About Those Kids with Bipolar Disorder

Can children have bipolar disorder? 

After years of being told that the typical age of onset of bipolar disorder is late adolescence or early adulthood, we are now overwhelmed with elementary school-aged children with mood disorders.

There’s no doubt that today bipolar disorder is overdiagnosed.  Rates of BP are soaring, and the NIH has even named BP a “fad diagnosis.”  Normal mood swings have been medicalized and countless people who face situational, non-social functioning difficulties are being prescribed very powerful, mind-altering medications.

Has this acceptance that occasional, manageable mood swings constitute a disorder now come to pediatrics?

It’s generally accepted that mental illness is a stress response.  People with a pre-disposition to a mental illness, or dysfunctional brain chemistry, encounter extreme stress that precipitates a psychiatric disease.

Big life challenges like independence, work, and serious romantic relationships, challenges that traditionally hit around age 20, were thought to contribute to the onset of diseases like bipolar disorder and schizophrenia.

Has life become so challenging and stressful for young children that now they are developing bipolar disorder?

Early onset BP is defined as an emergence of the disease before age 29.  But BP is being diagnosed in children as young as 7 or 8.

From an article in Scientific American about children with bipolar disorder:  “In a study published in 2007 psychiatrist Carmen Moreno, then at Gregorio Maran University General Hospital in Madrid, and her colleagues found a 40-fold increase between 1994 and 2003 in the number of visits to a psychiatrist in which a patient younger than 19 was given this diagnosis. By 2003, the researchers reported, the number of office visits resulting in a bipolar diagnosis in these youths had risen from 25 per 100,000 people to 1,003 per 100,000 people, a rate almost as high as that for adults.”

The diagnosis of BP in children has only gotten more common since then.

Some people fear that diagnoses for BP and the more common ADHD are being mixed-up as they share some symptoms in common.  This is significant since the medication for each disorder is ineffective against the other.  In some cases, the wrong medication will lead to dangerous side-effects, or even exacerbate a misdiagnosed condition. 

Rates of both conditions have sharply increased in children.  Caution in diagnosis is warranted.

While the frequency of childhood bipolar disorder has skyrocketed, is the possibility of bipolar disorder in children really anything new?

This concerned my wife and I in our decision to have a child.  Because of my struggles with bipolar disorder, our daughter is 9 times more likely to develop BP than children of parents without BP.  But if, god forbid, she does inherit the disease, how likely is it to appear while she is still a child?

I decided to set aside the more liberal diagnostic criteria of the recent past and look instead at what constituted a bipolar disorder diagnosis years ago, when I was diagnosed.  And when those diagnostic criteria were stricter, did BP appear in children?

I turned to the textbook Manic-Depressive Illness by Frederick K Goodwin and Kay Redfield Jamison, published in 1990.

They found that 20-30% of bipolar patients experience their first bipolar episode before age 20.  The most common age for the onset of symptoms was age 15-19.

In the few cases of prepubertal BP that Goodwin and Jamison could confirm, 18 of 19 children had a family history of manic depression.

The authors did find that the earlier the age of onset the more likely a person will suffer psychotic symptoms, and the more frequently episodes of mania or depression will occur.  Because of this they recommended identification of BP as early as possible.  Still, they found onset before age 12 unusual and almost unheard of.

The authors, citing research, wrote that BP in children prior to puberty was extremely rare.  However, they found that 3 in 10 pre-pubertal children exhibited symptoms of hypomania.  At the time there was no category of bipolar II, and hypomania in children, or adults, did not warrant the diagnosis of manic depression.

The Diagnostic and Statistical Manual of Mental Disorders IV, published in 1994, introduced a spectrum of bipolar disorders.  A person exhibiting episodes of hypomania, but never full-blown mania, could be considered as having bipolar disorder II.

With that change in criteria many children with difficult behavior could now be diagnosed as having bipolar disorder.  Many were and have been since.

It’s obvious that as the criteria for diagnosis changed, and as the spectrum of bipolar disorders became broader, more people, including children, met the new criteria for diagnosis.  What was considered BP in 1994, and since, is not the same as what was considered BP in 1990.

This change in diagnostic criteria and the desire to treat early-onset BP more aggressively has led to a diagnosis of BP in children to occur more frequently.  Much more frequently.

As a parent and a person who has lived with bipolar disorder for decades, I carefully monitor my daughter’s behavior.  She’s moody, like most kids, but fine.

A diagnosis of bipolar disorder is serious and life-changing.  The stigma against people with BP is real.  Parents should be reluctant to accept a diagnosis of BP for their child unless the child’s life is severely limited by their behavior and their moods.

The trend to medicalize all behavior is troubling, but some children do meet today’s criteria for a BP diagnosis.  Certainly, they should be treated.  But they should be treated very carefully and very minimally.

It’s safe to assume that more children were troubled by bipolar disorder than were diagnosed with it prior to 1994.  We just must be cautious to avoid the possibility that more children are diagnosed with BP than actually have it today.