• There is much controversy as to whether children can be diagnosed with bipolar disorder.
  • The controversy focuses on the facts that
    • most children do not exhibit the manic behaviors described in the DSM
    • most children do not shift their moods in the clearly defined patterns which meet the duration thresholds described by the DSM
  • Most children are diagnosed with a classification which allows for a sub-threshold presentation of symptoms. It is called Bipolar Disorder; Not Otherwise Specified.
  • Children with bipolar disorder are often severely ill, receive multiple other diagnoses and are often disadvantaged for a very long time before a proper diagnosis is made.

There is no simple answer to this question.  As discussed in the section “What is a Brain Disorder?” (click here) the field of psychiatry is in a period of flux.  There are few issues which have drawn as much debate, controversy and focus as the question of children and bipolar disorder.

Currently, the DSM lists bipolar disorder in the adult mood disorder section of the manual. This is because until relatively recently, it was not thought that children could experience manic symptoms. Indeed, some children do meet criteria for the adult classification of bipolar I or II as defined in the DSM, (see The DSM Definition of Bipolar Disorder) and now receive the diagnosis. These children experience clearly defined episodes of manic (or irritable) behavior marked with grandiosity which last for days and which cycle with longer periods of stability and depression.

However, the behavior exhibited by most children is not like that. Instead their moods changes with great frequency never allowing the manic (or depressed) mood to last long enough to meet the duration requirements of the DSM and they may not cycle between illness and stability. Further, many children do not exhibit the manic grandiosity which is required by DSM. These differences have fueled a debate over whether a child with this profile can actually be considered to have bipolar disorder or if perhaps the profile represents a different condition altogether.  (see DMDD; A New Classification for DSM) Regardless of which side of the debate an expert falls, it is almost universally recognized that these children are very ill and that further diagnostic clarification is needed.

To address the problem, a committee convened in 2000 and announced the creation of a sub-classification of bipolar disorder called Bipolar Disorder-Not Otherwise Specified (BP-NOS). Under this subcategory, children who were severely impaired by mood disorder but did not meet full criteria for bipolar disorder could still qualify for insurance and accommodation while research into their condition continued. Today, most children receive the NOS diagnosis.

Children diagnosed with BP- NOS 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. Affected children may switch from irritable, easily annoyed, angry mood states to silly, goofy, giddy elation…or they may fluctuate closer to one pole or the other. They can 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.

While the condition is of great concern and early intervention would certainly improve outcome, diagnosis of the disorder is often delayed by many years. 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 the bipolar diagnosis is made, or in place of it, other diagnoses such as attention deficit disorder obsessive compulsive disorder, major depression, separation anxiety disorder, oppositional defiant disorder and conduct disorder are assigned. This may result in treatment with stimulants or antidepressants–medications which can worsen a bipolar condition. Even after the bipolar diagnosis is given, most children continue to be diagnosed with one or more of these co-morbid diagnoses as well.

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, and 3) a clinician may be reluctant to diagnose bipolar diagnosis because the disorder confers a severe, life-long impairment for which strong medications are often in order.

Investigators supported by JBRF have arrived at a very different understanding of the condition which affects most children diagnosed with bipolar disorder. To read about that, please go to the website tab called “Information from JBRF Sponsored Research”.