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Over Diagnosis of Bipolar Illness in Children; DSM Adds New Child Diagnosis

With the revision of the DSM-IV, the “bible” of psychology, fewer children will be diagnosed with bipolar disorder. The DSM is the encyclopedia of mental disorders as recognized by the American Psychiatric Association. Doctors use the DSM to diagnose patients, while insurance companies use it to decide on reimbursement.

A significant change in the book will be the addition of a childhood disorder called temper dysregulation disorder. Many mildly aggressive, irritable children have been given a diagnosis of bipolar disorder when they may not have it.

A misdiagnosis results in children receiving powerful antipsychotic drugs used to treat bipolar disorder. The antipsychotic drugs have serious side effects such as metabolic changes.

Children as young as 2 years old have been diagnosed with bipolar disorder. Since the mid-1990’s, the number of children diagnosed with bipolar disorder has increased by 4,000 percent. Today there are an estimated 1 million children diagnosed.

Dr. Janet Wozniak, assistant professor of psychiatry at Harvard Medical School stated that when she was starting her career, “Papers about bipolar disorder in children would usually start out with the phrase, ‘Here’s a disorder that’s so rare maybe you’ll see one or two in your entire lifetime in practice.”

Bipolar illness is diagnosed as patients who experience one or more manic episodes and also experience major depressive episodes.

Manic episodes are when a person experiences an unusually euphoric or irritable mood that lasts for at least a week. During a manic episode, a person may have an inflated self-esteem, feel full of energy, and talk more than usual while not needing much sleep.

Mania also involves engaging in pleasurable things to excess, often with painful consequences, such as: engaging in unrestrained shopping sprees, sexual indiscretions, or foolish business involvements. During manic episodes, the person can alternate between euphoria and instability.

Major depressive episodes are characterized by at least two weeks of depressed mood or loss of interest. Additional symptoms include trouble sleeping, lack of interest, feeling sad, hopeless or discouraged, decreased energy or sense of worthlessness and guilt, and difficulty concentrating.

Dr. Wozniak started thinking about pediatric bipolar disorder when she was doing research with another child psychiatrist, Dr. Joseph Biederman, who was studying kids with attention deficit hyperactivity disorder.

He thought that there was a percentage of children he was working with whose anger symptoms seemed to surpass normal ADHD symptoms, which generally involves problems with impulse control. Wozniak found some kids who were still struggling with intense, uncontrollable outbursts of anger after they passed the preschool years.

Wozniak published an article stating that the serious mood disorder seen in kids diagnosed with ADHD, was a disorder stronger than ADHD; the kids were bipolar.

Dr. David Schaffer, one of the psychiatrists on the DSM 5 childhood committee behind the addition of temper dysregulation disorder, critiqued Wozniak’s research article about pediatric bipolar disorder because Wozniak and Dr. Biederman changed a critical diagnosis component.

A key feature of manic-depression is that it is episodic. Bipolar patients experience episodes of depression, episodes of mania, and episodes of normal moods.  The children Wozniak described as bipolar lacked the critical weeklong or month-long episodes.

Dr. Shaffer said that Wozniak and Biederman argued that bipolar episodes in children presented themselves in a different way.

“They said maybe in childhood the episodes would be very brief and very frequent,” says Shaffer. “These are called ‘ultra diem,’ you know, ‘many times a day.’ If you regarded every time children changed their mood, every time they lost their temper or became overexcited, as a mood episode, then they were really being misdiagnosed and were really cases of bipolar disorder.”

Researchers argue bipolar disorder should look the same in children and adults, and there wasn’t enough evidence that the children grew up to be bipolar. Bipolar adults didn’t necessarily have uncontrollable anger issues when they were children.

Temper dysregulation disorder is seen as a brain or biological dysfunction, not necessarily a lifelong condition. It can only be diagnosed in children over the age of 6 and onset must begin before the child is 10.

Symptoms include severe recurrent temper outbursts in response to common stressors. The person has to have had symptoms present for at least 12 months and can’t be free of symptoms more than 3 months at a time.

Temper outbursts can involve yelling or physical aggression, overreacting to common stressors, temper outbursts occurring on three or more times a week on average. The mood between temper outbursts is persistently negative, and in the past year the patient has not had a period longer than a day of elevated or euphoric mood.

Shaffer and his DSM collegues created a new diagnosis in hope that doctors will use this diagnosis over bipolar disorder.

“We were trying to find a way to adequately describe the really quite serious behaviors that many of the children who’ve been given [the bipolar label] have. So what we thought would be valuable would be to carve out a group with the most severe reactions: [children] who when they do lose their temper, do so with great force, and who are having [tantrums] frequently — two or three times a week — and between the big episodes, have an abnormal mood,” said Shaffer.

If your child is having behavior issues, difficulity focusing, or needs someone to talk to, Apex Behavioral Health can help your child with his or her needs.

Apex has child psychatrists and child therapists available for psychotherapy. Dr. Patil is our main child psychiatrist at Westland. If you have any inquiries, please call Apex Westland at 734-729-3133.