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Misdiagnosed? Bipolar Disorder is All the Rage!

How many children are being misdiagnosed? Medicated inappropriately?

boy raging
Feel confused or uneasy about your child's mental health diagnosis? Worried about whether it's accurate--or worse--if the wrong diagnosis will lead to unnecessary medication trials? 

Although misdiagnosis and inappropriate psychotropic medication use in children are hot topics in general, no diagnosis (in my clinical experience) is more frequently misdiagnosed than childhood bipolar disorder. And no influence is more underestimated than the hyperarousal state that goes hand in hand with video games--including non-violent ones--and other interactive screen use, such as texting and internet surfing.

Recently, I gave a lecture titled "The Negative Effects of Video Games on Mood, Behavior, and Cognition." The talk included cases of misdiagnosis and proved to be provocative, so I later blogged about a case of a child who developed a mental disorder precipitated by playing Wii . After posting the Wii story to Facebook, within hours I started receiving stories from other mothers who had noticed symptoms surrounding video game play. Here's an example: (name withheld for privacy)

COMMENTS: Wow am I glad I read this post on FB.
My 6-year-old son loves video games and once he got his Wii he would play for as long as we would let him. Over the last few months we have been weaning him slowly because we knew that too much is harmful but not knowing where that line is we still allow him about 3-6 hours a week.

I just recently took [him] to the pediatrician's for behavioral issues. She immediately implied that she thought that he was bipolar and urged me to get him to the psychiatrist and on meds asap. We decided to take it slow and try taking sugar out of his diet and modifying our reaction to his temper tantrums in lieu of rushing him to therapy [and starting medication].

This has really been a timely find and I look forward to learning more.

I got a chill after reading it. How many children were hastily being put on psychotropic medication unnecessarily? How many children were being labeled as bipolar when his or her "syndrome" might be environmentally-induced? Her story reaffirmed my conviction that people--parents, physician, and mental health clinicians--need information on this topic!

It occurred to me how many children I'd seen that were diagnosed as bipolar over the years who eventually stabilized and were taken off medication. Bipolar disorder is chronic, lifelong, and progressive. The fact that they stabilized and continued to be stable off medication meant those children were NOT bipolar, but only looked that way.

Due to a serious shortage of child psychiatrists, most children are first seen by their pediatrician or family practitioner, who typically has only a few months of training in child psychiatry; a family practice doctor may not have had any. This is despite the fact that 1 in 5 visits to pediatricians are due to psychosocial-related complaints, according to a CDC report. Since primary care visits may be only ten or fifteen minutes long, it is difficult if not impossible to do an adequate mental health assessment.  And while they may inquire about "screen time", they may not know just how powerful its toxicity can be, and simply advise the parent to "moderate". 

This particular pediatrician may have simply meant to refer the mother and her son to a child psychiatrist. However throwing out the words "bipolar" and "medication" would obviously be alarming to any parent. Even more concerning is that this tentative "diagnosis" could set up a chain of events that could lead to unnecessary medication use.

In this case, the primary care physician/pediatrician did not start a medication herself. I have seen, however, primary care physicians start a trial of an antipsychotic (especially if the child is aggressive) while waiting for the evaluation from the child psychiatrist. These medications can cause rapid weight gain, insulin insensitivity, and movement disorders. These are heavy duty medications, but also comprise the majority of medications FDA approved for childhood bipolar disorder.

A child psychiatrist might choose a milder mood stabilizer first before turning to more serious drugs, but since these are typically "off label" (not FDA approved for a particular diagnosis), primary care doctors won't typically be aware of how they can be used. (Note: Because it's very expensive to obtain FDA approval, only drug companies who have a drug whose patent hasn't expired will apply for indications. But that's a story for another day.)

If a child is truly bipolar disordered, aggressive treatment is both necessary and protective for the long term--but childhood bipolar disorder is uncommon, and is rare under the age of twelve. Family history is the most important risk factor--making it a real possibility if bipolar or other mood disorders run in the family, and conversely making a bipolar disorder much less likely if it does not.  Click here for a good discussion on assessment and treatment guidelines of bipolar disorder in children and adolescents.


When I was in my residency and fellowship training a little over a decade ago, we were taught to suspect bipolar disorder in children who were difficult to treat, raged, or couldn't sleep. Historically, childhood bipolar disorder was underdiagnosed, so it paid to keep it on your radar as a possible diagnosis. Now, we know these symptoms can be caused by stimulating video games putting the nervous system in a state of fight-or-flight. 

Consider the following:

  • From 1993-2004, the diagnosis of bipolar disorder in children increased by 40 fold (Moreno, et al 2007)
  • To prevent overdiagnosing of childhood bipolar disorder, but at the same time recognizing the phenomenon that more and more children are presenting with an inability to regulate their mood and behavior, new diagnoses are being considered such as Severe Mood Dysregulation and Temper Dysregulation Disorder.

Doesn't it make more sense that there is an environmental factor at work here, rather than a new psychiatric disorder, or an explosion of childhood bipolar disorder?

Parents can read descriptions of bipolar disorder in children, and easily make them fit their child's symptoms. Furthermore, trying to find answers on the internet and reading books like "The Bipolar Child"  may inadvertently lead parents down the wrong path. Many parents read this book and think, "Whoa! That's my child!" Don't get me wrong--this book is a classic. But many, if not most, childhood mental disorders have a mood component to them, and even many mental health clinicians mistakenly think that severe mood swings and aggression in children equals bipolar disorder.

Children's threshold for aggression is much lower than ours, because they have immature frontal lobes, making it harder to control impulses and regulate mood. Furthermore, many common childhood disorders, including ADHD, post traumatic stress disorder, and learning disorders affect frontal lobe functioning.  Ergo rage and aggression. All that rages is not bipolar!
boy raging

Here's a list (short version) of syndromes that are frequently misdiagnosed as childhood bipolar disorder because of their overlapping symptoms:

  • Overstimulation/hyperarousal from interactive electronic screens (video games, laptops, cell phones) The child need not be addicted to display symptoms.
  • ADHD--poor impulse control, tantrums, disorganized behavior, poor sleep
  • PTSD--hyperaroused nervous system, defensive/reactive, poor sleep
  • Reactive attachment disorder-same as PTSD, but with severe rages
  • Sensory processing disorder--the inability to integrate environmental cues causes child to feel stressed easily due to sensitivities and display poor mood regulation.

The point is, parents need to take a hard look at environmental influences, especially overstimulation from video games and other electronic screens.  You'll need to eliminate this factor for several weeks before an accurate assessment is even possible. Sure, your child might still have symptoms after you remove these offenders, but they will be less severe.

Your child's teacher, doctor, therapist, tutor--everyone!--will have a much clearer picture of what's going on, and progress will proceed much more smoothly. 

For more resources on reducing overstimulation, check out this free course ,screenfree.org's website.

 

Victoria L. Dunckley, M.D., is a board-certified child and adolescent psychiatrist specializing in treating children with complex diagnoses and/or treatment-resistant conditions.

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