Bipolar Disorder: Childhood’s Most Under-recognized Disorder

Abstract

Bipolar Disorder is one of the most under-recognized and misdiagnosed disorders in children and adolescents. One goal of this paper is to attempt explain why Bipolar Disorder is difficult to diagnose in children and how it is often misdiagnosed or missed in them completely. The second goal of this paper is to look at some of the promising research being done to make Bipolar Disorder easier to diagnose and separate from other childhood disorders that might occur with this disorder or share similar symptoms with it. In addition, we will look at a psychosocial treatment with pharmacotherapy that may help attain a remission of Bipolar Disorder in children.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Childhood’s Most Underrecognized Disorder

Why Bipolar Disorder in young children and adolescents is underrecognized and often misdiagnosed? The short answer here would simply be that the research on Bipolar Disorder in young children and teenagers is still being done and many questions have not yet been fully answered. One reason for this is because most of the research you will find on Bipolar Disorder in children and adolescents has been done only within the last twenty years, so in a sense research on Bipolar Disorder in children is still in its infancy. The slow start here may be because for a longtime psychiatrists, psychologists, and others in related fields were under the assumption that young children and teenagers could not either get Bipolar Disorder or that the worst or most obvious symptoms of this disorder would not appear until adulthood. Why intelligent people might have been in this mindset could stem from the fact that they know people can carry genes of medical disorders, like Huntington’s Disease, but never show symptoms of it until adulthood, so why could this not be true for some mental disorders too.

Why is bipolar disorder in children misdiagnosed or goes unrecognized?

Even with the great research that has already been done Bipolar Disorder in children and teenagers it is very difficult diagnose because children who have it will often have anxiety, depressive, and many other disorders cooccurring with it (American Psychiatric Association, 2013). Attention Deficit Hyperactivity Disorder is often misdiagnosed as Bipolar Disorder in children because symptoms overlap (American Psychiatric Association, 2013).  Rapid speech, racing thoughts, distractibility, and less need for sleep at night are symptoms seen in children with ADHD as well as children with Bipolar Disorder going through a manic period. Certain personality disorders are also shared by both these disorders (American Psychiatric Association, 2013). Unlike the adult version, Bipolar Disorder in children is more continuous. Children have

long-periods of rapid cycling and can shift from mania and depression several times a day. These shifts can be quite subtle in children. A child with Bipolar Disorder having a depressive episode may simply appear irritable and moody and a child having a manic episode may appear overly happy, silly, or goofy to the extreme (American Psychiatric Association, 2013).  Diagnosing a child with Bipolar Disorder would require you to talk to the child, interview family, teachers, and anyone else that deals with them on a regular basis, observe the child in different settings, look at medical records to see if a drug or condition is not causing the symptoms and even after doing all that and possibly more the child may not meet all the criteria for a Bipolar I or II diagnosis according to the DSM-V, but with enough symptoms a diagnosis of “Unspecified Bipolar and Related Disorder” might be possible (American Psychiatric Association, 2013).  In a sense, Bipolar Disorder in a young child or teenager is like a fiendish little gremlin that can look like other disorders, that has an evil kinship with Attention Deficit Hyperactive Disorder, that can present itself in different ways in different children, and one that can wreak as much havoc in a child’s mind as it can in an adult mind if not more, not to mention the stress it can put on families and relationships in general.

Statistics, general facts, and genetic connection

Sadly, there is nothing humorous about the facts we do know about Bipolar Disorder in general. Bipolar Disorder is a chronic debilitating condition that affects one percent of the world’s population and is the greatest cause for medical disability worldwide (American Psychiatric Association, 2013). People with Bipolar Disorder have high mortality rates with about one third attempting suicide once in their lifetime and one fourth completing their suicide (American Psychiatric Association, 2013). Bipolar Disorder also has a very strong genetic link because there is a ten-fold chance of it being passed on from one generation to the next, so the

closer the kinship to someone with it the more likely the disorder will be passed on. We also know that thirty percent of adults with the disorder show severe impairment in work role functioning. Cognitive tests done on both adults and children with Bipolar Disorder show that they do poorly on them (American Psychiatric Association, 2013). Unquestionably, the need for more study on Bipolar Disorder is clear and the fact that much less research has been done on childhood onset Bipolar Disorder than on adult onset strongly suggests an even greater need to learn more about this complex dreadful disorder in children.

