Controversies Concerning The Diagnosis and Treatment of Bipolar Disorder in Children

Parens and Johnston Child and Adolescent Psychiatry and Mental Health 2010, 4:9
http://www.capmh.com/content/4/1/9
COMMENTARY Open Access
Controversies concerning the diagnosis and

treatment of bipolar disorder in children
Erik Parens*, Josephine Johnston
Abstract
This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis
and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in
children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of
bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the pre-
sent, ending with current efforts to distinguish between a small number of children whose behaviors closely fit
DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but
whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of
that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disor-
der with Dysphoria.
Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians
offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM’s
diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compro-
mised. And because BP has a strong genetic component, the label can distract attention from the family or social
context.
Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data
supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more
than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany
pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much
on the child’s context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed
consent, they must be forthcoming with families about the relevant uncertainties and complexities.
Introduction in youth coupled with a rapid rise signaled a major

In September 2007, a group of researchers made head- practice change.
lines when they reported a forty-fold increase in the Once thought rare in pre-adolescents, BP is now
number of office visits in which children had a diagnosis increasingly diagnosed in children, including preschoo-
of bipolar disorder (BP)[1]. The researchers estimated lers [2]. The drugs used to treat it include mood stabili-
that whereas, in 1994-1995, in about 25 out of every zers and antipsychotics [3], which carry the risk of
100,000 visits a child had a bipolar diagnosis, the num- significant side effects. Perhaps even more than the
ber increased to 1,003 per 100,000 by 2002-2003. During diagnosis and treatment of Attention-Deficit/Hyperactiv-
the same ten-year period, office visits by adults with a ity Disorder (ADHD) and childhood depression before
BP diagnosis almost doubled from 905 to 1,679 per it, the ascension of the BP diagnosis in children and its
100,000 annually, suggesting that BP diagnoses reported treatment with medications whose risk/benefit profiles
by community-based clinicians have increased across are inadequately established have generated debate in
the age span. But the very low base rate of this diagnosis both lay and professional communities.
This commentary grows out of a workshop that
explored the debates regarding the increase of BP diag-
noses in children under 17. The workshop was the third
* Correspondence: parense@thehastingscenter.org
The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY, 10524, USA of five in a series aimed at exploring the controversies
© 2010 Parens and Johnston; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Parens and Johnston Child and Adolescent Psychiatry and Mental Health 2010, 4:9 Page 2 of 14
concerning the diagnosis and treatment of mood and a BP diagnosis but do not neatly fit DSM IV criteria.
behavioral disturbances in children; the workshop was We will suggest that, though in the US a BP diagnosis
highly interdisciplinary, including child psychiatrists, can get children the treatment, school accommoda-
psychologists, philosophers, sociologists, anthropologists, tions, and insurance reimbursements they desperately
and others. Our first commentary, which grew out of need and deserve, if applied too widely it can do more
our first workshop, explored the debates in general [4]. harm than good.
Our second commentary explained why informed peo-
ple can disagree about ADHD diagnosis and treatment; Disagreement about labels, but agreement that these
we explored the “zone of ambiguity” between those chil- children desperately need help
dren who clearly do–and those who clearly do not–have Some researchers, physicians, and parents argue that the
ADHD and the complexities of identifying and imple- sharp increase in rates of BP diagnosis simply reflects
menting effective treatment [5]. In this commentary, we overdue recognition of this disorder in children. As
focus on the intense and complex debate among child workshop participant and patient advocate Susan Resko
psychiatrists and psychologists about how best to con- urged us to remember, a 40-fold increase sounds like a
ceptualize the serious emotional and behavioral distur- lot until one recalls the raw percentages: from the BP
bances exhibited by the group of children currently diagnosis being present in 0.025% of office visits in 1994
receiving a BP diagnosis. to it being present in approximately 1.0% of the visits in
This series of workshops was funded by a National 2003. Moreover, these percentages refer to a clinic sam-
Institute of Mental Health (NIMH) grant to The Hast- ple, not the community at large.
ings Center, which is an independent, nonprofit, non- Those who are not alarmed by the increase suggest
partisan, bioethics research institute. The authors of this that in the past clinicians missed cases of BP because
commentary are scholars at The Hastings Center. One they did not understand that it can affect children and
of us has a background in philosophical bioethics (EP) because BP symptoms can look different in children and
and the other a background in law and bioethics (JJ). adults. As child psychiatrist David Axelson asked, “if it
Because neither of us has training in psychiatry, we is possible for children to suffer from anxiety, depres-
relied on the generous advice of child psychiatrist Dr. sion and other disorders experienced by adults, why not
Benedetto Vitiello at NIMH and former NIMH director BP?” Moreover, they emphasize that, untreated, these
Dr. Steven Hyman, who helped us identify a wide range children risk school failure, rejection by peers, physical
of views within child psychiatry and psychology. We injury, substance abuse, and even suicide–and their
also relied on the generous advice of anthropologist Dr. families can be torn apart.
Sarah Harkness to help identify individuals who study Others at the workshop argued that BP in children is
how social and cultural context can affect the interpre- poorly defined, which can lead to misdiagnosis and
tation of children’s emotions and behaviors. Almost inappropriate treatment. While children can have BP,
without exception, the experts we invited to the work- they maintain that it is extremely rare and that when it
shop accepted, even though we were able to offer only a is present the symptoms are very like those observed in
very modest honorarium. We held the workshop, con- adults. The recent increase in BP diagnoses in children
sisting of presentations and lengthy follow-up conversa- is due to a redefinition of mania, key to BP diagnosis.
tions, in New York City on April 24-25, 2008. (For Critics of this development hold that children are now
more on our method, see [4]). None of our advisors or receiving the BP diagnosis instead of one or more of the
workshop members, listed at the end of this commentary, diagnoses they might have received in the past (e.g.,
bears any responsibility for its contents. This is not a ADHD, oppositional defiant disorder [ODD], and con-
consensus document. duct disorder [CD], learning disorders, and pervasive
Our primary aim in this commentary is to fairly developmental disorders [PDD])–or instead of some
describe the debates that occurred at the workshop. As altogether new diagnosis (e.g., SMD). Some critics sug-
part of our effort to be as accurate as possible, we will gested that the BP diagnosis can be more palatable to
sometimes include workshop participants’ exact words. some parents, teachers, and physicians than other bet-
Based on our analysis of the presentations and discus- ter-fitting diagnoses, because the BP label attributes the
sion at the workshop, as well as our reading in the child’s problematic moods and behaviors to what is per-
professional literature, we conclude that the proposed ceived to be a context-independent, genetic disorder.
new diagnosis of SMD, on which the Diagnostic and Such critics suggest that the publication in 2000 of The
Statistical Manual (DSM) V’s proposed diagnosis of Bipolar Child by Dimitri and Janice Papolos [6] and a
Temper Dysregulation Disorder with Dysphoria (TDD) 2002 Time magazine cover story [7] precipitated a surge
is based, may help to clarify the debate about a of parents asking physicians to give their troubled chil-
troubled group of children who are currently receiving dren the BP diagnosis.
Critics are also concerned about the medications used under the description of” a given psychiatric diagnosis.
to treat BP. They observe that these drugs may not help Martin herself is diagnosed with BP and, because she
the child, may cause harmful side effects, and increase fully acknowledges the very real impact her moods and
the risk that other measures will be overlooked. Work- behaviors can have on her ability to flourish, she seeks
shop participant and child psychiatrist Mary Burke treatment for the disorder. Moreover, she is keenly
speculated that, in the underprivileged community aware that the cluster of behaviors that we call BP has
where she practices, one of the most effective ways to been recognized for millennia and across cultures. But
help children now receiving the BP diagnosis would be in saying that she “lives under the description of bipolar
to promote attachment and reduce stress on families– disorder,” Martin emphasizes the respect in which these
stress that falls disproportionately on the poor [8,9]. behaviors might have developed somewhat differently,
Consistent with Burke’s point about stress as a possible been interpreted somewhat differently, and responded to
precipitant of the symptoms associated with BP and somewhat differently in a different society or time [17].
other diagnoses, is the research of workshop participant Noticing the roles of interpretation and values in mak-
and child psychiatrist Boris Birmaher (and his collea- ing psychiatric diagnoses should make us less surprised
gues), which suggests that low socio economic status is to see controversies about whether a given set of beha-
predictive of worse long-term BP outcomes [10]. viors are bad enough to warrant a diagnosis and about
While there was sometimes deep disagreement at the what “the right” diagnosis is.
workshop about these points and others, there was uni- There is evidence that the pharmaceutical industry
versal agreement, including from those child psychia- plays a distressingly large role in shaping those interpre-
trists who have been vocal critics of the way in which tations and values [18-20]. We note in particular the
the BP diagnosis has been applied to children, that the concern regarding financial conflict of interest recently
children at issue desperately need help. As child psy- raised about some BP researchers. While we share many
chiatrist Gabrielle Carlson said, psychiatrists agree that of the concerns expressed in lay and academic publica-
“there is a group of children with severe irritability or tions about financial conflicts of interest and the role of
affective aggression or rages whose explosive behavior is the pharmaceutical industry in diagnosis development
significantly impairing, that we have been chasing with [21-25], exploration of these debates could not resolve
different diagnoses over the years, that populate child the important questions regarding diagnosis and treat-
psychiatry clinics, and that we haven’t had a great deal ment of BP that were the focus of our workshop and
of success in treating.” Regardless of which diagnostic are the focus of this commentary.
label is ultimately applied, the children at issue experi-
ence extreme and often debilitating moods and exhibit The rate of BP diagnoses is rising faster in the US than
deeply problematic behaviors, sometimes including sui- elsewhere
cidal and homicidal rages. Though debates about the diagnosis of BP in children
Clinical reports describe chronically impaired children can be traced back to the 1950s [26], and though Gab-
who are highly irritable, angry, explosive and dysphoric, rielle Carlson published “Bipolar affective disorder in
often as their baseline functioning [11-13]. They may childhood and adolescence” in 1983 [27], the rapid
also experience racing thoughts and periods of elation, increase in the number of diagnoses of BP did not begin
grandiosity, hypersexuality, and suicidality [14]. Vivid in the US until the mid 1990s [1,28] (see Table 1).
portraits of the suffering of children diagnosed with BP While some symptoms now associated with the BP label
(and of the suffering these children’s symptoms can can be found in previous versions of the DSM in
cause others) can also be found in some of the more descriptions of disorders such as “unsocialized aggres-
detailed media reports, including the Time magazine sive reaction of childhood,” “adjustment reaction of
cover story from 2002 [15] and a 2008 feature by jour- childhood,” and “schizophrenic reaction, childhood
nalist Jennifer Egan in the magazine section of the New type,” DSM’s description of BP did not in the past and
York Times [16]. does not now explicitly address diagnosis of this disor-
Psychiatric diagnoses are of course based on descrip- der in childhood.
tions of clusters of behaviors that everyone in a popula- The increase in diagnoses seems to begin with germ-
tion exhibits to some degree. Human beings, through inal 1994 and 1995 articles by Barbara Geller et al.,
our social institutions (in this case medicine), determine Janet Wozniak et al. and Joseph Biederman et al., which
when clusters of these behaviors impair functioning proposed that BP was more prevalent in children than
enough to warrant a disease label. To emphasize the previously thought [11,29-31]. When DSM-IV was pub-
role of flesh-and-blood humans in reaching those deter- lished in 1994, it contained a new section, “Disorders
minations, workshop participant and anthropologist Usually First Diagnosed in Infancy, Childhood, or Ado-
Emily Martin suggested that we might speak of “living lescence.” While this section does not specifically
Table 1 Timeline: The Recent Debate about BP in Children

