A very large increase in the number of discharges from acute-care settings with a primary diagnosis of BPD occurred among children and adolescents between 1996 and 2004. BPD was one of the least frequent diagnoses recorded among child inpatients in 1996, but was the most common in 2004. Among adolescents in 1996, there were twice as many discharges with a depressive disorder as with a BPD diagnosis, but by 2004 the rates were about equal. These increases significantly outpace the more modest rise in BPD among adults over the same period.
The survey years considered in this report coincided with payers’ efforts to constrain the use of costly inpatient services by stringent review in order to admit only patients who were utterly unamenable to safe management as outpatients. A rise in the proportion of admissions for more severe or dangerous behavioral disturbances, such as those common in BPD, might therefore appear even if diagnostic practices had remained the same. However, this study’s evaluation of hospitalization rates as a proportion of the population for each age group buttresses confidence that its findings do not artifactually arise because managed care progressively shunted less ill individuals from hospital admission.
Several phenomena may account for the growth in the assignation of BPD diagnoses to children discharged from inpatient care. Shorter lengths of stay may entail higher rates of readmissions (Wickizer et al 1999
). Because hospital discharges, not unique individuals, are the units of NHDS reporting, a portion of the increase might derive from more frequent rehospitalizations of those diagnosed with BPD. Although a potentially important contributor, this possibility is unlikely to explain the five-fold increase found only for this condition.
A second possibility is that clinicians now detect more BPD cases among youth and have become more apt to refer for inpatient care those who they previously might have regarded as evincing “only” conduct problems or troubled parent-child relationships. Nevertheless, it seems implausible that clinicians have become more alarmed by the harmful behavior disturbed youngsters display, and feel that hospitalization has become a more appropriate intervention, solely because these problems may represent a form of BPD.
Lastly, growth in the rate of BPD-diagnosed discharges might reflect a progressive “re-branding” of the same clinical phenomena for which hospitalized children previously received different diagnoses. The unchanged rate of conduct problem diagnoses over survey years represents an effective decline in light of the marked rise in overall population-adjusted rate of children’s psychiatric discharges. Clinicians may have responded to the higher hurdles for obtaining payer’s authorization for inpatient care by “upcoding” severe behavioral disturbances to a major mood disorder that connotes a more pernicious illness.
We suggested that community diagnostic practices have relevance for neuropsychiatric research, and this study’s findings hold specific implications for efforts to understand affective regulation problems among children.
First, clinicians may refer to studies of early-onset BPD a number of children likely to manifest broader phenotypes of psychiatric illness than those customarily associated with later-onset BPD. More families may now identify their child’s illness with BPD as well. It behooves investigators to scrutinize the appropriateness of that characterization for the research purpose at hand. Besides high clinical heterogeneity in patients referred by clinicians to studies of BPD, our data also suggested potential racial factors in BPD diagnosis that may affect recruitment. Demographic differences in BPD diagnoses in the earlier survey years showed lower rates among Black individuals, and Black males even more so, than among those in the White and Other NHDS race groups. This result echoes the similar discrepancies in diagnostic rates between racial groupings reported in adults (Kunen et al 2005
, Neighbors et al 2003
, and Strakowski et al 2003
) and adolescents (Delbello et al 2001
), but not previously reported among preadolescents. However, the latest three NHDS years show a steep increase in BPD discharges, especially for Black males. It would be a positive development if this trend corrects a bias that led to misdiagnosis in the past. In any event, the very existence of such dramatic swings underscores potential caprice inherent in current clinical diagnostic practices. The efforts of neuropsychiatric research to be inclusive and generalizable, while at the same time achieving the requisite specificity in case identification, stand to suffer if nonclinical factors distort the cohort of potential participants.
Second, trends over survey years intimated that increasing rates of BPD may represent a reconceptualization of youth previously diagnosed with conduct-related disorders. It therefore seems important to clearly delineate 1) how BPD differs phenomenologically from these other conditions, and 2) to include comparison groups of youngsters with ADHD comorbid with
ODD or CD, whose emotional lability is well-appreciated (Brotman et al 2006
). These comorbid ADHD+ODD/CD cases are important, because comparing children diagnosed with BPD to children with uncomplicated ADHD might well amount to an assessment of ADHD vis-à-vis ADHD with a comorbid disruptive disorder.
Third, these data confirm that children whom clinicians diagnose with BPD differ in significant ways from adults so diagnosed. Sex differences showing higher rates of BPD-related discharge among male children, but a predominance of females among adults, hint at a different disorder. Depression and psychoses are the acute problems that seem most often to occasion admission of adults, and fewer than 20% of discharges in each survey year contained the mixed-states specifier. For children, by contrast, depression is very uncommon as the prevailing mood disturbance in the context of BPD, and rates of psychosis have been too unstable over survey years to ascertain a reliable estimate. Throughout survey years, subtypes and episode specifiers for children have demurred from stating specific manic or depressive episodes. Bipolar I unspecified, was consistently more common among children than adults. Although this diagnosis denotes a specific major episode that falls short of duration criteria, its high prevalence alongside the high rates for mixed episodes suggests that well-delineated episodes characterized by a single dominant mood are uncommonly identified among hospitalized youth.
From a clinical standpoint, it is unclear how the pharmacotherapy of children admitted to inpatient care may have changed alongside higher prevalence of BPD-related discharges. A primary BPD diagnosis for a child with ADHD may dissuade clinicians from stimulant therapy, despite evidence that children with manic symptoms seem not to demonstrate behavioral toxicity with stimulant treatment, and benefit from improved attention and impulsivity, alone or under the cover of an antimanic agent (Carlson et al 2000
and Scheffer et al 2005
). A recent naturalistic study of behaviorally volatile children discharged from an inpatient service found large effects on externalizing behavior for treatment with stimulants, after controlling for baseline severity and coadministered medications (Blader 2006
). At the same time, antimanic and antipsychotic agents, many of which now have indications for mania, have for many years held a prominent role in the clinical pharmacotherapy of aggressive youth (Blader and Jensen 2007
). However, the evidence base to support their use among volatile, nonpsychotic children without major developmental handicaps remains slim, especially in combination with other agents which is the most common context for their use among hospitalized youngsters (Blader 2006
). The differences between adults and children diagnosed with BPD found in this study and elsewhere would justify skepticism for claims that agents with some evidence of efficacy among adults who have BPD are necessarily appropriate for children said to have the disorder.
All areas of clinical medicine both reflect and influence the social context of the time and place of their practice, and psychiatric diagnosis has particularly profound social implications. If clinical phenomena previously diagnosed as primarily disruptive behavior are more often designated as BPD, the attributional framework for severe behavioral volatility could change considerably. Specifically, a major mood disorder universally recognized as a neuropsychiatric illness would in essence supplant as an explanatory framework the sociogenic or volitional accounts still widely associated with disruptive disorders. A shift that appears to ascribe less blame to families and patients would likely find favor. It may also accelerate development and adoption of psychosocial treatment strategies that de-emphasize punitive consequences for misbehavior and focus instead on environmental adaptation, coping, and lifeskills development to mitigate the impact of the disorder for patients and families (Ducharme et al 2000
, Greene and Ablon 2006
, and Pavuluri et al 2004
). Nonetheless, adoption of psychiatric diagnoses for these purposes may inflate estimated prevalence and overbroaden phenotypic and genotypic variability in identified patient populations, and thereby confound efforts to improve understanding and treatment of the illnesses that afflict youth with severe mood and behavioral disturbances.