Diagnosing Bipolar Disorder in Adolescents
Before the 1990s, it was believed that children under the age of eighteen would have been rarely diagnoses with bipolar disorder. This all changed in the mid-1990s when there were 800,000 children labeled with bipolar disease and an astonishing number were under the age of five (Carmichael, 2008). The controversial findings have alerted psychiatrists and psychologists that the disease is much more common than originally thought (Carmichael, 2008).
Psychiatrists have been discontent with the number of children being labeled with bipolar disorder at alarming rates (Woziak & Biederman, 1995). Woziak, an assistant professor at Harvard Medical School of psychiatry, was educated with the idea that a professional in the psychiatric field would only see one or two cases of a child with bipolar disorder in a lifetime because of the rarity (Woziak & Biederman, 1995). Woziak, along with the famous Harvard child psychiatrist Dr. Joseph Biederman, felt that there were a number of children whose attention deficit hyperactivity disorder (ADHD) problems seemed to stem beyond the normal anger characteristics of ADHD (Woziak & Biederman, 1995). Woziak and Biederman (1995) completed research to reflect a much more violent attention deficit hyperactivity disorder with children showing signs of heightened uncontrollable temper tantrums, violent hitting, screaming and kicking beyond the normal irritability. These signs included children not being able to regulate impulses (Woziak & Biederman, 1995). Wozniak and Biederman (1995) explained the differences between attention deficit hyperactivity disorder, adolescent bipolar disorder, and temper dysregulation disorder; their research later redefined the definition of adolescent bipolar disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (Woziak & Biederman, 1995). The DSM-IV-TR is the official dictionary for diagnosing mental disorders that is acknowledged by American Psychiatric Association. The DSM –IV-TR assists health care providers with clients’ diagnoses and insurance companies with payment reimbursements (Woziak & Biederman, 1995). In February of 2010, Dr. David Shaffer explains how Woziak and Biedermans research changed the definition for adolescent bipolar disorder, “The defining feature of manic-depression was that it was episodic,” says Shaffer (Spiegel, 2010). “You had episodes of depression and episodes of mania and episodes of normal mood, and that was really, its defining characteristic” (Spiegel, 2010). In laymen’s terms, the child no longer fits the discrete week-long or month-long cycles of depression or normal moods episodes that are seen in adults. The episodes are radically different. Children cycle from brief and very frequent mood episodes that include manic, depressions and back to normal two or three times a week. These include frequent tantrums, enormous temper elevations between stages of abnormal moods (Fritz, 2005). Child psychiatrists have previously used the DSM-IV-TR to help diagnose children that suffer from aggressive or depression (ADHD) but missed the manic part (Spiegel, 2010). Children that suffer from bipolar disorder will usually show signs of ADHD and will have been treated for that but not for the co-existing mania that is easily overlooked (Carmichael, 2008).
A child psychiatrist from Stony Brook University, Dr. Gabrielle Carlson, disagrees with the new bipolar label because with this diagnoses, children are being misdiagnosed and given powerful medications. These medications can have life long affects on children.
One of these is the powerful drug valproate, a medication for seizure disorders, which has proved useful as a “mood stabilizer” in the treatment of bipolar adults but has yielded anything but clear results in children. The side effects can include fatal damage to the liver, pancreas, and brain, as well as the manculinization of female patients (as cited in Spiegel, 2010, p 4).
Instead of using the long and drawn out therapies that include parent training and modifying behaviors, mental health providers are not being allowed adequate time to diagnose behavior disorders. Children are being labeled with lifelong illnesses when only two percent out of the ten percent with explosive behaviors truly have classic bipolar disorder. When hospital stays are required for explosive behaviors in adolescence patients, fourteen percent are observable mania, a key component in bipolar disorder (Borrell, 2010). Dr. Carlson gives the example of children that have been diagnosed with conduct disorder as seen with destructive behaviors such as combativeness and aggressiveness. Treatments for this disorder are limited to basically prayers, diet, strict behavioral modifications, parent training, with little of traditional therapy (Spiegel, 2010). Importing new definitions for bipolar disorders behaviors or episodes allows psychiatrists the opportunity to label a set behavior as bipolar disorder.
Another advantage to the bipolar label, Carlson points out, is that the insurance industry saw bipolar as a biological or medical problem, while conduct disorder was seen more as a parenting problem, so insurance companies were reluctant to reimburse for it (Spiegel, 2010, p. 5).
