There is a great deal of controversy about the diagnosis of Bipolar Disorder in Childhood. Sometimes it can be difficult to differentiate AD/HD, irritable depression and Bipolar Disorder in children.
Books such as The Bipolar Child have received popular attention and raised public consciousness about difficult to treat children with explosiveness and rapid mood swings. While the book gives excellent descriptions of individual children, it is not a research-based document. We have seen an increase in the use of antipsychotics (such as risperidone and haloperidol )and mood stabilizers (such as valproate and lithium) in younger children.
Joseph Biedermann’s group at Harvard has published extensively about AD/HD and childhood Bipolar Disorder. They feel that it can coexist with AD/HD and can often be reliably diagnosed in childhood. Other researchers such as Peter Jensen (coordinator of the MTA Study) and Gabrielle Carlson of NIMH are more cautious about diagnosing childhood bipolar disorder. They feel that we do not yet have enough evidence to show that children with rapid mood shifts or explosiveness will grow up to have the same illness as adults with Bipolar Disorder.
When Bipolar Disorder starts in childhood, it tends to be more severe and the mood swings are more rapid. At times the mania and the depression may even be mixed. The “up” swings are often explosive or irritable. There may be fewer or no stable moods between swings. We look for severe mood shifts, pressured speech, episodic dangerously impulsive behavior, episodes of blind rage, thought disorder, paranoia or hallucinations. We also look for a family history of Bipolar Disorder or severe mood instability.
Given the uncertainty among experts, how do we treat difficult children with inattention, mood lability, explosiveness and rage? These children need a careful diagnostic evaluation and close follow up. Even when things appear stable, it is not a good idea to wait 4-6 months between clinical visits. Since these conditions can evolve over time, repeated evaluations may be necessary. Remember that medication response does not clinch a diagnosis. If we try to make a hard and fast diagnosis of Bipolar Disorder too early, we may have a lot of false positives. If a diagnosis of Bipolar Disorder becomes obvious when the child is 15, it does not mean that the earlier evaluators missed an obvious diagnosis.
If a child or adolescent does appear to have Bipolar Disorder co-existing with AD/HD, we may use mood stabilizers, antipsychotics, benzodiazepines and other medications. These medications can be a great help to certain children but they do have potential side effects. The family and the entire treatment team need to be involved in an overall plan. The use of stimulants in children with both AD/HD and Bipolar Disorder is controversial. I use them, but will first cover the individual with a mood stabilizer or an antipsychotic. These children and adolescents are at particular risk for substance abuse. It can be dangerous to combine illegal drugs with mood stabilizers. Start drug abuse education early!!