Bipolar disorder is a psychiatric disease that is severe and often recurrent that affects all behavioral and functional aspects. Regrettably, the correct diagnosis and enough mood stabilizer intervention of bipolar disorder are typically delayed by 8-10 years (Blader, 2006). The onset of adult bipolar disorder has been well studied; less attention has been directed to the childhood-onset of bipolar disorder. There is a lot of concern over young children being placed under psychotropic medication. The currently available research is incomprehensive and a lot is required to learn about children under treatment for different kinds of psychiatric disorders. New research in mental health is required to inform us on the best treatments suited for children with behavioral and disruptions (Zakriski, 2005). The diagnosis and medication of mental disorders such as bipolar disorder in children must consider changes and growth during their development period. This paper describes bipolar disorder in childhood and the justification of using diagnosis for psychotropic medications. To expand on the efficacy for use of psychotropics, the paper also looks at the possible consequences of misdiagnoses of bipolar disorder in childhood; examining the role of parents, teachers and psychiatrists in misdiagnoses of BD.
A Review of Related Literature
Understanding Bipolar Disorder and Diagnostic symptoms
Bipolar disorder in childhood refers to severe and often psychiatric conditions in children that affect their behavioral functioning. The symptoms of bipolar disorder are similar to Attention Deficit Hyperactivity Disorder (ADHD) in children (Zakriski, 2005). Common symptoms of mania such as, talkativeness, psychomotor agitation, and distractibility are present in both bipolar and ADHD disorders. Children meet guidelines of manic symptoms if they have euphoric mood swings. In addition, they meet these guidelines if they manifest three to four symptoms. Specific manic symptoms include decreased need for sleep, elated mood, aggressive behavior, hypersexuality and uninhibited social interactions. However, children with ADHD differ from those with bipolar disorder in some ways. ADHD children do not exhibit some of symptoms present in bipolar disorder children, such as, persistent mood liability, excessive tantrums and rage, grandiosity, intentional aggression, suicide tendencies, and others (Zakriski, 2005).
Many children diagnosed with bipolar disorder meet the guidelines of mania. These children may also have ADHD symptoms. Children with bipolar disorder with coexisting ADHD, presents severe consequences with a probability of psychotic symptoms. Children with bipolar conditions are commonly affected by learning disabilities, particularly if there is coexisting diagnosis of ADHD. In addition, half of kids who experience depression and anxiety tend to develop bipolar disorder. Bipolar disorder children can be volatile, short-tempered and difficult to manage generally. In essence, bipolar disorder in children has strong symptoms that overlap other psychiatric disorders (Zakriski, 2005).
Childhood Bipolar Disorder, Diagnosis and Psychotropic Treatment
The development of child psychiatry has seen a marked increase in the rate at which children are diagnosed with bipolar disorder. Moreno et al (2007) established a 40% increase in outpatient pediatric visits linked with bipolar disorder between 1994 and 2003. Blader (2007) established the frequency of discharges of youth with bipolar disorder in US hospitals to have risen from 1.3 to 7.3 per 10,000 between 1996 and 2004. According to Heflinger (2008), the rate of psychotropic medication for children with behavior disorders is high and controversial. Heflinger (2008) further notes increased rates in psychotropic treatment on youth with behavioral disorders in the early 1990s. Most medical prescriptions are off-label and pose potential health risks to children and adolescents. Furthermore, the problem becomes serious as there are no efficacy data in place to support use of psychotropic medications (Zakriski, 2005).
Hallfors (1998) determined optimal treatment for children and adolescents as both psychosocial and pharmacological, and puts into consideration the broader aspects of the environment. In their study, Hallfor (1998) looked at the medical rates of adolescents with behavioral disorders of serious nature admitted in intensive residential treatment centers (IRTC) or specialized treatment group homes (STGH). Both IRTC and STGH programs use cognitive-behavioral treatment techniques with medication management stress that considers minimum optimal medication level for every youth (Hallfor, 1998). The IRTC program monitored youth between the ages of 7 to 18 in residential treatment program for 24 hours. The program was designed to provide medical care to seriously disturbed youths who need supervision, safety and counseling but do not need inpatient psychiatric care (Zakriski, 2005).
