Bipolar disorder, a mental illness that causes extreme shifts in mood, energy and functioning, was once considered a rare condition in children.
- Since the mid-1990s, the number of kids diagnosed with it increased by 4,000 percent. That dramatic upsurge sparked controversy among clinicians and researchers, with many arguing that children were being misdiagnosed—and were consequently receiving unnecessary antipsychotics.
- In an effort to address this, the upcoming (2013) draft of the Diagnostic and Statistical Manual of Mental Disorders (DSM) proposes an alternative diagnosis, called temper dysregulation disorder with dysphoria (TDD). TDD is characterized by severe temper outbursts alternating with negative mood states, but unlike bipolar disorder, doesn’t include any symptoms of mania, nor is it a life-long disorder.
Over the last 15 years, there’s been much debate about how to categorize children with serious behavior problems—with irritable, angry, grumpy and sad moods.
- Some research suggested that these children were experiencing a childhood version of classic bipolar disorder, and so the adult concept of bipolar disorder was expanded to include a wide range of children with dysregulated or bad behaviors and/or sad/grumpy or irritable moods.
- Unlike the adult disorder, having symptoms of mania were no longer required.
- This resulted in a major explosion in the rates of diagnosis of bipolar disorder.
There are problems with this diagnosis of pediatric bipolar disorder:
- Long term studies do not suggest that most children diagnosed with bipolar disorder have the disorder as an adult: A child diagnosed with childhood bipolar should continue to exhibit signs of bipolar disorder as they grow into adulthood. Most studies have shown that kids diagnosed with childhood bipolar disorder (the broad type) are no more likely to develop classic bipolar than their peers. While it’s clear that these children do have a legitimate mood disorder, it doesn’t appear to be bipolar disorder.
- Analyses of psychiatric diagnoses in clinical practice suggest that many of these bipolar diagnoses in children are NOT being made based on clinical criteria. In fact, many of these youth, when administered a KSADS or other controlled interview, actually meet criteria for other diagnoses, such as ADHD and oppositional defiant disorde
- Treatment of many children diagnosed with the more broad and encompassing bipolar disorder diagnosis do not respond to treatment for bipolar disorder.
The new diagnosis of TDD contains the core symptoms of what was formerly diagnosed as the broad type of childhood bipolar disorder:
The proposed criteria include:
- severe recurrent temper outbursts that are grossly out of
- proportion to the intensity of the situation
- frequency of at least three temper outbursts a week
- temper outbursts ongoing for at least one year
- temper outbursts present in at least two settings (for
- example, at home and at school)
- onset before age 10
Unlike bipolar, TDD isn’t seen as a lifelong condition. It also doesn’t respond well to the classic drugs prescribed for bipolar disorder and warrants a different treatment approach. Researchers expect that many of these children will continue having difficulties into adulthood—they just won’t have bipolar disorder.
Does classic bipolar disorder exist in children?
- Although most people are in agreement that classic bipolar can present in childhood, it’s extremely rare.
- At specialty centers for pediatric mood disorders, clinicians are often un-diagnosing 65 to 80 percent of the children coming in for a second opinion.
What are some of the consequences of children being misdiagnosed as bipolar?
- Many children were treated with a variety of powerful antipsychotic and anti-epileptic medications.
- Unfortunately, these drugs don’t appear to be effective for many children and have significant side effects.
- Finally, labeling children bipolar at a young age is quite stigmatizing, as most people think of bipolar disorder (as known in adults) as an extremely serious lifetime condition.
How can a diagnosis of TDD lead to different treatment and outcomes for children with mood dysregulation?
- Since these children do not respond to the medications intended for the treatment of bipolar disorder, then acknowledging that TDD is not simply bipolar disorder in children will pave the way for new research about effective treatment for this syndrome.
- The treatment for children with TDD, as with other mental health treatment, should be multidimensional and should never be solely pharmacological., with a goal of helping the child develop the tools he needs to deal with life and the world.
- Hopefully, physicians will match the intensity of the intervention with the severity of the child’s presentation, so that psychosocial interventions can be utilized alone when appropriate, and so that more modest medications can be used prior to using the more powerful medications .