Promising research in childhood Bipolar Disorder goes in many directions

The goal of many researchers investigating Bipolar Disorder in children is to increase their knowledge in general and to gain a better understanding of the cognitive changes in children, so they can find ways to more easily distinguish it from other symptomatically closely related childhood disorders, like ADHD because just like any other disorder or condition earlier diagnosis improves outcomes. Other research relating how stress plays a role in childhood Bipolar Disorder and of course other research utilizes what has been learned thus far to look at innovative treatments that go beyond pharmacotherapy.

Research toward earlier diagnosis

In one study they looked at individual subcomponents related to executive cognition to advance knowledge on this disorder and they found that adults and children do show similar deficits in cognition in executive functions (Bearden et al., 2007). The researchers admitted that more longitudinal studies need to be done, but the promise of the research in this area is that it may someday be able to develop a test to better distinguish Bipolar Disorder from other childhood disorders, like ADHD, which would allow childhood Bipolar Disorder to be diagnosed earlier (Bearden et al., 2007).  In another study seeking a greater understanding of the cognitive functions in childhood Bipolar Disorder with a focus on being able to design a specific treatment to improve impairment and academic performance they hypothesized that children with Bipolar Disorder I and II with full on mania or hypomania would have certain deficits, including those in learning (Dickstein et al., 2016). Their thought was that these cognitive differences might be used to develop some type of markers both biologically and behaviorally which might result in better and earlier diagnosis of Bipolar Disorder as well as some treatment approaches in children and adolescents with Bipolar Disorder (Dickstein et al., 2016). One example of a treatment or aid is computer assisted cognitive remediation (Dickstein et al., 2016).

Study centered on a treatment idea

A study centered on a treatment idea was done to acquire some preliminary information on the feasibility and possible efficacy of a manualized cognitive behavioral treatment for teens or adolescents with Bipolar Disorder (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). The study was successful to some extent in that they did find that it was feasible to use individually delivered cognitive -behavioral therapy with pharmacological treatment (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). The treatment showed promise because improvement in teens with Bipolar Disorder was clearly shown. In addition, teens in both manic and depressive periods shown improvement, so treatments in this direction have the potential to be quite effective (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). Researchers did suggest that more randomized studies on this are needed to be done, but they were successful enough to illustrate the potential of cognitive behavioral treatments for children with Bipolar Disorder (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006).

 

 

Why Bipolar Disorder in children looks a lot like ADHD

Continuing the search for a marker to identify Bipolar Disorder in children earlier, a study that centered on impaired verbal declarative memory in children was done (Glahn et al., 2005). Since this is considered a marker for Bipolar Disorder in adults, researchers were trying to find out if children suffered from exactly the same type impairments here (Glahn et al., 2005). Their results did show that these impairments are common to both adults and children with this disorder and that comparable brain systems are compromised (Glahn et al., 2005). This study takes early steps in examining memory and learning processes more specifically in children with Bipolar Disorder I and appears to be in line with or according to the diagnosis in the DSM-5 (Glahn et al., 2005). Again, research in any direction like this could bring about earlier diagnosis of Bipolar Disorder in children and may help distinguish it more clearly from other disorders. One disorder that Bipolar Disorder shows a clear comorbidity with is ADHD, so with a focus on that researchers in another study tried to find out if a unique pattern of neuropsychological deficits is characterized in children with Bipolar Disorder (Henin et al., 2007). They did this by examining whether children with Bipolar Disorder and those with ADHD displayed neuropsychological deficits and whether those deficits were more severe in one disorder than the other (Henin et al., 2007). Their results showed that the neuropsychological performance in children with Bipolar Disorder is very similar to children with ADHD alone (Henin et al., 2007). This research clearly illustrates why Bipolar Disorder in children is difficult to diagnose early and easy to misdiagnose. The work done here directly relates to the evaluation and treatment of Bipolar Disorder in children (Henin et al.,2007). Unfortunately, you cannot treat a disorder until you can clearly distinguish it from another and this study showed some clear parallels between Bipolar Disorder in Children and in children with Attention Deficit/Hyperactive Disorder.