The STGH program, on the other hand, was medically-directed as a secure residential treatment for adolescents aged 10 to 18 years. The program was supervised 24 hours within family-friendly environment for children with psychiatric disorders. Both studies examined the use of psychotropic medications and the rate of disruptive behavior and limitations in these programs. The overall results indicated a 35.8% fall in the number of adolescents on medication from the time they were admitted to discharge (Hallfor, 1998). The results also indicated a decrease in the frequency of disruptive behavior by 51.8% (Heflinger, 2008). The programs also recorded a 69.5% reduction in the use of restraints for each adolescent during their intensive residential program. The youth joined these intensive residential treatment programs with high psychotropic medication rates. These results provide a significant treatment and policy implications for treatment of children with behavioral disorders such as, bipolar disorder (Hallfor, 1998).
Olfson et al (2006) depict recent research that shows increased prescription of psychotic drugs in children. As a consequence, child psychiatrists increasingly assess and medicate children who take psychotropic drugs. These psychiatrists also intensively consult with parents, teachers and other psychiatrists who may have concerns over the side effects of use of psychotropic medications (Gureasko-Moore, 2005). According to Kubiszyn (2005), “the US Food and Drug Administration warnings and advisories on public health issues abut the use of psychotropic drugs has enhanced children drug safety interest” (P. 21).
Efficacy for Studies in Psychotropic Medications in Children
Documented empirical studies on psychotropic medications are lacking. This creates adverse effects on the treatment of behavioral disruptions in children and adolescents. It also limits the provision of sufficient services to children and adolescents with behavioral conditions such as bipolar disorder. As a result children and adolescents with these disorders receive inadequate care and treatment based on limited scientific evidence of medication safety. Scientific evidence related to treatment work appropriately for particular diagnoses and patients. Other factors that may result in many children being diagnosed with psychiatric disorders such as bipolar are; reduced medical funding, poor mental health reimbursements for mental health services, and others. These factors cause children undergo medication when there is little efficacy and safety for use of psychotropic medication in children (Olfson, 2006).
There are genuine concerns by many over-prescription of psychotic drugs on children. The available studies are insufficient and much more research needs to be done to provide insight into children who are treated with drugs of all kinds of disorders. Much research is also required in mental health field to determine appropriate treatments for children with emotional and behavioral disruptions. Children are constantly experiencing change and growth during their periods of development. These changes must be put into consideration when diagnosis and treatment of mental illnesses are examined (Hallfor, 1998).
It is advisable for parents to promptly seek professional assistance for their children. This is because some of the children’s emotional and behavioral disruptions are mild and short-term, thus requiring no treatment; other mental problems persist for some time and take serious proportions, thus requiring parents to seek professional assistance immediately. Situations occurring every day can result in changes in behavior. Such behavior adjustments must be recognized and differentiated from symptoms of serious conditions. Much attention should be focused on conditions that are severe, persistent and affect daily functioning of children. Parents should seek professional help at once if for instance they notice conditions such as changes in child’s social withdrawal, lack of sleep or appetite, fearfulness and other disruptive conditions (Zakriski, 2005).
Childhood bipolar disorder and other mental disorders can be diagnosed through observable symptoms (Zakriski, 2005). These signs and symptoms must be considered by qualified clinicians in view of the child’s level of development, socio-physical environments, information from parents, and teachers (Conor, 2006). Qualified clinicians then make their assessments based on guidelines established by professionals. The task of diagnosis is quite challenging in children as they cannot display their thoughts and feelings appropriately. In general, severe and persistent mental conditions that affect the daily functioning of children must be referred to a child psychiatrist. Much care should be exercised to assist a suffering child since mental or behavioral disorders can affect the way a child grows (Zakriski, 2005).
There are some specific circumstances in which it is advisable to use psychotropic medications in children. Psychotropic medications should only be recommended to children with emotional or behavioral symptoms, when expected benefits of treatment exceed the dangers (Conor, 2006). Normally some of these conditions are severe and persistent, thus, can cause serious challenges to children if left untreated. This may follow when psychosocial treatment may not be effective. There are no documented studies that provide information on the safety and efficacy of psychotropic treatments in children (Conor, 2006). Parents are encouraged to be more inquisitive and evaluative with the assistance of the doctor on the dangers of commencing and continuing children on psychotropic medications. They must get all the details about the prescribed medications prescribed for their children; including the side effects. Parents must learn which side effects are tolerable and those that are risky. They should also bear in mind the aim of a particular medication, such as, specific behavioral change. Parents and clinicians must avoid at all costs prescribing multiple psychotropic medications to children, unless it is very necessary (Conor, 2006).
