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Why it is Hard to Get a Diagnosis of Bipolar Disorder for a Child

Challenges and difficulties in dignosing bipolar in a child.

Bipolar disorder only started to become accepted as an illness children can have in the late 1990s. The journey to full acceptance of bipolar disorder as a childhood illness has been difficult and is still ongoing. Even with the recognition of childhood bipolar disorder, it is hard, if not extremely challenging and difficult, to get a diagnosis of bipolar disorder in children.

Not only are the tools used to diagnose bipolar disorder based on how the disorder presents in adults, not children, but most of the doctors and professionals who must diagnose children received their medical training before bipolar disorder was accepted, or even understood, as an illness that could occur in a child.

Complicating things further is that bipolar disorder in a child can be missed or even misdiagnosed as something else. Bipolar disorder shares symptoms with general anxiety disorder (GAD), Attention Deficit/Hyperactivity Disorder (ADHD), and oppositional defiant disorder (ODD).

Trying to distinguish if symptoms in a child are from bipolar disorder or something else is difficult enough. Adding to this difficulty is that children cannot often share what they are feeling, when they feel a certain way, what might "trigger" them, or how often they feel a certain way and how long that feeling lasts. Though it may be difficult to arrive at a diagnosis of bipolar disorder in a child, any delay in diagnosing the disorder – or worse yet, misdiagnosing the disorder – can have dangerous consequences, since bipolar disorder worsens over time.

According to Eric Youngstrom, Ph.D., and associate director of the Center for Excellence for Research and Treatment of Bipolar Disorder (CERT-BD) at the University of North Carolina’s Chapel Hill School of Medicine, childhood bipolar disorder is a "high-stakes diagnosis." In an article in bp Magazine, Dr. Youngstrom shared that untreated bipolar disorder can lead to worse scenarios – "If we mistakenly diagnose a bipolar child with something else and treat it [instead], the medications can make the bipolar worse."

Unfortunately, there are no biological markers or diagnostic tests for bipolar disorder in either adults or children. With children, doctors are stuck using criteria designed for adults (which specifies frequency and duration of manic, hypomanic, and depressive moods), and then must rely on parents, caregivers, and teachers to provide information about moods, behaviors, and symptoms – which can complicate things even more – parents and teachers are more likely to notice and complain about a child’s anger and rages (irritable, disruptive behaviors) than about periods of elation (silly, goofy, giddy behaviors).

In most cases, even with information from parents, caregivers, and teachers, doctors are left trying to distinguish between bipolar disorder and other illnesses, which can be very difficult with a young child who may not clearly fit the criteria for bipolar disorder or other illnesses. Rosalie Greenberg, M.D., a child psychiatrist in Summit, New Jersey, and author of "Bipolar Kids: Helping Your Child Find Calm in the Mood Storm", believes doctors need to play detective – they need to look for patterns of behavior, such as, sleep disturbances, grandiosity, flights of idea, high distractibility, and high energy.

Many doctors believe that diagnosing bipolar disorder in children can be a huge challenge and that both doctors and parents need to “play detective.” David J. Miklowitz, Ph.D., and director of the Child and Adolescent Mood Disorders Program (CHAMP) at UCLA, asks the question. "What does the criteria of bipolar disorder (designed for adults) look like in a child?" His answer is that doctors (and parents) have to look for phases of illnesses and co-occurring functioning problems in the child – children with bipolar disorder have particular problems in functioning in the roles that are expected of them. Some examples include: being kicked out of daycares; other parents who tell you to come pick up your child since their child can’t get along with them; huge meltdowns at supermarkets and other stores; and fits of rage at the dentist and doctor.

The types of behaviors and symptoms seen in children with bipolar disorder are often not the same as those seen in adults. Bipolar disorder affects children in unique ways and adds to the difficulty in getting a diagnosis of childhood bipolar disorder based upon criteria and tests designed for adults. Dr. Joseph Gonzalez-Heydrich, M.D., chief of Children’s Hospital Boston’s Psychopharmacology Program, says that unlike adults, children continuously experience extreme spikes of highs and lows – often many times in a single day. Dr. Gonzalez-Heydrich believes that doctors need to distinguish between symptoms of different illnesses and look for the differences. An example he shares is about rages experienced by children. "Children with bipolar disorder usually exhibit signs of mixed mania and depression. They’re simultaneously depressed, angry, and irritable, with severe oppositionality, and can be aggressive and violent during rages. These rages are usually severe and prolonged compared with the outbursts by children with ADHD or impulse control, which are typically brief, impulsive, and of mild-to-moderate intensity."

With all the challenges in diagnosing a child with bipolar disorder, this can leave parents feeling helpless and frustrated. Parents are trying to do anything and everything they can to help a child that they can clearly see has something going on. This is compounded by the fact that there are still psychiatrists and doctors who either don’t believe children can have bipolar disorder or are unwilling to give that diagnosis (or label) to a child. In this case, parents can try and educate doctors and professionals by bringing them evidence and data (articles, books, home videos, detailed notes, life charts); change doctors if that option is available; or see if the doctor will address the symptoms and behaviors and treat them accordingly, even if they are unwilling to put a name to a diagnosis.

Ultimately, for parents, learning how to advocate for your child and becoming informed about mental illness, especially bipolar disorder (if this is what it is believed your child has) may be the most important factor for parents seeking an accurate diagnosis and appropriate treatment for their child.



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