The Importance of Properly Diagnosing Early Onset Bipolar Disorder

Although early onset bipolar disorder (EOBD) was first described in 150 AD, the diagnosis remains surrounded in controversy because no such diagnosis exists. A person either meets the criteria for bipolar disorder set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or not. The problem is that, as with DSM-IV, the criteria describe bipolar disorder as it exists in adults. The child phenotype differs markedly from adult onset bipolar disorder. Children with this disorder exhibit a more chronic form of irritability, more rapid mood swings, intense emotional outbursts, and impulsive aggression.

An additional complication when making the diagnosis in children is that most of the symptoms associated with EOBD also exist in ADHD, OCD, and ASD. Moreover, children with EOBD also have high rates of comorbid conditions.

Though it was hoped that DSM-5 would resolve the main concerns, the following issues remain unaddressed:

  1. Technically, EOBD diagnosis still does not exist.
  2. Teens and children must meet adult criteria to be diagnosed as bipolar.
  3. Many children who would have received a diagnosis of bipolar disorder prior to the publication of DSM-5 will now receive a diagnosis of disruptive mood dysregulation disorder (DMDD).

Despite the hope for some consensus, experts in the field have yet to reach agreement on (a) what symptoms constitute the core features of EOBD, (b) how to differentiate bipolar disorder from other childhood disorders, and (c) how best to manage children who have the disorder.

When Drs. Richard M. Marshall and Berney J. Wilkinson began seeing children who exhibited severe symptoms of bipolar disorder, they used omnibus rating scales as part of their initial diagnostic assessment. To their surprise, many of the scales completed by parents and teachers had ratings in the normal range even though the children had symptoms of bipolar disorder. An item analysis revealed that existing rating scales did not contain a sufficient number of items associated with the disorder. To address these shortcomings, Marshall and Wilkinson developed the Pediatric Behavior Rating Scale (PBRS), a standardized, norm-referenced parent and teacher rating scale for use with children ages 3 to 18 years.

Rather than providing specific diagnoses, the PBRS enables clinicians to identify the core features of EOBD, thereby serving as the critical first step in differential diagnosis and intervention planning. The PBRS provides clinical researchers with another tool to assist in (a) defining this disorder, (b) differentiating EOBD from related disorders, and (c) evaluating the efficacy of interventions aimed at alleviating its symptoms.

Approximately 20% of our nation’s 50 million K–12 students meet diagnostic criteria for a mental disorder, and 10% experience significant functional impairments at home, at school, and with peers. Nevertheless, children exhibiting such symptoms are often punished for willful disobedience rather than receiving effective treatment. In fact, 80% of children with mental illness remain undiagnosed and untreated, resulting in increased risk for suicide, school failure, and criminal behavior. Accurate differential diagnoses of EOBD and related disorders is the key to effective interventions.

Unless otherwise cited, source material is attributed to:
Marshall, M. M., & Wilkinson, B. J. (2008). Pediatric Behavior Rating Scale. Lutz, FL: PAR.

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