In stark contrast, in the adult population of individuals with bipolar disorder, females outnumber males slightly (Egan 2008, p.11).These discrepancies indicate a profile of a more 'difficult child' rather than the specific disease-related pattern of manic depression. The malleable nature of childhood reality presents another difficulty in diagnosis. While a dissociation from reality is one of the manifestations of bipolarity in adults, "it's normal for children to pretend that they are superheroes, or believe that they can run faster than cars, whereas in an adult, these convictions would be signs of grandiosity" (Egan 2008, p.1). The changing face of psychiatry is another possible social explanation for the increase in diagnosis. More and more non-clinicians are involved in the diagnostic process: a critical shortage of child psychiatrists in non-urban areas may result in a difficult child being diagnosed by a by family doctor or pediatrician. The health insurance industry is also an influence: "managed care usually pays for a single, brief psychiatric evaluation (and it strictly limits the number of therapy appointments a year) -- not nearly enough time, many say, to accurately diagnose a condition in a mentally ill child" (Egan 2008, p.4).

Clinicians with a background in psychiatry are more easily able to spot mania, and not confuse it with hyperactivity. Mania is defined in DSM-IV as a distinct period of an abnormally elevated or irritable mood, accompanied by at least three out of seven other symptoms, including distractibility, indiscretion, grandiosity, and a rapid flow of ideas, activity increase, sleep deficit and talkativeness (Egan 2008, p.5). Said one psychiatrist of a child he had interviewed who was suspected of being bipolar: "I'm not seeing clear patterns of distinct periods of being accelerated and talking and moving and thinking with an intensity of mood that just overflows and then goes back to his usual state…the intense anger outbursts can happen in kids with bipolar disorder, but they can happen with other mood disorders, or with ADHD and severe oppositional behavior. He's only 7 years old. This could be the very early signs of bipolar, and it may not be until two, three, four,...

Although he acknowledged the boy needed treatment of some kind, he was hesitant to make a formal diagnosis.
The severe side effects of the drugs used to treat bipolarity make over-diagnosis a serious issue. Additionally, misdiagnosis can result in the child receiving an inappropriate course of treatment. Diagnostically if a child really has ADHD, behavior modification and treatment with stimulating, rather than sedating, or worse, antipsychotic drugs to improve his focus may be more appropriate. Or if a child with autism is diagnosed as bipolar the child will not get language and social-skills therapy he needs (Egan 2008, p.5).

Perhaps the most damming indictment of the diagnostic trend is what has happened to the first 'graduating crop' of the new face of bipolar children. "Now that I've worked with kids long enough, you see some that had this mood instability or irregularity and were diagnosed as bipolar. But then you see them as they're older, and they're off in college and not having these labile mood swings anymore. You really wonder, what was it?" said one psychiatrist (Eagan, 2008, p.11). Children receiving the diagnosis usually have need for some sort of behavioral treatment to deal with the normal stressors of school and home life. But whether linking their illness to the adult form of bipolar disorder, and treating it with similar drugs is helpful remains an open question -- even as diagnostic rates continue to climb.