The use of psychotropic medications affects children differently compared to adults. This explains variances in dosage. There is always rapid growth in children’s brains compared to adults. Researches on animals reveal the development of neurotransmitter systems that are sensitive to medications. Adequate research is needed to find the effects and benefits of psychotropic medications. It is also important to note that serious untreated mental disorders can negatively retard or damage brain development in a child (Gureasko-Moore, 2005).
Bipolar disorder together with other mental disorders such as depression, and anxiety were believed to begin only after childhood. However, the true facts are that they can commence in early childhood. In the US, approximately 1 out of 10 children and adolescents have mental disorders. Attention deficit hyperactivity disorder (ADHD) is the most diagnosed and treated as childhood mental disorder (Gureasko-Moore, 2005).
The treatment of individuals under the age of 19 (children) with bipolar disorder in usual practice presents ethical and regulatory challenges. Some of these challenges are common to general pediatric treatment or to the use of psychotropic medications in children. This section addresses issues that are relevant to the treatment of bipolar disorder in children. Children are usually brought to medical treatment by responsible adults under their care. The relationship between medical practitioners and children is mediated by the parent, that is, purely from legal and ethical perspectives. The establishment of diagnoses of bipolar disorder in children depends on the parents as source of information (Blader, 2006). Currently, diagnostic biological indicators of bipolar disorder are not available. Therefore, diagnosis relies on careful medical evaluation. It is not always easy for clinicians to directly observe the child displaying the signs of bipolar disorder. Young children lack the insight or cognitive skills to report symptoms of bipolar disorder. Thus, parental information plays a significant role in bipolar disorder diagnosis process (Heflinger, 2008).
Parents make absolute decisions about treatment of their affected children. Normally, children with bipolar disorder find no problems with their moods or behaviors and therefore no requirement for treatment. Attempts to explain the nature of the disorder and treatment purpose to children should always be made as permitted by their cognitive capacities and the medical status. The final decision to begin treatment rests on the child’s parents (Hallfor, 1998).
Treatments of children with bipolar disorder are based on clinical guidelines. These guidelines are informed by expert advice and in part with research studies, which are few in children with bipolar disorder. These guidelines provide a general guide to doctors with knowledge that there may be wide differences in the way individual patients are treated. These treatment guidelines may be subject to change based on emerging new information from progressive research (Heflinger, 2008). Clinicians should inform parents of the current state of treatment of bipolar disorder and be made to know that, despite expert agreement that children with bipolar disorder get pharmacological medication to stabilize mood, the effectiveness of treatment in preventing recurrence and enhancing prognosis remains not documented. Since response to treatment is highly variable across patients, getting an effective treatment remedy is much a process of trial and error. Parents and their patients must have knowledge of these limitations (Gureasko-Moore, 2005).
Parents contribute essential information in the diagnosis process of bipolar disorder. Besides making these contributions, parents are also responsible for: implementing prescribed treatment; monitoring the adverse effects occasioned by treatment; and reporting both benefits and potential limitations to the attention of the medical practitioner. These functions are necessary provided some of the medications used in the treatment of bipolar disorder have a narrow therapeutic index or can cause infrequent but serious adverse effects. It is critical for clinicians to inform the parents about the potential benefits and harms of treatment. They should also inform parents about the monitoring procedures that need to be implemented during treatment to reduce risks. Therefore, time and effort require to be committed to parent education (Shaw, 2010).
Clinicians are not supposed to prescribe treatment to children without evidence of the capacity of parents to supervise. Some family situations, as a result of environmental stressors constrain the orderly approach to treatment. Currently, there are no general guidelines available for these circumstances. Each case has to be dealt with depending on individual needs and characteristics. When children reach adolescent stage, they are expected to be actively involved in the treatment decision-making process. They gradually take responsibility for their care. Legally, parents remain responsible for treatment decisions, but active participation of the adolescent in decision process to treatment is necessary. However, bipolar disorder often affects insight and judgment. Adolescents may turn down treatment or refuse to follow the laid down prescription. Adolescents with bipolar disorder are in great danger of engaging in alcohol and substance abuse (Olfson, 2006). They also risk engaging in other risk behaviors, such as, irresponsible sexual activity which makes the adolescent vulnerable to dangers of infection, and unplanned pregnancies. Again a number of mood stabilizers can cause harm to a developing fetus since they are teratogenic. These elements make the management of bipolar disorder in adolescents difficult (Shaw, 2010).
