Nicole Hall
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Pediatric Bipolar Disorder: An epidemic of sickness or misdiagnosis?
Introduction: Pediatric Bipolar Disorder and its Importance
There is a disorder within the brain that is rapidly increasing within children in the United
States. This is a disorder that can greatly affect and individual’s mood, behavior, energy, and can
cause manic episodes. Pediatric Bipolar Disorder, also known as manic-disorder, is a disorder
affecting the brain with children and adolescents. Some diagnose it as “frequent, brief, intense
outbursts of mood and behavioral deregulation” (McClellan. 236). According to Sahling,
“Between 1994 and 2003 there was a 40-fold increase in diagnosing bipolar disorder in children”
which caused many people to become interested in the subject(Sahling. 215). Over the past
decade, the amount of children diagnosed with this disorder has increased so rapidly it is
questioned whether it is being diagnosed and treated properly. If this condition is being
misdiagnosed and mistreated, these children are being given serious psycho-affective drugs such
as lithium. Adolescents should not be on drugs that affect their mental condition unless
absolutely necessary. Controversy spreads over whether children should be treated early on, how
they should be treated, and if the disorder is being properly diagnosed or thrown around too
casually. More research needs to be done on every part of the subject because with such an
increase in patients, there are either a large number of misdiagnosed children or there is an
epidemic that needs to further looked into.
Guidelines to Diagnosing Pediatric Bipolar Disorder
The controversy of diagnosing PBD has been ongoing for years yet it seems that not
much progress has been made. According to Mick, “one possible reason for the ongoing
controversy about pediatric bipolar disorder is that heterogeneity in the presentation of the
disorder has led to different assessment methodologies that could lead to different conclusions
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and descriptions of children with bipolar like symptoms that are independent of the underlying
psychopathology being assessed” (Mick et all. 1). Many different approaches are taken to
diagnose PBD and there are not very strict or intricate guidelines on the subject. There are not
structured diagnostic guidelines available on the subject so some physicians have turned to using
the Child Behavior Check List (CBCL) (Society of Biological Psychiatry, 931). This method was
not specifically made for PBD but it showed a “consistent pattern of impairments in syndrome
congruent CBCL scales suggesting that it may be a useful diagnostic” while there are no other
ones to go by (Society of Biological Psychiatry, 932). The CBCL may be adequate for
diagnosing but it seems as if something could be made specifically for the disorder that was more
precise. The checklist will never be as good as a concrete diagnostic guideline made specifically
for the disorder. Staton believes that “recurrent, or chronic, simultaneous presence of any two of
the symptoms elation, grandiosity, and racing thoughts and a total of five DSM-IV manic
symptoms (without specific cardinal symptom, duration, or episodicity requirements)” will make
it obvious which patients have BD and which ones have other disorders. (Staton, Volness,
Beatty. 205). If Staton is right, then there does not need to be anything further done on the
guidelines of diagnosing pediatric bipolar disorder: but if he is correct then the sudden, and
drastic, increase in children with PBD does not make sense.
The rapid increase in diagnosis of bipolar disorder in children has even caught the
attention of other countries. Holtman, Bolte, and Poustka argue that America’s standards in
diagnosing BD are much different than those of other countries. Their studies show that three out
of four children previously diagnosed with BD in the United States were diagnosed with other,
less extreme, disorders in Europe. (Holtman et al 1). This suggests that the United States is either
diagnosing BD too loosely or Europe is not properly diagnosing their patients. Either way is
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harmful to children and the medical population. Miss-diagnosing will cause the child to get
inappropriate, and possibly harmful treatment, and will also cause the medical population to look
a lot less credible because of the mere amount of diagnoses that were not properly handled in
either case.