Early Gabrielle Carlson et al. observe that bipolar symptomatology in preadolescent children can include severe irritability and emotional
1980s lability (as opposed to the classic symptoms that appear in adults and adolescents) [27].
1994 Geller et al. report in Journal of American Academy of Adolescent and Child Psychiatry (JAACAP) conversion to BP in 32% of a sample of
children with major depression [31].
1995 Geller et al. in Journal of Affective Disorders suggested that children and adolescents with rapid-cycling mania characterized by elevated/
expansive and/or grandiose mood have BP; the researchers did not use irritability to characterize BP because it also commonly appears
in ADHD [29].
1995 Wozniak et al. [11] and Biederman et al. [30] in two JAACAP articles report that 16% of a clinical population of children met the criteria
for mania primarily by exhibiting chronically irritable mood and describe their use of the Child Behavior Checklist to confirm their
diagnoses of BP in these children.
1998 Klein et al., critique the move to consider chronic irritability a form of mania [47].
2000 Publication of The Bipolar Child by Demitri and Janice Papolos, a book aimed at parents, whose success coincides with an increase in
visits to doctor’s offices by parents regarding a bipolar diagnosis for their children [6].
2002 Time magazine runs a cover story on children with BP [15].
2003 Leibenluft et al. describe a new syndrome, Severe Mood Dysregulation, (SMD), which aims to bring some conceptual order to the
increasingly heterogeneous class of children receiving a BP diagnosis [28,48,49,51].
2005 Article by Kowatch et al. describing treatment guidelines for children and adolescents with BP published in JAACAP. Accompanying
commentary calls attention to lack of evidence that childhood diagnosis is contiguous with adult BP and critiques some symptoms as
difficult to distinguish from developmentally normal childhood behavior [46].
2006 Brotman et al. use the label Severe Mood Dysregulation in the title of a scientific article, offering a new label for many children now
receiving the BP diagnosis [49].
2007 JAACAP publishes practice parameter for diagnosis and treatment of BP in children and adolescents. Parameter follows Geller et al.
diagnostic criteria more than those proposed by Biederman et al. but warns of difficulty differentiating symptoms from normal
childhood behavior and urges periodic revisions of any diagnosis and treatment plan [57].
2007 Archives of General Psychiatry publishes study reporting a 40-fold increase between 1994 and 2003 in the number of office visits in which
children (0-19) had a diagnosis of BP [1].
2009 Zito et al. report a 10-year trend for Medicaid-insured youth with clinician-reported pediatric bipolar disorder showing a proportional
increase in minority youth with this diagnosis from 1997 to 2006 (23% increase in African-American and other minorities and
corresponding drop in white youth) [85].
Crystal et al. report that poor children are four times more likely than wealthy children to receive atypical antipsychotics [70].
2010 Olfson et. al. report a doubling of the number of privately insured 2-5 year-old children with a psychiatric diagnosis who receive an
antipsychotic, and lament the sparseness of non-pharmacological mental health resources [3].
Authors working on DSM V propose adding new diagnostic category, which is based on Severe Mood Dysregulation and may be called
Temper Dysregulation Disorder with Dysphoria [54].
mention BP, it does contain the observation that “many (children brought to physicians’ offices) reveal higher
disorders included in other sections of the manual have diagnostic rates in the US than many other nations. Psy-
an onset during childhood or adolescence [32].” chiatrist and workshop member, Claudia Mehler-Wex,
Since then, diagnoses of BP in children in the commu- reported that, whereas 6% to 19% of children and ado-
nity have increased in the US [1,28]. Pre-school-age chil- lescents in US clinical populations are diagnosed with
dren are now among those receiving this diagnosis [2], BP [34-36], the diagnosis is virtually never made in Eng-
which a short time ago was not thought to exist in early land (1.7 cases/100,000/year)[37] nor Ireland (2.2 cases/
elementary school age youth (6-9 years) or even in early 100,000/year) [38]. Mehler-Wex reported that countries
adolescence (10-14 years). In addition to calling atten- like Spain, India, Finland, Denmark, and Germany also
tion to the increasing rate of diagnoses in children, fall well below the diagnostic rates of the US. (Brazil,
critics have observed that the numbers are higher in the where 7.2% of the clinical population is diagnosed with
US than elsewhere and it seems that the US is the only BP [39], is the only country with diagnostic rates close
country where BP is diagnosed in pre-school-age chil- to the low end of the estimates for the US).
dren. This situation suggested to workshop participant Mehler-Wex offered several reasons for higher rates of
and child psychiatrist Jon McClellan (citing Soutullo et BP diagnoses in US children. First, DSM IV diagnostic
al. [33]) that something is askew in US diagnostic prac- criteria for BP cast a wider net and capture more
tices, and not, or not simply, in US genomes or affected individuals than do the International Statistical
environments. Classification of Diseases and Related Health Conditions
While there are not good data comparing prevalence 10 th Revision (ICD 10) criteria used in Europe. For
rates in the general population of children in different example, where DSM IV requires only one episode of
countries, the data comparing clinical populations mania, or one episode of depression plus one episode of
hypomania, to warrant a BP diagnosis, ICD 10 requires superwoman with a clear indication that she is about to
one episode of depression plus at least two episodes of jump from a hotel balcony, there is good reason to infer
mania [32]. Moreover, according to Mehler-Wex, practi- the presence of a symptom. Other times the answer will
tioners in the US use lower thresholds for identifying be less obvious.
symptoms than do their counterparts in Europe. Many In children and in adults, it can be tempting to con-
of the children diagnosed with BP in the US would else- clude that a given medication’s ability to reduce a parti-
where be diagnosed with hyperkinetic disorder (roughly cular symptom confirms a diagnosis, but it does not.
the ICD equivalent of ADHD), a different mood disor- Gabrielle Carlson offered the example of the atypical
der, or a disruptive behavior disorder. antipsychotic risperidone (Risperdal), which is effective
Another reason offered to explain higher diagnostic at reducing aggression or rages in children diagnosed
rates is that, as indicated by rates of stimulant and anti- with BP–but is also effective in reducing aggression or
depressant use, US culture is in general more congenial rages in children with one or more disruptive behavior
than European cultures to psychiatric diagnoses and disorders (ADHD, ODD, and/or CD) and below average
their pharmacological treatment in children. If, as psy- intelligence [41] as well as in children with autism [42].
chiatrist Peter Kramer once suggested, the US was a Carlson suggested that atypical antipsychotics reduce
country of “pharmacological Calvinists,” it no longer rages the way aspirin reduces fever: “Regardless of
seems to be [40]. whether the underlying cause is viral or bacterial, aspirin
On the other hand, workshop participant and child will reduce fever. But if the patient has a bacterial illness
psychiatrist Joseph Biederman argued that nothing is and the aspirin masks the symptoms temporarily, you’ll
“askew.” His explanations for the difference in preva- think you’ve treated something you haven’t. The patient
lence rates included: that Europeans are biased against won’t get the antibiotic she needs.”
recognizing psychiatric disorders in children; that Eur-
opeans and American reporting practices lead to differ- The DSM IV view of the BP spectrum
ences in prevalence rates that are only apparent; and DSM-IV lists four BP subtypes: BP-I, BP-II, Cyclothymic
that US rates of diagnosis reflect a deeper understanding Disorder, and BP-NOS [32]. In adults, the bar to getting
of the disorder among US psychiatrists. the BP-I diagnosis is set fairly high and the classic
symptoms of mania (even when mixed with depressive
Diagnosing psychiatric disorders in children can be symptoms) are relatively easy for a well trained physi-
challenging cian to identify. Much of the disagreement about diag-
Before taking a closer look at the debates in the US, we nosing BP in children, however, revolves around
should recall two reasons that it can be difficult to diag- determining just what mania looks like in children.
nose psychiatric disorders in children. Psychiatric disor- According to DSM IV, a full-blown Manic Episode
ders are predictable clusters of emotional, behavioral entails “a distinct period of abnormally and persistently
and sometimes somatic symptoms that cause impair- elevated, expansive, or irritable mood” lasting for at
ment and emerge on a spectrum. Bright lines do not least 1 week. The central question in the pediatric
separate individuals whose emotions and behaviors are debate is whether this episodicity criterion should be
and are not disordered enough to receive a BP diagno- altered to include children who exhibit chronic irritabil-
sis. Second, because different diagnoses, some of which ity or cycle very rapidly between elevated mood and
are themselves contested (e.g., CD, ODD, PDD, ADHD, euthymia or depression. Under DSM, to meet the cri-
and BP) can share some of the same symptoms, decid- teria for mania, when the patient’s mood is elevated or