Parents are relieved by the new label because the blame is no longer viewed as lack of parenting skills, but rather a genetic problem that medication and therapy will hopefully round into a normal child. If the conditions were medical, then the insurance companies would pay for it, but if it was not medical, then it would be looked upon as just irresponsible parenting (Spiegel, 2010).
Dr. Carlson does not see the label necessarily as a bad thing; these children have serious dysfunctions in the brain, regardless of what the diagnosis is named. Arguing that labeling children with bipolar disorder behaviors when abnormal behavior issues arise has caused a plethora of controversy in the world of child psychiatry and seems to be overly diagnosed in the last twenty years (Spiegel, 2010).
Kaplan (2011) explained that prescribing medications to children that were intended for adults without knowing the effectiveness or potential side effects could be potentially deadly. The evidence supports that childhood bipolar disorder does not surface during childhood (Kaplan, 2011). It is difficult to understand how so many mental health professionals could endorse the new disorder without more scientific evidence. With adult bipolar disorder, the person will show signs that are out of character and usually cycles from extreme highs to devastating lows. As with a child, this is not the case because the signs involve moods, tantrums, and the inability to pay attention, or irritability (which could also be symptoms of ADHD or oppositional defiant disorder) (OD) (Kaplan, 2011).
Kaplan (2011) states that sixty to ninety percent of children diagnosed with bipolar disorder are also labeled with ADHD. While ADHD children respond positively to stimulant medication when diagnosed properly, psychiatrist and psychologist are leery of prescribing a stimulant to a bipolar patient because they are adamant that ADHD medication or stimulants will aggravate the patient’s manic; therefore, as a result, the one medication that helps ADHD is withheld (Kaplan, 2011).
Dr. Gregory Fritz (2005) clearly found that what used to be thought of as an extremely rare illness is now being treated with great regularity in young adults. In most cases, the diagnosis is between twenty to thirty years, but the second highest age group is fifteen to nineteen years-of-age. Fifty-nine percent of the patients diagnosed with bipolar disorder disease first remembered onset symptoms in childhood or adolescence (Fritz, 2005). Most remember being either depressed or having a combination of depression and mania. Symptoms in childhood or adolescence are usually a little different than the adult manic. The child manic is best described as showing rapid cycles of irritability, temper tantrums, and angry attacks on others. The indication just described can be seen in all children at one point and time, but it is the frequency and intensity of warning signs that lead to the consideration of bipolar disorder. Professionals are also including bedwetting, low self-esteem, carbohydrate craving, “silliness, goofiness or giddiness,” and separation anxiety (Fritz, 2005). Symptoms are diagnosed as two states as hypomania and mania which are identical but differentiate by duration and intensity. Mania requires either a week of mood disturbance or psychiatric hospitalization, whereas a hypomania episode involves more mild or moderate symptoms lasting at least four days (Fritz, 2005).
In children and adolescents, the manic episodes include mood changes with highs and lows for more than a week at a time. During these episodes, the child must demonstrate at least three additional symptoms to be actually classified as bipolar: elaborateness, decreased need for sleep, excessive talking or rapid speech, running ideas, distractibility, increased goal-directed activity or agitation, and/or engagement in excessively pleasurable activities (American Psychiatric Association, 2000). In younger children, the mood cycling can be more complex: going from one extreme to the other a number of times a day, often complicating the diagnoses (Apps, Winkler, & Jandrisevits, 2008). Daily evaluations are the key to diagnosing a younger child so that patterns can be established and recorded. Mood elevations can display mania as cheerful, extremely silly, or extra happy. These inappropriate and uncomfortable moods swings cannot be redirected by an adult and are often viewed as bad parenting (Apps et al., 2008). Parents describe the household environment as “walking on eggshells” in an attempt to avoid extreme outburst from the child. Children that display these outbursts have a difficult time with easy tasks and often erupt in uncontrollable temper tantrums and acts of physical and verbal aggression (Apps et al., 2008). Grandiosity in adolescents is considered by many to be a significant indicator of mania. Children with bipolar disorder have self images of being stronger, smarter and more capable of doing tasks. They come across as bossy, and play becomes authoritative with other children and adults instead of equally interactive. Grandiosity in a bipolar child exhibits the true belief that the child can do anything, from flying off the roof to running a zoo (Apps et al., 2008).
