Review of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis,by Stuart L. Kaplan

When a raging child is brought for the first appointment with a child and adolescent psychiatrist or other clinician with the question of “does my child have bipolar disorder,” the response is often quite polarized. On the one hand, there is the view that “bipolar disorder” is common, and, therefore, that it is more than likely that an explosive child has it. The other view is considerable skepticism indicated by a suppressed “eye roll.” The thesis set forth in Kaplan's Your Child Does Not Have Bipolar Disorder will resonate with clinicians who have observed this.

Kaplan “calls it as he sees it” in this review of one of the most controversial topics in child and adolescent psychiatry today: The diagnosis of bipolar disorder in children. Kaplan's opinion is that bipolar disorder is overly and wrongly diagnosed in children, leading children both to receive unhelpful treatments with potentially serious side effects and not to receive proven treatments to help their symptoms, namely stimulants. He refers to “pediatric bipolar disorder” as a “diagnosis with little evidence to support it” and “actually a severe form of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).” The book is for parents of “very angry children with ADHD,” but it is also an educational read for anyone in the field of psychiatry.

Kaplan is a clinical professor of psychiatry at Penn State College of Medicine in Hershey, Pennsylvania. He is board certified in adult as well as child and adolescent psychiatry. He has served as director of child and adolescent psychiatry at Long Island Jewish Medical Center-Zucker Hillside Hospital, St. Louis University, and Penn State College of Medicine. He has an outpatient practice and a blog on the topic of bipolar disorder in youth. Although he has published on topics that include depression in adolescence, emotion expression in children with ADHD, enuresis, pediatric psychopharmacology, and pharmacologic treatment of ADHD and depression in youth, he has not been a “player” in the bipolar disorder research arena.

Kaplan strategically builds his argument throughout the three sections of the book: Part I, Critique of Pediatric Bipolar Disorder; Part II, Medications and Pediatric Bipolar Disorder; and Part III, Advice for Parents. Like others writing on the bipolar controversy, he reviews and compares diagnostic criteria for mania, ADHD, and ODD, and then discusses areas of symptom overlap, for example, being talkative, increased motor activity, distractibility, and impulsivity. He includes a short description of what the Diagnostic Statistical Manual of Mental Disorders (DSM) is for parents who may not be familiar with psychiatric diagnoses and how they are made as well as common criticisms of the DSM. Despite DSM's shortcomings, Kaplan argues that it remains the current gold standard for diagnosis, and should be adhered to, so that diagnoses can be made consistently. In fact, he points out that the some of the leading researchers in this area, specifically Joseph Biederman of Harvard University and Barbara Geller of Washington University and their research groups have actually not adhered to Diagnostic Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for the diagnosis (American Psychiatric Association 1994).

Kaplan feels that the aforementioned researchers went astray by providing different definitions to be used for pediatric bipolar disorder. Biederman and colleagues use severe, explosive physical aggression as diagnostic, whereas Geller identifies grandiosity and elation, idiosyncratically in ways that have not actually been established as developmental equivalents of symptoms such as elation (e.g., “periods of silliness and giggling”) and grandiosity (“bragging”). The arguments are old ones, espoused clearly in a “point/counterpoint” in the Journal of the American Academy of Child and Adolescent Psychiatry (Biederman et al. 1998): Is there a juvenile form of bipolar disorder or is this “severe ADHD.” Kaplan points out that adults with bipolar disorder tend to have distinct mood episodes every few months, not every few minutes and that the best prospective studies of children with bipolar parents (Egeland 2000, 2003; Meyer 2004; Duffy 2007), find no cases of bipolar disorder found before age 12. Regarding epidemiology, Kaplan cites recent estimates of the prevalence of child bipolar disorder as 5% in the United States. As bipolar disorder is a lifelong psychiatric condition, Kaplan argues that it is not possible for the diagnosis to be five times more common in children than in adults, but rather that this must be a separate illness entirely (although some researchers use the decline in diagnosis with age to indicate that there is a developmentally specific form of bipolar disorder (Cicero et al. 2009).

Kaplan identifies the book, The Bipolar Child by Demitri Papolos and Janice Papolos, as being central to the popularization of the diagnosis, although other media got on the band wagon as well, for example, a Time Magazine cover story in 2002, a Newsweek cover story in 2008 and a New York Times Magazine article in 2008. Although the book and articles point out that the diagnosis is controversial, they do not provide information on opposing opinions. In his section “Professional Support for the Diagnosis,” Kaplan even critiques the National Institute of Mental Health for supporting the diagnosis by holding a research roundtable on the topic and providing funding for studies related to the disorder. It is worth noting, however, that what emerged from the roundtable was addressing the question of chronic, severe irritability versus episodic irritability, which is seen with the more classic definition of bipolar disorder (Leibenluft et al. 2003). This is what has helped clarify the symptom, genetic, treatment, and outcome differences. Although Kaplan mentions the work of Leibenluft on severe mood dysregulation briefly, this topic warrants expansion. Kaplan's book was published in 2011, and in it he sites work by Leibenluft from 2003, but leaves out all of her research in the interim. In his opinion, children with severe mood dysregulation, the term given to chronically irritable and explosive children, have combined ADHD and ODD, a fact pointed out by Carlson in 2007. The fact that this research designation was adopted by the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) committee and transformed to a condition called “disruptive mood dysregulation disorder” has stirred up its own controversy (American Psychiatric Association 2013). As of yet there is little research to support its existence, let alone an evidence base for treatment recommendations. Perhaps Kaplan could write a blog post on this topic, as it certainly relates to his area of interest.

