Diagnosing Bipolar Disorder in Kids: Here's the DSM-5's Controversial New Update

When it comes to bouts of teenage rage, there are tantrums—and then there are tantrums. Diagnosable ones.

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Many kids prone to explosive anger, in fact, are labeled bipolar. It’s part of the reason that, in the past decade alone, diagnoses of the disorder in children have soared by a staggering 40 percent, with some estimates putting the prevalence rate as high as 3 percent in adolescents. And that’s particularly noteworthy considering that, before the mid-1990s, almost no one diagnosed bipolar disorder in kids.

What’s happened between then and now has been the fascinating evolution of a pediatric disorder, driven by major psychiatric studies changing the way symptoms of the condition are seen in kids, and culminating, for now at least, with this month’s controversial release of the DSM-5, the official bible of American mental illness.

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The fifth edition of the Diagnostic and Statistical Manual, published by the American Psychiatric Association and used to diagnose patients, is the first major rewrite of the near-1,000-page guide in 20 years. It’s also the most closely scrutinized, hotly contested revision yet. Among the various contentious changes this time around is the introduction of Disruptive Mood Dysregulation Disorder, or DMDD, meant to help address the ever-rising number of temper-prone kids getting diagnosed as bipolar.

“The road to mental health begins with an accurate diagnosis,” David Kupfer, chair of the DSM-5 Task Force that authored the changes, told Yahoo! Shine.

It’s how he explained the need for adding DMDD, which addresses children who have chronic irritability, as well as frequent episodes of temper outbursts several times a week for more than a year. Those temper outbursts, according to the diagnostic guidelines, are not your typical tantrums; they are, rather, explosions that are grossly out of proportion with the situation, out of sync with the child’s development level, occur at least three times a week, and began happening before the child was 10 years old. Parents of explosive toddlers and preschoolers need not worry. The diagnosis should not be made before the age of 6 or after 18. 

Currently, Kupfer said, children suffering from these types of rages are being misdiagnosed with bipolar disorder, which means they’re not being properly or successfully treated—and, in the process, may be overmedicated with drugs carrying potential side effects from severe weight gain to diabetes. However, treatments for DMDD are unclear at this point, experts agree, and trial studies are just now testing the effects of antidepressants and stimulants as a possibility.

“The new diagnosis in DSM-5 aims to give these children a diagnostic home and ensure they get the care they need,” he noted. “In addition, these children exhibit extreme, recurrent temper outbursts that are severely impairing. Misdiagnosis limits effective treatment options for the child and also negatively impacts data validity and future research.”

But there’s still plenty of disagreement within the psychiatric community about these temper outbursts, with many doctors believing that they can, in fact, be part of a bipolar diagnosis, which often presents much differently in children than in adults. The main difference between the two diagnoses is that bipolar children may be more prone to manic episodes as opposed to temper tantrums.

It’s part of why responses to the changes, both by professionals and parents, have been deeply divided, with detractors concerned that DMDD has not yet been properly researched, and that the new diagnosis may actually exacerbate, not temper, the risk of overmedicating adolescents. Psychiatrist Allen Frances, for example, who was a DSM task force member when changes were made for the fourth edition, has said in various forums that DMDD will effectively “turn temper tantrums into a mental disorder,” which he calls a “puzzling decision based on the work of only one research group.”

And David Axelson, director of the University of Pittsburgh’s child and adolescent bipolar services outpatient program, calls the decision to add it to the DSM-5 “really premature.” He points to a recent study in the American Journal of Psychiatry on the high prevalence of the primary symptoms of DMDD, and the possible outcomes of including it in the new DSM, as raising concerns about the “validity of the diagnosis.”

Which is worrisome, noted Axelson, because diagnoses are important in choosing treatments for mental disorders in children, which can be “a bit of a high-stakes situation.” Bipolar disorder calls for antipsychotic meds that come with the potential side effects, he explained. But if the presence of bipolar is missed, and is instead identified as ADHD, depression or anxiety disorder, which symptoms can mimic, there’s another big risk: “Those medications, when prescribed without mood stabilizing medication, can really worsen, we think, the outcome for kids with bipolar disorder.”

Dr. Axelson’s preference of what to do with DMDD, he added, would have been to add it to the appendix of the manual, where it would have been noted as worthy of further study—the route used for the more gradual introduction of disorders including binge eating and premenstrual dysphoric disorder, both being added this year.

Even Ellen Leibenluft, chief of the bipolar spectrum disorders section at the National Institute of Mental Health, who lead the existing DMDD research and who was involved in the DSM-5 revision process, was unsure about adding the diagnosis.

“I was not pushing for it,” she told Shine. “I was torn.” But, she said, “These children with the new diagnosis are as sick as those with bipolar disorder,” and they need a home in the DSM, too. So Leibenluft said she can see both sides of the discussion. “There’s no question that psychiatric diagnosis has got a lot of problems right now,” she said, “but you have to do the best you can with the knowledge base you have in 2013.”

Indeed, some parents see the addition of DMDD as hopeful. “We are cautiously optimistic because we think it will encourage more research,” said Susan Resko, executive director the Balanced Mind Foundation, a non-profit support organization for families of children with mood disorders. Though the organization is unsure how schools and insurance companies will respond to the new diagnosis, in regard to providing services and coverage for those services, Resko told Shine that the issue is “nuanced,” and that the real issue is kids who are in need.

“There are cries that we’re over-diagnosing,” she said. “Well, the kids were always there, and they’re struggling. These kids are severely ill, and at risk for school failure or suicide.” And finally having a diagnosis that fits them may make a difference, she said.

Those are the feelings of one Pennsylvania mom, whose 13-year-old daughter was diagnosed with Mood Disorder Not Otherwise Specified (NOS) when she was about 9 years old. “Am I excited about the new diagnosis? Hell yes,” said the mom, who had just learned about DMDD from her child’s psychiatrist, and who asked that Shine not use her name in order to protect her daughter’s privacy.

The new disorder, the mom explained, sounded very much like her child, who is “irritable all the time,” and prone to both depression-like “holes” and volatile outbursts at the slightest provocation.

“She’s very keyed into facial expressions. You kind of have to be like a robot around her because if you look at her in a certain way she could explode,” she said, adding that she has sometimes been prone to violence, and that she frequently refuses to go to school. “But I can’t go in there and force her because I’ll get my nose broken.” She admits that dealing with her daughter sometimes feels like “living with an abusive spouse,” which keeps her on eggshells daily. Still, she adds, “I think she realizes sometimes that this is not really who she is.”

Currently, the young teen is being treated with both behavioral therapy and a mood stabilizer that comes with the potential side effect of a life-threatening rash. It’s a medication used for kids with bipolar disorder, though she does not fit all the criteria for a bipolar diagnosis.

For the first time in a while, she added, she’s feeling hope about her daughter’s condition, because of the introduction of DMDD. “For a while I didn’t care what they called it. But now it needs to have some sort of name,” she said. “I feel it will give some validation to what we as families go through, and hopefully, with it, there will be more understanding of our children and their needs.” 

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