The Bipolar Epidemic in children: Too many children getting misdiagnosed?

The statistic seems alarming. Hospital stays for bipolar disorder among children aged 1 to 17 years increased 434 percent from 1997 to 2010, the Agency for Healthcare Research and Quality recently reported. This rise in diagnoses started in the mid-90s when bi-polar disorder for children was heavily marketed and promoted in the psychiatric community. As bipolar diagnoses has increased, we've seen a decrease in other diagnoses such as disruptive and intermittent explosive.

A classic bipolar adult patient. As a trainee, graduate student I saw my first bipolar patient almost 35 years ago.  A wealthy executive with a large corporation, he became energized one week with new ideas on how to revolutionize his company. This led to a trip to Manhattan where he charged a limo rental and expensive hotel to his corporate account. Married with children, he picked up a young man and they flew to a tropical island for a few days. He had written all his ideas in a journal during this time, which were later found to be totally incoherent. Finally after a week, he started to realize what he had done after waking from a long sleep and went into a deep depression. He was fired from his job and his wife wanted him out. Then here he was in my tiny basement office at the county mental health office asking for help.

As a trainee, I had a difficult time sorting out being fascinated with the story and figuring out how to help him, but in my mind this was, and still is, classic bipolar, a manic phase with no inhibitions, followed by a crashing depression, and lack of self-control throughout a two week period, all occurring in a brilliant, skilled executive and bringing him to ruin.

A bipolar child. Twenty years later, I saw my first child bipolar case, an 11 year old who in our first session assured me that she could make the family court judge do anything she wanted, and she could.  With a very high IQ and the ability to manipulate people, she convinced those around her that her mother, an executive with a government contractor, led a life of unusual debauchery and decadence, and this child demanded to be placed in foster care.

The mother reported that the father had been diagnosed with bipolar, and also had bouts of grandiosity, and had vanished at one point to start a new career and a new family thousands of miles away.  Despite the fact that repeated investigations of this child's claim yielded no verification of any abuse and anything irregular, this patient got what she wanted.

Over the next two years, she repeated the same claims of abuse in every foster home or group home she was placed, with high energy, and then would have bouts of severe depression in which she could not get out of bed.  All of the therapists interpreted the depressed episodes as evidence of abuse.  These cycles of over the top claims followed by crashing depression went on for years, but no one called it bipolar.

Eventually, she became an emancipated minor when she was pregnant at 17 and vanished. These cases of high manic energy, cycling with depressed mood, with grandiosity and euphoria, mark the classic cycling bi-polar.  Clearly it can occur in adults, and can be observed in children who have inherited this trait.

Bipolar diagnosing in the past 20 years. What has been labeled child bipolar for the past 20 years is something else entirely. While it includes these types of cases which involve cycling mood swings and extreme behavior, it has also included all cases of children who are expressing intense emotional distress. A two-year-old with intense rage and tantrums, a strong emotional reaction to a parental separation or a family move, intense frustration due to a significant learning disability can all be easily and incorrectly labeled bipolar disorder.  Childhood bipolar has increased in its frequency of diagnosis and is often treated with some fairly strong medications.

While the American Academy of Child & Adolescent Psychiatry has always stated in their guidelines that children diagnosed with bipolar need to meet the adult criteria, marked by hyperexcitabilty and hyperirritability, it is clear that all children have a harder time controlling their emotions than adults and many children reacting to situations, could be identified as having bipolar disorder.

I have seen several children who are truly suffering from post-traumatic stress problems, labeled as bipolar.  One middle school student had witnessed the suicide of a parent, and seven years later due to a bipolar diagnosis that was assigned to him, could not enlist in the Navy.  One of the hazards of a bipolar diagnosis is that it implies a lifelong disability.

The end of bipolar disorder in children? The new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V), scheduled to come out next month is attempting to sort out and help clinicians distinguish between classic, cycling bipolar and children who have intense emotions that are not cyclical and not necessarily associated with the other behaviors of bipolar disorder.

To that end, the American Psychiatric Association is proposing a new diagnostic category "Disruptive Mood Dysregulation Disorder" (DMDD) which is more simply a child who has having very intense, out of control emotional outbursts, not typical for age, several times per week or more. While critics feel that this may result in more children being diagnosed with a disorder, when what they are having is temper tantrums. I think it might help, and at least it will take the bipolar label, with all of its implications of life long disorder, off children who eventually learn to control themselves and no longer fit a diagnosis.

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