Children with severe developmental disabilities are frequently misdiagnosed as having bipolar disorder. These disabilities may include autism, genetic disorders affecting the brain, and intellectual disability (formerly called mental retardation). A significant percentage of these children are severely aggressive. It is the severe aggression that drives the parents of these difficult children to seek help from physicians in managing behavior; medications are one major component of the medical response to the intractable aggression that may accompany severe developmental disabilities.
As an example of the high rates of aggression and irritability that can be found in developmental disabilities, Dr. Susan Mayes and colleagues in a recent paper have documented the high levels of aggression and irritability that often accompany the diagnosis of autism (Research in Autism Spectrum Disorders, 6:1-10, 2012). In their study, 302 children had high functioning autism ( IQ greater than 80) and 133 children had low functioning autism (IQ less than 80). Only 17% of the parents of the autistic children regarded the children as pleasant, happy and cooperative; 92% of the parents of the autistic children regarded them as irritable, moody, and uncooperative. 40% of the autistic children met DSM IV criteria for oppositional defiant disorder (angry, resentful, argues with adults, loses temper, defiant). Anger and oppositionality in the autistic children were unrelated to IQ but were related to gender, with autistic males having higher rates of oppositional defiant disorder than autistic females (See Autism and Attention Deficit Hyperactivity Disorder, this blog, http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201203/autism-and-attention-deficit-hyperactivity-d-0 ).
The belief that severe aggression is symptomatic of bipolar disorder in children is widely held amongst parents and professionals. There is no evidence to support this belief and it has been challenged by a large number of persuasive studies. Aggression alone, no matter how severe, is not sufficient for meeting the DSM IV criteria of Bipolar Disorder. Yet, for many clinicians attempting to manage aggressive developmentally disabled children, the (mis)diagnosis of bipolar disorder seemed to be clinically useful. It provided an explanation for the severe aggression found in developmentally disabled children and seemed to provide a pharmacological strategy for managing the behavior. The pharmacological approach suggested by the diagnosis of bipolar disorder in developmentally disabled, aggressive children is to use the same medications that are used in adults with bipolar disorder.
These agents include anticonvulsant medications such as carbamazepine (Tegretol), lamotrigine (Lamitcal), and valproate (Depakote), and the mood stabilizer, lithium. These agents are largely ineffective in aggressive developmentally disabled children and have an array of unpleasant and potentially life threatening side effects. The unwarranted use of the diagnosis of bipolar disorder in these children may serve as a pretext for the use of these medications.
Antipsychotics such as risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), haloperidol (Haldol), and chlorpromazine (Thorazine) are helpful in managing the aggression of most aggressive children in including children with developmental disabilities. This class of medications has its own array of side effects, but they are usually helpful in reducing aggression. With careful observation most side effects can be minimized.
The prescribing pattern for treating the aggression in these children is often multiple medications to be used at the same time in substantial doses. Such children are often are given lithium, along with an anticonvulsant and an antipsychotic. If this mixture is not effective in reducing the aggression, a second antipsychotic and a second anticonvulsant medication might be added.
With enough medications at high doses, most children respond with sizable decreases in defiant, aggressive behavior. My clinical impression is that it is the antipsychotics that are largely responsible for the decrease in aggression; the anticonvulsant medications and lithium are unnecessary. Parents and professionals distressed by children’s assaultive behavior are understandably reluctant to risk a return of these frightening behaviors by discontinuing anticonvulsant medications or lithium. The result is that these children often remain unnecessarily on combinations of these medications for years.
Copyright Stuart L. Kaplan, M.D.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.