Tammy Seltzer, senior staff attorney at the Bazelon Center for Mental Health Law, talks about schools' responsibilities in supporting bipolar children.
Tammy Seltzer: Basically, schools have done an abysmal job addressing the needs of children with emotional and behavioral disorders, and that's even once they've identified them. And, schools have historically done a very poor job of identifying children with emotional and behavioral disorders.
National studies have shown that anywhere from five to nine percent of all children have a serious emotional, behavioral problem, but schools identify only less than one percent of those children in their care as needing special education services because of an emotional or behavioral problem.
Karen Brown: What do you attribute this failure to?
Seltzer: Well, schools tend to view children with behavioral problems as problem children rather than children who have a condition that needs special attention, such as a child who has diabetes may need special attention to make sure that they take their medication or that they eat when they're supposed to be eating or check their blood sugar levels when they need to. Unfortunately, schools, like many people at large, see children with behavioral problems as problem children or children who are the products of bad parenting.
Schools have an obligation to identify children whose behavior interferes with their learning or the learning of other children. That's federal law, and it's really very disappointing that 30 years after the special education law was passed, that school systems still seem so resistant to meeting the needs of children with disabilities, but particularly the needs of children with behavioral disorders.
And I think it's short-sighted that schools seem much more interested in acting tough than in wanting to solve behavioral problems which they can do without spending a lot of money and which they can do in such a way that it would improve the school environment for all of their students.
Dr. Demitri Papolos, coauthor of the book The Bipolar Child and Director of Research for the Juvenile Bipolar Research Foundation, talks about the psychiatric community's response to bipolar disorder in children.
Dr. Demitri Papolos: Historically, there has been a strong bias against making the diagnosis in childhood. And there's been a myth and an assumption that the condition could only first manifest itself in puberty - and then it was rare. Where that myth came from is uncertain, there are different views about that. But the other problem is that the diagnostic manual that is used by professionals around the country and even around the world, the criteria that were developed, were all developed based on studies of adults.
So the current, diagnostic criteria that we use to make psychiatric diagnoses, is not reflective of the presentation of this illness in childhood. In fact, if you use the current diagnostic criteria, which are adult criteria, you probably would only diagnose 25% of the cases of kids with early onset bipolar disorder. So, there are really significant differences in the way we diagnose in an adult or a child and that remains an area of controversy and it's not even planned to revise the definitions, and the next revision of the DSM 4 is not planned before 2010.
Those of us who recognize that right now, this is becoming a national public health nightmare because of the misdiagnosis and inappropriate treatments that alter the course of the illness, will be able to move and establish a consensus in the field so that we will have at least some better way of describing and recognizing the condition.
Rachel Klein, clinical psychologist and professor of psychiatry at the Child Studies Center of New York University, is skeptical about the scale of the "bipolar child" epidemic.
Rachel Klein: Adult bipolar disorder is not associated with abnormal intelligence or competence. As a group, adults with bipolar disorder are high achievers, better educated than the average, etc. This is not true of the kids. So, you say, "Where do you draw the line?" Well, if a kid has trouble in school, can't get along with peers, is unable to function in the family, there is something wrong. It's not that tantrums that define the problem, it's the child's ability to just assume the roles that are expected for his or her age. It's not so in adult bipolar disorder. When people are not affected by either depression or mania, they function very well. Or they function adequately. I don't think that's true of these children that are described as bipolar.
Karen Brown: So, it's more systemic in these kids. These are the kids that are going to be left out of games. Whereas, with an adult, they're only going to be left out of social situations when they are in one of these two states. Is that right?
Klein: Actually, when adults are manic, depending on the severity, they're extremely compelling and seductive. I mean in the best sense of the word. They're appealing because of their enthusiasm, their ability to take on things, they carry people with them. They're better able to talk the bank into giving them a loan, into convincing people to do what they want. But that's not true of these kids. These kids don't have added social competence as a result of being manic. I don't want to imply that mania is adaptive. It's not. It can be terribly destructive, and it often is. But, among these kids, you don't get this picture of an over-enthusiastic individual who gets carried away too far. You get a kid who's chronically angry, irritable, unhappy, miserable.
Brown: Do you have a sense that there's an urge to look for a diagnosis when, in fact, you just have is a difficult child?
Klein: It's very hard for parents to hear, "We don't know. We don't know what to call what's wrong with your child." And I think it's perfectly human to want to identify something as it. But, I can't blame parents for being the driving force in this epidemic. I think the profession, ultimately has to take responsibility for it. But, I think that there are parents who welcome the opportunity to essentially "understand" that there's something wrong with their child. It's not just that they're not nice enough or consistent enough, it's that this child has something wrong with him. And it has a name. Having a name is not a bad thing. It's a good thing because what's the point of giving something a name? It helps to define the treatment and that's a very important goal. That's why we want to diagnose something, in order to help it. But in this instance, diagnosing bipolar disorder in children does not help with treatment. It does not guide treatment. There is no treatment established. And there's not even good clinical reports that suggest what you should do.
Brown: Is there a disadvantage with calling an eight-year-old bipolar? Is the label itself a problem?
Klein: Yes, I think it is a problem when it's not accurate. The problem is that we will use medications that are known to be effective in bipolar disorders and those are: lithium, which is extremely effective in bipolar disorder, and the anti-convulsants. But these don't work in children. So why do we have to expose children to treatments that are not going to help them? They're not "dangerous," so there isn't great concern, but it's costly and it takes time. So, even though the children are not in danger, I don't think we can be cavalier about giving treatments that have no demonstrated efficacy. And that's what will happen.