Shweta Krishnan

Shweta Krishnan Writing Sample - Short article The Young Bipolar Child Imagine a 5-year-old child who talks animatedly about running the country, winning the Nobel Prize or going to the moon. But his school records show he is failing his classes. His teacher notices that he is mostly disinterested, restless and irritable. On some days, he throws violent tantrums and plays dangerous games. His mother even discovers that he has touched other children inappropriately, or used offensive phrases in conversation. If the boy was older than ten, child psychiatrists around the country would readily diagnose him with bipolar disorder, a mental illness in which patients suffer alternating bouts of maniac elation and depression. But the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, the book that sets the guidelines for the diagnosis of psychiatric illnesses, does not identify or define bipolar disorder in children younger than ten. This, coupled with a dearth of research in children under six, has fueled a divide among American psychiatrists. “It is an extremely sensitive topic in psychiatry today,” said Dr. Mark Olfson, a child psychiatrist at Columbia Univeristy. “Many doctors feel that young children should not be diagnosed of this disorder at all. But there are others who feel very passionate about diagnosing this disease.” In the last 15 years, one school of doctors has increasingly diagnosed young children with bipolar disorder using adult criteria in the DSM- IV. The manual classifies bipolar disorders in adults into four categories, based on the severity of the depression and the elation. When a bipolar adult feels elated, he or she often talks excessively, spins wild tales and displays high levels of confidence. They also feel powerful, and sometimes experience an increased sexual drive. In depressed phases, they can be self-effacing, suicidal and extremely moody. In bipolar children doctors looks for similar signs: loquaciousness, tantrums, a wild imagination and a sense of authority. Some of these children are also sexually inappropriate for their ages. Depressed children are restless and irritable, and highly likely to fail at school. “We see a lot of very young children who also show these symptoms,” said Dr. Mani

Shweta Krishnan

Pavaluri, the head of the mood disorders clinic at the University of Illinois, Chicago. “Most of them are bipolar.” But critics feel that these symptoms could point to other pediatric psychiatric illnesses. One of them is Attention Deficit Hyperactivity Disorder, in which children are restless and very likely to fail at school; another is Oppositional Defiant Disorder, a mood disorder in which children throw tantrums, and play dangerous games. Dr. Joyce Harrison, who specializes in mood disorders in preschool children, said that some of them had a combination of both. She also said that children who were abused at homes were likely to be moody or restless. “Sexually abused children are very curious about sex,” she said. “Sometimes a talk with the family helps.” In spite of the criticism, there was a nationwide 40-fold increase in the diagnosis of bipolar disorder in young children in the last ten years, according to a study conducted at Columbia University. This increase in diagnosis was not followed by an increase in research. “We need some kind of consensus on diagnostic criteria, before we can enroll children for research,” said Dr. Olfson. He also said that many children who are diagnosed of bipolar are reclassified within months as suffering from some other pediatric illness. “So we do not know who to include in the study yet.” Despite the lack of studies, doctors prescribe antipsychotics, widely used in adult psychiatry, for the diagnosed children. All these drugs are still unapproved by the F.D.A for use in children under eight. “Most of these drugs cause metabolic disorders even in older children and adults,” said Olfson. Weight gain, a common side effect of most antipsychotics in use today, can lead to diabetes and heart disorders when teenagers take these drugs over six months, studies show. However, experts say that the side effects may show sooner in younger children. “That only makes the picture worse,” said Olfson. There are also no studies to show the effect of these drugs on the developing brain, doctors said. Most antipsychotics modify the chemicals secreted in the brain. While this could be beneficial for bipolar children, doctors do not know if they can harm the brain cells in normal children, who are wrongly diagnosed. Experts also say that parents sometimes pressurize doctors to diagnose and medicate a child. “Most parents want a label,” said Dr. Olfson. “They want a quick cure.”

Shweta Krishnan

Now as the American Psychiatric Association prepares to update the DSM, American psychiatrists hope that the fifth edition, slated for publication in May 2013, will them understand this disease better. Though DSM V will not carry an entire section on pediatric bipolar disorders, it will advise doctors on how to classify tantrums and violent behavior in children. It will also tell them how to differentiate between ADHD, ODD and Bipolar disorders. Experts also hope that this will help them go ahead with research in very young children. “The DSM should set this controversy to rest,” said Dr. Anya Ho, who heads the depression clinic at UCSF. “Psychiatric illnesses are not tangible and without guidelines even the best doctors can go wrong.”

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