Bipolar Disorder in Children: Over or Under Diagnosed?

The diagnosis of bipolar disorder in children and teenagers has more than tripled, but the two extreme characteristics of the mental condition has left doctors wondering where to draw the line in deciding whether children are bipolar or just being kids.

The two main signs of bipolar disorder include manic behavior and depression, and doctors say it is often difficult to diagnose those characteristics in children, particularly those who are not teens.

Nonetheless, the number of bipolar diagnoses in children has been growing.

About 800,000 children and teenagers were diagnosed as bipolar and treated in 2003, according to a study published in the Archives of General Psychiatry in September, an increase from just 20,000 in 1994.

Bipolar disorder, known as a manic-depressive illness, causes significant shift’s in an individual’s mood, energy, often affecting the way they function in normal everyday activities.

The problem, some say, is that children do not act like adults, making it difficult to characterize their behaviors as manic-depressive, according to Dr. Jennifer Shu, a pediatrician at the Children’s Medical Group in Atlanta.

Shu said erratic or odd behaviors in children are often mistaken for kids just being kids.

“If anything, it’s under diagnosed,” said Shu. “Mental health in kids is difficult to diagnose, because kids don’t show symptoms like adults. Because it’s rare, doctors may not expect it. When there’s irritability and high maintenance in a child, most people may just chuck it up to normal childhood."

The Signs

Bipolar disorder is believed to affect about 1 to 2 percent of adults and 1 to 5 percent of children, said Shu.

The signs and symptoms of manic bipolar disorder may include increased energy and activity, restlessness, an extreme high or euphoric mood, irritability, racing thoughts, sleeplessness, unrealistic expectations, and denial over an increased period of time.

The depressive characteristics include long-lasting sadness, anxiety or emptiness, hopelessness, guilt, loss of energy, restlessness, and change in appetite and sleep patterns or thoughts of suicide. However some with bipolar may have mixed manic and depression signs.

“It’s hard to diagnose, so in that case, it can be a grey area,” said Shu. “At what point in the spectrum is it ding-ding-ding? Where do they reach that point? We are all moody and we all have lows and highs, and if they last a little longer than usual, then it may be something else. Lots of kids also have trouble sleeping, so that may be overlooked.”

Bipolar disorder in children is often mistaken for other conditions such as impulse disorder, depression or attention deficit hyperactivity disorder (ADHD), particularly in children aged 4 or 5, according to Dr. Michael Brody, a children’s psychiatrist at the University of Maryland.

Brody says that he has no problem diagnosing adults with bipolar, but he is skeptical of diagnosing the disorder in children. In the past 14 years, dozens of parents have brought children believed to be bipolar to Brody. Of the dozens, he has diagnosed just one as bipolar — a teen — due to concerns that the children’s' symptoms may be something else.

And children often are not upfront with their depression.

“When a kid is depressed, they don’t say I’m depressed," Brody said. "They become hypochondrial, become bored or are constipated.”

The criteria currently used by medical professionals, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), helps doctors pinpoint specific factors and breaks down bipolar into four different levels including those with more depressive episodes, more manic and a mix of both.

Brody believes that this may have increased the diagnosis in the past couple of years as well, by specifically distinguishing the severity of bipolar in an individual and whether they are more manic or depressive. A newer, more-defined version, DSM-V is in the works and may help psychologists clearly diagnose bipolar.

Medication Versus Therapy

Brody said medication can help severely ill children. He prefers children to start on therapy, but said that insurance companies often do not support this so most parents opt for the easier option of medication, especially when they are dealing with a difficult child and are in need of a quick fix.

Brody said labeling kids as bipolar too soon may leave them with a detrimental stigma later in life, which is why diagnosis should be definite.

“Labeling kids with bipolar has major implications in employment and college application," he said. "To label a child at 4-years-old with bipolar, it has a lot of implications. You have to talk to people. Don’t just write a prescription for a kid that is out of control. I understand parents are desperate and medical care is costly. A child lives in an environment and is affected by that environment. As a parent, you can make it better or worse.”

Shu said parents should look to a psychologist for a bipolar diagnosis, rather than a pediatrician.

“In kids, they are usually more fussy than depressed, and it’s similar to a lot of ADHD symptoms," she said. "Most of the time, parents will come to me with symptoms, but the best thing to do is go to a child psychiatrist over a period of time.”

Brody said that, once published, the new DSM-V may be able to clearly diagnose more kids. Even so, he would still recommend a therapy component in addition to medication.

"Therapy is not only talk, but maybe they need special schooling," said Brody. "Maybe the parent needs help. It’s an involved thing and not as simple as giving a pill.”