Education plan for children with Bipolar Disorder that takes their cognitive difficulties and deficits into account    

Another study that was simply an in-depth review of the current literature on the neurocognitive impairments in children, under eighteen, with Bipolar Disorder found that children with Bipolar Disorder show deficits in a wide range of cognitive areas (Horn, Roessner, & Holtmann, 2011). Their results revealed a consistent pattern in impairments in verbal memory and in working memory (Horn, Roessner, & Holtmann, 2011). The researchers thought here was that these deficits needed to be incorporated into an individual treatment program, so the underlying goal of this review was toward identifying neurocognitive tests for evaluating these impairments in juvenile Bipolar Disorder in clinical practice (Horn, Roessner, & Holtmann, 2011). In concert with other studies they did find that there were no differences found between the deficits or impairments found in adults and children with the disorder (Horn, Roessner, & Holtmann, 2011). However, the researchers felt these deficits in children with Bipolar Disorder did need to be incorporated into an individual and school’s educational plans because they thought children might benefit from a treatment approach that takes their cognitive difficulties or deficits into account with some focus on teaching them skills to deal with the mood and neuropsychological issues (Horn, Roessner, & Holtmann, 2011). In addition to trying to garner a better understanding of the cognitive impairments in children with Bipolar Disorder studies down these avenues gives us practical insights and applications at clinical levels (Horn, Roessner, & Holtmann, 2011).

Negative effects of life events on children with Bipolar Disorder

A study that took an entirely different approach by focusing on how life events might influence child and adolescent Bipolar Disorder did find that children with Bipolar Disorder experience significantly high rates of life stress compared to children with other mental disorders (Johnson & McMurrich, 2006). Teenagers with psychopathology are more than likely to report two types of stressors failure and being misunderstood (Johnson & McMurrich, 2006). Their findings did show that negative life events are tied or associated with the course of teen or adolescent bipolar disorder and that the effects of life events are entangled or wrapped up with emergent symptoms of the disorder and family difficulties (Johnson & McMurrich, 2006). A question other studies in this area will need to work on is how these life events might make symptoms of childhood bipolar disorder worse. This study indicates an even greater need for early diagnosis of Bipolar Disorder in children, so clinicians can get in front of any external issues that might make the symptoms their patients present with worse.

Do parents with Bipolar Disorder pass learning issues down to their healthy children?         

      This research study was an investigation into the intellectual functions and academic performance or achievement abilities in healthy children of parents with Bipolar Disorder to see if these children exhibited any nonverbal learning disabilities (NLD) (McDonough-Ryan et al., 2002). The results of this study did show that children with parents who have Bipolar Disorder do demonstrate cognitive abnormalities and academic weaknesses relative to those children with healthy parents. However, the actual pattern of deficits is not consistent with NLD (McDonough-Ryan et al., 2002). This study was done to see if there was any cognitive link to parents with Bipolar Disorder in healthy children (McDonough-Ryan et al., 2002). This look at healthy children of parents with Bipolar Disorder is a different approach toward finding a way to diagnose Bipolar Disorder in children earlier. If you look at those children who have not inherited the disorder from their parents, you might be able to figure out a marker in those children who might inherit the disorder or in those who might inherit the disorder in the future.

A look at executive functioning in children with Bipolar Disorder through parental reports.

     The study looks at executive functioning in teens or adolescents with Bipolar Disorder who are in a manic or mixed mood state by garnering or collecting data from their caregivers (Shear, DelBello, Rosenberg, & Strakowski, 2002). From the information they gathered they studied their performance on those tasks related to or mediated by executive functions by utilizing a behavior rating inventory of executive function (Shear, DelBello, Rosenberg, & Strakowski, 2002). When compared to the results of healthy teens, they showed significant elevation through all measured functional domains, even among those children who had Bipolar Disorder, but not ADHD (Shear, DelBello, Rosenberg, & Strakowski, 2002). The thought behind this study was to study well-defined adolescent cases with Bipolar Disorder to perform everyday activities that are believed to be related to or dependent on executive functions (Shear, DelBello, Rosenberg, & Strakowski, 2002). These results taken together suggest that the functional deficits measured by the brief behavior rating inventory of executive functions in the sample of teens with Bipolar Disorder might potentially affect not only their current psychosocial functions, but long-term outcomes (Shear, DelBello, Rosenberg, & Strakowski, 2002). Researchers in this study, like many, were hunting for a way to diagnose Bipolar Disorder in children earlier and a way to distinguish it more clearly from other disorders. The difference is researchers in this study focused on the manic and mixed moods of this disorder alone.

