Psychological Science and Bipolar Disorder in Children and Adolescents
By Eric A. Youngstrom, PhD
Recent epidemiological data indicate that 4% of the general adult population will have either bipolar I or bipolar II disorder at some point in their lives, and the rate might be as high as 6% for the youngest cohort (Kessler, Berglund, Demler, Jin, & Walters, 2005). These are shocking figures - my graduate school psychopathology textbook cited a 1% prevalence for bipolar disorder (BD). BD takes a tremendous toll, with mood disorders ranking in the top ten causes of death and disability around the world (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006). These numbers also omit the "spectrum" cases affected by cyclothymia, or bipolar disorder "not otherwise specified;" but these appear to be even more common in adults, and they are associated with high rates of impairment, treatment seeking, and suicide risk (Judd & Akiskal, 2003; Lewinsohn, Seeley, & Klein, 2003).
A considerable amount of time passes from when symptoms first begin to create problems and when patients finally receive a diagnosis and appropriate treatment. Three different surveys of patients have found median lags ranging from 11 to 19 years between the onset of mood symptoms and formal BD diagnosis (Calabrese et al., 2001; Hirschfeld, Lewis, & Vornik, 2003; Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994). More than half of adults affected with bipolar disorder had their mood disorder begin at age 16 or younger (Kessler, Berglund, Demler, Jin, & Walters, 2005).
The rate of diagnosis in children has changed drastically in the last ten years in the U.S.A. For most of the past century, pediatric BD was considered so rare that case reports were published to describe the phenomena when it appeared. Now pediatric BD has been the cover story for Time magazine, had its own M-TV special, spots on "20-20" and "The Oprah Winfrey Show," and more than a dozen new trade books published on it in the last five years. Marketing research in 2001, before the media blitz, indicated that roughly 100,000 children were medicated for BD in the U.S.A. The rate of diagnosis has more than doubled in the last ten years in outpatient (E. A. Youngstrom, Youngstrom, & Starr, 2005), residential (Naylor, Anderson, Kruesi, & Stoewe, 2002, October) and inpatient settings, with bipolar disorder being the most common diagnosis in children under age 12 receiving psychiatric hospitalizations according to data from the Centers for Disease Control (Blader & Carlson, 2006).
There are good reasons to be worried about the rising diagnosis in youths. Even if the diagnoses were all accurate, little is known about the long term side effects of the medication regimens being used, and there are no medications with FDA approval for treating mania in children or adolescents. The state of affairs in 2006 is probably that bipolar disorder is both under-diagnosed and over-diagnosed at the same time.
An R-Rated Diagnosis?
There are several issues that ratchet the tension about pediatric BD even higher, including concerns about the age of onset. BD clearly has a strong genetic contribution, and genes of risk will be present from the moment of conception. The challenge is to decide how early it is possible for environmental experiences to promote gene expression in ways that we would recognize as a mood disorder.
Another set of controversies tug around whether the mood disturbance needs to be episodic (as seen in "classic" bipolar disorder) versus being more chronic (as often seen in youths), or whether people must show episodes of extreme elated/giddy/goofy mood in order to be called bipolar, versus mostly feeling irritable and aggressive. There also is debate about the rate at which moods "cycle" from mania to depression in children. Occurrence in adults at a rate of four or more episodes in a year is linked to earlier age of onset, more substance use, poorer response to lithium, more comorbid mental health issues, and higher risk of suicide. If four episodes per year signify such a different clinical course, many clinicians are alarmed and dubious about reports that children with "bipolar" disorder cycle tens of thousands of times in a year (Geller & Luby, 1997).
These controversies and the media attention showered on the diagnosis have led to some backlash, where many decide that bipolar is an "admission for adults-only" diagnosis. However, denying the possibility of its occurring can be as dogmatic and unscientific as is the zealous labeling of lots of children as having "BD."
What Psychology Can Contribute
As a discipline, psychology can make huge contributions to our understanding, assessment, and treatment of bipolar disorder. These include:
Critical thinking and strong research designs: Psychology's tradition of empiricism can accelerate progress in contentious areas. As investigators, we contribute most when we are not too skeptical to even engage with the topic, but instead get close to the data and let it shape our thinking.
