Is bipolar disorder over diagnosed in children?

In my opinion, bipolar disorder (BPD) is an overused and misused diagnosis in children. Between 1994 and 2003, there has been an alarming 40-fold increase in the diagnosis of BPD in children (Sahling, 2009), making it the most common psychiatric diagnosis requiring hospitalization in children under the age of 12 (Parry & Allison, 2008). This diagnosis has been applied to children as young as 2 years of age, and some have suggested that it can be diagnosed in utero (Sahling, 2009). I believe, however, that the evidence shows that BPD is the latest of diagnoses adopted by psychiatry which label children whose behavior falls outside the “normal” parameters. Controversy abounds related to the diagnostic criteria and methodology used in assessing BPD in children (Bradfield, 2010), for clinicians still use the DSM-IV (developed for adults) to diagnose children. The National Institute of Mental Health acknowledged that it is premature to include new diagnostic criteria for pediatric BPD in the DSM-V, citing disagreement and lack of research as the rationale (Parry & Allison, 2008). Psychiatrists readily admit that the current criteria found in DSMIV are inadequate and do not capture the clinical manifestations of BPD in children. The inconsistency in diagnostic criteria has led to confusion and controversy regarding what symptoms should be used to diagnose BPD in children and how best to treat this disorder. BPD in children has been described as including the following symptoms: elated mood, irritable mood, inflated self-esteem or grandiosity, decreased need for sleep, pressure speech, constant goal-directed activity, search for pleasurable activities, depression, and psychotic behaviors (Bradfield, 2010). Researchers suggest that there are diurnal variations with early morning somnolence followed by increasing irritability and hyperactivity in the evening (Parry & Allison, 2008). The criteria for diagnosis fail to clearly delineate normal behavior from that which is aberrant. In the absence of universally accepted criteria for diagnosis, clinicians and psychiatrists engage in broad interpretation of childhood behavior and can label behaviors previously considered normal as pathologic. For example, researchers suggest that children with BPD can have hourly mood swings, unlike adults with BPD whose extremes in mood can last weeks or months. In previous decades, the normal mood variations in children might have been attributed to a child’s sedentary day at school and the need to expend energy once at home. Today, however, that extra energy could be the basis for a diagnosis of BPD and treatment with medications. Many children diagnosed with BPD have been previously diagnosed with attention deficit hyperactive disorder (ADHD) and 8 and 10 million children are prescribed psychostimulant medications (Sahling, 2009). Treatment with medications such as Ritalin can result in iatrogenically induced symptoms of mania and depression leading to a misdiagnosis of BPD, and children are subsequently treated with mood stabilizers and antipsychotics such as lithium or risperidone. Research suggests use of these medications may result in a decrease in brain mass and function, and can interfere with normal growth and development (Sahling, 2009) Further, children who had previously been diagnosed with ADHD, oppositionaldefiant disorder, and conduct disorder are then “re-categorized” as having BPD (Parry & Allison, 2008). It is time for nursing to consider this topic seriously and question the overdiagnosis of BPD in the pediatric population.