What is Juvenile Bipolar Disorder?
There is no simple answer to this question. As discussed in the section “What is a Mental Disorder?” (click here) the field of psychiatry is in a period of flux. The result of this is a debate between adherence to the prevailing definition of bipolar disorder and articulation of new ideas.
At this time, the Diagnostic and Statistical Manual (DSM) lists a classification of bipolar disorder in the section of the manual which discusses mood disorders that affect adults. The presence of mania in children was not generally acknowledged until recently. However, there is broad recognition that most children do not present a similar symptom profile to the adults who are classified with bipolar disorder. Since there is no pediatric classification of the mood disorder, clinicians who wish to assign a bipolar diagnosis must assign the diagnosis through the existing adult classification.
While most children do not meet criteria for bipolar I or II as defined in the DSM, there is a population of children who do. Accordingly, these children experience cyclical episodes of manic (or irritable) behavior marked with grandiosity interspersed with longer periods of stability and depression.
However, most children do not fit this profile. Typically their manic behavior is often characterized by persistant irritability and their changes of mood can occur with great frequency. Both of these differences have been the source of heated debate as to whether, with this profile, a child can be considered to have bipolar disorder at all or if perhaps the profile represents a different condition altogether. (see A New Classification for DSM: TDD/DMDD)
To address the problem of very ill children in need of a diagnostic home, in 2000, a committee convened and announced the creation of a sub-classification of bipolar disorder called Bipolar Disorder-Not Otherwise Specified (BP-NOS). Under this subcategory, while research continued, children who were severely impaired by mood disorder but did not meet adult criteria could still qualify for insurance and accommodation.
Under the more common diagnosis of BPD- NOS children are typically characterized by abrupt swings of mood and energy that occur multiple times within a day. Intense outbursts of temper, poor frustration tolerance, and oppositional defiant behaviors are commonplace in early-onset bipolar disorder. Affected children can switch from irritable, easily annoyed, angry mood states to silly, goofy, giddy elation. They experience low energy periods of intense boredom, depression and social withdrawal, have low self-esteem and often have suicidal thoughts. Often these children are very bright and capable but greatly challenged by their illness.
At this point, most children receive the NOS diagnosis. But additionally, most of these children also receive one or more of other diagnoses including, major depression, separation anxiety disorder, obsessive-compulsive disorder, oppositional defiant disorder, conduct disorder and attention deficit disorder.
Several factors make a timely diagnosis of any bipolar disorder classification difficult:
1) Mania in children has only recently been acknowledged.
2) Impaired behavior and developmentally healthy but challenging behavior can often be mistaken for each other.
3) A clinician may be reluctant to diagnose bipolar disorder as the diagnosis confers a severe, life-long impairment for which strong medications are often in order.
Recent studies have found that from the time of initial manifestation of symptoms, it takes an average of ten years before a diagnosis is made. Frequently, before a bipolar diagnosis is made, or in place of it, any or some of the other diagnoses listed above are assigned. This may result in treatment with stimulants or antidepressants – medications which can worsen a bipolar condition.
We have included the full DSM text for the classifications Bipolar Disorder I, II and NOS in the section of this website entitled “Diagnosis by the DSM” (Click here).