Another aspect that makes it increasingly difficult to make guidelines to diagnose
pediatric bipolar disorder is the debate on whether it is the same disorder as adult bipolar
disorder. There is an ongoing debate on whether they should be tackled as the same illnesses or if
they should be considered completely opposite. The rates PBD diagnoses cause this debate to
become complicated. McClellan argues that “if the rates are the same, either the age at onset has
shifted markedly downward (or accurate identification is now possible at a much younger age),
adult prevalence rates are grossly underestimated, and/or the overall prevalence of the disorder is
increasing at a remarkable rate” (McClellan, 236). If these rates are accurate and the adult rates
are also precise then the only other possibility it seems is that Pediatric Bipolar Disorder and
adult-onset Bipolar Disorder are not the same illness (McClellan, 236). It is impossible to come
up with proper guidelines if there cannot even be a consensus made on what the disorder is.
There needs to be more research done on what Pediatric Bipolar Disorder actually is instead of
physicians just assuming it is the same as adult onset Bipolar Disorder.
Many studies have shown differences between adult and child onset BD which
compliments McClellan’s statement that there is a large likelihood that childhood and adult BD
cannot be the same illness. Maniscalco and Hamrin observed that adult patients showed periods
of mania with depression and well periods while children had longer episodes of constant
conduct problems with mania mixed in (Maniscalco, Hamrin. 344). Children and adults are
showing different symptoms that are most definitely mood related and manic, but that are not the
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same in the way they are shown. The symptoms are being shown differently so it only makes
sense that the possibility of two different disorders be taken into account.
The Treatment of Child Onset Bipolar Disorder
There is a large debate on the appropriate treatment of patients with childhood onset
bipolar disorder. A lot of this debate seems to stem from the issue discussed previously of almost
nonexistent diagnostic guidelines. According to Littrell and Lyons, “Rather than looking for
treatments perhaps more appropriate for younger children, drugs with proven efficacy in treating
Bipolar Disorder in adults (lithium, atypical antipsychotics, anticonvulsants) were extended to
the treatment children with Bipolar Disorder diagnoses” and this created a large amount of
controversy within the field of psychiatry (Littrell, Lyons. 965). According to this view, there has
been an insignificant amount of research in order to properly treat children suffering from BD.
This lack of research can potentially harm the adolescents being given treatment. More research
should be done on treatment because “safety and efficacy of psychotropic medication might
differ between children and adults” and no significant amount of research is being done to keep
the children in this issue safe (Findling et al. 410).
There have been many difficulties in finding treatment for the disorder in the research
that has been conducted. Many adolescent patients displaying bipolar disorder also suffer from
other similar disorders such as ADHD. Both ADHD and bipolar disorder must be treated with
the proper medication in these children so finding the proper mixture can be difficult (Kowatch
et al 979). The proper types and amounts of drugs have to be administered to treat every disorder
the child suffers from. Without the proper treatment the child could still experience symptoms
from one of the disorders or could experience negative side effects from the mixture of
medications. Although there have not been many studies conducted on different treatments in
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children, according to some, “it appears that adolescents are as responsive to treatment with
lithium as adults with mania” (Kowatch et al 979). This is based off of a few small scale studies
since there is not an abundance of research on the topic. Since the studies are very limited and
small scale, they are not extremely convincing or reliable. An abundance of research needs to be
conducted because different results can be found from each study.
The studies that Kowatch researched were focusing solely on the medications already
created for adults with BD. According to McClellan, “Treatment guidelines for pediatric bipolar
disorder are primarily based on the adult literature, which justifiably promotes aggressive
pharmacotherapy” (McClellan, 237). McClellan considers this a very bad way of treatment
methodology for children and argues against Kowatch in the fact that “the placebo controlled
pediatric trials supporting lithium are greatly limited by sample sizes and diagnostic variability
and probably do not justify an A rating” (McClellan, 238). It is hard to distinguish which view is
correct because of the lack of current research on the topic. Unfortunately, even if Lithium is not
the best medication for children with PBD, it “continues to be the only FDA approved
medication for twelve to eighteen year olds with bipolar disorder” (Hamrin, Pachler. 47). Until
research is done and appropriate medications are found, children are being diagnosed with a
strong psychotropic drug that may or may not be beneficial.