A comparison of the dysfunction between type 1 Bipolar Disorder and II in children

     The goal of this study was to determine phenotypic cognitive profiles of patients with Bipolar Disorder. In other words, a composite of characteristics in patients with Bipolar Disorder (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). To do this they studied both type I and II Bipolar Disorder and compared them both with healthy people (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). They found that patients with type I Bipolar Disorder performed more poorly compared to healthy people on all domains they looked at, but they also found the type I Bipolar Disorder patients to be far worse off than those with type II Bipolar Disorder (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). Findings like these could move us closer to creating or developing effective cognitive interventions tailored to the distinct types or sub types of Bipolar Disorder in children (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). The researchers proved their hypothesis in finding that children with type I Bipolar Disorder showed more severe and wide spread cognitive dysfunction and the results indicated that the most notable deficits in all groups were in verbal learning and memory (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). Researchers here felt that any treatment should target these areas (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). This kind of research is an attempt to try to define Bipolar Disorder by looking at the characteristics of it and trying to create a profile from the information.

A child and family based or focused Cognitive Behavior Therapy

     This study was a report of a group adaption of child and family based or focused Cognitive Behavior Therapy (CFFT-CBT), nicknamed Rainbow (West et al., 2009). The object of the study was to find out if this therapy was feasible and acceptable to families and if the treatment resulted in any significant improvement (West et al., 2009). The treatment resulted in significant improvement in manic symptoms, but not in depressive symptoms and in the psychosocial function post treatments (West et al., 2009). One great outcome, but not necessary for the success of the study was that parents reported being able to cope with their child’s illness much better (West et al., 2009). This is important because any kind of mental illness puts an unusual amount of stress on families. This group psychosocial treatment with pharmacotherapy might help bring about or attain remission of symptoms (West et al., 2009). This is just the beginning, but this is a crucial area for research because the need for psychosocial treatments for bipolar disorder to be used in conjunction with pharmacotherapy may help to combat the chronic and devastating course of this disorder (West et al., 2009). Any integrated treatment that has the potential to not only improve the quality of the lives of patients but reduce the public health burden must be considered (West et al., 2009). Discovery of more treatments for this disorder are critical, so more studies in this direction are just as important as those that search for a way to diagnose it earlier or distinguish it better from other disorders.

Conclusion

     The research on pediatric Bipolar Disorder discussed in this paper of what has been done and is being done to understand, diagnose earlier, and to treat this devastating disorder in children represents just a few grains of sand in a beach of information yet to be discovered and learned from research on childhood Bipolar Disorder. The research on Bipolar Disorder in children thus far is inspiring and dynamic in nature for it goes in many directions and that must never stop because the need to unmask this gremlin of a disorder in children and make it easier to identify and distinguish from the other childhood disorders it hides among or shares clear comorbidity with like ADHD is critical to recognizing it sooner and avoiding misdiagnosis. If this can be achieved, Bipolar Disorder in children could be treated sooner and sooner is always better than later as far as outcomes are concerned.

To illustrate the issue of not being able to identify Bipolar Disorder in children easer or more clearly consider how devastating it might be for a mother to have been told by one psychologist or psychiatrist that her child has ADHD only to find out from another a few years later that her child has Bipolar Disorder or vice a versa. If you were the mother or even a father in this scenario, would you not be wondering how a psychiatrist or psychologist could make such a huge error in diagnosis. Unfortunately, what they would not know and would not ever understand no matter how clearly it was explained is how a mistake like this could be made. The sad truth is according to just the information discussed here this mistake could be made very easily by a psychiatrist or psychologist. One might argue that it was a rush to judgement or to a diagnosis, but that may or may not be the case. A psychiatrist or psychologist could have interviewed parents, teachers, and others that deal with the child on a regular basis, obtained medical records on the child, looked at school records, observed the child at multiple times in multiple locations, interviewed the child, considered some potential environmental factors and from all accounts did the homework necessary to make a diagnosis and still make a mistake. Yes, everything does have to fit the criteria in the DSM-V to make a diagnosis of Bipolar Disorder but finding that the symptoms in the child you studied also somewhat matches ADHD with another disorder can still leave you without a clear diagnosis of either or leave with just enough symptoms to contemplate a diagnosis of Unspecified Bipolar and Related Disorder. People always like to use the phrase “the devils in the details,” but when it comes to diagnosing Bipolar Disorder in children the devil is in a huge complex forest of details that can make it look like other disorders, be hidden among other disorders, function in concert with other disorders, and that has a close kinship, as far as symptoms are concerned, with ADHD which is a disorder that is diagnosed in children with such great regularity that it would make even the wisest psychologist or psychiatrist pause to consider it. Hopefully someday research on Bipolar Disorder in children will clear this forest a little for psychiatrists and psychologists, but until then Bipolar Disorder in children will remain either under-recognized or occasionally misdiagnosed in children.