Kaplan speculates that the bipolar diagnosis is popular among parents because parents see ADHD as associated with stigma and bipolar disorder as associated with being creative and smart. He also wonders if physicians prefer the diagnosis, perhaps because severely emotional behaviors present a challenge for treatment and diagnosis.

The book covers a number of key topics beyond the bipolar controversy, including depression in children; “the myth of suicide” with antidepressants; and medications used to treat bipolar disorder, depression, ADHD, and ODD. Kaplan reviews pertinent research on the medications, specifically lithium, divalproex, and risperidone, and provides understandable explanations of different study designs for the lay reader, that is, open label versus randomized double-blind placebo-controlled studies. He notes that the literature reports mixed results for these medications in the treatment of pediatric bipolar disorder, and that they have significant side effects. Despite the significant risks of these medications and the limited evidence base for their effectiveness, their use in the pediatric population is on the rise.

The book's best chapter is on stimulant medications. Parents who question whether to have their child take a stimulant medication for ADHD would have many of their anxieties quelled by reading this chapter. Kaplan cites research that 50–90% of children diagnosed as “bipolar” also are diagnosed with ADHD. However, some psychiatrists have had reservations about prescribing stimulants secondary to the concern that it may cause a worsening in bipolar symptoms. Kaplan calls this a “false belief,” and says that stimulants are the class of medication that can be the most helpful both for ADHD symptoms and for the aggression that is commonly associated with ADHD, and he summarizes the evidence base that leads to those conclusions. Kaplan accurately summarizes common parental concerns in starting a simulant medication: guilt that they should be more involved, fear that their children will lose some of their personality, and worry that the medical field pushes these medications on children for financial benefit. Lastly, common side effects and ways to manage them are reviewed, which is an essential read for anyone who provides stimulant education to parents.

In his chapter “Bad Science,” Kaplan points out flaws in recent research that have served to promote the diagnosis of pediatric bipolar disorder. He includes the misidentification of criteria described previously in this review. He also notes that the use of semistructured interviews, which is supposed to safeguard reliability of diagnosis, has been inconsistent in terms of who is interviewed, how responses are interpreted, and what symptoms are counted toward what diagnosis, so that researchers end up comparing apples and oranges. He is especially annoyed by the school of thought that attributes development of bipolar disorder later in life to use of stimulant medication in childhood, referred to by Kaplan as the “chicken or egg” phenomenon. He argues that children who receive stimulant medication tend to be more psychiatrically ill to start with; therefore, the illness occurs prior to any medication.

Kaplan concludes his book with Part III “Advice for Parents.” He implores them not to forego treatment with stimulant medication for co-existing ADHD symptoms, and not to think of their child as a “guinea pig” or as being experimented on by medical professionals (a common reaction many parents have to medication changes). He states that “careful adjustments of doses and changing medications to get the best result are hallmarks of good medical care.” He recommends using antipsychotic medication for severe aggression. He reiterates that the false diagnosis of bipolar disorder leads to unnecessary treatment with lithium or anticonvulsant medication. Lastly, Kaplan recommends use of a behavior modification program for oppositional children, and provides step-by-step instructions on how to implement such a program.

Kaplan does not break new ground with this book. A number of leaders in the field have espoused similar viewpoints for many years (e.g., Rachel Gittelman Kline and Gabrielle Carlson, who were commented on in the book, and many others). The book does serve as a “media antidote” to the many books on the subject telling parents that their child does have bipolar disorder. It is a good review of a complex and controversial topic, and covers a wide array of topics in psychiatry other than bipolar disorder; that is, ADHD, ODD, depression, suicide, and psychopharmacology. Perhaps the title could have been Your Child Does Not Have Bipolar Disorder … But This Book Can Help What They Do Have, as Kaplan gives definitive advice and guidance. The review of relevant research was easy to understand, and Kaplan's interpretations added support to his argument. The rich clinical examples throughout the book helped to illustrate key topics clearly. Although geared toward parents of children who have been or might be diagnosed with bipolar disorder, it would also add to the education of medical students, residents, and fellows in psychiatry. Critiques include that it omitted applicable research on severe mood dysregulation, and that it set up the “straw man” that DSM is the absolute guide to psychiatric diagnosis.