ing which diagnostic label(s) to apply to a particular expansive she must exhibit at least 3 of the following 7
patient can be challenging. symptoms: grandiosity, decreased need for sleep, pres-
Moreover, identifying symptoms and making a diagno- sure to keep talking, flight of ideas, distractibility,
sis can be harder in children than in adults. Younger increased goal-directed activity, or excessive involvement
persons can have difficulty noticing and describing in pleasurable activities that have a high potential for
symptoms and providing accurate accounts of time of painful consequences. Alternatively, to meet the criteria
onset and duration of symptoms (although children for mania, when the patient presents with irritability,
always have a secondary informant). Further, given how she must exhibit at least 4 of those 7 symptoms.
rapidly children’s brains develop, even practitioners can DSM sets the bar for BP-II lower in the sense that one
and do disagree about whether a given behavior or does not need a full-blown Manic (or Mixed) Episode;
mood is developmentally appropriate or a symptom of having one or more episodes of Major Depression accom-
disorder. Is, for example, a 4-year-old’s claim that she is panied by at least one hypomanic episode suffices. (In
superwoman a sign of imagination, self-confidence, or hypomania the symptoms are the same as in mania, but
grandiosity? If a child accompanies her claim to be their duration is shorter–4 days instead of 1 week–and
they are less impairing.) The bar is lower still for Cyclothy- irritability. In two 1995 papers, Wozniak et al. and Bie-
mic Disorder because one only needs numerous periods of derman et al. determined that 16% of their clinical
hypomanic symptoms and periods of depressive symptoms population met the criteria for BP (they did not specify
that do not meet criteria for Major Depressive Disorder. which BP subtype they observed)[11] primarily because
The Cyclothymic Disorder label, however, is rarely applied of chronic irritability. They then argued that children
to adults or children. Finally, to receive the BP-NOS diag- who, based on a time-consuming structured interview,
nosis, one does not need to meet the criteria for any of the fully satisfied their understanding of DSM III criteria for
preceding 3 subtypes of BP. For example, one may have an mania, could also be identified with a relatively simple,
abnormal mood, constituted by a rapid alteration between cheap, easy-to-use symptom checklist, the Child Beha-
manic and depressive symptoms, but those symptoms do vior Checklist (CBCL) [30]. While acknowledging the
not meet the minimal duration criteria for a Manic Epi- limitations of their study and the need for more
sode or Major Depressive Episode. research, Biederman et al. argued that, because “the clin-
Workshop discussion and debate focused not on diag- ical picture of pre-adolescent mania is very severe and
nosis of those rare children who exhibit discrete epi- impairing, there is a pressing need to refine our methods
sodes of mania and meet full DSM criteria for BP-I, but of diagnosing mania in such children (ital. added) [30].”
on whether the majority of the children described by (Critics of Geller’s approach observe that 97.9% of the
researchers like Geller et al. and Biederman et al. were sample she reported in 1995 paper also exhibited irrita-
best captured by the BP label or by some other diagno- ble mood and that her later studies found rampant irrit-
sis. Child psychiatrists’ thinking about these difficult-to- ability in her sample [35,43], raising questions about
diagnose children has evolved in, very roughly speaking, whether Geller et al. and Biederman et al. are really
three stages since 1994. observing different symptoms or are simply using differ-
ent terms to arrive at the same diagnosis.)
Stage 1: Expanding the definition of BP To support his group’s refined or expanded under-
Geller et al., Wozniak et al., and Biederman et al., were standing of childhood mania, Biederman (citing Perlis et
not the first to challenge the view that mania is rare in al. [44]) observed at our workshop that about 65% of BP
children, but their 1994 and 1995 papers have proved adults report having BP symptoms as children or adoles-
highly influential. cents that were missed by their physicians. He therefore
In 1994, Geller et al. reported that 32% of a sample of infers that BP symptoms can look different in children,
79 children diagnosed with major depression had con- and that clinicians can miss pediatric mania if they are
verted to BP-I or BP-II when followed over a 2-5 year looking for the classic adult presentation.
period [31]. The following year, Geller et al. reported Many workshop members were not persuaded by
diagnosing 26 children aged 7-18 years with BP using a either expanded conception of mania. Aside from con-
semi-structured diagnostic interview instrument [29]. cerns about reinterpreting the episodicity requirement,
They sought to define BP in a way that would allow there were also concerns about whether the observed
them to cleanly distinguish it from ADHD: because one irritable or elevated moods were properly understood as
of the cardinal symptoms of mania–irritability–is also a symptoms of BP. Jon McClellan, for example, was criti-
symptom of ADHD, they would not give a BP diagnosis cal of what was being counted as grandiosity, noting
to children who exhibited only irritability. On their that “Normal children display numerous behaviors and
approach, for mania to be present (and for a BP diagno- beliefs that would be considered pathological by adult
sis to be made), children had to exhibit elevated or standards [45].” He also suggested that many of the chil-
expansive mood or be grandiose. Crucially, they also dren Biederman et al. diagnose with BP are just “moody
maintained that manic and hypomanic symptoms look kids with rage outbursts and aggression.” Gabrielle Carl-
different in children than in adults. Specifically, they son observed that “euphoria is easy to find if you’re
modified DSM’s criteria to allow a diagnosis of mania in hunting for it, and if you infer it from merely being
children who rapidly cycled from mania or hypomania silly"–as one could given some of the language in the
to euthymia or depression, including those who 2005 treatment guidelines for BP in JAACAP [46]. She
switched moods in the course of a day, and those whose did, however, acknowledge that episodic euphoria–
symptoms did not have onset at the same time [29]. euphoria that represents a dramatic shift from that
(Barbara Geller declined to participate in our workshop.) child’s usual mood and that appears with other symp-
At about the same time as Geller et al., were expand- toms–may be easier to identify.
ing or reinterpreting the DSM account of a manic epi- Biederman, however, argued that in its intensity, fre-
sode characterized by elevated mood, Biederman et al. quency, and association with “out-of-control aggressive
and Wozniak et al. were expanding or reinterpreting the behavior,” the irritability associated with BP is “qualita-
DSM account of a manic episode characterized by tively distinct” from the irritability associated with other
childhood disorders (such as ADHD or CD). He argued describing a group of children who share severe irritabil-
that, much like a neurologist can determine the differ- ity and hyperarousal symptoms with BP I children, but
ence between a seizure associated with petit mal and who exhibit chronic irritability and do not share the hall-
one associated with temporal lobe epilepsy, so can a mark elevated mood or grandiosity required by the DSM
properly trained child psychiatrist distinguish between diagnosis of BP I. These children were said to exhibit
the different types of irritability associated with different developmentally inappropriate reactivity to negative
diagnoses. emotional stimuli, such as “outbursts characterized by
Rachel Klein argued, as she had in JAACAP in 1998, yelling and/or aggression [28],” which occur at least
that it is a mistake to interpret chronic irritability as 3 times a week, and are impairing in at least 2 settings
mania [47]. For irritability or elevated mood to count as (home, school, peers). To receive the SMD syndrome
a symptom of BP, it must appear in distinct and sus- label, children must experience symptoms for at least a
tained episodes–not as chronic or rapidly cycling. As year without more than 2 symptom-free months. Onset
Klein put it, episodicity is a sine qua non of BP. begins before age 12 (according to Leibenluft et al.’s
data, average age of onset is 5.1 years) (personal com-
Stage 2. Tightening the definition of BP and beginning munication). A prevalence study by Brotman et al.
to define a new diagnosis found that SMD is relatively common in children, with
In the early 2000s, some researchers began to speak of a a prevalence rate of 3.3% [49].
BP spectrum, stretching from Narrow Phenotype BP to Children with SMD also exhibit ADHD- and mania-
Broad Phenotype BP. Narrow Phenotype children were like symptoms, including 3 of the following: insomnia,
largely synonymous with strictly defined BP-I patients. intrusiveness, pressured speech, flight of ideas/racing
In 2003 Ellen Leibenluft et al., described the Broad Phe- thoughts, distractibility, and psychomotor agitation [28].
notype children: But the severity of the irritability and the intensity of
mood/anxiety symptoms are greater in youths with
Children exhibiting the broad phenotype may ulti- SMD than the average child receiving the ODD and
mately prove to be a heterogeneous group. Some ADHD diagnoses. Moreover, the ADHD plus ODD
may eventually meet the strict criteria for (hypo) diagnosis fails to capture the mood and anxiety symp-
mania; the course of others’ illness may be consis- toms that characterize SMD youths.
