Improving the Diagnosis of Bipolar Disorder in Children

Approximately 1.5% of the population, worldwide, bipolar disorder is not uncommon. However, bipolar disorder in children presents differently than it does in adults, an important difference which is not addressed in our current diagnostic manual (DSM-IV-TR). As a result, it is frequently misdiagnosed.

Let’s look at the facts:

What does bipolar disorder look like in adults?

The bipolar spectrum, consists of: 1) bipolar I disorder (alternating episodes of mania and depression, or mania alone); 2) bipolar II disorder (recurrent depressive episodes with occasional hypomania) – most common; 3) cyclothymic disorder (persistent, recurrent periods of hypomania and depression which is less severe than in bipolar I or II; 3) bipolar disorder, not otherwise specified (bipolar symptoms which do not meet full criteria for other disorder within the bipolar spectrum).

Depressive episodes are nearly identical to those within major depressive disorder, including depressed, anhedonia (lack of pleasure in activities), sleep disturbance, appetite disturbance, decreased concentration, indecision, agitation, low self-esteem, pessimistic thoughts, guilt, helplessness, suicidal ideation. These depressive episodes differ from manic depression in that they are likely to have a specific “trigger,” develop more gradually, and may have atypical features.

Manic episodes typically have a sudden onset, following a depressive episode, and are characterized by markedly elevated mood, euphoria, irritability, decreased need for sleep, increased activity, talkativeness, increased flow of ideas, impulsivity (often dangerous activities), delusions of grandiosity (feeling all-powerful), and psychotic symptoms (auditory and visual hallucinations).

Bipolar disorder typically involves an average of 8 to 10 manic or depressive episodes over one’s lifetime, although 15% have a rapid cycling of episodes (four episodes or more per year). The course of the disorder typically increases in intensity and duration over many years. The degree of impairment ranges widely, from mild to nearly continual symptoms. Bipolar disorder can be quite serious, if left unaddressed. 15% to 20% of untreated bipolar patients commit suicide. And, only one third of patients with bipolar receive treatment. It is thus important to understand accurate diagnosis in order to best plan for treatment.

How is bipolar disorder treated?

Pharmacotherapy options for bipolar disorder, include mood stabilizers (which decrease mania and offset depression), atypical antipsychotics (addresses aggression, psychosis, and mania), antidepressants (may be risky, as they have the potential to trigger mania and/or worsen the course of the disorder), and /or anxiolytics (sleep difficulties, anxiety). In recent years, great strides have been taken in demonstrating the efficacy of psychotherapy, namely cognitive behavioral therapy (CBT).

How common is bipolar disorder in children?

59% of persons diagnosed with bipolar disorder experienced symptoms as a child. And, a significant number of children are identified as having other psychiatric difficulties as young children; 25% of children with ADHD and 33% of children with depression are later diagnosed with bipolar disorder.

How is childhood onset bipolar disorder different (and why is it often misunderstood)?

• Children typically cycle multiple times per day. They do not typically exhibit the depression/mania pattern that adults do; the pattern associated with adulthood bipolar disorder does not typically emerge until mid to late adolescence.
• Children with bipolar disorder often present as tired in the morning with increasing energy as the day progresses.
• Additional possible signs of bipolar disorder in children include: irritability, depression, rapid mood changes, explosiveness, lengthy, destructive, tantrums or rages, separation anxiety, defiance, inattention, hyperactivity, sleep disturbance, bed wetting, night terrors, unusual cravings for sweets or carbohydrates, impaired judgment, racing thoughts, pressured speech, risk-taking behavior, delusions, hallucinations, grandiose/unrealistic belief in one’s own ability (e.g., ability to fly), or taking on too much.
• Common early symptoms include: difficult to soothe, oversensitive to sensory stimulation, easily frustrated, difficulty controlling anger, uncontrollable, violent tantrums or ranges that persist for an unusual length of time are disproportionate to the trigger event, distractible, impulsive, difficult to control bursts of energy, disruptive, stubborn, bossy, oppositional, or disobedient.

Why is this concerning?

It should be noted that although there is scientific literature describing how childhood onset bipolar disorder presents differently than it does in adulthood, our diagnostic manual (DSM-IV) has yet to define criteria for children. Consistently, bipolar disorder is often misdiagnosed in children (as ADHD, ODD in childhood and as schizophrenia, PTSD, and personality disorder in adolescence) or not evaluated at all.

Even in adulthood, bipolar disorder is often a diagnosis made over a period of observed behavior; there is an average of 10 years between symptom emergence and treatment. Without proper diagnosis of children with bipolar disorder, children are at risk of worsening of symptoms, school problems, interpersonal and family problems, residential placement or hospitalization, substance abuse, and suicide.

Early identification and intervention including medication, cognitive behavioral therapy, parenting techniques and other behavioral strategies can be effective in managing bipolar symptoms.  Thus, advocacy and education are so important.  Education our doctors, our schools, and our communities hold the potential to help the lives of many children and their families.

Have you been an advocate for community mental health education in some way?

Dr Deibler

Lead photo available at 123rf

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From Psych Central's World of Psychology:
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Undiagnosed and Misdiagnosed Childhood Bipolar Disorder (January 30, 2013)

    Last reviewed: 27 Jan 2013