The increase in the diagnosis of bipolar disorder in pre-pubertal children has been recognized as a major misunderstanding of the diagnosis of bipolar disorder that the National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA) in DSM-5 have attempted to address. http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201309/nimh-greases-the-skids-bipolar-disorder-in-chidren.
NIMH published several review articles explaining DSM bipolar disorder criteria in an effort to minimize its overdiagnosis in children, and the DSM-5 Children’s Committee created a new diagnosis (disruptive mood dysregulation disorder, DMDD) to reduce the overdiagnosis of bipolar disorder in children. http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201312/dmdd-the-wrong-diagnosis-in-the-wrong-place
One of the main reasons for the overdiagnosis of the disorder is that chronic, severe irritability in children has been vigorously advocated as representing the mania of bipolar disorder by influential academicians at several prestigious institutions. The view advanced is that the mania of child bipolar disorder is a persistent behavioral characteristic - a trait; it is something that is there all of the time. These children have severe irritability that is present all of the time.
This view of bipolar disorder as a chronic trait contrasts greatly with both the DSM- IV and the DSM-5 definitions of bipolar disorder. Both DSM-IV and DSM-5 view bipolar disorder as an episodic disorder in which the patient appears dramatically different from usual. The manic episode required for the diagnosis of bipolar disorder on average last about one to two months and per DSM-IV and DSM-5 must be present for at least seven days. Patients are easily recognized as behaving differently from their usual selves during these episodes. A diagnosis of bipolar disorder requires a change in the patients’ behavior from their usual behavior. More specifically, patients must have a manic state for a specified period of time to merit the diagnosis; the mania is not a trait.
In contrast, to the temporary state of a manic episode, ADHD is a trait diagnosis. Patients with ADHD and irritability have a longstanding illness that often begins in the preschool years, continues through childhood, and may extend into adolescence and adulthood. Patients with ADHD and irritability often remain irritable for long periods of time throughout their childhoods. This is their usual behavior ---it does not reflect any change (1).
Despite the efforts of APA and NIMH, the overdiagnosis of bipolar disorder in children does not seem to have decreased. In my clinical practice, I see children with chronic irritability and ADHD misdiagnosed with bipolar disorder on a daily basis. What may be responsible for the persistence of this misdiagnosis? Although there are many possible answers to this question, one of the main forces may be the failure to educate practitioners in the use of DSM criteria to correctly diagnose bipolar disorder in children. Bipolar disorder in children began to reach epidemic proportions in approximately 1996, and many practitioners began to learn to incorrectly diagnose it from their senior teachers during their training. What is learned during those impressionable student years is not easily given up or changed. Generations of physicians and other practitioners have learned to misdiagnose the chronically irritable child with ADHD as having bipolar disorder.
In addition, all U.S. physicians must earn a number of continuing medical education (CME) credits to retain membership in professional organizations and to maintain their licenses. There are a wide array of professional activities that earn CME credit. One activity is to read material prepared by medical journals along with pharmaceutical companies and publishing companies and take the quiz at the end of the article. The completed quiz may be mailed in to the sponsoring agency. If the questions to the quiz are answered correctly, a CME certificate will be mailed out to the physician at no charge.
The Psychiatric Times is a newsletter that offers CME credit for many of its articles. One such article described bipolar disorder in children as a chronic, unvarying state disorder. Among the ten quiz questions at the end of the article is question #7.
#7. The natural course of bipolar disorder in pediatric cases tends to be:
A. Episodic and acute
- Chronic and continuous.
The correct answer for CME credit is B, but the correct answer based on current scientific understanding of the disorder is A. With continuing education such as this, the misdiagnosis of bipolar disorder in children will persist.
- Skirrow, C. et al., An update on the debated association between ADHD and bipolar disorder across the lifespan. J. of Affective Disorders141: (2012) 143-159.
- Wozniak, J. The clinical and treatment implications of co-occurring mania and ADHD in youths. Psychiatric Times, Credit granted December 2011-December 2012. Currently available online.
Copyright Stuart L. Kaplan, MD, 2014
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com. http://www.amazon.com/Your-Child-Does-Bipolar-Disorder/dp/0313381348