The Diagnostic Difficulties of Childhood Bipolar Disorder
The idea of childhood bipolar disorder was dismissed as a rare event until about 20 years ago when some researchers began to explore the idea that pediatric bipolar disorder was more common than previously thought. The researchers noted that many adults with bipolar disorder reported that their symptoms started before age 18. Some case reports over the years also suggested that mania could occur in younger adolescents and pre-pubertal children.
Over the next few years a theory evolved that childhood mania may look different than adult mania; specifically, childhood mania looks more irritable than euphoric and more chronic than episodic when compared to adults.
Chronic emotional dysregulation — a range of difficulties with modulating emotional responses — was identified as a core component of pediatric bipolar disorder. This was quite different from the defining feature of bipolar disorder being discrete mood episodes, which had defined the bipolar I diagnosis in adults for many years.
This theory took hold and became accepted practice quickly, in part because chronic irritability and emotional dysregulation are primary symptoms in many of the most challenging children seen by child psychiatrists. Bipolar diagnoses in children skyrocketed, as did the use of powerful antipsychotics and mood stabilizers to treat the children with these diagnoses. Since then, experts in the field have diverged into two general schools of thought:
The narrow, more conservative approach to diagnosing bipolar disorder in children relies on the presence of well-defined episodes of mood and energy changes. This approach is similar to the approach used to diagnose bipolar in adults. It’s helpful in avoiding overdiagnosis and unnecessarily exposing children and teens to powerful antipsychotics and mood medications.
The broad approach looks at chronic mood dysregulation as part of a spectrum of mania and bipolar disorders. Proponents of this approach are more concerned about the potential harm of missing a diagnosis of bipolar disorder in children and teens.
Research continues to try to sort out the differences between bipolar disorder in children and adults, but because of different underlying diagnostic approaches, the studies often measure different things and can be quite conflicting.
Currently, the most rigorous research indicates that although some children who are irritable and dysregulated ultimately develop bipolar disorder, most don’t. The ultimate goal is to be able to diagnose bipolar disorder accurately in children and teens so as not to miss a diagnosis of bipolar disorder when one is warranted and not to apply the diagnosis when something else is the root cause.
A brief interview isn’t adequate for a diagnosis of bipolar disorder in a child or teen. Get a careful evaluation, preferably with a board-certified child and adolescent psychiatrist, before you accept a bipolar diagnosis for your child.