tent with dysthymia, major depressive disorder, or At our workshop, Leibenluft began to sketch the
some form of disruptive behavior disorder; and still argument that SMD meets the Robins and Guze cri-
others may prove to have a syndrome that is not teria for a valid diagnosis [50]. SMD children are at
well captured by the current diagnostic system [48]. significantly increased risk for developing depression–
not BP–at age 18 [49]. These children are less likely to
That is, while there was a small group of children who have parents with BP than are children with BP [51].
did warrant the Narrow Phenotype BP (or BP I) label, When playing frustrating games, the brains of children
there was a larger group that would be better be captured with SMD and BP respond differently (as measured by
under the rubric of Broad Phenotype BP. Some of the EEG) [52]. A new study by Brotman, Leibenluft, and
children in that latter, heterogeneous group might some- others, using fMRI, finds that children who have
day exhibit BP I, some might be conceptualized as exhi- received the BP, SMD, and ADHD diagnoses exhibit
biting depression or a disruptive behavior disorder–and unique neural correlates in emotion processing of neu-
some might best be conceptualized as having a disorder tral faces [53].
that was not articulated in DSM IV. That is, Leibenluft et Some challenges were put to Leibenluft at the work-
al. were suggesting that some children who had been shop. Biederman argued that no new nosological entity
receiving a BP diagnosis might be better served by a new is needed because the ADHD and ODD diagnoses
diagnosis, perhaps called Severe Mood Dysregulation (or, together adequately capture the children Leibenluft
as the DSM V editors are currently proposing, “Temper et al. are classifying as SMD. Sociologist Ilina Singh
Dysregulation Disorder with Dysphoria”) [39]. asked if part of Leibenluft’s argument was circular
because, by invoking emerging neuroimaging data pur-
Stage 3: Severe Mood Dysregulation category porting to show that the brains of children with SMD
gains support and BP function differently [28], the assumption is made
As others became familiar with the SMD label, and as that we already know just what we are trying to figure
the data showing differences between SMD and BD out: what SMD is. Leibenluft responded pragmatically:
grew stronger, Leibenluft et al. largely dropped the “You have to start somewhere. Start with observation,
Broad Phenotype BP label. In 2006, SMD appeared for test, now look at brains, refine categories. It’s an itera-
the first time in the title of a scientific article [49], tive process”
Gabrielle Carlson, who has long treated and written diagnostic cousins, the overall treatment plans and prog-
about children with the constellation of symptoms at noses for the children are different. For example, stimu-
issue, believes that, in addition to recognizing the differ- lants can trigger mania in people with BP [55], and
ence between SMD (or BP, for that matter) and ADHD, there is evidence that antidepressants can also [56].
physicians also need to recognize the possibility that Conversely, children who actually have ADHD, depres-
children who receive one of those diagnoses might actu- sion, or anxiety and who are treated with the standard
ally have a learning disorder or a PDD spectrum disor- BP medications may experience the side effects of those
der. Such children, Carlson argued, exhibit the sorts of medications and not improve. Moreover, because DSM’s
aggressive rages that Leibenluft links with SMD (and diagnostic labels are meant to facilitate research, apply-
that Biederman links with BP). While largely agreeing ing them inconsistently can compromise it [57].
with Leibenluft et al., Carlson was stressing how easy it As Carlson also emphasized, focusing on BP can
is to miss a learning disorder or a PDD spectrum disor- “blind clinicians to the fact that there are other things
der, among others. In a similar vein, Mary Burke voiced they might be focusing on.” That is, because BP is asso-
the concern that some children diagnosed with BP ciated with high heritability estimates and is treated pri-
might more helpfully be diagnosed with PTSD or what marily with medications, physicians may (erroneously)
she calls “parent-child relationship disturbance” (PCRD), infer that psychosocial treatments will not be helpful, or
which in her clinical experience are often overlooked. may be less inclined to delve deeply into the quality of
We recognize the magnitude of the contributions the child’s home environment or family relations.
made by Biederman et al. and Geller et al.: with their
research they have brought much needed attention to a Complexities surrounding pharmacological treatment
group of deeply troubled children. “Diagnostically home- As indicated by the 2007 practice parameter that
less children,” as Carlson calls them, can be very diffi- appeared in JAACAP, the first mode of treatment for
cult to help and to get help for from educational, children with strictly-defined mania is a combination of
medical and other support systems. Because of the way drugs, including traditional mood stabilizers such as
mental health and special education services are cur- lithium, anticonvulsant mood stabilizers such as dival-
rently funded in the US, an ill-fitting diagnosis can be proex (Depakote) and carbamazepine (Tegretol), and the
more helpful than no diagnosis in securing services newer, “atypical” antipsychotics such as olanzapine
(such as hospitalization and prescription medications) as (Zyprexa), quetiapine (Seroquel), and risperidone (Ris-
well as disability status and other support services. perdal). However, there are virtually no published
Researchers, too, usually need a DSM diagnosis if they research studies evaluating either the long-term (i.e.,
hope to find funding for their research. (We note, longer than 6 months) effectiveness or the safety of
though, that NIMH is keenly aware of, and attempting these pharmacological combinations. Support for their
to help researchers deal with, the ramifications of this use is based on studies of individual medications or, in
nosological debate.) Despite these pragmatic concerns, rare instances, on adjunctive treatment.
however, we were persuaded that departing from a nar- Moreover, according to some workshop participants,
row interpretation of the DSM criteria risks confusing the efficacy of some individual medications used to treat
the discussion about the nature of the mood and beha- children with BP is either unimpressive or not yet ade-
vioral problems suffered by the children at issue. We quately established. Workshop participants Gabrielle
believe that a new diagnosis, along the lines of SMD, Carlson and Julie Zito assessed the data on the efficacy
could prove more helpful to children, families, physi- of the mood stabilizers lithium, divalproex, and carba-
cians and researchers. Indeed, it was recently announced mazepine in treating children as “weak.” That is,
that either SMD or TDD is being considered for inclu- response rate (the ability to reduce symptoms of mania
sion in DSM V [54]. by 50%) in these medications did not beat placebo.
Response rates for atypical antipsychotics show a better,
Why does the diagnostic label matter? 60-80% response with monotherapy for treatment of
Overall treatment recommendations, monitoring, and acute mania or mixed episodes compared to about a
prognosis can be different for a child diagnosed with BP 25% response to placebo [58].
and a child diagnosed with, say, ADHD, a learning dis- As the authors of the 2007 JAACAP practice para-
ability, or PTSD. However, because the medications meter lament, due to limited studies in youth, “most of
used to treat these different diagnoses can also be the the treatment recommendations for early-onset BP are
same, one might ask: what difference does it make derived from the adult literature [59].” Of the 18 or so
which diagnosis a child receives? medications routinely prescribed for the treatment of
Gabrielle Carlson responded that even if many of the BP, the FDA has approved only four for use in children,
same medications are prescribed for BP and some of its specifically: lithium for children over 12 years old,
risperidone (Risperdal) [60] and aripiprazole (Abilify) for combination with an additional drug(s); and additional
children over 10, and haloperidol (Haldol) for children drugs are sometimes needed to treat side effects of
over 3. (In addition, an advisory panel to the FDA another effective but poorly tolerated medication.
recently recommended approval of quetiapine [Seroquel] As the number of BP diagnoses in children has
and olanzapine [Zyprexa] for children over 13 years, increased, so has the number of prescriptions in at least
although official FDA approval has not yet been made.) two of the drug classes listed above: anticonvulsants and
All other medications are used off label, including when atypical antipsychotics. In a 2009 article in Health
approved medications are used to treat children younger Affairs, Stephen Crystal et al. describe not only sparse
than the specified age limits. While off-label use of med- data regarding the efficacy of the newer or “atypical”
ications is common in medicine, including in children, it antipsychotics and plentiful data regarding their meta-
is far from ideal. Experience with other medications has bolic risks, but they also describe a trend whereby low-
shown that because children are physiologically different income American children are as much as four times
from adults, medications that are generally safe and more likely than higher-income children to receive aty-
effective in adults are sometimes unsafe or ineffective in pical antipsychotics (for BP and other psychiatric diag-
