Is there an epidemic of bipolar disorder in children and adolescents in the US? While good, population-based statistics that document the prevalence of pediatric bipolar disorder are lacking, every child mental health professional confronts the problem on a regular basis. A cursory search readily reveals more than a dozen books in the lay press dealing with early onset bipolar disorder, following the widely read descriptive book, The Bipolar Child. Clearly, in less than a decade what used to be an extremely rare illness in children and adolescents is now being diagnosed and treated with great regularity.

The change in practice is astonishing to those of us whose professional careers have encompassed it. Even in the 1980's, bipolar disorder was not considered a childhood illness any more than was Alzheimer's disease. Our diagnostic Bible, the DSM III, essentially defined away the possibility of bipolar disorder occurring in prepubertal children and no one looked for it; not surprisingly, it wasn't found. A correction was needed, and the pendulum certainly has swung.

Today reasonable estimates place the prevalence of bipolar disorder in adolescents at about 1% and in children, at about 0.3%. The most common age group for the initial diagnosis is between 20 - 30 years, but the second highest incidence occurs between ages 15 - 19 years. Once investigators started systematically asking adults with bipolar disorder when they had the onset of their first symptoms, it became clear that 20 - 30% were symptomatic during childhood or adolescence.

Controversy still exists regarding the way symptoms of bipolar disorder present in youngsters. Since there is no blood test or x-ray finding that constitutes the "gold standard" for the diagnosis of bipolar disorder, symptoms of mood, behavior or cognitive disturbance are of central importance. The latest edition of the DSM still does not distinguish the symptoms of mania as seen in adults (racing thoughts, pressured speech, grandiosity, deceased need for sleep, etc.) from the way mania presents in childhood, but clinical and some research reports that do so are available. When children and younger adolescents are manic, they tend to be irritable and prone to aggressive outbursts. Rather then discrete episodes, manic children are described as exhibiting continuous or rapid cycles of irritability, temper tantrums and angry attacks on others. These reports also document the chronic and severely disabling nature of the disorder when it occurs in childhood, suggesting that early onset bipolar disorder may be an especially severe variant of the adult version.

This major change in how childhood bipolar disorder is viewed is not without controversy. First, temper tantrums, irritability, moodiness and difficult behavior are not pathological symptoms in and of themselves; all children exhibit them from time to time and psychologically normal adolescents do so often. Rather, it is the frequency and intensity of symptoms that lead to the consideration of bipolar disorder, and such quantification is far from standardized. Some zealous professionals and parents have broadened the bipolar symptom list to include such generic items as bedwetting, low self-esteem, carbohydrate craving, "silliness, goofiness or giddiness," and separation anxiety. In the extreme, when such inclusive and non-specific diagnostic criteria are applied, it is a wonder that any child is not bipolar.

A further problem has to do with distinguishing bipolar disorder from other, more common forms of childhood psychopathology - attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD) most prominently. There is substantial symptom overlap among these disorders, but even taking this into account statistically, there is a high tendency for the disorders to occur together in the same child. Unfortunately, the treatment for one disorder may worsen the co-occurring disorder. For example, stimulant medications are helpful in ADHD but often exacerbate the bipolar disorder.

Thus, mental health professionals are truly challenged when they attempt to diagnose and treat bipolar disorder in children and adolescents. The presenting behaviors are usually serious and disabling, so waiting for the child to outgrow them is not an option. The extensive lay literature readily available on the internet means that parents often have determined the diagnosis themselves before the first meeting, and the accompanying affect and opinions may be intense.

Little research is available on diagnostic guidelines and respected experts have widely divergent opinions. Even less research has been done on the efficacy of mood stabilizing agents in treating children and adolescents - but anecdotes abound. Either a large, new group of youngsters with a disabling psychiatric disorder has come forward (where were they before and how were they treated?) or we are relabeling as severely pathological behaviors that were previously seen as only mildly abnormal. Alternatively, it is possible that a more stressful world, closer living conditions as children stay inside, and a higher level of stimulation work together to unleash latent bipolar disorder in younger individuals. Only time and better research will tell.

The Brown University Child and Adolescent Behavior Letter, February 2005
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