Adolescents find it problematic to undergo involuntary treatment unlike younger children. Adolescents cannot exercise their full rights to self-determination because they are under the legal age of 18. Therefore, for evaluation, treatment or release of information require permission from parents unless waived by law. For most adolescents, parents are responsible legally for their decisions for treatment. Differences between adolescents and their parents can be the source of considerable disruption and greatly impacts successful treatment implementation (Conor, 2006).
Consequences of Misdiagnosis of bipolar Illness in children
Proper diagnosis of bipolar disorder by qualified professionals is very essential. It is true that most psychotropic medications recommended to children are usually performed by general primary care practitioners with less specialized training in mental health and medication. These practitioners use brief interviews, with fewer follow-ups and in some instances succumb to pressures from frustrated teachers and parents to recommend medications for children (Shaw, 2010).
Today, bipolar disorder is so casually diagnosed that any kid with symptoms such as insomnia, frustration, anger, aggression, or sadness is likely to be considered bipolar (Heflinger, 2008). Children may display some of these behavioral disruptions for completely different reasons which might not require psychotropic medication. Further, Heflinger (2008) stated that, “children might behave this way due to a host of factors, such as; being abused, bullied, frightened, grieving, or are making adjustments to situations such as family divorce” (p. 143). Although majority of children with these symptoms normally have bipolar disorder, many others are wrongly diagnosed when in an actual sense they are afflicted from an entirely different condition. Heflinger (2006) lamented that, “it is unfortunate that children whose symptoms closely qualify the criteria of other disorders, such as; depressive disorders, adjustment disorders, anxiety disorder, post-traumatic stress disorders, oppositional defiant disorder, and others are careless considered to suffer from bipolar disorder” (p. 140). To aggravate the problem, many physicians feel that children with bipolar syndrome require nothing more than medication. Therefore, medicine is often the only treatment offered to diagnosed children, creating a formidable constraint to appropriate interventions and therapies (Gureasko-Moore, 2005).
Although these situations of misdiagnosis are more disturbing, the most reprehensive misuse of this psychiatric diagnosis is its use in ordinary belligerent children. According to Conor (2006), parents, teachers, and psychiatrists assume typical defiance, misbehavior, and other demeanors of disruptive children as signs of bipolar disorder. General mental health practitioners use the bipolar diagnosis as a justification for taming disruptive children by sedating psychiatric drugs (Shaw, 2010). These drugs usually have serious, permanent and sometimes lethal side effects (Conor, 2006).
Initiating treatment on the basis of incorrect diagnosis usually results in the application of medications when they are completely not required, or to prescribing incorrect medication. Those children misdiagnosed and placed under incorrect drug prescriptions generally do not recover. Unfortunately, or tragically so, when symptoms of these children continue unchanged or perhaps even worse, psychiatrist usually assumes that the medication, not the diagnosis, needs to be adjusted. These child psychiatrists rarely consider the possibility that the bipolar diagnosis was incorrect to begin with. Instead, they routinely adjust the treatment by adding one or more medications to those already prescribed. Thus, misdiagnosis of bipolar disorder places a child on a treacherous path toward overmedication and away from effective treatment (Conor, 2006).
The Role of Parents, Psychiatrists, and Teachers in Misdiagnosis of Childhood Bipolar
Teachers, parents and psychiatrists have their own unique understandings of the emotional world and behaviors of children. Combined together, the experiences and perspectives of parents, psychiatrists, and teachers offer a more overall understanding of childhood (Shaw, 2010). However, for different reasons, parents, psychiatrists and teachers have unfortunately played a significant role in exacerbating childhood bipolar illness.