children [61-63]. noses) [70]. As Crystal et al. also say, however, no one
Because many children with BP can also have another knows at this point why poor children receive treatment
diagnosis (or diagnoses) such as ADHD, depression, with antipsychotics at such a high rate. One possible
anxiety, ODD, or OCD, additional medications may be explanation has to do with social control, or an unwill-
added to the drug regimen, including antidepressants, ingness to invest in costly non-pharmacological
stimulants, and first-generation antipsychotics such as approaches for poor children. Another explanation
haloperidol (Haldol) and chlorpromazine (Thorazine). would observe that because poorer children are sub-
And because every medication can have side effects, still jected to greater stress than wealthier children, their
more medications can be added to the regimen to treat symptomatology may be worse [71], which may make
the side effects. more intensive pharmacotherapy appropriate.
The side-effects problem is as worrisome as it is famil- Julie Zito presented community-based population data
iar. Atypical antipsychotics are associated with extreme at the workshop showing between 2- and nearly 6-fold
restlessness, uncontrollable speech and involuntary increases in the use of anticonvulsants by children aged
movements, and to a lesser degree tardive dyskinesia as 0-19 years across a 10-year period [72]. Anticonvulsants
well as drowsiness, increased metabolic problems, and of course also have non-psychiatric uses, but in one
significant weight gain [64-66]. The latter side effect cre- study Zito and colleagues reported that 81% of youth
ates additional risks, including juvenile diabetes and high who received an anticonvulsant-mood stabilizer were
cholesterol [57]. Mood stabilizers such as lithium and prescribed it for a psychiatric diagnosis and only 19%
anticonvulsants also carry the risk of significant weight had a seizure-related diagnosis [73].
gain, drowsiness, and decreased cognition, as well as the Zito also presented demographic data showing that
development of tremors. Many of these medications children taking anticonvulsants are increasingly under
carry risks to fetuses, leading the JAACAP practice para- 13 years old, male, and African American (14% in 2004-
meter to recommend that clinicians perform adjunctive 2005 compared with 6% in 1996-1997) [74]. The same
pregnancy tests and specifically warn female patients data show that 50% of the children taking anticonvul-
and their families about concerns regarding the anticon- sants have a BP diagnosis, and that 38% received a sti-
vulsant valproate and polycystic ovary disease [57,67,68]. mulant, 40% an antipsychotic, 52% an antidepressant,
Pharmacoepidemiologist Julie Zito pointed out that, and 12% another psychotropic medication (including
while the complicated and difficult symptoms associated lithium) in addition to the anticonvulsant. Zito et al.
with BP call for complex treatment regimens, we know found that in 2004/2005 pediatricians and other non-
that, as a general rule, “the larger the number of medica- psychiatry specialists wrote a larger proportion of antic-
tions used to treat a condition, the greater the risk of onvulsant-mood stabilizer prescriptions for youth with
adverse events [69].” Yet, as Mary Burke suggested, psychiatric diagnosis than in the previous decade [75].
“treatment guidelines support polypharmacy,” as do the When Gabrielle Carlson asked the deceptively simply
realities of clinical practice. “If you only have 20 minutes question, “Do we know if, after taking these drugs, these
a month [with a child]” she argued, “it is easy to add a kids are better off?” Julie Zito answered, “We have little
second antipsychotic.” Joseph Biederman, however, data on the effectiveness of treatment in community
offered reasons to explain and defend polypharmacy, populations. I can tell you about risks from some post-
including: children with BP often also have other disor- marketing systems, e.g. the FDA Adverse Event Report-
ders and therefore require more than one medication; ing System, but there is insufficient evidence of benefits
one drug alone may not be as effective as that drug in in community-treated populations.” Zito herself then
asked, “When will we get serious about outcomes by and described the barriers to greater availability of these
developing the infrastructure, design and measurement treatments.
protocols to provide the benefit and risk information we David Miklowitz, focused on four psychosocial treat-
need to assess medication outcome in community popu- ments: family focused treatment (FFT), interpersonal
lations [76]?” and social rhythm therapy (IPSRT), Cognitive Behavioral
Of course, against the potential side effects and the less- Therapy (CBT), and psychoeducation. These therapies
than-ideal efficacy of these agents must be weighed the were selected in part because they have shown efficacy
risks of not treating children with prescription medica- in adults with BP. He explained that two or more treat-
tions. When a child’s moods and behaviors are causing ments are often best used in combination because those
her significant distress and are impairing her ability to that focus on early recognition of prodromal signs and
learn, develop friendships, and participate in family life, medication adherence affect mania more than depres-
physicians and parents may decide that medication treat- sion and those that focus on interpersonal coping strate-
ment is the only, or is an important, way to stabilize the gies affect depression more than mania. Miklowitz also
child so that her well-being can be preserved or addressed stressed that treatments of three or fewer sessions do
through psychosocial or educational interventions. Many not work as well as treatments of twelve or more
workshop participants, including those critical of current sessions.
prescribing practices for BP, agreed that there are times One target of psychosocial therapies is stress manage-
when not medicating a child carries serious risks. ment, because stress and trauma are both contributing
Our goal here is not to assess the validity of the evi- causes to and results of manic episodes. Psychologist
dence for any drug or treatment approach. Instead we Mary Fristad emphasized environmental precipitants of
seek simply to emphasize that the facts are not as com- mania, stressing what she labeled bi-directional causa-
plete as families and physicians would wish them to be. tion. “If you have mania” she explained, “then you create
Prescribing medication is always a balancing act, with a lot of trauma in your life and trauma precipitates
physicians and parents weighing what is known about [mania].” It is clear that early life stress can have a life-
the drug’s effectiveness and side effects against the sever- long impact on neurochemistry, endocrine responsivity
ity of the symptoms the medication will target. In the and behavior, and adult studies have shown that early
case of the drugs used to treat BP (and related disorders) manic episodes are more likely to be triggered by stress-
the balancing act can be difficult due to a lack of agree- ful life events than later manic episodes [77], all of
ment about the diagnosis and a lack of information about which indicates the potential value of working with chil-
the safety and efficacy of the medications. Physicians and dren and adolescents to manage stress and trauma.
other mental health care professionals have an ethical Stress can include anything from the expressed emotion
obligation to be honest with parents about these com- of family members, peers, and teachers, to hypercritical-
plexities. Policy makers, funders, and researchers have an ity, to sexual abuse. Unfortunately, Fristad explained,
ethical obligation to ensure that research is funded and particularly given the apparently strong genetic compo-
conducted to fill these knowledge gaps. nent of BP, parents who themselves have the disorder
are at increased risk for being less attentive, less active,
Psychosocial treatment more over-protective, and more tense, which can create
There was agreement at our workshop, as there is in stress and trauma for their children.
much of the literature, that medications will often be Miklowitz presented data from several adult studies
the first-line treatment for children diagnosed with BP [78], including one that compared the effectiveness of
or presenting the specific symptoms discussed here. each of FFT, IRST, CBT and psychoeducation in nearly
However, many workshop participants also stressed that 300 adults with BP [79]. He also discussed four studies
psychosocial treatments can complement pharmacother- in adolescents [8,80-82], one study of children and ado-
apy, and they lamented a lack of attention to these treat- lescents [83], and two studies in children [84]. In each,
ments. Child psychologist David Miklowitz quipped, the study population was assigned to either psychosocial
“We’re getting to the point where psychosocial treat- treatment(s) or a form of community or collaborative
ment is being called non-pharmacological treatment.” care. In all studies, the group of patients receiving one
The workshop members who spoke about “non-phar- or more of the psychosocial treatment(s) was on average
macological” treatments spent little time trying to distin- more likely to have (depending on the particular study’s
guish among closely related diagnoses. Instead, they design) recovered from an acute episode of BP, experi-
described different psychosocial interventions, summar- enced improvement in their levels of depression or
ized what is known about the effectiveness of these mania, received a reduced score on a psychiatric rating
interventions at changing behavior and assisting children scale, or improved on symptom measures. This data led
