Q. Is bipolar disorder more difficult to diagnose in children than it is in adults?

A. My answer to this question is YES. Bipolar Disorder is very hard to diagnose in children because childhood onset presentations differ a bit from what would typically be seen in adults.
The salient features of childhood onset BPD are:

  • Frequent, short periods of intense mood changes accompanied by demonstrable irritability and pronounced agitation
  • Daily mood cycling is more common in children, less common in adults
  • The high incidence of multiple co-existing disorders with symptom overlap seen in children

The prime example of a co-existing condition with symptom overlap is ADHD. Two of the symptoms presumed to be evidence of a mood disorder (Bipolar) – irritability and hyperactivity – are also key criteria for an ADHD diagnosis. The symptoms of Oppositional Defiant Disorder, Conduct Disorder and Anxiety Disorders in children also overlap with those in pediatric Bipolar Disorder.

Another issue complicating the diagnosis of BPD in children is that there is no consensus on how to measure symptom severity. If a child is perceived as disruptive, it could be evidence that his or her behavior deviates wildly from the mean, or it could be that the individual(s) describing, assessing or attempting to diagnosis the child is overly intolerant of unruly behavior. From a clinician standpoint, there are many that do not possess the temperament or objectivity to be diagnosing bipolar disorder in children, and therefore shouldn’t be doing so.

In spite of how far we have come, we are still at an early stage of defining, assessing, diagnosing and even treating this disorder in children. In our current age of managed care-imposed time constraints often accompanied by a quick-fix mindset, we too often operate in “diagnostic rush to judgment” mode. And a troubling, and potentially dangerous precedent is set because we don’t know yet to what extent symptoms of irritability and agitation will predict which children will develop the adult form of Bipolar disorder. So the saga will continue – too many children will be diagnosed when they shouldn’t be or will not be diagnosed even though they should be, as a result of how widely or narrowly we cast the net.

There is good news. Pediatric bipolar disorder is getting much more attention than it did just a decade ago. Rising interest will inevitably lead to more scientific discovery, hopefully better treatment, and possibly even additional resources targeted to pediatric mental illness.