Research in the subject of treating Pediatric Bipolar Disorder
A minimal amount of research has been done of the proper treatment of childhood onset
bipolar disorder. One research project done on the subject was when “Geller evaluated 25 youth
with bipolar disorder and comorbid substance dependence in a 6-week double-blind randomized
placebo-controlled trial” (Hamrin, Pachler. 46). The purpose of this study was to view the effects
of Lithium on children with PBD. The outcome of this study was that 46% of children given
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lithium improved while only 8% of the placebo group showed a difference (Hamrin, Pachler.
46). Another research project was done later on that used a different method of testing the same
medication. Oddly, this research showed no difference between placebo and lithium groups
(Hamrin, Pachler. 47). One study states that Lithium had great effects on children with BD while
the other shows the exact opposite. This mixture of outcomes in medication research makes it
impossible to decide the proper treatment for PBD.
There has also been research done on whether drugs can decrease the chance of the
bipolar disorder extending into adult bipolar disorder. The kindling technique, “If a low level of
electrical current is repeatedly applied to the brain of a rodent, over time, the animal will become
sensitized to the current”, was used in order to research the possibility that medication could
lower the change of adult BD developing (Littrell, Lyons. 966). Overall, both studies showed
that the treatment in children did not decrease the possibility of adult onset bipolar disorder
(Littrell, Lyons. 968). According to Littrell and Lyons, “there is little to suggest strong efficacy
for early intervention in these studies” and if this is the case, then treatment of children does not
have a significant effect on whether or not they have bipolar disorder in adult hood (968). If the
treatment of children does not have a significant effect on their adult lives then there is a strong
possibility that the children should not be treated with such strong psychotropic drugs such as
Lithium.
Consensus of the Data
There are many differences and similarities between the views displayed on Pediatric
Bipolar Disorder. One of the most significant similarities is the consensus that there is an
insignificant amount of research done on the topic and that there needs to be a lot more done.
Both articles talking about treatment and diagnosing agreed that there was not a large amount of
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research on the topic which made it difficult to come to a conclusion because of the lack of
research. Although there is a debate over what type of treatment to use and how to diagnose
PBD, many agree that there needs to be research done on what pediatric bipolar disorder truly is
and if it should be treated similarly to adult onset bipolar disorder.
Conclusion
There has not been enough research done on the subject of pediatric bipolar disorder. It is
hard to come to a conclusion on whether adult methods should be used on children suffering
from the disorder because there is not a definite way of describing PBD due to the lack of a strict
guideline. The use of Lithium in treatment of the disorder in children showed a range of
outcomes which make it impossible to come to a conclusion. Many more studies need to be done
in order to fully understand the effect of lithium. There also needs to be a consensus on whether
PBD is the same as adult BD or if they are different in the ways they manifest themselves due to
age group. Without coming to a conclusion on these things and researching thoroughly, it is
impossible to avoid misdiagnoses, mistreatment, and it is entirely too possible to harm children
by treating them in the wrong way.
The misdiagnoses and mistreatment of this disorder can harm the next generation of
Americans. The drugs being given to adolescence with PBD are serious psycho-affecting drugs
that can easily affect their mental being. Pharmacists, psychologists, psychiatrists, family
doctors, families (especially those that have children previously diagnosed with things such as
ADD and ADHD), and those that care about the medical care being given to children and
adolescents need to further research this topic. The treatment being given to children and
adolescents for PBD needs to be looked at by professionals and pharmacists because there are
exponential differences in medicating children versus adults. Those in the medical profession
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need a proper guideline to diagnose children with bipolar disorder and need to research this
before excessively diagnosing children with BD. Overall, everyone should be alarmed by this
subject because it is possible that a significant amount of children in the next generation are
being given treatment that could essentially harm them in a short or long term way.
Works Cited
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3. Kowatch, Robert, Gopalan Sethuraman, Judith Hume, Michelle Kromelis, and Warren
Weinberg. "Combination Pharmacotherapy in Children and Adolescents with Bipolar
Disorder." Society of Biological Psychiatry. (2003).
4. McClellan, John. "Commentary: Treatment Guidelines for Child and Adolescent Bipolar
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