Can kids really have bipolar disorder? It’s a seemingly simple question with a complicated answer, depending upon who you ask. This month marks Children’s Mental Health Awareness Week, and there is perhaps no bigger controversy in the world of child psychology than diagnosing children with bipolar disorder.
Formerly known as manic depression, bipolar disorder is a serious brain illness that causes dramatic shifts in a person’s mood, energy and activity levels, including manic episodes of hyperactivity and risk-taking, and depressive episodes of extremely low energy and unhappiness.
According to the National Institute of Mental Health, bipolar disorder affects 2.6 percent of American adults and up to 3 percent of adolescents in the United States. But the prevalence of the disorder in children isn’t well established due to ongoing disagreement about symptoms in children, concerns over misdiagnosis and the safety of available treatment options.
Before the 1990s children were rarely diagnosed with bipolar disorder, due to the fact that symptoms in children don’t usually fit with those outlined in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, the standard classification of mental disorders used by professionals in the United States.
“The presentation of illness in most children is different than that of adults. While both children and adults can exhibit manic periods characterized by elation/euphoria, as well as irritability/aggression, they don’t exhibit the same duration of episodes as adults,” says Dr. Demitri Papolos, a pioneer in the field and Director of Research at the Juvenile Bipolar Research Foundation. “Children typically have more rapid or ultra-rapid mood swings, often cycling within the day.”
Additionally, there have always been concerns about labeling behavior that may be challenging, but is developmentally typical (such as outbursts, energy level fluctuations and sleep changes) as symptoms of a severe, lifelong disorder for which strong medications are prescribed.
Still, as Papolos and others continued their research, they began raising concerns that perhaps some of the millions of children being diagnosed with ADHD or depression were, in fact, suffering from early-onset bipolar disorder.
As a result, between 1994 and 2003, the number of doctor visits associated with bipolar disorder in children went up 40-fold, according to a 2007 study in the journal Archives of General Psychiatry. When the book The Bipolar Child, written by Papolos and his wife, Janice Papolos, was published in 1999, it brought the issue mainstream.
Dr. Leslie A. Hulvershorn, Chief of the Pediatric Mood Disorders Clinic at Riley Hospital for Children at Indiana University Health, says, “Thirty years ago, seeing a five-year-old with bipolar disorder would have been unheard of, but in the last twenty years, we have seen a very, very dramatic increase of kids diagnosed with the disorder. So it raises the question; is this an epidemic, or is this just a change in how it’s being diagnosed? I believe it’s the latter.”
Bipolar disorder is a difficult illness to diagnose in adults, let alone in children, whose behavior is naturally more erratic. But experts stress that the symptoms of the disorder in children go far beyond the normal ups and downs of growing up.
According to the National Institute of Mental Health, a child experiencing mania may:
● Feel very happy or act silly in a way that’s unusual for them or others their age
● Have a very short temper
● Talk really fast about a lot of different things
● Have trouble sleeping but not feel tired
● Have trouble staying focused
● Do risky things
While children having a depressive episode may:
● Complain about pain a lot, such as stomachaches and headaches
● Sleep too little or too much
● Feel guilty and worthless
● Eat too little or too much
● Have little energy and no interest in fun activities
● Think about death or suicide
Symptoms of depression often appear first among those with bipolar disorder, and can go on for years before the individual experiences his or her first bout of mania. “We usually see depression early on, but what nails the diagnosis is the mania,” Hulvershorn says. “When the mania stays mild, it feels really good, but it can quickly get out of control.”
Concerns about misdiagnosis
With such a broad range of symptoms, it’s easy to understand how bipolar disorder can initially be diagnosed as something else, especially among children.
For example, researchers say 90 percent of the symptoms of early-onset bipolar disorder overlap with ADHD. Other common diagnoses with similar symptoms include OCD, oppositional defiant disorder and disruptive mood dysregulation disorder. Unfortunately, this can result in children being given medications, such as stimulants or antidepressants, that can worsen the symptoms of bipolar disorder.
“When a child is very distractible and restless and can’t sit still, teachers will often think, ‘This could be ADHD,’ and the pediatrician, based on these and other symptoms that closely overlap those of bipolar disorder, diagnoses the child with ADHD and typically recommends a trial of stimulants,” Papolos says. “The parents may seem something of a response as attention improves, but other problems begin to emerge, including increased irritability, aggression or psychosis.”
A changing mindset
The DSM has been updated in recent years to reflect changing opinions surrounding bipolar disorder, adding a diagnosis called “Other Specified and Unspecified Bipolar and Related Disorders” to encompass children’s often atypical symptoms.
Treating bipolar disorder in kids can include stabilizing the child’s mood, treating sleeping disturbances and psychotic symptoms and focusing on therapy to help the child understand the nature of the illness.
Still, it’s not a diagnosis that should be entered into lightly, stresses Hulvershorn. “Parents should know that if you think your kid has bipolar disorder, it’s pretty rare, but it is possible,” she says. “Do your research. Seek a second opinion. You would hate to have a kid taking medications that they don’t need.”
For more resources about bipolar disorder among children, visit these websites:
The National Institute of Mental Health
Mental Health America
The Juvenile Bipolar Research Foundation: