by A.F. Hutchinson
, Copywriter | February 03, 2010
Ethan H. Kisch, M.D., Medical Director of Warwick, R.I.-based Quality Behavioral Health, specializes in pediatric psychiatric disorders, including bipolar disorder. "It's well known that many more children are being diagnosed with bipolar disorder than were diagnosed a decade ago," he concurs. "There has been some question as to whether the diagnosis is valid. One of the people that have spoken most fervently about this issue is Gabrielle Carlson, M.D., who is on the faculty at SUNY Stony Brook. She has taken the position that many kids who have problems with mood regulation disorders have been misdiagnosed with bipolar disorder, but in fact, they are diagnostically homeless; they don't fall into any of the categories currently represented in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV)."
In an editorial published in the August 2007 edition of the American Journal of Psychiatry, Carlson wrote, "Although most clinicians feel they use DSM-IV criteria for diagnosis, the huge increases in rates of bipolar diagnosis made in the community over the past decade suggest that clinicians may be applying the criteria in ways that are inconsistent." She points to the definition of rages as one example. "Rages are anger episodes called "mood swings" when described by parents and are explosive outbursts clearly out of proportion in both intensity and duration to the precipitant. This symptom is felt to capture the extreme irritability seen in mania. However, the irritability that often characterizes rages may occur in conjunction with many childhood disorders, most notably attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorders, depressive disorders, and autism spectrum disorders."
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Kisch concurs. "It may be that some of the kids are over-diagnosed with bipolar disorder, but those who don't have bipolar disorder by a variety of schema still have major problems with mood regulations and fall into (the) diagnostically homeless category."
C is for controversy
The American Psychiatric Association produces the DSM, which classifies mental disorders by a system of codes which are used by mental health professionals to submit payment claims to payers. If a code doesn't exist for a particular condition, the clinician attempting to make the diagnosis doesn't get paid. In a joint statement, published in the April 2009 issue of Pediatrics, the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry agreed that many pediatric developmental and behavioral issues don't meet the criteria for a diagnosis as outlined in the DSM-IV. "The current array of diagnostic codes does not fully capture the wide range of developmental and behavioral problems presenting in children," the statement reads. "Consequently, absent the codes acceptable to payers, primary care clinicians are typically not paid for their time spent identifying, treating, and managing these problems." The manual's current iteration, DSM-IV, is being revised; the updated manual is slated for release in May 2013.