Developmental perspectives: Psychology recognizes that the same risk factor can lead to highly different outcomes, or that similar outcomes can be the endpoint of highly different mechanisms. Most of what gets labeled "bipolar disorder" in childhood is probably not going to look like "classic" BD in adulthood. Instead, pediatric BD probably involves a mix of different causes and courses. So does adult BD, though (Tsuchiya, Byrne, & Mortensen, 2003). In a way, pediatric BD has the advantage of not being so reified that we assume that it is a single entity. A developmental psychopathology approach that focuses on the interplay of temperament and environmental risk factors, is likely to be a productive model for describing pediatric BD. Psychology has been more willing than many other disciplines to "color outside the lines" of diagnostic categories, which also will help identify cross-cutting factors and developmental continuity.
Improved assessment: Psychometrics and careful attention to factors influencing agreement across parent, teacher, clinician, and youth ratings are unique strengths of a psychological approach to assessment. Our group's work has concentrated on comparing different questionnaires as aids for diagnosing bipolar disorder as well as measuring response to treatment (E. A. Youngstrom et al., 2004; E A Youngstrom et al., 2005). Bipolar disorder appears especially likely to be misdiagnosed as schizophrenia or conduct disorder in African American or Latin American families, and psychological research is beginning to isolate the factors contributing to this pattern (Bhatnagar, Youngstrom, Flowers, Calabrese, & Findling, under review). This work has culminated in recommendations for evidence-based strategies of assessment for pediatric bipolar disorder, using a combination of techniques that lessens the risk of over-diagnosing a trendy but rare condition while improving early detection of cases (E.A. Youngstrom, Findling, Youngstrom, & Calabrese, 2005).
Improved treatment: There is no cure for bipolar disorder, and the best pharmacological treatments often are less effective because of problems with adherence. "Pills do not come with skills," and psychoeducation and psychotherapy are crucial ways of building positive skills to improve relationships, promote academic and vocational success, and produce better coping and quality of life (Fristad, Goldberg-Arnold, & Gavazzi, 2002).
Improved management: BP is much like diabetes and other chronic illnesses. It requires lifelong vigilance and a preventive stance. The tools developed in health psychology for managing chronic conditions such as diabetes would be tremendously helpful for families learning to monitor sleep, social activities, and diet to not just stabilize illness but to enhance positive outcomes (Danielson, Feeny, Findling, & Youngstrom, 2004).
Bipolar Disorder - It's Not Just for Clinicians Anymore
It would be a mistake to consider bipolar disorder solely as an issue for "clinical psychology." Psychological science has a lot to offer, and much that could be learned working with BP. Here is a brief list of "teasers":
Study of emotion. BP offers a fascinating window into emotion recognition as well as emotion regulation.
Positive emotions. Is it possible to have too much of a good thing? The experience of mania raises interesting questions about whether positive emotions such as joy or exuberance can be pushed to extremes where they lose their adaptive or prosocial qualities.
Creativity. Intriguingly, BP is linked with exceptional creativity in family members as well as affected adults during periods of good functioning. It is less clear if this is true in affected children, or what could be done to enhance the creative aspects of the syndrome.
Group dynamics. Having a mood disorder creates challenges and changes in the way that families, as well as peer groups, interact. It would be fascinating to bring attachment research techniques or "social information processing" models to bear on pediatric bipolar disorder (Miklowitz, 2004).
Are there sharp edges to temperament? When do we cross from temperament or personality into a qualitatively different phenomenon? These sorts of boundary issues have implications for social psychology and for our understanding of individual differences. They also establish the foundation for early intervention and prevention work by helping distinguish between what is personality versus prodromal illness.
There are other connections to physiological psychology, personality research, parenting, and the effects of sleep and diet on mood and energy. Bipolar disorder -- and the underlying genes of risk and interpersonal processes -- offers a fascinating window into the role of mood and cognition on the development of identity. Working in this area guarantees there will be no lack of challenges, but it is doubly rewarding: Not only are there exciting questions inviting basic science research, but the results have the potential to immediately change lives for the better.
