We all understand that bipolar disorder is a mood disorder, characterized by periods of depression and mania, that many of us have seen in adults.
That manic component can include euphoric mood, pressured speech, hypersexual behavior, grandiosity, excessive spending, delusions, and diminished need for sleep. The degree of mania can sometimes reach a psychotic level, meaning its scale is disconnected from reality. For example, a manic adult’s delusions might include his ability to solve the energy crisis or move the world toward peace.
Dr. Michael Jellinek
The manic adult is driven in a very active and pressured way. In fact, it’s not uncommon for them to end up in an emergency department. They might, for example, get on a plane as part of some grandiose delusion. When they land, they are alone, in a different city, and acting psychotic. This bizarre behavior gets them transferred to the nearest hospital. We all understand that that happens.
But are there any kinds of behaviors in childhood and adolescence that mimic, parallel, or predict this kind of adult behavior? Pediatric patients certainly experience depression, but are there behaviors that cycle and look like something we call “mania”?
The differential diagnosis is really essential, but it’s not easy. The pediatricians’ job with these children is to recognize a potential mood disorder in terms of depressive symptoms, agitation, and irritability. Consider the symptoms, the age, and the context.
Assess your patient for behaviors that are intense and outside the range of what you typically see in the primary care setting. A mood disorder that has become a daily, dominant feature in the family is telling. Look for a persistent, chronic pattern of agitation and irritability – with frequent explosive and sometimes violent outbursts – to move your diagnosis more solidly in the direction of potential bipolar disorder. A very strong family history of bipolar disorder or mood disorders can support this direction in your diagnosis.
Even child and adolescent psychiatrists have not reached a consensus on whether these behaviors reflect a childhood form of bipolar disorder, or instead a distinct proposed disorder in the DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders) called disruptive mood dysregulation disorder (DMDD). This is an area of active controversy in our field (more on that later).
There is enough behavior in childhood and adolescence that reflects dysregulation in temper and agitation about different things, so proceed slowly before you label your patient with a mood disorder. Be careful not to overlap your diagnosis with behaviors that might be related to a child’s temperament or social circumstances (in which the behaviors could be understood as coming from environmental/family factors rather than from an internal mood state). For example, abuse from a parent or older sibling can lead to a miserable life, and a child’s irritable, angry, and moody tantrum behaviors might be completely unrelated to bipolar disorder or temper dysregulation.
That being said, when you meet one of these kids or talk to people who live with them, it’s very clear there is something wrong. Although the term “bipolar disorder” could be overextended among children and adolescents, it does not mean that there is not a group of kids who are very, very difficult to manage because of their chronic mood state.
In your differential diagnosis, distinguish these behaviors from those associated with substance use, oppositional defiant disorder, and/or attention-deficit/hyperactive disorder that is unresponsive to treatment.
Substance use is certainly associated with moodiness and dysregulated behavior. If I told you that an adolescent was using cocaine or was a young alcoholic, you would not be surprised to find out that she also was depressed, irritable, and agitated with a labile mood.
The pattern of behaviors can be a clue as well. You might see similar behaviors in a child with oppositional defiant disorder, but the parents will report that the behaviors emerge in specific situations. For example, a child might throw a tantrum when he objects to something, but not spontaneously or as a matter of essentially daily routine.
Once a diagnosis of severe mood disorder is suspected (and when bipolar or DMDD is considered likely), the management of one of these kids is probably beyond the scope of a typical primary care practice. Pediatricians have a great role to play in child and family mental health, but the severity of these behaviors indicates the need to refer to a child and adolescent psychiatrist.
Part of the reason for the controversy in this area is that we’re at an early point of differentiating kids with these behaviors. In the absence of genetic or biochemical markers, we’re trying to figure this out through observation, interviews, family histories, and follow-up. Maybe there are two, three, or more subtypes of these mood states, and we’re lumping them together without a valid basis. Maybe there are threads in childhood that we can follow to adult bipolar disorder, or threads we can follow to the proposed DMDD. We just don’t know yet.
Currently, there are camps debating this dilemma within child psychiatry. Some of the roots of this controversy began with the identification of a subset of children with ADHD who also had additional comorbidity related to their mood. Some were comorbid with depression and did not respond well to their ADHD medication. Clinicians began to wonder – especially as they looked more closely – whether these children really did have ADHD, or did they have a mood disorder that included depression and behaviors that included irritability and agitation? This generated more questions: Did the behaviors come and go? Were their hyperactive symptoms really part of a manic mood? Is this an early form of bipolar disorder in childhood or early adolescence, especially with a relevant positive family history?
Clearly, these children were miserable. They were very difficult to raise because of their mood swings. Some displayed quite agitated temper tantrums that did not seem to make sense; they got upset over something minor or even out of the blue without explanation (again, an internally generated irritability and agitation).
In an effort to help these patients and their families, some child psychiatrists tried medication that was not typical for ADHD. They wanted to determine, for example, if medication that was indicated for mood disorders and even bipolar disorders in adults could stabilize these childhood behaviors. The ultimate goal was to help these children function better at home and school, and to live more happily.
In fact, some of the children responded to medications that were not for their original diagnosis of hyperactivity. Some people began calling those children “bipolar.”
As often happens in medicine, some may have expanded the use of that term beyond its initial precision. These children didn’t have the family history, their depression was not as severe, or maybe their irritability could be explained through a more thorough evaluation.
As the number of children who were being diagnosed as bipolar increased, their age range went younger and many of them received powerful medications.
Others clinicians felt that this adult diagnosis was being inappropriately stretched to apply to children. They agreed that there are children who seem to have irritability, agitation, and violent temper tantrums, and to be very disruptive and difficult to manage at home and school. But they didn’t want to use an adult term to describe this behavior, or to call these children ADHD because they didn’t fit that diagnosis. The clinicians began using the term DMDD: These children were “dysregulated” because their moods were not regulated in the developmentally expected manner, and because temper and irritability were among the manifestations.
Additional guidance may come from the working groups for the DSM-5. As they prepare for it, experts are debating that we shouldn’t call kids with these symptoms bipolar, but rather DMDD, and that we should try to study them within that framework. But that view is not unanimous and the answer is not yet final.
Dr. Michael Jellinek is a professor of psychiatry and pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.)–Wellesley Hospital and chief of clinical affairs, Partners HealthCare. He said he has no relevant disclosures.