and families to cope with difficult moods and behaviors, Miklowitz to state that, as a rule of thumb, one or more
psychosocial treatments “should accompany pharma- breaks between normal enough to leave alone and atypi-
cotherapy for early onset BP.” (We are not aware of any cal enough to warrant intervention), both over- and
studies that have attempted to discern whether some under-diagnosis are likely problems, although we did
psychosocial interventions are more effective in children not pursue these problems at this workshop. Instead, we
who receive the BP label versus those who receive the focused on the controversies surrounding what “actual”
SMD label.) BP looks like in children.
Indeed, Miklowitz stressed that the studies cited above In the mid-1990s, researchers led by Joseph Bieder-
are just a beginning, and that more research is needed man and Barbara Geller re-described the syndrome of
to better understand how, why, and when various thera- mania, key to any BP diagnosis. As a result, children
pies work. In particular, he argued that the goals of each who exhibit, in the case of Geller et al., primarily rapidly
treatment are not always clear. For example, which cycling elevated/expansive and/or grandiose mood, or in
treatments are trying to modify treatment adherence, the case of Beiderman et al., primarily chronic irritable
which family and peer relationships, and which the abil- mood, have received a diagnosis of BP. These concep-
ity to recognize and act on prodromal symptoms? One tualizations of the disorder, in combination with other
barrier to such research is, according to Julie Zito, social and clinical factors, have fueled a significant
NIMH’s failure to prioritize effectiveness research. increase in the number of children diagnosed with and
Cost is not only an issue in the context of research. treated for BP. Insofar as everyone agrees that some
Stephen Crystal et al. have observed that “nonpharmaco- fraction of these children warrant the BP diagnosis, an
logical alternatives, which may involve teaching children increase in diagnostic rates is a good thing. The debate
problem-solving skills and teaching their parents to is about how large that fraction is.
reward positive child behavior, are costly and difficult to Recently, Leibenluft and colleagues have proposed that
disseminate [70].” Many workshop participants empha- many children currently diagnosed with BP may be bet-
sized that this cost can effectively reduce the availability ter thought of as exhibiting a syndrome they call SMD.
of psychosocial treatments and lead physicians and In addition, other researchers and clinicians have argued
families to focus primarily or solely on medication. Psy- that a BP diagnosis may blind physicians to or mask the
chosocial treatments need to be delivered by trained presence of disorders such as severe ADHD, CD, ODD,
professionals, over a period of weeks or months, and are PTSD, PDD or some autism spectrum disorders. This
not always fully covered by medical insurance. Unlike year, the committee responsible for writing the next
appointments focused on medication management, psy- iteration of the DSM proposed the addition of a new
chosocial treatment appointments can last 30-50 min- childhood disorder to be called Temper Dysregulation
utes and may require active participation of multiple Disorder with Dysphoria, which is based on Leibenluft
family members. While such treatments may signifi- et al.’s description of the SMD syndrome.
cantly improve a child’s symptoms and functioning, and Based on our reading in the literature and discussion
while in the long term they may provide patients and at our 2-day workshop, we (the non-psychiatrist
their families with tools and strategies to manage and authors) were persuaded that the BP label may fit poorly
control symptoms without close supervision, in the many (quantification is difficult) of the children who
short-to-medium term they are expensive and time con- have received it over the last decade. We were also per-
suming, requiring energy and commitment from all suaded that, when DSM IV’s criteria for BP are strictly
involved. NAMI representative Darcy Gruttadaro noted applied to children, and psychiatrists revisit the diagno-
that “ [while] families want more than medication, sis and treatment plan periodically, the results can be
financial incentives and our stressed health care system potentially life-saving and may reduce years of suffering
favor writing scripts.” To improve the accessibility of for the child and family. Clearly, more research is
these therapies, health care reform must improve conti- needed to improve our understanding of the best way to
nuity of care and assure parity between mental health conceptualize the relationships among the different clus-
and medical services. These improvements are especially ters of symptoms that over the last 15 years increasingly
important for this difficult-to-treat population, regard- have been captured with the label BP. DSM V appears
less of the diagnostic labels we conclude are most to be addressing this challenge.
helpful. We understand that greater nosological clarity may be
difficult to achieve, and that an ill-fitting diagnosis can
Concluding observations sometimes be more helpful to children, families, and
Children and families can suffer terribly as a result of researchers than no diagnosis at all. It is a deeply regret-
the serious disturbances in children’s moods and beha- table feature of our current mental health and educa-
viors described here. Because moods and behaviors are tional systems that some DSM diagnoses are better than
distributed continuously in a population (without clean
others at getting children and families access to the care University of Pittsburgh Medical Center-Western Psychiatric Institute and
Clinic, USA;
and services they so desperately need. Joseph Biederman, Chief, Clinical and Research Programs in Pediatric
Additional clinician training may also be needed. Psychopharmacology and Adult ADHD, Massachusetts General Hospital,
Symptom checklists cannot substitute for thorough eva- Professor of Psychiatry, Harvard Medical School, USA;
Boris Birmaher, Endowed Chair in Early Onset Bipolar Disease and Professor
luations. Current training practices, as well as reimbur- of Psychiatry, University of Pittsburgh Medical Center-Western Psychiatric
sement policies, may leave some child and adolescent Institute and Clinic, USA;
psychiatrists unable to deliver the “biopsychosocial” care Mary Burke, Associate Medical Director, Edgewood Center for Families and
Children, Associate Clinical Professor, UCSF/Langley Porter Psychiatric
that so many agree is the gold standard. In addition to Institute, USA;
funds for research and training, clinical and educational Sidney Callahan, Distinguished Scholar, The Hastings Center, USA;
resources must be available to these children and their William B. Carey, Clinical Professor of Pediatrics, University of Pennsylvania
School of Medicine, Division of General Pediatrics, The Children’s Hospital of
families to relieve immediate stress and to work towards Philadelphia, USA;
long-term recovery, symptom remission, and reduced Gabrielle A. Carlson, Professor of Psychiatry and Pediatrics, Director, Child
impairment. These resources represent a significant and Adolescent Psychiatry, Stony Brook University School of Medicine, USA;
Peter Conrad, Harry Coplan Professor of Social Sciences, Department of
financial burden that cannot be borne by families alone. Sociology, Brandeis University, USA;
Given the evolving state of the research, physicians Michael B First, New York Psychiatric Institute, Department of Psychiatry,
making a BP diagnosis or treating children with a BP Columbia University, USA;
Mary A Fristad, Professor, Psychiatry & Psychology, Director, Research &
diagnosis must remain apprised of the debates and fol- Psychological Services, Division of Child & Adolescent Psychiatry, The Ohio
low the AACAP practice parameter’s recommendation State University, USA;
to revisit the diagnosis and treatment plan at regular Darcy Gruttadaro, Director, Child & Adolescent Action Center, National
Alliance on Mental Illness, USA;
intervals. Though we appreciate the concern regarding Sara Harkness, Professor of Human Development, Pediatrics &
“truth dumping” (where a physician shares an over- Anthropology, Director, Center for the Study of Culture, Health, and Human
whelming number of partial facts with a patient), that Development, University of Connecticut, USA;
Kelly J. Kelleher, Professor of Pediatrics, Public Health, and Psychiatry,
concern should not prevent physicians from being hon- Colleges of Medicine and Public Health, and Department of Psychiatry, The
est with families. Although it may initially be distressing Ohio State University, Vice President for Health Services Research, Director,
for patients and their families to hear that a diagnosis is Center for Innovation in Pediatric Practice, Columbus Children’s Research
Institute, USA;
not universally accepted and that treatment responses Rachel Klein, Fascitelli Family Professor of Child and Adolescent Psychiatry,
are debated, providing a false sense of certainty under- Director, Institute for Mood and Anxiety Disorders, New York University Child
mines the respect for persons necessary in the physi- Study Center, USA;
Ellen Leibenluft, Chief, Section on Bipolar Spectrum Disorders, Emotion and
cian-patient relationship. Moreover, it may cause Development Branch, Mood and Anxiety Disorders Program, National
confusion and disillusionment in the future, if the diag- Institute of Mental Health, USA;
nosis is revised or if treatment recommendations are Emily Martin, Department of Anthropology, Institute of the History of
