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What is the diagnosis of bipolar disorder?

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Practicing since : 2003
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Over the years, there have been heated controversies about attention-deficit hyperactivity disorder (ADHD). Perhaps the most heated current controversy involves the diagnosis of bipolar disorder in children and adolescents. What position do you take over this controversy and why? Is this a condition that has been improperly under-diagnosed in minors, or are proponents over-diagnosing bipolar disorder in difficult minors?
Posted Sat, 22 Dec 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 13 hours later

Indeed, the diagnosis of Bipolar disorder in children and adolescents is a controversial and debate-provoking issue. Some of the reasons why there is controversy in the first place are:

1) Adolescence is an age group where mood swings and drastic changes in behaviour are considered as part of the developmental process. So, delineating what is normal and what is abnormal can be quite challenging for anyone, even for professionals.

2) The presentation of Bipolar disorder in children and adolescents is different from the presentation in adults. Children often do not present with the typical symptoms of depression or mania. Mood swings in children can be extremely fast, and various angry and irritable behaviors are very common. Some of the behaviours which can be indirect proxy presentations of mood symptoms are:

- Oppositional behavior
- Separation anxiety
- Rages & explosive temper tantrums (lasting up to several hours)
- Distractibility
- Hyperactivity
- Impulsivity
- Restlessness/ fidgetiness
- Silliness, goofiness
- Risk-taking behaviors

Sometimes, even seemingly unrelated symptoms like declining academic performance, school refusal, recent onset of bedwetting (after bladder control has been attained previously), change in food habits, like craving for sweets or carbohydrates, recurrent pains or somatic symptoms, etc. etc. can be manifestations of underlying mood disorders.

3) Unlike adults, where the episodes of mania or depression usually last for weeks or months, in younger peoplethese episodes can last just for a few days; often, there may be even day to day fluctuations or mixed symptoms at the same time. So, diagnostic evaluation itself is challenging.

4) It is a well known fact that generally, there is possibility for any psychiatric diagnoses to change or be revised at a later stage (a good example would be Danial's case). This instability in psychiatric diagnoses is more so in the adolescent age group, and so giving a major diagnosis such as a Bipolar disorder may a very thin line to tread.

Now clinicians, researchers as well as lay people have a divided view regarding the diagnosis of Bipolar disorders in children and adolescents: the basic question of debate being -"Are we over-diagnosing or under-diagnosing Bipolar disorders in children.
Let us examine each of these views.

A) A substantial proportion of people, especially lay people, child rights activists and anti-psychiatry movement followers strongly feel that Bipolar disorders are being over-diagnosed in children. The arguements they put forth are:

- It is not necessary or correct to "pathologize" behavioural deviations, which are ever so common in this age group.

- Though we know well that there may be a lot of variations in the persentation of mood symptoms, duration of episodes, etc., still there are actually no separate criteria for the diagnosis of Bipolar disoredr in children. Only the adult criteria have to be used and it is left to the clinician's discretion and judgement to make the call. This could greatly affect the reliability and validity of the diagnosis.

- It is too early to give a child or adolescent this diagnosis, because this requires adequate longitudinal observation and hence clinical judgement cannot be made reliably before reaching adulthood.

- Critics argue that a bipolar diagnosis may be used to 'palm off' difficult to handle adolescents (for the sake of convenience), who may actually need psychotherapy and behavioural interventions (which can be very effort taking and a long drawn process).

- "Branding" a child or adolescent as having a major mental illness, will have a negative impact on the child's self-esteem and may lead to even more problems due to social stigma.

Now, the other school of thought, probably more prevalent among clinicians, especially child psychiatrists and psychologists is that Bipolar disorders are actually under-diagnosed in children and adolescents.

- The primary reason they put forward is a lack of proper understanding about the diversified presentations of Bipolar disorder in this age group. This leads to 'missing' this diagnosis frequently.

- By brushing off mood and behavioural flucuations (which if carefully looked for would amount to a bipolar diagnosis), as "normal variations" in behaviour or as part of a normal developmental process, we would be only denying the young person of an opportunity to recieve vital help.

Early diagnosis of this disorder can ensure that with early treatment, the adverse impacts of further episodes can be avoided. Suicide rates can also be minimized.

My position would be that while it is important to be aware of the fact that childhood and adolescence is a period where a lot of behavioural changes are considered as part of normal development, it is also equally important to be be vigilant to the diverse and sometimes indirect presentations of Bipolar disorder, so that minors with this illness are not overlooked and denied vital treatment. Also, establishing a separate set of diagnostic criteria for mood disorders in children and adolescents may be one solution to avoiding under-diagnosis or over-diagnosis.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
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