 

References

Glahn, D. C., Bearden, C. E., Caetano, S., Fonseca, M., Najt, P., Hunter, K., & … Soares, J. C. (2005). Declarative memory impairment in pediatric bipolar disorder. Bipolar Disorders, 7(6), 546-554. doi:10.1111/j.1399-5618.2005.00267.x

 

Bearden, C. E., Glahn, D. C., Caetano, S., Olvera, R. L., Fonseca, M., Najt, P., & … Soares, J. C. (2007). Evidence for disruption in prefrontal cortical functions in juvenile bipolar disorder. Bipolar Disorders, 9(Suppl1), 145-159. doi:10.1111/j.1399-5618.2007.00453.x

 

Johnson, S. L., & McMurrich, S. (2006). Life events and juvenile bipolar disorder: Conceptual issues and early findings. Development And Psychopathology, 18(4), 1169-1179. doi:10.1017/S0954579406060561

 

Schenkel, L. S., West, A. E., Jacobs, R., Sweeney, J. A., & Pavuluri, M. N. (2012). Cognitive dysfunction is worse among pediatric patients with bipolar disorder type I than type II. Journal Of Child Psychology And Psychiatry, 53(7), 775-781. doi:10.1111/j.1469-7610.2011.02519.x

McDonough-Ryan, P., DelBello, M., Shear, P. K., Ris, M. D., Soutullo, C., & Strakowski, S. M. (2002). Academic and cognitive abilities in children of parents with bipolar disorder: A test of the nonverbal learning disability model. Journal Of Clinical And Experimental Neuropsychology, 24(3), 280-285. doi:10.1076/jcen.24.3.280.980

 

Dickstein, D. P., Axelson, D., Weissman, A. B., Yen, S., Hunt, J. I., Goldstein, B. I., & … Keller, M. B. (2016). Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder. European Child & Adolescent Psychiatry, 25(6), 625-638. doi:10.1007/s00787-015-0769-2

 

West, A. E., Jacobs, R. H., Westerholm, R., Lee, A., Carbray, J., Heidenreich, J., & Pavuluri, M. N. (2009). Child and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Pilot study of group treatment format. Journal Of The Canadian Academy Of Child And Adolescent Psychiatry / Journal De L’académie Canadienne De Psychiatrie De L’enfant Et De L’adolescent, 18(3), 239-246.

 

Horn, K., Roessner, V., & Holtmann, M. (2011). Neurocognitive performance in children and adolescents with bipolar disorder: A review. European Child & Adolescent Psychiatry, 20(9), 433-450. doi:10.1007/s00787-011-0209-x

 

Feeny, N. C., Danielson, C. K., Schwartz, L., Youngstrom, E. A., & Findling, R. L. (2006). Cognitive-behavioral therapy for bipolar disorders in adolescents: A pilot study. Bipolar Disorders, 8(5 pt 1), 508-515. doi:10.1111/j.1399-5618.2006.00358.x

 

Shear, P. K., DelBello, M. P., Rosenberg, H. L., & Strakowski, S. M. (2002). Parental reports of executive dysfunction in adolescents with bipolar disorder. Child Neuropsychology, 8(4), 285-295. doi:10.1076/chin.8.4.285.13511

Henin, A., Mick, E., Biederman, J., Fried, R., Wozniak, J., Faraone, S. V., & … Doyle, A. E. (2007). Can bipolar disorder-specific neuropsychological impairments in children be identified?. Journal Of Consulting And Clinical Psychology, 75(2), 210-220. doi:10.1037/0022-006X.75.2.210

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).  Arlington, VA: American Psychiatric Publishing.