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Pediatric Bipolar Disorder

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The existence of a mood disorder in adults involving severe mood swings from states of deep depression to states of elation has been recognized now for over a century. This disorder is commonly referred to as manic-depression but is now formally referred to as bipolar disorder, referring to the two "poles" of depression and mania.  Until recently, however, youth were rarely diagnosed with this disorder. Bipolar disorder has also become a controversial area within the field of children's mental health. There is little disagreement about whether it exists. The disagreement is about the symptoms of bipolar disorder in youth and how they differ from those in adults.

First, Some Definitions

Bipolar disorder involves episodes of both major depression and mania. (To clarify, major depression is another, separate mood disorder involving these same symptoms of depression but without the occurrence of symptoms of mania). The diagnostic manual used by mental health professionals is based on the diagnosis of bipolar disorder in adults. The following lists consist of behaviors observed by parents of children diagnosed with bipolar disorder. 

Behaviors connected to major depressive episodes:

  • Marked decrease in interest in or pleasure from life, sometimes expressed by boredom
  • Agitation and irritability
  • Sleeping too much or inability to sleep
  • Significant change in appetite
  • Change in observed activity level (usually slowed down or dragging)
  • Loss of energy
  • Inability to concentrate
  • Frequent sadness or crying
  • Feelings of worthlessness or guilt
  • Thoughts of death or suicide or self-destructive behavior

Behaviors connected to mania:

  • Elevated, expansive or irritable mood
  • Inflated self esteem or grandiosity (an unrealistic sense of one's capabilities)
  • Significantly decreased need for sleep
  • Much more talkative or pressured speech (speech so rapid that the words bump into and overrun each other)
  • Racing thoughts or flight of ideas (completely disconnected thoughts)
  • Distractibility
  • Excessive involvement in multiple projects and activities
  • Highly risky pursuit of pleasurable activities (for example, activities involving drugs, alcohol, or sex)

The combination of episodes of mania and major depressive episodes is what constitutes classic bipolar disorder. However, more than one type of bipolar disorder exists. For more information on the different types of bipolar disorder, see the appendix.

The Controversy

As mentioned earlier, mental health practitioners disagree about the symptoms of bipolar disorder in youth and how they differ from those in adults. In adolescents, where the presentation of the disorder more closely resembles that seen in adults, there is much less controversy.

More controversy exists in children when there appears to be a more chronic course, including more irritability and unstable moods, including severe temper outbursts. In short, where does a child with ADHD, oppositional behaviors, and a fair degree of crankiness/moodiness end, and where does a child with bipolar disorder begin?

While no one has the definitive answers to these questions, there are competing schools of thought on this issue. Some experts feel that children with severe irritability, emotional instability, and severe temper outbursts are, in fact, suffering from bipolar disorder as it appears in childhood and should be treated accordingly. Other experts feel this approach will lead to the overdiagnosis of children who in fact suffer from disorders other than bipolar disorder. These experts argue for a narrower definition of bipolar disorder which includes episodic mood swings, elevated or expansive mood - not just irritable mood - and grandiosity or inappropriate euphoria (extreme joyfulness).

These experts clearly recognize that this definition excludes a number of children with episodes of mood instability, explosive rage episodes, extreme irritability, and agitation.  There is no disagreement that children with these symptoms are impaired. However, experts differ on whether or not such children should be diagnosed with bipolar disorder.  Experts also differ on what would be the most appropriate and effective treatment for them.

There are also other factors that can seriously complicate the diagnosis of bipolar disorder in children. A history of severe emotional trauma such as physical or sexual abuse can lead to mood swings, emotional outbursts, hallucinations, and extremely severe behavioral problems, including sexualized behaviors that can resemble bipolar disorder. Improving our understanding of all of these issues depends on further research into these disorders as they appear in children and adolescents. Fortunately, some of this research is currently underway and holds the promise of better answers to these important questions in the future.

Bipolar Disorder in Children and Adolescents

In adults, bipolar disorder commonly involves separate episodes of major depression, alternating with separate episodes of mania. In children mixed states (a mix of mania and depression) and rapid cycling (mood swings) may be much more common. (3) This can make the diagnosis of bipolar disorder much more challenging in these age groups.

Many clinicians have observed that the symptoms of bipolar disorder appear to change as children develop, though these observations have not been confirmed by long-term studies. In younger children chronic irritability and mood instability without classic mood swings may predominate. These symptoms most closely resemble a mixed state of the disorder. In older children and adolescents, episodes including euphoria, grandiosity and paranoia may predominate.  In all age groups hyperactivity, distractibility and pressured speech are seen. In general, the older the individual, the more the symptoms may resemble those seen in adults.

Bipolar disorder and ADHD

As any parent of a child with ADHD has probably already noted, there is a significant overlap in the symptoms of mania, and to a lesser extent depression, and the symptoms of ADHD. ADHD, mania and depression may all involve inability to concentrate and problems with distractibility. Mania and ADHD may both involve hyperactivity and impulsivity. Though the symptom overlap is significant there are several factors that can help to distinguish these disorders.

ADHD in children usually does not involve mood symptoms such as depression and euphoria to the extent seen in bipolar disorder. ADHD symptoms usually first appear early in childhood while the onset of bipolar disorder appears to occur later in childhood or adolescence (4). ADHD also usually involves normal sleep, at least once a child has settled down in bed and is ready for sleep.  Mania, in contrast, involves decreased need for sleep with the individual still "raring to go" the next day despite little sleep. The family history can be helpful, as both disorders appear to run in families. 