Bipolar disorder tends to run in families (U.S. Department of Health and Human Services, National Institutes of Health, 2008). Children with direct relatives who have the disorder are four to six times more likely to have the illness, along with being more likely to have symptoms of ADHD and anxiety disorders (U.S. Department of Health and Human Services, National Institutes of Health, 2008). A number of illnesses coexist with bipolar disorder in children and teens. Alarmingly high instances of alcoholism and substance abuse can often be seen in young people with this disorder (U.S. Department of Health and Human Services, National Institutes of Health, 2008). Bipolar disorder research shows that children who have been diagnosed early in childhood will commonly also have ADHD. With these co-diagnoses of bipolar and ADHD, the child may experience difficulty focusing or controlling their behavior even when they are not manic or depressed. In adolescent patients with only ADHD, research stated that ADHD does not have manic episodes. Anxiety disorders such as generalized anxiety or separation anxiety disorders also commonly occur with bipolar disorder patients that are children and adults. Children who display anxiety disorders will have more mental disorders that require hospitalization (U.S. Department of Health and Human Services, National Institutes of Health, 2008). Other challenging problems that develop include trouble in school, running away, fighting, and even suicide. Early treatment can be the defining factor in helping avoid these challenging problems (U.S. Department of Health and Human Services, National Institutes of Health, 2008)
Early detection may include the use of pediatric behavior rating scales (PBRS) that can be used by parents, grandparents, or teachers, but are later assessed by a mental health professional. These assessment tools are standardized paper tools that ask a number of questions about the daily routes of the adolescent ages three to eighteen. The parent tool includes 102 items and the teacher tool 95 (Marshall & Wilkinson, 2008). The behavior scales are very user friendly with only four responses that explain the child’s behaviors over a month long period. The behavior ratings are never, sometimes, often, or always (Marshall & Wilkinson, 2008). The evaluator must have known the child for at least four weeks and have had daily contact, or if the relationship has been for a number of months or years, it requires contact several days a week (Marshall & Wilkinson, 2008).
Eight critical scales exist in the evaluation: Atypical, Irritability, Grandiosity, Hyperactivity/Impulsivity, Aggression, Inattention, Affect, and Social Interactions. These scales help detect the behaviors that are seen in psychotic disorders such as false conspiracies, hearing voices, delusions, self mutilation, and uncontrollable fears (Marshall & Wilkinson, 2008).
The Irritability scale was used to reflect different irritabilities that could lead to severe emotional deregulation or outbursts that are behavioral or emotionally triggered. The Grandiosity scale includes items to help with identifying the inner self: emotions, bullying tendencies, threats, thefts, lies, and uncontrollable outbursts. Aggression is the sixth scale and gauges how the adolescent reacts to others including objects or animals. The Inattentive scale assesses the attention, focuses, and distractibility of the adolescent (Marshall & Wilkinson, 2008).
The eight scales focus on different categories incorporated into a larger overall evaluation of the juvenile. Assessing the suicidal ideas, possible mood disorders, or learning disabilities is best detected by the use of the Affect scale. The Social Interaction scale helps the mental health care assessor understand how the individual socializes, such as: number of friends outside of the family, relationships with others, and social interactions (Marshall & Wilkinson, 2008).
The PBRS is a standard Parent and Teacher assessment tool that is administered and scored by school counselors, clinical psychologists, pediatricians and psychiatrists to help detect symptoms of early onset adolescent bipolar disorder. Each test typically takes anywhere from fifteen to twenty minutes and an additional fifteen to twenty minutes to hand score it (Marshall & Wilkinson, 2008). After hand scoring, conversion tables are grouped for gender and age to help determine the corresponding T-scores and percentile ranks (Marshall & Wilkinson, 2008). The PBRS authors have reviewed the emerging consensus among the mental health professionals and have found that not only has the PBRS help detect the symptoms of early onset adolescent bipolar disorder, but has also aided with the diagnosis of Attention Defiance Hyper Disorder, Conduct Disorder, Oppositional Defiant Disorder and Pervasive Development Disorder (Marshall & Wilkinson, 2008)
How does the mental health disorder bipolar present itself when considering Erickson’s theory of child development? Erickson’s theories were developed around the stages of life. The first stage is the “hope” stage which occurs from birth to one year old. In this stage, if the parents were unreliable, the child would find it hard to trust (Shaffer & Kipp, 2007). Bipolar disorder was rarely seen in this stage because of the parent’s confidence of handling an unruly child, unaware of the probability that the child may be having a potential mental health problem (Apps et al., 2008).