Production of Knowledge, New York University, USA;
altered. Roy P. Martin, Professor Emeritus, Department of Educational Psychology,
If physicians are to fulfill their ethical obligation to University of Georgia, USA;
facilitate truly informed consent, they must be forth- Karen Maschke, Editor, IRB: Ethics and Human Research, Research Scholar,
The Hastings Center, USA;
coming with families about the relevant uncertainties Jon McClellan, Professor, Department of Psychiatry, University of
and complexities. This may not be easy, but it is essen- Washington, USA;
tial. No one should be surprised that in such a massively Claudia Mehler-Wex, Department of Child and Adolescent Psychiatry/
Psychotherapy, University of Ulm, Germany, USA;
complex arena of inquiry, there is uncertainty and dis- David J Miklowitz, Professor of Psychology and Psychiatry, Department of
agreement even among the most well intentioned and Psychology, University of Colorado, USA;
well informed professionals. Jefferson Prince, Instructor in Psychiatry, Massachusetts General Hospital,
Psychiatrist, North Shore Medical Center, USA;
Susan Resko, Executive Director, Child & Adolescent Bipolar Foundation,
Conflicts of interests USA;
The authors have no conflicts to claim. The workshop John Z. Sadler, Daniel W. Foster Professor of Medical Ethics, Professor of
Psychiatry & Clinical Sciences, Director, UT Southwestern Program in Ethics in
was funded by grant U13 MH78722 of the National Science and Medicine, Department of Psychiatry, University of Texas
Institute of Mental Health to the Hastings Center (Prin- Southwestern, USA;
cipal Investigator: Erik Parens, Ph.D.) Kenneth F Schaffner, University Professor of History and Philosophy of
Science, Professor of Psychiatry, University of Pittsburgh, USA;
Ilina Singh, Wellcome Trust University Lecturer in Bioethics and Society,
London School of Economics and Political Science, United Kingdom, USA;
Acknowledgements
Bonnie Steinbock, Professor, Department of Philosophy, University at
We thank three anonymous reviewers for the significant time they took to
Albany-SUNY, USA;
make constructive criticisms and specific suggestions. We thank Polo Black
Charles M. Super, Professor of Human Development and Family Studies,
Golde and Ross White for their research assistance.
Co-Director, Center for the Study of Culture, Health, and Human
Workshop participants were:
Development, University of Connecticut, USA;
David Axelson, Associate Professor of Psychiatry, University of Pittsburgh
Benedetto Vitiello, Chief, Child & Adolescent Treatment & Preventive
School of Medicine, Director, Child and Adolescent Bipolar Services,
Intervention Research Branch, National Institute of Mental Health, USA;
Julie Magno Zito, Professor of Pharmacy and Psychiatry, University of 23. Smith R: Medical journals are an extension of the marketing arm of
Maryland, USA. pharmaceutical companies. PLoS Med 2005, 2:e138.
24. Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ,
Authors’ contributions Goldman J, Kassirer JP, Kimball H, Naughton J, et al: Health industry
Both authors contributed equally to this article. practices that create conflicts of interest: a policy proposal for academic
medical centers. JAMA 2006, 295:429-433.
Received: 8 October 2009 Accepted: 10 March 2010 25. DeAngelis CD, Fontanarosa PB: Impugning the integrity of medical
Published: 10 March 2010 science: the adverse effects of industry influence. JAMA 2008,
299:1833-1835.
References 26. Carlson GA, Glovinsky I: The concept of bipolar disorder in children: a
1. Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M: National history of the bipolar controversy. Child Adolesc Psychiatr Clin N Am 2009,
trends in the outpatient diagnosis and treatment of bipolar disorder in 18:257-71, vii.
youth. Arch Gen Psychiatry 2007, 64:1032-1039. 27. Carlson GA: Bipolar affective disorder in childhood and adolescence.
2. Wilens TE, Biederman J, Brown S, Tanguay S, Monuteaux MC, Blake C, Affective disorders in childhood and adolescence New York: SpectrumCantwell
Spencer TJ: Psychiatric comorbidity and functioning in clinically referred DP, Carlson GA 1983.
preschool children and school-age youths with ADHD. J Am Acad Child 28. Leibenluft E, Rich BA: Pediatric bipolar disorder. Annu Rev Clin Psychol
Adolesc Psychiatry 2002, 41:262-268. 2008, 4:163-187.
3. Olfson M, Crystal S, Huang C, Gerhard T: Trends in Antipsychotic Drug Use 29. Geller B, Sun K, Zimerman B, Luby J, Frazier J, Williams M: Complex and
by Very Young, Privately Insured Children. J Am Acad Child Adolesc rapid-cycling in bipolar children and adolescents: a preliminary study.
Psychiatry 2010, 49:13-23. J Affect Disord 1995, 34:259-268.
4. Parens E, Johnston J: Understanding the agreements and controversies 30. Biederman J, Wozniak J, Kiely K, Ablon S, Faraone S, Mick E, Mundy E,
surrounding childhood psychopharmacology. Child Adolesc Psychiatry Kraus I: CBCL clinical scales discriminate prepubertal children with
Ment Health 2008, 2:5. structured interview-derived diagnosis of mania from those with ADHD.
5. Parens E, Johnston J: Facts, values, and Attention-Deficit Hyperactivity J Am Acad Child Adolesc Psychiatry 1995, 34:464-471.
Disorder (ADHD): an update on the controversies. Child Adolesc Psychiatry 31. Geller B, Fox LW, Clark KA: Rate and predictors of prepubertal bipolarity
Ment Health 2009, 3:1. during follow-up of 6- to 12-year-old depressed children. J Am Acad
6. Papolos D, Papolos J: The Bipolar Child New York: Broadway Books 2000. Child Adolesc Psychiatry 1994, 33:461-468.
7. Kluger J, Song S: Young and bipolar. Time 2002, 160:38-46. 32. Task Force on DSM-IV and other committees and work groups of the
8. Miklowitz DJ, Biuckians A, Richards JA: Early-onset bipolar disorder: American Psychiatric Association: Diagnostic and Statistical Manual of Mental
a family treatment perspective. Dev Psychopathol 2006, 18:1247-1265. Disorders Washington, DC: American Psychiatric Association 2004.
9. Sund A, Wichstrom L: Insecure attachment as a risk factor for future 33. Soutullo CA, Chang KD, Diez-Suarez A, Figueroa-Quintana A, Escamilla-
depressive symptoms in early adolescence. J Am Acad Child Adolesc Canales I, Rapado-Castro M, Ortuno F: Bipolar disorder in children and
Psychiatry 2002, 41:1478. adolescents: international perspective on epidemiology and
10. Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, phenomenology. Bipolar Disord 2005, 7:497-506.
Leonard H, Hunt J, Iyengar S, et al: Clinical course of children and 34. Biederman J, Faraone SV, Wozniak J, Mick E, Kwon A, Cayton GA, Clark SV:
adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 2006, Clinical correlates of bipolar disorder in a large, referred sample of
63:175-183. children and adolescents. J Psychiatr Res 2005, 39:611-622.
11. Wozniak J, Biederman J, Kiely K, Ablon JS, Faraone SV, Mundy E, Mennin D: 35. Geller B, Zimerman B, Williams M, DelBello MP, Bolhofner K, Craney JL,
Mania-like symptoms suggestive of childhood-onset bipolar disorder in Frazier J, Beringer L, Nickelsburg MJ: DSM-IV mania symptoms in a
clinically referred children. J Am Acad Child Adolesc Psychiatry 1995, prepubertal and early adolescent bipolar disorder phenotype compared
34:867-876. to attention-deficit hyperactive and normal controls. J Child Adolesc
12. Biederman J, Mick E, Faraone SV, Van Patten S, Burback M, Wozniak J: A Psychopharmacol 2002, 12:11-25.
prospective follow-up study of pediatric bipolar disorder in boys with 36. Hunt JI, Dyl J, Armstrong L, Litvin E, Sheeran T, Spirito A: Frequency of
attention-deficit/hyperactivity disorder. J Affect Disord 2004, 82(Suppl 1): manic symptoms and bipolar disorder in psychiatrically hospitalized
S17-S23. adolescents using the K-SADS Mania Rating Scale. J Child Adolesc
13. Biederman J, Faraone SV, Wozniak J, Mick E, Kwon A, Aleardi M: Further Psychopharmacol 2005, 15:918-930.
evidence of unique developmental phenotypic correlates of pediatric 37. Sigurdsson E, Fombonne E, Sayal K, Checkley S: Neurodevelopmental
bipolar disorder: findings from a large sample of clinically referred antecedents of early-onset bipolar affective disorder. Br J Psychiatry 1999,
preadolescent children assessed over the last 7 years. J Affect Disord 174:121-127.
2004, 82(Suppl 1):S45-S58. 38. Scully PJ, Owens JM, Kinsella A, Waddington JL: Schizophrenia,
14. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, DelBello MP, schizoaffective and bipolar disorder within an epidemiologically
Soutullo CA: Diagnostic characteristics of 93 cases of a prepubertal and complete, homogeneous population in rural Ireland: small area variation
early adolescent bipolar disorder phenotype by gender, puberty and in rate. Schizophr Res 2004, 67:143-155.
comorbid attention deficit hyperactivity disorder. J Child Adolesc 39. Tramontina S, Schmitz M, Polanczyk G, Rohde LA: Juvenile bipolar disorder
Psychopharmacol 2000, 10:157-164. in Brazil: clinical and treatment findings. Biol Psychiatry 2003,
15. Kluger J, Song S: Young and Bipolar. TIME 2002. 53:1043-1049.
16. Egan J: The Bipolar Puzzle. New York Magazine 2008. 40. Kramer P: Listening to Prozac New York: Viking 1993.
17. Martin E: Bipolar Expeditions: Mania and Depression in American Culture 41. Croonenberghs J, Fegert JM, Findling RL, De Smedt G, Van Dongen S:
Princeton, NJ: Princeton University Press 2007. Risperidone in children with disruptive behavior disorders and
18. Tereskerz PM, Hamric AB, Guterbock TM, Moreno JD: Prevalence of subaverage intelligence: a 1-year, open-label study of 504 patients. J Am
industry support and its relationship to research integrity. Account Res Acad Child Adolesc Psychiatry 2005, 44:64-72.
2009, 16:78-105. 42. McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, Arnold LE,
19. Spielmans G, Parry P: From Evidence-based Medicine to Marketing-based Lindsay R, Nash P, Hollway J, et al: Risperidone in children with autism