Bhatnagar, K., Youngstrom, E. A., Flowers, A., Calabrese, J. R., & Findling, R. L. (under review). The effects of ethnicity on diagnostic rates of bipolar spectrum disorder and manic symptom expression in youth ages 5-17 years
Blader, J. C., & Carlson, G. (2006, April). BPD diagnosis among child and adolescent U.S. psychiatric inpatients, 1996-2003. Paper presented at the NIMH Pediatric Bipolar Disorder Conference, Chicago.
Calabrese, J. R., Shelton, M. D., Rapport, D. J., Kujawa, M., Kimmel, S. E., & Caban, S. (2001). Current research on rapid cycling bipolar disorder and its treatment. Journal of Affective Disorders, 67, 241-255.
Danielson, C. K., Feeny, N. C., Findling, R. L., & Youngstrom, E. A. (2004). Psychosocial Treatment of Bipolar Disorders in Adolescents: A Proposed Cognitive-Behavioral Intervention. Cognitive & Behavioral Practice, 11, 283-297.
Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2002). Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disorders, 4, 254-262.
Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1168-1176.
Hirschfeld, R. M., Lewis, L., & Vornik, L. A. (2003). Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. Journal of Clinical Psychiatry, 64, 161-174.
Judd, L. L., & Akiskal, H. S. (2003). The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. Journal of Affective Disorders, 73, 123-131.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003). Bipolar disorder in adolescents: Epidemiology and suicidal behavior. In B. Geller & M. P. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 7-24). New York: Guilford.
Lish, J. D., Dime-Meenan, S., Whybrow, P. C., Price, R. A., & Hirschfeld, R. M. (1994). The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. Journal of Affective Disorders, 31, 281-294.
Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., & Murray, C. J. (2006). Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet, 367, 1747-1757.
Miklowitz, D. J. (2004). The role of family systems in severe and recurrent psychiatric disorders: a developmental psychopathology view. Development and Psychopathology, 16, 667-688.
Naylor, M. W., Anderson, T. R., Kruesi, M. J., & Stoewe, M. (2002, October). Pharmacoepidemiology of bipolar disorder in abused and neglected state wards. Paper presented at the Poster presented at the National Meeting of the American Academy of Child and Adolescent Psychiatry, San Francisco.
Tsuchiya, K. J., Byrne, M., & Mortensen, P. B. (2003). Risk factors in relation to an emergence of bipolar disorder: A systematic review. Bipolar Disorders, 5, 231-242.
Youngstrom, E. A., Findling, R. L., Calabrese, J. R., Gracious, B. L., Demeter, C., DelPorto Bedoya, D., et al. (2004). Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 847-858.
Youngstrom, E. A., Findling, R. L., Youngstrom, J. K., & Calabrese, J. R. (2005). Toward an evidence-based assessment of pediatric bipolar disorder. Journal of Clinical Child and Adolescent Psychology, 34, 433-448.
Youngstrom, E. A., Meyers, O. I., Demeter, C., Kogos Youngstrom, J., Morello, L., Piiparinen, R., et al. (2005). Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings. Bipolar Disorders, 7, 507-517.
Youngstrom, E. A., Youngstrom, J. K., & Starr, M. (2005). Bipolar Diagnoses in Community Mental Health: Achenbach CBCL Profiles and Patterns of Comorbidity. Biological Psychiatry, 58, 569-575.
About the Author
Eric Youngstrom is an associate professor of Psychology at the University of North Carolina at Chapel Hill. He is the first recipient of the Early Career Award from the Division of Child and Adolescent Clinical Psychology, and has also been an American College of Neuropsychopharmacology Travel Fellow. Youngstrom is a member of APA and its divisions 5 and 53. He is the principal investigator on an NIH-sponsored multi-site collaboration to improve the diagnosis of bipolar disorder in children and adolescents, especially in underserved populations. His doctorate in clinical psychology is from the University of Delaware, with a pre-doctoral internship at the Western Psychiatric Institute and Clinic. Youngstrom studies the emotions, developmental psychopathology, and the clinical assessment of children and families. Youngstrom has published more than 85 peer reviewed publications on the clinical assessment, emotion, or bipolar disorder, and he has served as an ad hoc reviewer on more than thirty prominent psychology and psychiatry journals.