DSM Bipolar in Children

DSM is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association and is the defining resource for psychiatric disorders. DSM provides the criteria used by professionals to determine a psychiatric diagnosis. While the DSM outlines the diagnostic criteria for bipolar disorder in adults (adult-onset), it does not provide a separate diagnosis for bipolar disorder in children (early-onset). This is not an omission or glaring oversight, it is because this is a new field. Child and adolescent bipolar disorder has only been recognized and researched in the last decade.

DSM and Bipolar Disorder

• The most recent edition of DSM (DSM-IV) was published in 1994. At that time, bipolar disorder was thought to occur only in adults. Since then, scientific knowledge about the brain has taken giant leaps. Thanks to pioneering research, professionals now know that early-onset bipolar disorder is a reality. While experts have developed and continue to refine diagnostic tools for early-onset bipolar disorder, an officially approved guideline is not found in the DSM simply because a new version has not been released since 1994.

Early-Onset versus Adult-Onset

• Bipolar disorder in children appears differently than the picture described for adults in the DSM. Adult-onset bipolar disorder follows a distinct pattern of mood swings between mania and depression. The DSM states that the mood phases must be pronounced and evident for a specific period of time, with the minimum duration being one week. Children with bipolar disorder do not meet these criteria. They typically experience rapid mood cycling, sometimes going through many phases of mania and depression in one day. This rapid cycling also tends to blur the line between one mood phase ending and another beginning. The presentation may be one of a chronic persistence of irritability and mood swings. Experts in child and adolescent bipolar disorder have conducted research and confirmed that it can be diagnosed in children.

Diagnosing Early-Onset Bipolar Disorder

• The first difficult step in diagnosing bipolar disorder in children is separating it from the many other disorders or behavioral issues that may cause mood swings and masquerade as bipolar disorder. Disorders that are often confused with bipolar are Attention Deficit Hyperactivity Disorder (ADHD), oppositional defiant disorder, conduct disorder, Asperger's Syndrome and anxiety disorder. Determining the underlying cause is a critical step because bipolar disorder is treated with strong medications that won't have any benefit--and may even aggravate other disorders--if the child is misdiagnosed. An appropriate diagnosis also requires distinguishing between problematic yet typical emotional and behavioral issues versus those that define a serious disorder. In addition to evaluating the criteria defined in DSM for mania and depression, professionals assess other characteristics that are commonly shared among children with bipolar disorder, including difficulty sleeping, separation anxiety, raging and oppositional behavior.

Treatment of Early-Onset Bipolar Disorder

• The first goal of treatment is to stabilize the mood swings with medication. The types of medications used include mood stabilizers, anticonvulsants, antipsychotics, benzodiazepines and antidepressants. With a long history of successfully treating manic symptoms, lithium is usually the first choice. Anticonvulsant medications have also been proven to treat manic episodes. This class of medications includes Depakote, Tegretol, Lamictal, Topamax and Trileptal. Antipsychotics such as Risperdal, Zyprexa, Abilify and Geodon help to prevent episodes of mania and depression. They also treat anger and aggression. Antidepressants are used only with great caution as they can trigger a manic episode or rapid cycling. Psychological therapy for both the child and family is an important part of the treatment process. Methods such as cognitive behavior therapy, interpersonal and social rhythm psychotherapy and family focus therapy help teach skills that will be critical to help children learn to manage the emotional and behavioral issues accompanying bipolar disorder.

Beyond Diagnosis

• Bipolar disorder is a lifelong illness that will have to be monitored and treated for the remainder of the child's life. The ultimate quality of life---the long-term outlook---for children and adolescents with bipolar disorder will be determined by the treatment and guidance they receive from the moment they are diagnosed. It is important to seek the help of professionals who are experts in early-onset bipolar disorder. It is vital for parents to learn about the disease, the challenges, the medications and therapies. The depth of their involvement---their ability to be an advocate and proactive member of the team---will make all the difference as their children learn to cope with this serious, complex disease.