Depression and bipolar disorder

People who suffer from depression, including those who suffer from major depressive disorder, may also eventually exhibit symptoms of bipolar disorder. It is harder to tell the difference between depression and bipolar disorder in children than in adults. Children with depression more often appear irritable than sad. This presents another overlap with the irritability seen in bipolar disorder. Children and adolescents are also by their nature prone to some degree of unstable mood. Determining where this type of moodiness ends and bipolar disorder begins in a depressed young person can present a challenge.  Looking for the presence of other symptoms of mania or elevated mood, including the presence of euphoria or grandiosity at some point, is important in making this diagnostic distinction. 

Further complicating the picture is the fact that both adults and younger people who initially exhibit symptoms only of depression may later develop bipolar disorder. The risk of depression turning into bipolar disorder is estimated at 10 percent or less in adults but appears to be as high as 20-40 percent in children and adolescents. (3)  Several risk factors for the eventual development of bipolar disorder in addition to early onset of depression have been identified, including psychosis, sudden onset, severely slowed or retarded movement, antidepressant-induced mania or elevated mood, and family history of bipolar disorder (4).

Treatment

Bipolar disorder is a serious disorder that can cause significant problems in school, the family, and the community. Untreated bipolar disorder can lead to hospitalization, drug abuse, accidents, or suicide. Parents who suspect that their child has bipolar disorder should find a child psychiatrist or psychologist who can evaluate the child.

The comprehensive treatment of bipolar disorder, like all other mental illnesses in children and adolescents, involves a multi-modal approach.  Of course the first step in treatment is a comprehensive diagnostic evaluation performed by a child psychiatrist or psychologist with experience in the diagnosis of bipolar disorder in children and adolescents. Once the diagnosis is established ongoing treatment can begin. Medications form the foundation of this treatment. These medications have been found effective in adults and are currently being tested in children. At this point medication treatment of bipolar disorder involves the use of a mood stabilizer, which helps to prevent symptoms of mania while also hopefully improving symptoms of depression. In cases where depression remains a problem, the physician may consider prescribing an antidepressant as well as a mood stabilizer. Antidepressants in bipolar patients must be used cautiously, however, as they may cause a manic state.

Some clinicians are reluctant to prescribe stimulant medication for children who meet criteria for ADHD but who also have, or may have, bipolar disorder, because of a concern that bipolar symptoms might become worse. Currently, there is not evidence that this is the case, and research suggests that in general, children who have both ADHD and bipolar disorder can benefit from stimulant medication (5). However, it is important to be extremely careful in monitoring these children's response to medication.

Other treatments are also very important in the management of this illness. They include measures to try to ensure regular sleep, which helps to keep mood stable. Therapy that educates the child about the importance of taking medication is also important. This is especially true for adolescents where any chronic illness can make it more difficult to achieve independence. Additionally, the family will benefit from comprehensive education and support as they help their child to deal with this very challenging illness. Academic interventions may also be needed (see the What We Know sheet on eduational rights). Finally, coexisting illnesses (other illnesses also present) including ADHD need to be treated. 

Appendix

The "classic" combination of mania and major depressive episodes is now referred to as Bipolar I Disorder. Major depressive episodes combined with a less severe expression of manic symptoms (called hypomania) is referred to as Bipolar II Disorder. Hypomania combined with a less pronounced and more longstanding form of depression (known as Dysthymia) is referred to as Cyclothymia.  Symptoms of mania and a major depressive episode may also occur in combination simultaneously, this is called a Mixed State of Bipolar disorder.  Finally, though episodes of mania and major depression classically occur in well-defined episodes, some people suffer from rapid swings between the two mood states that is referred to as Rapid Cycling. Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, Mixed States and Rapid Cycling States are all considered to be bipolar spectrum disorders.

References

  1. Weller, E.B.; Weller, R.A.;and Fristad, M.A. (1995). "Bipolar disorder in children: misdiagnosis, underdiagnosis and future directions," Journal of the American Academy of Child and Adolescent Psychiatry 34:709-714, 1995.
  2. Weller, E.B.; Weller, R.A.; Danielyan, A.K. (2004) "Mood disorders in prepubertal children." In Wiener, J.M., Dulcan, M.D. (editors). Textbook of child and adolescent psychiatry. Washington, D,C.: American Psychiatric Publishing: 418.
  3. Akiskal, H.S. (1995). "Developmental pathways to bipolarity: are juvenile onset depressions pre-bipolar?"  Journal of the American Academy of Child and Adolescent Psychiatry. 34:754-763.
  4. Strober, M.; and Carlson, G. (1982). "Bipolar illness in adolescents with major depression: clinical, genetic and psychopharmacologic predictors in a three-to-four year prospective follow-up investigation," Archives of General Psychiatry 39:549-555, 1982.
  5. Carlson, G.A.; Loney, J.; Salisbury, H.; Kramer, J.R.; Arthur, C. (2000). "Stimulant treatment in young boys with symptoms suggesting childhood mania: A report from a longitudinal study." Journal of Child and Adolescent Psychopharmacology 10(3): 175-184.

Suggested Reading:

Birmaher, B. (2004) New hope for children and teens with bipolar disorder. Pittsburgh, PA: Three Rivers Press.

Child and Adolescent Bipolar Foundation: www.bpkids.org

Kowatch, R.A.; Fristad, M.; Birmaher, B. et al. (2005) Treatment guidelines for children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44: 213-235.

Lederman, J and Fink, C. (2003) The Ups and Downs of Raising a Bipolar Child: A Survival Guide for Parents. New York: Fireside Books.

McClellan, J. (2005) Commentary: Treatment guidelines for child and adolescent bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 44: 236-239.

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