Medicine: Evidence from Internal Industry Documents. Journal of and serious behavioral problems. N Engl J Med 2002, 347:314-321.
Bioethical Inquiry 2010. 43. Tillman R, Geller B: Controlled study of switching from attention-deficit/
20. Healy D: The latest mania: selling bipolar disorder. PLoS Med 2006, 3:e185. hyperactivity disorder to a prepubertal and early adolescent bipolar I
21. Campbell EG, Weissman JS, Ehringhaus S, Rao SR, Moy B, Feibelmann S, disorder phenotype during 6-year prospective follow-up: rate, risk, and
Goold SD: Institutional academic industry relationships. JAMA 2007, predictors. Dev Psychopathol 2006, 18:1037-1053.
298:1779-1786. 44. Perlis RH, Miyahara S, Marangell LB, Wisniewski SR, Ostacher M, DelBello MP,
22. Angell M: Industry-sponsored clinical research: a broken system. JAMA Bowden CL, Sachs GS, Nierenberg AA: Long-term implications of early
2008, 300:1069-1071. onset in bipolar disorder: data from the first 1000 participants in the
systematic treatment enhancement program for bipolar disorder (STEP- 66. Safer DJ: A comparison of risperidone-induced weight gain across the
BD). Biol Psychiatry 2004, 55:875-881. age span. J Clin Psychopharmacol 2004, 24:429-436.
45. McClellan J: Commentary: treatment guidelines for child and adolescent 67. Rasgon N: The relationship between polycystic ovary syndrome and
bipolar disorder. J Am Acad Child Adolesc Psychiatry 2005, 44:236-239. antiepileptic drugs: a review of the evidence. J Clin Psychopharmacol
46. Kowatch RA, Fristad M, Birmaher B, Wagner KD, Findling RL, Hellander M: 2004, 24:322-334.
Treatment guidelines for children and adolescents with bipolar disorder. 68. Jiang B, Kenna HA, Rasgon NL: Genetic overlap between polycystic ovary
J Am Acad Child Adolesc Psychiatry 2005, 44:213-235. syndrome and bipolar disorder: The endophenotype hypothesis. Med
47. Klein RG, Biederman J, Pine DS, Klein DF: Resolved: mania is mistaken for Hypotheses 2009.
ADHD in prepubertal children: Negative. J Am Acad Child Adolesc 69. Choonara I, Conroy S: Unlicensed and off-label drug use in children:
Psychiatry 1998, 37:1093-1096. implication for safety. Drug Safety 2002, 25:1-5.
48. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS: Defining 70. Crystal S, Olfson M, Huang C, Pincus H, Gerhard T: Broadened use of
clinical phenotypes of juvenile mania. Am J Psychiatry 2003, 160:430-437. atypical antipsychotics: safety, effectiveness, and policy challenges.
49. Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Health Aff (Millwood) 2009, 28:w770-w781.
Egger HL, Angold A, Pine DS, Leibenluft E: Prevalence, clinical correlates, 71. Marchand WR, Wirth L, Simon C: Adverse life events and pediatric bipolar
and longitudinal course of severe mood dysregulation in children. Biol disorder in a community mental health setting. Community Ment Health J
Psychiatry 2006, 60:991-997. 2005, 41:67-75.
50. Robins E, Guze SB: Establishment of diagnostic validity in psychiatric 72. Zito JM, Safer DJ, dosReis S, Gardner JF, Magder L, Soeken K, Boles M,
illness: its application to schizophrenia. Am J Psychiatry 1970, 126:983-987. Lynch F, Riddle MA: Psychotropic practice patterns for youth: a 10-year
51. Brotman MA, Kassem L, Reising MM, Guyer AE, Dickstein DP, Rich BA, perspective. Arch Pediatr Adolesc Med 2003, 157:17-25.
Towbin KE, Pine DS, McMahon FJ, Leibenluft E: Parental diagnoses in 73. Zito JM, Safer DJ, Gardner JF, Soeken K, Ryu J: Anticonvulsant treatment
youth with narrow phenotype bipolar disorder or severe mood for psychiatric and seizure indication among youths. Psychiatr Serv 2006,
dysregulation. Am J Psychiatry 2007, 164:1238-1241. 57:681-685.
52. Rich BA, Schmajuk M, Perez-Edgar KE, Fox NA, Pine DS, Leibenluft E: 74. Zito JM, Hundley SD, Safer DJ: National trends in the ambulatory
Different psychophysiological and behavioral responses elicited by treatment of youth with anticonvulsant-mood stabilizers for psychiatric
frustration in pediatric bipolar disorder and severe mood dysregulation. disorders (Poster). 2008 American Academy of Child and Adolescent
Am J Psychiatry 2007, 164:309-317. Psychiatry 2008.
53. Brotman MA, Rich BA, Guyer AE, Lunsford JR, Horsey SE, Reising MM, 75. Zito JM: Pharmacoepidemiology: recent findings and challenges for child
Thomas LA, Fromm SJ, Towbin K, Pine DS, et al: Amygdala Activation and adolescent psychopharmacology. J Clin Psychiatry 2007, 68:966-967.
During Emotion Processing of Neutral Faces in Children With Severe 76. APHA Joint Policy Committee: Regulating Drugs for Effectiveness and Safety:
Mood Dysregulation Versus ADHD or Bipolar Disorder. Am J Psychiatry A Public Health Perspective: Position Paper 2006.
2010, 167:61-69. 77. Goodwin FK, Jamison KR: Manic-Depressive Illness: Bipolar Disorders and
54. American Psychiatric Association: Disorders Usually First Diagnosed in Infancy, Recurrent Depression New York: Oxford University Press 2007.
Childhood, or Adolescence 2010. 78. Miklowitz DJ, Goldstein MJ: Bipolar Disorder: A Family-Focused Treatment
55. Wingo AP, Ghaemi SN: Frequency of stimulant treatment and of Approach New York: Guilford Publications 1997.
stimulant-associated mania/hypomania in bipolar disorder patients. 79. Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, Wisniewski SR,
Psychopharmacol Bull 2008, 41:37-47. Kogan JN, Nierenberg AA, Calabrese JR, Marangell LB, Gyulai L, et al:
56. Ghaemi SN, Wingo AP, Filkowski MA, Baldessarini RJ: Long-term Psychosocial treatments for bipolar depression: a 1-year randomized
antidepressant treatment in bipolar disorder: meta-analyses of benefits trial from the Systematic Treatment Enhancement Program. Arch Gen
and risks. Acta Psychiatr Scand 2008, 118:347-356. Psychiatry 2007, 64:419-426.
57. McClellan J, Kowatch R, Findling RL: Practice parameter for the 80. Miklowitz DJ, George EL, Axelson DA, Kim EY, Birmaher B, Schneck C,
assessment and treatment of children and adolescents with bipolar Beresford C, Craighead WE, Brent DA: Family-focused treatment for
disorder. J Am Acad Child Adolesc Psychiatry 2007, 46:107-125. adolescents with bipolar disorder. J Affect Disord 2004, 82(Suppl 1):
58. Carlson GA, Merry S: Bipolar Disorder in Children and Adolescents. S113-S128.
Dulcan’s Textbook of Child and Adolescent Psychiatry Washington DC: 81. Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD,
American Psychiatric Pub 2010. Beresford CA, Dickinson LM, Craighead WE, Brent DA: Family-focused
59. McClellan J, Werry J: Practice parameters for the assessment and treatment for adolescents with bipolar disorder: results of a 2-year
treatment of children and adolescents with bipolar disorder. American randomized trial. Arch Gen Psychiatry 2008, 65:1053-1061.
Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc 82. Feeny NC, Danielson CK, Schwartz L, Youngstrom EA, Findling RL:
Psychiatry 1997, 36:157S-176S. Cognitive-behavioral therapy for bipolar disorders in adolescents: a pilot
60. U.S.Food and Drug Administration: FDA Approves Risperdal for Two study. Bipolar Disord 2006, 8:508-515.
Psychiatric Conditions in Children and Adolescents. U S Food and Drug 83. Pavuluri MN, Graczyk PA, Henry DB, Carbray JA, Heidenreich J, Miklowitz DJ:
Administration website 2007. Child- and family-focused cognitive-behavioral therapy for pediatric
61. Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL: Off- bipolar disorder: development and preliminary results. J Am Acad Child
label psychopharmacologic prescribing for children: history supports Adolesc Psychiatry 2004, 43:528-537.
close clinical monitoring. Child and adolescent Psychiatry and Mental Health 84. Fristad MA, Gavazzi SM, Mackinaw-Koons B: Family psychoeducation: an
2008, 2:24. adjunctive intervention for children with bipolar disorder. Biol Psychiatry
62. Safer DJ: Should selective serotonin reuptake inhibitors be prescribed for 2003, 53:1000-1008.
children with major depressive and anxiety disorders? Pediatrics 2006, 85. Ibe A, Zito J, Safer D, Magder L, Bronner Y, Valluri S: Impact of New-Onset
118:1248-1251. Pediatric Bipolar Disorder among Medicaid-insured Youth. 2009 American
63. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Psychiatric Association Annual Meeting 2009.
Brent DA: Clinical response and risk for reported suicidal ideation and
suicide attempts in pediatric antidepressant treatment: a meta-analysis doi:10.1186/1753-2000-4-9
of randomized controlled trials. JAMA 2007, 297:1683. Cite this article as: Parens and Johnston: Controversies concerning the
64. Goldstein BI, Birmaher B, Axelson DA, Goldstein TR, Esposito-Smythers C, diagnosis and treatment of bipolar disorder in children. Child and
Strober MA, Hunt J, Leonard H, Gill MK, Iyengar S, et al: Preliminary Adolescent Psychiatry and Mental Health 2010 4:9.
findings regarding overweight and obesity in pediatric bipolar disorder.
J Clin Psychiatry 2008, 69:1953-1959.
65. Correll C, Zuckerman IH: Second-generation antipsychotic-induced weight
gain and metabolic abnormalities [abstract]. Abstracts of American
Academy of Child and Adolescent Psychiatry 2003, 47.

Controversies Concerning The Diagnosis and Treatment of Bipolar Disorder in Children

Uploaded by

Copyright:

Available Formats

Controversies Concerning The Diagnosis and Treatment of Bipolar Disorder in Children

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Controversies Concerning The Diagnosis and Treatment of Bipolar Disorder in Children

Uploaded by

Copyright:

Available Formats

Parens and Johnston Child and Adolescent Psychiatry and Mental Health 2010, 4:9

COMMENTARY Open Access

Controversies concerning the diagnosis and

Introduction in youth coupled with a rapid rise signaled a major

Table 1 Timeline: The Recent Debate about BP in Children

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.