Harvard Mental Health Letter

Bipolar disorder in children

Difficult to diagnose, important to treat

Childhood bipolar disorder made unwanted headlines in December 2006 when a four-year-old child in Massachusetts died as a result of a drug reaction. Given a diagnosis of bipolar disorder and attention deficit hyperactivity disorder (ADHD) at age 2, she was taking an antipsychotic drug, an anticonvulsant, and clonidine, a blood pressure medication that is sometimes used to treat complex behaviors that include agitation and hyperactivity. The cause of the death may have been an overdose of clonidine, and the girl's parents have been charged with homicide. This tragedy has given wider publicity to a continuing controversy about the diagnosis and treatment of bipolar disorder in children.

The disorder was once thought to be rare — according to a 1997 estimate, occurring in only one out of 20,000 children. Now, though, it's believed that at least a third of the time, the symptoms of bipolar disorder appear first in childhood or adolescence — at a rate that may be closer to one in 200. Some believe this indicates belated recognition of a previously neglected condition. Nearly two-thirds of children and adolescents with mood disorders of all kinds, they say, are still not diagnosed or are inadequately treated. Others suspect that the diagnosis of bipolar disorder is being overused. As a result, they say, drugs are dispensed too freely and not enough attention is paid to social and psychological issues that may include abuse and trauma or simply family conflict and inadequate parenting skills.

Symptoms

The main reason for the past neglect of this diagnosis and the present concern about it is that the symptoms rarely follow a discrete pattern. Children, especially young children, usually do not show the adult cycle of distinct mood swings from mania to depression lasting for several months, with intervals of normal mood in between. Many symptoms that may be a result of bipolar disorder also occur in other childhood disorders: moods fluctuating in very rapid cycles, even sometimes from hour to hour; irritability and agitation instead of euphoria; or bursts of rage. Children can become dangerous to themselves and others. There are reports of three-year-olds so violent that their parents fear for their own safety and four-year-olds who throw hour-long tantrums on being asked to tie their shoes.

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