disorder does exist in children and adolescents and may well have been underdiagnosed in the past, so the increased attention to the disorder has brought needed treatment to children.

However, some irritable, explosive children are lumped into the bipolar category, possibly because no other label seems to fit, said discussant Gabrielle Carlson, M.D., a professor of psychiatry and pediatrics and director of child and adolescent psychiatry at Stony Brook University School of Medicine in New York.

Other researchers have proposed a diagnosis of “severe mood dysregulation” for these children, who are characterized by chronic irritability, hyperarousal, and hyper-reactivity, but not the episodic manic symptoms typical of DSM-IV bipolar illness.

“The emphasis on bipolar disorder as an explanation [for this behavior] has also communicated the unhealthy idea that children’s behavioral problems lie outside the child’s or the family’s control,” said Josephson. “It changed the point of control from the child to ‘chemicals.’ That leads to misguided therapies, focusing on disease elements to the neglect of psychosocial aspects of development.”

A number of changes within the profession of child psychiatry also have contributed to the confusion over diagnosis and nomenclature, he said.

These include having less time available for clinical work and for collecting developmental and family histories. There is a narrowing emphasis on neuroscience today, along with insufficient integration between the biological and psychological sides of psychiatry.

In her discussion, Carlson reported that she sees children with what she called “difficult temperaments.” They have rages and meltdowns, adapt poorly to change, and have trouble transitioning. They exhibit poor sleep patterns, poor planning and working-memory abilities, and a need for immediate gratification.

Like children with pervasive developmental disorders, they misread social cues and can’t put their frustrations into words.

“I call these children ‘diagnostically homeless’ because there is still not a systematic way of identifying them,” she said. “These explosive outbursts are the most lethal thing we have in child psychiatry and are responsible for much disability.”

Part of the problem is that the outbursts appear in a variety of disorders described in DSM-IV—oppositional defiant disorder, attention-deficit/hyperactivitity disorder, bipolar disorder, and others. They are therefore analogous to a high fever: they complicate a number of disorders, said Carlson.

“We should consider them as a modifier for existing disorders, like we do with psychosis,” she said.

Criteria for bipolar disorder can be confusing in young patients, especially when discrete episodes of illness are often less discernable than they are in adults. Conflicting diagnoses arise from clinical observation of dysregulated affect and behavior or, more specifically, rages and other emotional outbursts, said Josephson.

In fact, some dysregulation may be inevitable, he said. “All children have poorly regulated, irritable behavior at some point in their development, so learning how to regulate behavior and affect are normal, fundamental processes of child development.”

But the extreme outbursts that bring parents into the clinic are not solely the responsibility of the child, said Josephson.

“Kids do not do this alone,” he said. “Regulation in child development is deeply embedded in the child’s relations with others, especially caregivers.”

Thus, poor regulation of affect and behavior has roots beyond disease, he said. Many of those roots are planted firmly in the whole family’s life experience.

For instance, parents who yell at their children are modeling impulsivity and contributing to the child’s psychopathology.

Many of these children also have a sense of entitlement, which is often based in either indulgence or emotional neglect by the parents. Indulgence removes roadblocks to frustration and, with them, any incentive to develop self-regulation, he said. Neglect communicates the feeling that the child is on its own in the world and has to look out for himself or herself because no one else will.

Intervention involves work with the entire family, said Josephson. The child’s view of his entitlement is a target, but so are parental and marital dynamics. Parents must be educated to tolerate the child’s rage. Indulgent parents must learn not to give in easily, while neglectful ones must be helped to engage the child.

“Clinicians must hold families empathically accountable for how they interact with their children,” said Josephson. “Parents must then be empathically available to their children and must hold them accountable for their behavior.”

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Aaron Levin

Psychiatric News December 17, 2010
Volume 45 Number 24 Page 26
© American Psychiatric Association