Role of Parents in Misdiagnosis of Childhood bipolar disorder
For children to function responsibly as adults, they need a host of skills. Some of the skills children require involve: the ability to cope with frustration as part of life; the ability to manage disappointments; and to exercise self-control to delay gratification and make mature choices. Society today has unfortunately compromised the discipline of children to a position of less importance. Many parents today are more permissive compared to their own parents. They are not doing a good job when it comes to guiding their children on how to behave. When parents indulge children’s whims and placate them whenever they are least frustrated, these children will not learn how to function successfully either in adolescence or adulthood. In the current situation, the consequences of indulging go well beyond making a monster for the family, school and neighborhood to deal with. Many spoilt children who rage at least disappointment are now at significant risk for bipolar disorder misdiagnosis and antipsychotic drug prescription (Shaw, 2010).
Undisciplined children and out of control, are likely to get psychiatric diagnoses because many child psychiatrists tend to fear to suggest that parents are in any way responsible for their children’s difficult behavior. When psychoanalytic approaches dominated psychiatry from the 1940s through to 1970s, therapy tended to blame mothers for their children’s psychological disturbances. This has however changed over the past decade. Now child psychiatrists fear to even intimate that parents are in any way the cause of their children’s negative behaviors (Conor, 2006). Behavioral disruptions such as temper tantrums and classroom disruptions by defiant children are now associated exclusively with chemical imbalances and neurotransmitter deficits. Child psychiatrists who challenge this school of thought are termed as old-fashioned and not conversant with current practices (Conor, 2006).
Currently, many parents possess much information that makes them think they are qualified to diagnose their children and then demand a prescription of a drug of their own choosing. These parents are usually aware that if the first doctor refuses to prescribe what they want, the next one will. Doctors pressured by time working within the constraints of a health maintenance organization often accept without question the assessment offered by the parent. It is unfortunate that research by parents is gleaned from magazines advertisements, websites and articles which offer little more than partial or completely inaccurate information (Moreno et al, 2006). Certainly, they cannot be compared with thorough evaluation of a qualified professional. Descriptions from sources such as the internet tend to downplay the seriousness of psychiatric conditions and the dangerous side effects of many psychiatric drugs. Parents have taken advantage of putting their children on psychiatric medication as a method of dealing with unruly children. This complacency by medical practitioners sets the stage for misdiagnoses and drug prescriptions (Zakriski, 2005).
In sum, in the current situation of permissive parenting, many children exhibit behavior that is out of control. Consequently, the current practice in child psychiatry encourage medical practitioners to explain all disruptive behaviors in children as resulting exclusively from faulty brain chemistry rather than poor parenting. Many parents find it a relief to inform that their children’s belligerence, defiance of aggressiveness is a result of psychiatric condition and the responsibility of poor upbringing of their children (Shaw, 2010).
Role of Psychiatrists and children bipolar Disorder
Some psychiatrists think that the tremendous rise in the number of children diagnosed with bipolar disorder is due to improved diagnostic techniques. Nevertheless, majority of psychiatrists believe that bipolar disorder diagnoses are frequently applied as a justification to medicate children’s minds as a fast remedy convenient for parents, teachers, and doctors (Moreno et al, 2006). As a result, ordinary unruly behaviors are being attributed to a chemical imbalance, and children are being treated inappropriately just to calm them down. Many medical health practitioners find it easier to inform parents that their child has brain disorder than to prescribe parental changes (Shaw, 2010).
The stage is usually set for misdiagnoses if the psychiatrist does not take enough time to understand thoroughly the child’s problems. For example, a doctor might arrive at incorrect diagnoses, based on incomplete information. A child who is easily angered, loses temper when he or she doesn’t get their way, and refuses to perform his or her chores and homework is taken to a psychiatrist for consultation. The child is oppositional, goes against rules at school and at home, and engages in arguments with teachers and parents. He or she ignores his or her parents concerning bedtime and stays up late playing video games. At school, the child purposefully antagonizes the teacher by clowning and interfering with the studies of fellow classmates simply for his entertainment value. Doctors usually prescribe amphetamines for the diagnosis of ADHD. This prescription assists the child to perform his or her homework efficiently. It must be noted that amphetamines can assist anyone concentrate and focus better, regardless of whether one has ADHD or not (Gureasko-Moore, 2005).
The diagnosis of this same child might change completely if the parents report that the child is easily angered, has tantrums, is not sleeping at night, and clowns around in class. Under these circumstances, the psychiatrist might conclude that the child has bipolar disorder. Doctors usually prescribe powerful psychotropic drugs such as, mood-stabilizing medications and antipsychotics. These drugs would assist sedate the child; the child would definitely sleep well after a dose of these medications. The child would appear calmer and less angry the overall. Mood stabilizers and antipsychotic drugs have the ability to calm any child regardless of his or her psychiatric diagnosis. When sedating the child causes him or her to be a little less unruly, the doctor will view this response as a confirmation of diagnoses of bipolar disorder. A sedated child is nonetheless not necessarily a more complicated child.
