By David Joel Miller.
Do children really have mania?
Parents bring children into the emergency rooms and the psychiatric facilities because their child “flips out” and begins damaging property. Say the child begins breaking out all the windows in a row of buildings. They are angry and out of control. Efforts to get them to stop are unsuccessful and they may continue even when threatened with violence. Is this an early sign that the child has Bipolar disorder?
Diagnosing Bipolar Disorder in children is highly controversial. To make that diagnosis we need to know if children really have episodes of mania or hypomania. No mania and there should be no Bipolar Diagnosis. Anger and mania are related; they may overlap but are they part of the same thing? The researchers in this area are clearly not in agreement. I will save my opinion for the end.
Children have temper outbursts. If we reduce the level of symptoms needed to include those outbursts as a mental illness all children would get the label and the diagnoses would become meaningless.
To be considered Mania it should last 7 days, for Hypomania an episode needs to last for at least four days. This rules out all those brief temper outbursts from consideration. It also excludes those times when any and all of us might have a time period of excitement when we sleep less or are excited to pursue a new activity, like a new love interest.
Recently there has been an increase in the use of the Bipolar NOS diagnoses in children because this allows for some judgment calls as to the length of episode needed to make the diagnosis. One study (Stringaris et al. 2010) looked at children who had been diagnosed with Bipolar and concluded there was no evidence of mania in children under the age of thirteen, meaning no child that young should be getting the diagnosis of Bipolar. Other researchers disagree.
Stringaris did find that of those children who had brief episodes, too brief to meet criteria for a hypomanic episode, fully 25% did go on to develop all the symptoms needed to diagnose Bipolar Disorder within two years. His conclusion is that we should wait until the teen years and the full criterion is met before diagnosing Bipolar Disorder.
This is a problem for me. Why would we begin treating a child if they do not have an illness? No diagnosis no treatment. So to get the family the help they need, we need the diagnosis. If not Bipolar Disorder then what would we call this child’s problem? Also, the study tells us that 25% of these brief episodes will develop symptoms in 2 years. What about 10 years or 20? I have not yet found research that answers those questions.
Early onset researchers come up with a different answer. Telling us that – Mania, Bipolar one, mostly starts in the adolescent period (McNamara, 2010.) This study goes on to cite 6 factors that may constitute risk factors for the early development of Bipolar Disorder.
One significant risk factor is a history of being the victim of abuse and neglect. We know that early childhood experiences can induce changes in the wiring of the brain. So can later life traumas. Psycho-social stressors are also listed as risk factors. These are also risk factors for personality disorders and other mental illnesses.
This tells us that experience and learning can be risk factors for developing Bipolar Disorder.
A family history of Bipolar is also a risk factor. Not just family members living in the home, but first-degree family members who have any mood disorder, whether in the home or not, appear to increase the risk of developing Bipolar.
That says that heredity is a risk factor for Bipolar Disorder.
A history of substance abuse, prescribed antidepressants and stimulants and dietary deficiencies all have been implicated as having a connection to Bipolar disorder.
See: Do medications and drugs cause Mania or Bipolar Disorder and other Co-occurring blog posts
Lastly, McNamara sums up the argument for diagnosing Bipolar Disorder in children by saying that most people who go on to get the diagnosis had “prodromal” or early symptoms 10 full years before they were diagnosed.
We know from other mental health research that the sooner an illness is recognized and treated the better the chance of a full recovery.
Children who have a brief – one day temper or behavioral outburst are unlikely to be having Bipolar disorder. This is anger or bad behavior and you should try treating them for anger and behavior first. But the pattern needs monitoring.
There are dangers from over treating psychiatric illnesses in children and there are dangers of under-treating. Pick a provider you trust and listen to their advice and judgment. I especially recommend a consultation with a child psychiatrist whenever possible.
Don’t adopt a wait and attitude, even if you decide to skip the medication for now, if your child has these kinds of symptoms get the child counseling or therapy.
Care to share or comment?
Has your child had outbursts that looked like mania or hypomania and have you considered the possibility they may have Bipolar disorder?
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