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Can children have bipolar disorder?

Q: Can children have bipolar disorder? If so, how are they diagnosed? –Lynn

Dear Lynne,

medication for pediatric bipolar disorderDuring my career, I have encountered a steadily increasing number of people who believe that they – or their dog, their roommate, their boss, their spouse, or their kid – have bipolar disorder. More often then not, they’re wrong. There seems to be a great deal of misinformation and misperception about the disorder. Here’s a quick and confusing rundown:

Formerly known as manic-depression, bipolar disorder is characterized by one or more manic episodes (we’ll define that shortly) with major depressive episodes. Or, it can include major depressive episodes punctuated by hypomanic episodes (we’ll define that, too). Or, it can include mixed episodes (symptoms of mania and depression occurring in the same day). Or, it can include rapid cycling (four or more episodes in a year). There are also several modifiers that can be placed on the diagnosis, such as “with seasonal pattern” and the ever-popular catch-all, “with atypical features.”

Whew. Now that no one is confused, let’s move on.

Properly diagnosing bipolar disorder involves gathering a thorough history of symptoms and ruling out other possibilities like substance abuse. To complicate matters, other problems can take on the appearance of bipolar disorder, especially in children. It’s little wonder there is so much confusion.

Mania and hypomania seem to be the most misunderstood components of bipolar disorder, so let’s illustrate by way of examples. The first is Ellen, a young woman with long-standing symptoms that include hypomania:

“Although Ellen reports chronic depression, when she is asked about ‘high’ periods, she describes many episodes of abnormally elevated mood that have lasted for several months. During these times she would function on 4 or 5 hours of sleep a night, run up huge telephone bills, and feel that her thoughts were racing. She was able to get a lot done, but her friends were obviously concerned about the change in her behavior, urging her to ‘slow down’ and ‘calm down.’ She has never gotten into any real trouble during these episodes” (Spitzer, et al., 2002, p. 66).

Like Ellen, many folks enjoy the energy and productivity that accompanies hypomania. The agitation that it brings can get uncomfortable, though, and some with the disorder are distressed by the knowledge that their happy hypomania will be followed by a painful descent into depression.

While hypomania can have its enjoyable moments, full-blown mania is a different story. There’s nothing fun about it. Consider the case of E.F.:

“Two weeks before admission [to a hospital], the co-workers in the factory noticed that the patient began to talk a great deal and that he began to sing very loudly. Quite suddenly he declared that he was going on the stage or else would join a professional baseball team…. He sent a telegram to a Boston baseball team, which was at that time playing in the South, asking the manager for a position. He told his family that he was going to make a great deal of money and they should finance him for the trip. He slept very poorly and was very restless at night” (Spitzer, et al., 2002, p. 530).

Mania is a painful experience, and it is painful for loved-ones to watch. Imagine trying to piece your life and relationships back together after a bout of reckless, sometimes dangerous behavior, and/or hospitalization.

But What About the Children?
Getting back to the question at hand, you may have noticed a problem with the examples above: neither of them were children. Until recently, bipolar disorder was generally assumed to be an adults-only disorder, and so diagnostic criteria ignored children.

To complicate pediatric diagnosis, problematic behaviors that have come to be associated with pediatric bipolar disorder – such as aggressiveness, irritability, emotional swings, difficulty concentrating, social anxiety, and so on – are characteristic of any number of environmental, developmental, emotional, or cognitive problems in kids.

Interestingly, the wildly increasing number of pediatric bipolar diagnoses may be due in part to an earlier trend of under-diagnosis – if the condition exists at all in children. Prior to the recent increase, the professional literature saw a spate of articles suggesting that most clinicians failed to recognize the condition. We may be witnessing an overcorrection by clinicians who have become hypersensitive to symptoms resembling bipolar disorder. It’s hard to blame them since untreated bipolar disorder increases the risk of suicide among adolescents.

So why does proper diagnosis matter – why not simply diagnose anyone who may have the symptoms? Because the first-line response to bipolar disorder involves medications with serious side-effects. They include mood stabilizers such as lithium and anticonvulsants like Depakote. Manic episodes may require barbiturate sedatives like Klonopin or Ativan, and most physicians add antipsychotic medications like Risperdal to the mix (Sadock & Sadock, 2003, p. 570).

That type of cocktail is a life-saver when applied with good timing and accurate diagnosis, but I have met an unfortunate number of patients stuck on those medications with no clear history of bipolar symptoms. As a result, they typically report feeling like “zombies” who cannot clearly focus, feel, or think. For children, these potent meds can be physically dangerous, and they can stunt cognitive and emotional development.

In fact, these meds can actually inflame a problem that resembles (but is not) bipolar disorder. For example, systematically abused children have difficulty developing skills for regulating their emotions. The abused child’s emotions may become increasingly chaotic over time while other kids are becoming more skilled at managing their feelings and impulses. To a concerned adult, that could resemble… you guessed it: bipolar disorder.

I’m not suggesting that all kids who are misdiagnosed are abused. There are any number of reasons that a child may appear emotionally chaotic. The added tragedy occurs when a child is erroneously prescribed medications that blunt emotions, making it even harder to practice and develop social and emotional skills.

That said, honest-to-god bipolar disorder is a serious problem, and medication remains the first-line treatment.

The recent, wildly fluctuating diagnostic trends suggest that psychologists and psychiatrists have much to learn about properly diagnosing bipolar disorder, especially in children. The good news is that ongoing research abounds.

In the meantime, I would exhaust other explanations before accepting this diagnosis for my child (a skilled, reputable child psychologist can help). In general, the chances that a child’s odd behavior is the result of bipolar disorder are low, and the cognitive and emotional costs of bipolar treatment are high. To paraphrase grandpa: measure twice, cure once.

-IS

Footnotes
From the article: “As a percentage of total office-based visits, visits with a diagnosis of bipolar disorder increased among youth from 0.01% (1994-1995) to 0.06% (1996-1997), 0.15% (1998-1999), 0.29% (2000-2001), and 0.44% (2002-2003)…” There are two ways to read that sentence, but the article makes it clear that it is referring to office visits resulting in a pediatric diagnosis of bipolar disorder. The diagnosis also increased among adults “from 0.31% to 0.32%, 0.38%, 0.50%, and 0.50% during the same periods, respectively.”

References
Sadock, J.B. & Sadock, V.A. (2003). Synopsis of Psychiatry. Philadelphia: Lippincott, Williams & Wilkins.

Moreno, C., Gonzales, L., Blanco, C., et al. (2007). National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Archives of General Psychiatry, 64(9). 1032-1039.

Spitzer, R.L., Gibbon, M., Skodol, A.E. et al. (Eds.; 2002). DSM-IV-TR Case Book. Washington, DC: American Psychiatric Publishing, Inc.