If a child is misdiagnosed, their actual problems would not be properly addressed. Permissive parenting causes oppositional defiant disorder which should never be treated with medications. Treatment of ODD includes involves educating parents for the purpose of helping them learn behavioral management techniques that stop their children’s belligerent behaviors. However, rushed diagnoses and hastily prescribed psychotropic medications, conceal parents with the proper advice on how to manage their ODD child (Heflinger, 2007). Behavioral intervention is necessary. Without this intervention, the child would more likely receive more drugs and different drugs with an attempt to control each symptom that did not respond to the original medications. Effective communication and thoughtful evaluation are absolute. Getting the right diagnosis is necessary for proper treatment to be accorded. Or else, medical practitioners might continue to needlessly medicate children (Heflinger, 2007).
The efforts of the American Academy of Child and Adolescent Psychiatry (AACAP) to create new diagnostic criteria for child bipolar disorder, are more worrying than the current diagnostic practices of child psychiatrists (Blader, 2007). Already child psychiatrists stretch and distort the available criteria for the purpose of justifying the criteria of diagnosing belligerent children who throw tantrums with this kind of condition. AACAP proposed guidelines for childhood bipolar, however, are adopted by DSM editorial staff. Many children would indeed fit the criteria for the diagnosis of bipolar disorder (Blader, 2007).
Role of Teachers and Children Bipolar Disorder
The amount of funds allocated for instruction in public schools is usually limited. Thus, public schools operate under a restrictive budget. In addition, public schools are obligated to offer education to all children, their physical and mental challenges notwithstanding. Thus, when a way can be discovered for dealing with academic or behavioral challenges in students that do not touch the school budget, many headteachers will be happy to exercise that alternative. This is because school administrations normally get extra funds from state and federal governments for every student identified with psychiatric condition. In case the child is provided nothing more than psychiatric medication that would likely be offset through the child’s parents’ medical insurance, then extra resources can be redirected by the school into its general educational budget. In essence, schools gain financial and are not required to cover the cost of treatment for students who get psychiatric diagnoses and are treated exclusively with medication.
Teachers normally meet resistance from school administrators when they agitate for their learners to get extra services that special education offers. These services may include personalized aides in the classroom, speech therapy, or special equipment to cater to student learning inadequacies. School administrators, trying actualize their already stretched budgets; prevent teachers from recommending special education services to families, even when they offer appropriate interventions. Other school administrators go full length to threaten teachers with a sack if they dare inform students and their parents about special education services to which the students deserve. Therefore, a number of families end up being encouraged to seek psychiatric treatment for their children; children who may simply have academic difficulties. Instead of giving families alternative, safe and appropriate classroom interventions that would reduce school budget, administrators would direct parents to address behavioral problems of their kids with medical practitioners.
School administrators or teachers find it easy to intimidate parents with expulsion if they don’t prescribe their children psychiatric medication. If school management is able to convince a family to treat their children to deal with their disruptive behaviors, they manage to save the school budget of extra academic services costs. This undue influence on parents is disastrous to the well-being of the child.
In sum, bipolar disorder treatment includes prescription of psychotropic medications. These prescriptions involve; mood stabilizers and antipsychotics. Studies related to the use of psychotic medications in children are scanty. Much of the developed professional criteria of bipolar disorder are based on studies done on adults and not children. It is significant to note that the severity of symptoms diagnosed in children with bipolar disorder necessitated psychotropic treatment (Shaw, 2010).
Antipsychotic treatment is used to control psychotic symptoms, such as hallucinations and delusions, to stabilize mood and reduce agitation. Psychotic medication in children can be tricky given limited amount of studies and complexity surrounding its diagnosis. The few available studies report short-term results. There are no long-term investigations on psychotic medications used in children that have not been thoroughly investigated. Psychotropic treatments are used as the first mode of treatment before psychosocial intervention efforts due to extreme mood liability present in children with bipolar disorder. This paper has described bipolar disorder in children and justification of diagnosis (Shaw, 2010).
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