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Many traits that are characteristic of bipolar disorder in children-such as irritability and a bad temper-are also features of conduct disorder, oppositional-defiant disorder, attention deficit hyperactivity disorder (ADHD), and similar disorders-a similitude that contributes heavily to the challenge of diagnosing bipolar disorder. That's one of several cautions offered to pediatric clinicians and psychiatrists at a roundtable of experts convened at the annual meeting of the American Psychiatric Association in Toronto in May.
"The temper that children with bipolar disorder have is not just the terrible twos or a bad hair day," said Joseph Biederman, MD, professor of psychiatry at Harvard Medical School. "Many engage in planned, aggressive behavior, which relates to symptoms of conduct disorder."
Barbara Geller, MD, professor of psychiatry at Washington University in St. Louis, differentiated between bipolar disorder in adults and the illness in children.
Elation is one of the symptoms that characterize bipolar disorder in children, Dr. Geller noted. Furthermore, grandiosity is a cardinal symptom. An example of grandiosity in the young bipolar patient, she illustrated, is the child who believes he can fly, tries to do so, and ends up in the hospital with fractures-or worse-if he is not restrained. Another example of grandiosity is the child who walks into a classroom and behaves as if she is "in charge." Dr. Geller stressed the importance for clinicians of differentiating normal and pathologic elation when evaluating a patient for bipolar disorder.
"If children were not happy at Christmas or visiting Disneyland, we would think something is wrong," explained Dr. Geller, in getting across the point about context-appropriate behavior. Likewise, "if children keep making faces in the classroom-like [comic actor] Jim Carrey does-and are disruptive and frequently sent to the principal's office, that is an example of pathology."
Dr. Geller also cautioned that mania in children with bipolar disorder is unlike that seen in patients with ADHD.
It can be difficult, panelists noted, to determine if a child's behavior is pathologic or a manifestation of a chaotic, dysfunctional home life. When such uncertainty exists, it is appropriate for the diagnostician to conduct a trial of taking the child out of his family environment and sending him to stay with a relative or family friend for a period. A documented lack of change in behavior from one environment to another, according to Dr. Geller, can help establish a diagnosis of bipolar disorder.
Last, pediatric bipolar disorder impairs children's lives, emphasized Robert Kowatch, MD, professor of psychiatry and pediatrics at the University of Cincinnati and director of the pediatric mood disorders center at Cincinnati Children's Hospital Medical Center.
"[Children with bipolar disorder] don't do well in school, and many have unrecognized learning disabilities," said Dr. Kowatch. "They have poor peer relationships, and they feel they are bad kids and have low self-esteem.
"It has to be pointed out to them that, just as diabetics can't control their insulin levels and need medication, bipolar disorder means that they need medications to control their moods," Dr. Kowatch concluded.
Louise Gagnon, Correspondent