For every 10 kids who enter Elmore Academy, a correctional facility in southern Minnesota, three or four take psychotropic drugs for bipolar disorder or mood problems.
By the time they leave, only one or two remain on the potent medications, according to estimates by Dr. Terence Cahill, the facility's consulting physician.
"These kids go off the medication and they do just fine," he said. "People are treating bad behaviors with medication."
The experience at Elmore Academy reflects a larger trend: the over-diagnosis and over-treatment of bipolar disorder among American children in the past two decades. Clinic visits for bipolar youth quadrupled between 1995 and 2003, reaching 800,000, one study found.
Today, mental health experts generally agree the label has been issued too liberally -- to thousands of children whose problems don't match criteria for the disease -- and that powerful psychotropic drugs have been prescribed too often.
But even as American psychiatry gets its house in order on the issue, an unsettling question remains: If these troubled kids aren't bipolar, what is wrong with them?
Some doctors believe the children are suffering from unrecognized trauma such as violence or poverty -- a hazard that is common among youth in state child protection and corrections systems. Others believe there is no current explanation that makes sense, and are creating a new diagnosis to fit children whose rapid tantrums and mood swings result in bipolar labels.
Still others believe these children are exposed to so much visual media and stress that they can no longer govern their emotions.
If these theories are right, they could alter treatment for thousands of children. Some could be spared the use of mood stabilizers or antipsychotics -- powerful drugs that can have severe side effects ranging from significant weight gain to muscle tics to hallucinations.
"Clearly with adults with bipolar disorder, medication is very necessary," said Libby Bergman, a therapist with the Family Enhancement Center in Minneapolis. "In childhood, I think it slows the children down, making them easier to manage, but I don't know that medication always solves the problem.
"And it isn't necessarily the safest thing," she added. "I don't think we have any idea what those types of psychotropic medications can do to the developing brain."
One emerging theory is that the affected children have suffered trauma -- perhaps outright abuse, or perhaps subtler forms such as living with divorce, poverty or crime.
Parents seek medial solutions
Children coping with trauma can seem agitated and aggressive -- the calling cards of pediatric bipolar disorder. A misdiagnosis can be reinforced by parents, who want medical solutions for their kids and might not recognize -- or want to admit -- the daily trauma their children experience.
"It's not as if they had one car accident or they witnessed one episode of abuse of a loved one," said Dr. Michael Sutherland, a child psychiatrist in Duluth. "In a lot of cases, it's kids that have been forced to live in kind of scary or neglectful conditions."
Guardian ad litem Denise Graves has seen the criss-crossing of trauma and bipolar symptoms among children in the child-welfare system -- and has stepped in to oppose prescriptions for foster children whose problems didn't seem medically related.
"How do you separate that [trauma] from a true, organic mental disorder?" she said. "It's hard to differentiate because of the tragic lives they've led."
Several studies suggest that doctors err on the side of medicating foster children. In November, a study published in the journal Pediatrics found, paradoxically, that foster children were as likely to take multiple psychotropic drugs as children receiving disability benefits due to diagnosed disorders.
This month, the U.S. Government Accountability Office found that foster children were more likely to receive five or more psychotropic drugs at once -- or to receive drugs at dosages above federal safety thresholds -- than other children on Medicaid programs.
If trauma is the root of the problem for some children, psychiatrists say, they would be better served by therapy and identifying what's wrong in their lives, rather than with powerful medications.
"Most of the time there is something that has happened in a child's life, something that got them stuck developmentally," said Sue Sexton, a St. Paul psychologist who treats kids with stress-related disorders.
Until the 1990s, doctors were ridiculed for suggesting bipolar disorder in children. Then an influential Harvard psychiatrist concluded that the disorder simply looked different in kids. While adult bipolar disorder features prolonged mania and depression, Dr. Joseph Biederman concluded that the disorder surfaced in children in the form of rapid bursts of aggression. Doctors welcomed the diagnosis, because it gave a name to the baffling symptoms and aggression they saw in some of their patients.
The next fad diagnosis
Now some mental health experts worry that trauma is becoming the next fad diagnosis. "There is always the possibility that any diagnosis can become soup du jour," even when the underlying disease actually exists, said Dr. Joseph Lee, a child psychiatrist at Hazelden's Center for Youth and Families in Plymouth.
Lee said the profession won't solve the bipolar mystery in children until therapists sort out another factor: the role of illicit drug abuse. "By default," he said, "you can't make a lot of these diagnoses if there's the presence of substances."
When children are admitted to Hazelden, Lee tries to determine how much their problems reflect addictions, behaviors or mental disorders. He obtains a thorough family history, looking for clues that patients are predisposed to anxiety, addiction or other problems.
The teens sent to Elmore Academy have the same complex stories: Many have histories of family trauma and substance abuse. Confinement to Elmore spares them from both, Cahill said, making it easier to determine whether their problems reflect bipolar disorder and whether they are on medications they don't really need.
"Let's see how you look when you get off your chemical, and then maybe we can get you off of our chemicals," Cahill said. "If they're sober and they're accessible, it's amazing what you can do with kids without having to give them medication."
Another theory points to the high-stress, media-intensive environments in which kids are raised. Children's brains are "sculpted" by their experiences, particularly by emotional or intense experiences. The more children are exposed to stress, anxiety and grief, the more their brains are hard-wired to react instinctively to emotional experiences, said Dr. L. Read Sulik, a child psychiatrist in Fargo, N.D.
"Our kids today are by and large stimulated at a much higher level and stressed at a much higher level than before," he said. "We should be stepping back and saying: What is changing that we are seeing such an increase in the number of children that are having significant emotional and behavioral problems?"
Sulik advises parents to teach "hyperaroused" children to soothe themselves. Stress breeds stress, he said, so frustrated parents will fuel frustrated children. Simple things like sufficient sleep, meals and exercise can help, he said.
A national panel of child psychiatrists is creating a new disorder, called disruptive mood dysregulation disorder, that would fit more of these children better than a bipolar diagnosis.
The disorder would apply to children who are generally irritable and prone to temper outbursts out of proportion to the social situations they are in. Treatment is unclear, though studies are underway to determine if antidepressant drugs would help and whether antipsychotics are necessary.
Two existing conditions
Another theory comes from Dr. Stuart Kaplan, author of the book "Your Child Does Not Have Bipolar Disorder." The Pennsylvania psychiatrist believes children diagnosed with bipolar disorder suffer from two existing conditions: attention deficit/hyperactivity disorder, and oppositional defiant disorder.
The proposed new disorder is merely "bipolar light," in his view, and still implies the need for medication.
That's a distinction that has to do with the "mad or bad" debate. Bipolar is a "mad" disorder, an inherited chemical imbalance for which children can't be held accountable, he said. On the other hand, ODD is a "bad" disorder, a combination of temper and disregard for authority that requires therapy and discipline.
If he is right, Kaplan said, these children need therapy for ODD and stimulant drugs for ADHD -- drugs often denied to bipolar children for fear they will fuel their aggression. Regardless, the new disorder would be an improvement, Kaplan said, to the bipolar label that steers some kids to wrong treatments and dampens their outlooks for the future.
"Kids are growing up now and finding out they don't have bipolar disorder," he said. "One day, one of these kids is going to write a great memoir or make a great movie dramatizing the enormity of the injustice that's been done to them."
Jeremy Olson • 612-673-7744