Can children really have bipolar disorder?

by James Baker, MD

Using the diagnosis “bipolar disorder” for children with problems in mood has been controversial ever since a surge in its use in the mid-1990’s.

A recent article in the Los Angeles Times gives the pros and cons on the use of “bipolar disorder” in children through the opinions of two psychiatrists on opposite sides of the controversy.

The problem with using “bipolar” is that it requires a too-loose interpretation of the symptoms seen in adults with bipolar disorder. That is, the symptoms in children aren’t really like those seen in adults.

But while there is disagreement about the label, there is consensus that children with wide mood swings need help.

Now it is becoming increasingly clear that children with up-and-down mood probably have some other problem, not bipolar disorder. I like the description of these children as emotionally “dysregulated,” that is, their brain cannot seem to keep their emotions regulated or stable.

That seems to better describe what we see in practice, which is children with severe irritability or very angry (as opposed to impulsive) aggression that causes them problems at home and school: severe mood dysregulation (SMD).

Still, I think that Dr. Gabrielle Carlson gets to the heart of the matter in a quote from the LA Times article::

…In our current climate of insurance reimbursement, doctors cannot spend the time they need to fully diagnose these kids. The problem is that kids are being labeled with something we think we know, and which is lifelong. Even with the new diagnosis, very often they may receive the same medication anyway…

Child psychiatrists don’t have much time with kids. Then we spend what precious little time we have trying to come up with the “right” diagnosis, even though it probably won’t change the medicine we give. In doing so, we give the child a diagnosis that might last a long, long time.

In the process we ignore a lot of information unrelated to diagnosis that would help tailor a much better interventions — information like how mom and dad are getting along, whether or not the home is safe, whether mom has to work so many hours each day to make ends meet that she has little time for her son, and the like.

In most cases, proper treatment for the psychological and social world in which a child lives goes much farther toward helping his behaviors than having the right label on his behavior.

James Baker is a child and adolescent psychiatrist with Metrocare Services who blogs at Mental Notes.

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  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    Do adults really have ADHD?

  • http://twitter.com/pnschmidt pnschmidt

    The issue is this: many adults with bipolar disorder had symptoms during childhood and adolescence. Early detection of these issues (however they are labeled) can help affected people with the transition. Second, some children with severe mood dysregulation benefit from the medication used to stabilize adults with bipolar disorder. Finally, by knowing which young people suffer from troubling mental illness, we can better recognize when medication is necessary, relieving patients of the need to attempt to self-medicate with the compounds to which they have access.

  • Greg

    The fact is, about 70% of adults with classic manic-depressive disorder (now called Bipolar) report that their illness began BEFORE they became adults. Were this any “regular” illness, such as heart disease or cancer or diabetes, pediatricians and health policy people would be jumping on the prevention and early treatment bandwagon. But as “mental” illness is so often stigmatized and marginalized, and because in the past, there was this myth that childhood was some sort of Utopian and carefree period of life, these individuals’ concerns were ignored until the illness became so disruptive to their lives that some action had to be taken.

    By then, often so much damage has been done to their relationships, families, education, careers, and ultimately brain, that the treatment ended up having to focus on “managing” the illness and mopping up the shrapnel, as it were. The reason to identify bipolar disorder earlier is to perhaps mitigate the intensity of the disease when it becomes full-blown. The problem is that often the initial signs do not exactly mirror what comes later – impulsivity and poor attention are hallmarks of mania in adults, but in children, could easily be misdiagnosed as something else. So caution should remain in diagnosing children too early, but at the same time, to ignore these children is to make the same mistakes we made before.

  • JC

    I live near Boston and was diagnosed bipolar as a 12 year old in the late 90′s by a doctor on staff at Child Psychiatry with Joseph Biederman @ MGH.

    I was medicated out of my mind (and body) and everything that was happening in my life and within my family was totally ignored.

    My “child psychiatrist” was and still is a paid consultant for more than a half dozen drug companies.

    The effects of that diagnosis on my life will never go away and those effects have all been negative.

    It let to a downward spiral with too many psychiatric treatments and hospitalizations before leveling out. I had a much brighter future ahead of me without having my life ripped away from me.

    My mother has severe personality pathology and the doctor never did anything about it. In fact, his approach and attitude toward my ” illness” went hand in hand with my mother’s desire for me to be sick and the results were something I hope no child has to go through ever again.

    My feeling is if a bipolar child doesn’t look like a bipolar adult ( with clear cut mania), then he or she isn’t bipolar.

    Thanks for spreading the word Dr. Baker.

  • http://www.bipolarkidconnection.com Rebecca

    As a parent of a child who has been diagnosed bipolar I think that the fact that the title is so controversial wastes time. My husband is bipolar and so too is my daughter. For doctors who do not believe that it is possible I ask them why my daughter tries to jump out windows? Why does my daughter rage for hours at a time? Why does my daughter feel so different from other kids? I ask these nonbelievers why is it so unlikely that a child with a bipolar parent and another parent who suffers from severe depression be bipolar? It is a genetic disorder. As for her psychiatrist… he has spent several 1- 1 1/2 hour appointments with this family to diagnose her. The other thing that is so interesting is that the antipsychiotic medications have made a huge difference. So I am a believer.

    • CharismaCrystal

      It seems like you’re quite strong: It can’t be hard to live with two people you love, who are bipolar.
      Of course kids suffer from Bipolar, but what begs the question is: to what extent?

  • Lisa

    Happy Hospitalist,

    Yes, adults really have ADHD.

  • http://www.nopointsforstyle.com Adrienne

    I think this issue is often misunderstood. The question is not, “can children be mentally ill?” The question is, “what is an appropriate diagnostic category for this specific group of children?”

    No one is saying that children can’t have bipolar disorder, just that, perhaps, it’s not possible to gather the necessary information for that diagnosis in children under 16, or 14, or whatever age is appropriate.

    My child is mentally ill and his current diagnosis is bipolar (among some other things) and I welcome a change in diagnosis to something specific to children. It doesn’t mean he won’t ultimately be diagnosed with bipolar, but it seems to me that we only call him that now to make the insurance company happy. Is he ill? Yes, very. Does he seem like the bipolar adults I’ve known? Sort of, but some of the criteria for a bipolar diagnosis in adults are pretty normal for kids.

    In any case, there’s a precedent for this kind of two-tier diagnostic categorization. Children aren’t diagnosed with personality disorders; we say they have conduct disorder until they have passed adolescence. I see the movement away from pediatric bipolar and toward the diagnosis of severe emotional dysregulation (except in those rare cases in which children present with classic bipolar symptoms) as similar.

    And for the record, the lack of access to high-quality, comprehensive mental health care in the US is criminal. The fight we’ve had to fight? No room here to share the details, but if my husband and I, with our many years of education and good health insurance, have had such a struggle? Something is deeply, hugely broken. HOW are minimally educated people navigating our terrible system? I can’t even begin to imagine.

  • Mel

    I agree with you. I have a friend who was on drugs at a very young age. At 11, in the mid 90′s, her mother took her to a shrink and had her diagnosed with bipolar. She was put on lithium (along with the drugs she was taking). Never mind the drugs, or the fact that her home life stunk, and she was just angry. Now, as an adult of 30 something, she’s stuck with that diagnosis. She is perfectly functional without any medication, raising a perfectly normal child of her own. So, how does she get rid of a 20yr. old wrong diagnosis??

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