The Bipolar Child: A Challenging Diagnostic Task
anonymous Asks ...
Can an 8 year old boy be bipolar? Half the time when I visit my nephew he is so hyper (manic?) that you can't get him to stop talking nonsense for a second and other times when I come over he is sullen and withdrawn and he does not want to leave his room. My sister says his teachers at school are also confused about his behavior but she is in total denial and she thinks he is totally normal.
Dr. Richard Schultz Says ...
Thank you very much for your question.
In direct answer to your question, yes, it is in fact possible for a bipolar mood process to manifest in young children. This has typically been considered rather atypical, with usual onset of bipolarity not occurring until late teens to 20's in males, and somewhat later in females. Bipolar disorder can appear along a wide spectrum of severity, and with a variety of presentations, so diagnosing it, especially among a child, can be quite a complex task. There may be full blown manic and full blown depressive episodes, only manic episodes, or less severe "hypomanic" and/or "dysthymic" episodes. The condition can also present with "mixed" episodes, which come across more as irritability and agitation than as mania or depression. Kind of hard to imagine a kid who DOESN'T fit one of these descriptions, huh? (let alone an adult).
So, throw all of these potential "flavors" into the mix with a development process that is, even among the so-called "normal" kids out there, rather challenging, and you have what a patient of mine calls "Jambalaya Soup." What makes this diagnosis even more difficult in a child are factors such as (1) normal temperament that may not "fit" with the environment (for example, high energy child is matched with lower key parent thus creating conflict and even more mood and energy swings for the child), (2) other psychosocial stressors (personal, family-related, academic, etc.) that may account for the shifts you have observed (remember, most 8 year-olds are not as good as talking about what is happening inside of them as most adults are, thus there is a tendency for feelings to get "acted out" versus verbalized), (3) learning or attentional problems which create frustration or sensory challenges and may be having a negative impact on the regulation and/or display of energy, emotion, or social behavior (4) other mood struggles other than bipolar, such as depression, anxiety or reaction to trauma.
So, because the diagnosis is a complex one to make correctly, and because the initiation of treatment for a bipolar condition will typically involve the use of powerful mood stabilizers that will carry side effects, and because all of this can be quite disruptive to the child's life and their self-concept, the need for a conservative and judicious diagnostic process is certainly called for. Of course, this is predicated on the fact that the symptoms observed are deemed by the child's guardian(s) to warrant such attention. I hear that your sister has thus far been on the side of not taking action, and this is an entire "Q & A" unto itself. If action were to be taken, I would suggest first speaking with the child's pediatrician to discuss the presence of complicating factors such as those noted above, as well as a screening for other medical issues which might be generating symptoms that mimic mood instability (metabolic, hormonal or blood sugar abnormalities, for example). Next, I would consult with an excellent child and family psychologist to screen for other psychosocial or behavioral issues. Finally, with the cooperation and blessing of the psychologist and PCP, I would suggest consulting a pediatric psychiatrist. Go to the best one in town (versus those left in the insurance network...this is NOT a place to skimp!), and proceed with care. Basically, you want to look for all OTHER potential causes first, deal with those, and only then proceed to the possibility of bipolar disorder as a diagnosis.
I hope you found this reply to be of some use. Thank you again for writing. Please do keep me posted, feel free to write back if you need advice about your sister's stance, and let me know if I can be of any additional assistance.
Richard E. Schultz, Ph.D.