Bipolar Disorder in Children: still not addressed

The Juvenile Bipolar Research Foundation expresses its extreme disappointment that no changes have been proposed for DSM5 that would provide a means to more clearly diagnose, guide treatment and promote research on children who experience non-classic bipolar disorder.  Two important research trends of the last decade made expectation of such an announcement unquestionable:

  • the unequivocal acknowledgement that children experience bipolar disorder, and
  • the overwhelming shift in the field to recognize bipolar disorder as a dimensional rather than dichotomous illness which sheds further legitimacy upon the various subsyndromal presentations often seen in children.

These two trends compel diagnostic clarification and recognition beyond the strict criteria of BP I or II or the vague diagnosis of BP-NOS, a classification which invites confusion and controversy.

The analysis of Birmaher et al., (2009)[1] of the COBY study effectively puts these facts together:  Clinical Course of Children and Adolescents With Bipolar Spectrum Disorders.

The results of this and other emerging pediatric studies suggest strong general similarities in the longitudinal course of bipolar disorder in youths and adults, which is mainly manifested by subsyndromal symptomatology and rapid mood changes. However, there is evidence that very early onset confers greater liability for a more chronic and fluctuating course, mixed/cycling episodes, high rates of comorbid disorders, and increased rates of mood disorders in families. Converging with these accounts are reports indicating that adults whose onset of bipolar disorder dates to childhood have a more severe and chronic course, lower quality of life, and more episodes, changes in mood polarity, suicidality, and comorbidity. 

Regardless of whether research has focused on children or adults, findings consistently report that patients who experience subsyndromal BD suffer impairments equal in severity to those who fulfill DSM I or II criteria.

A thorough review of the literature that has accrued since publication of DSM-IV-TR indicates that changes should be recommended that would reflect our most current state of knowledge and provide more meaningful clarification, for children and adults alike, of a life-threatening illness.  At a minimum, even if the Work Groups are not prepared to take on the issue of more realistically defining bipolar disorder in adults, the findings presented by Birmaher et al., (2009) provide sufficient characterization of the symptom phenomenology of BD I, II and NOS in children to compel a pediatric classification which may improve the identification of the illness in children.

Instead, the Work Groups have chosen to improve the categorical reliability of the DSM both through text changes that will assure more consistency between diagnoses and by the proposal of a diagnostic category that preserves the categorical integrity of episodic mania.  We can not help but feel that they have side-stepped an important responsibility.

We are aware that the announcement of the TDD proposal has already resulted in the diagnosis of the condition within the community.  We certainly hope that the DSM leadership will be true to its word and take very seriously new information that has been brought to their attention as the result of this public comment period.  We hope that the size of the text-box provided for those comments in no way reflects the amount of room for adjustments.


[1] BirmaherB, Axelson D, Strober M, et al. (2006). Clinical course of children and adolescents with bipolar spectrum disorders.  Arch Gen Psychiatry, 63:175-183

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