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Pediatric Mood Disorders Clinic
Teaching Rounds

Child and Adolescent Bipolar Disorder

Judy Tai, MS-3

Bipolar disorder (BPD) in children has not been a well-studied phenomenon. However, available data strongly suggest that prepubertal-onset BPD is a nonepisodic, chronic, rapid-cycling, mixed manic state that may be comorbid with ADHD and conduct disorder (CD) or have features of ADHD and/or CD as initial manifestations. Children are rarely euphoric, and usually more irritable with "affective storms."

Children often present with different symptoms than adults due to age-specific behavior. BPD may be underdiagnosed because only the most severe cases are reported; episodes that only last a few weeks might be tolerated by parents as a phase of growing up. [citation]. The prevalence has been estimated to be at least ˝ of BPD in the adult population.

Clinical Characteristics of BPD in children:

1. It is important to evaluate the child’s affect in relationship to historical features: for example, "it may be very misleading to see a happy child laughing in the office in the context of a miserable home and school history."
2. Grandiosity in children should meet two criteria:

1. Failure to follow the laws of logic
2. Firm belief

For example, children may harass teachers on how they should teach the class. Children with BPD may also exhibit stealing behavior that is different from CD in that children with BPD steal and believe that they are above the law, thus satisfying criteria for grandiosity.

1. Mania in children is often manifest by high activity levels in the bedroom prior to sleep. The other expected components of mania such as pressured speech, racing thoughts, and flight of ideas are also present. Increased motor activity and goal-directed behaviors in children often translate into normal activities done in profuse amount – making phone calls, joining social clubs, rearranging furniture. Hypersexuality is manifest by masturbation or inapproriate sexual comments. Spending sprees usually result in the calling of 900 numbers or ordering things from television commercials.
2. One of the most important things to keep in mind is that children with BPD can be very rapid cyclers, often cycling several times a day.

Differential Diagnosis of BPD:

1. Sexual abuse
2. Language disorders (must be differentiated from flight of ideas)
3. ADHD
4. CD – poor judgment and grandiosity
5. Substance abuse

References:

Geller, B MD; Luby, J MD; Child and Adolescent Bipolar Disorder: A Review of the Past 10 Years. J of Am Acad of Child and Adolesc Psych, Sep 1997, 36(9):1168-1176.

Wozniak, J MD; Biederman, J MD, et al; Mania-Like Symptoms Suggestive of CHildhood-Onset Bipolar Disorder in Clinically Referred Children. J of Am Acad of Child and Adolesc Psych, Jul 1995, 34(7):867-876.