There is more at the site beyond what I quoted here.
The Bipolar Child Newsletter
November, 2006 Vol. 23
--Janice Papolos and Demitri F. Papolos, M.D.
http://bipolarchild.com/newsletters/0611.html
What Does the DSM-IV Say About Children and Mood Disorders?
Children are mentioned in the DSM-IV, but they are to be diagnosed according to adult criteria. And this is where huge problems develop. Clinical investigators are beginning to realize that bipolar disorder in childhood presents in a very different pattern--one that bears little resemblance to classical cycles of mania and depression as they are expressed in adulthood. For instance, children have more irritable moods with explosive outbursts, and their cycles of mania, hypomania, and depression are far more rapid than the typical adult presentation. Yet the DSM-IV specifies that a mood episode must last for a specified period of time.
For instance, duration criteria for the diagnosis of a hypomanic episode requires a "period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." (Italics ours.) Yet a significant proportion of early-onset bipolar children have a form of the condition that is marked by frequent mood and energy shifts that occur multiple times throughout the day.
For a depressive episode, the DSM-IV duration criteria is even more demanding: The manual requires at least a two-week period with five or more depressive symptoms. Therefore, by definition, an individual who has rapidly shifting mood states of less than the required duration cannot be formally diagnosed as having bipolar disorder.
A separate and distinct category--Bipolar Disorder Not Otherwise Specified (NOS)--was established to include disorders with bipolar features that do not meet full duration criteria. While most children with bipolar disorder fit into this category, still it is not an accurate description of the condition as it presents in childhood.
So, Haley's doctor and other clinicians and researchers are in an extremely difficult position: When they attempt to diagnose children with bipolar disorder, either they cannot use DSM-IV criteria and must describe these children as having "mania-like symptoms," or they must modify other diagnostic instruments in order to treat the primary problem. Alternatively, they can diagnose BP-NOS.
How Does Bipolar Disorder Actually Present in Childhood?
Children with bipolar disorder veer from irritable, easily annoyed, angry mood states to silly, goofy, giddy elation, and then just as easily descend into low energy periods of intense boredom, depression and social withdrawal, fraught with self-recriminations and suicidal thoughts. These abrupt swings of mood and energy can occur multiple times within a day, and intense outbursts of temper (rages that can go on for hours), poor frustration tolerance, and oppositional defiant behaviors are commonplace. The children frequently suffer severe anxiety--separation anxiety, generalized anxiety, and panic disorders--as well as obsessive-compulsive symptoms, particularly aggressive obsessions, hoarding, the need for symmetry and ritual requests for reassurance.
Moreover, many of the children have sleep disturbances, often accompanied by night terrors, nightmares filled with blood and gore and themes of pursuit and abandonment, as well as other arousal disorders of sleep.
Accompanying elevated periods of mood may be an increased sexuality (hypersexuality). It is an accepted fact that hypersexuality is a symptom of hypomania or mania in an adult who has bipolar disorder. In young children, the symptom may manifest as a fascination with private parts and an increase in self-stimulatory behaviors, a precocious interest in things of a sexual nature, and language laced with highly sexual words or phrases.
Psychotic symptoms, such as delusions (fixed irrational beliefs), and hallucinations (hearing voices, seeing things that others don't see) are not uncommon. Sometimes the voices and visions are compelling; often they are threatening, critical, or instruct the child to act on aggressive impulses towards others or self.