The second stage, transitioning from one to three years old, is when the child starts to explore the world and learns right from wrong (Shaffer & Kipp, 2007). This is the stage where mental health professionals tend to disagree. Can a child so young start to show signs of adolescent bipolar disorders or is this a stage that children normally act out and have temper tantrums as part of Erickson’s exploring stage? A parent or caregiver might see signs of a young child experiencing uncontrollable emotional outbursts, or the child having extreme fear of a parent leaving them. If a child can have bipolar disorder episodes, the episodes are often misinterpreted by bystanders as unfit parents. The parents may react with sternness or timeouts, of which neither will work with a child truly cycling through episodes of bipolar (Apps et al., 2008). Erickson’s stage of transitioning will be put to the test with a bipolar disorder child because emotions, reactions, and disciplines are all functions that the child will not be able to control (Shaffer & Kipp, 2007). Stage three is considered the decision making stage that transpires during the age of three to six. This stage is when the child may lash out at other children, adults, or even animals. The more restrictive the caregiver is, the more the child may cycle with highs to lows; the symptoms may also become more evident and regular with additional cycling or openly irritable moods in this stage (Apps et al., 2008).
Erikson explained the fourth stage at the ages of six to eleven, as when the child develops a sense of self-worth (Shaffer & Kipp, 2007). A child diagnosed with bipolar disorder will often show grandiosity which can be socially devastating to the child and how other adolescents socialize with them, possibly having fewer friends, noticing social differences and feeling inferior or worthless (Apps et al., 2008). From the ages of eleven to the mid twenties, Erickson’s states the adolescent begins to form self-identity and roles of self-worth (Shaffer & Kipp, 2007). During these stages, the bipolar disorder behaviors can be seen more vividly in episodes such as: false conspiracies, hearing voices, delusions, self- mutilation, and uncontrollable fears. This becomes a very difficult stage for the bipolar disorder patient because the realization sets in and the patient must take accountability for the disorder through medication, therapy, or both. During this stage of life, the young adult will be more likely to abuse alcohol and drugs and on the average have a greater risk for attempting suicide than if diagnosed later in life (U.S. Department of Health and Human Services, National Institutes of Health, 2008)
In Erickson’s sixth stage of relationships, dating and falling in love are the primary tasks for individuals from twenty to forty years. This stage is where intimacy versus isolation develops (Shaffer & Kipp, 2007). The adult may have trouble forming relationships in this stage not only because of the label of bipolar disorder, but also the emotional roller coaster that the partner of a bipolar disorder adult has to coexist with. If the adult has difficulty coexisting with another person, then the feelings of isolations, loneliness and self worth are likely to result (U.S. Department of Health and Human Services, National Institutes of Health, 2008). However, with the correct diagnosis and long term treatment, over half of the people diagnosed will recover over a year’s time and go on to lead normal lives (U.S. Department of Health and Human Services, National Institutes of Health, 2008).
Generativity versus stagnation stage develops from age forty to sixty five and is primarily when the middle age adult focuses on work and raising a family. An adult that is unable to find self gratification from work, family or companionships will show signs of becoming inactive or self centered (Shaffer & Kipp, 2007). If the individual becomes inactive and self centered, a caregiver may have to step in and offer emotional support, understanding, patience, encouragement and remind the bipolar disorder sufferer that with time and treatment the situation will improve. For caregivers of adults with bipolar disorder, this may become the norm (U.S. Department of Health and Human Services, National Institutes of Health, 2008).
Erikson’s stage of old age involves integrity versus despair, which includes the reflections of years previously experienced with the most important accomplishments and the major disappointments. As senior citizen, the feeling of having an accomplished life leads to contentment and self satisfaction. If the senior citizen develops despair or dissatisfaction with the life’s journey, the feelings of depression and hopelessness may develop (Shaffer & Kipp, 2010).

References
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U.S. Department of Health and Human Services, National Institutes Of Health. (2008). In Bipolar disorder in children and teens: a parent’s guide (pp. 1-22). Retrieved from http:www.nimh.nih.gove/health/publications/bipolar