Children and adolescents with bipolar disorder are often referred to psychiatrists because of disruptive behaviors at home and in school. They exhibit poor academic performance, disturbed interpersonal relationships, increased rates of substance abuse, legal difficulties, multiple hospitalizations, and high rates of suicide attempts and completions.1,2 Many have comorbid psychiatric problems—particularly attention-deficit/hyperactivity disorder (ADHD).
Although few studies have examined this complex diagnosis, we do know that bipolar disorder presents differently in children and adolescents than in adults. Prodromal symptoms can appear early—before kindergarten in some children. Early recognition therefore is key to effectively treating these sick and often complicated patients.
How often a clinician encounters a child or adolescent with bipolar disorder depends largely on the practice setting (Box).1,3,4 Wherever you practice, however, you can recognize and treat pediatric bipolar disorder if you keep in mind that its presentation and disease progression differ from the adult type.
Pediatric versus adult symptoms
Prodromal symptoms—such as episodes of depressed mood or hopelessness and excessive mood lability—have been detected in youths who later were diagnosed with bipolar disorder. More than one-half of 494 adult members of the Depression and Bipolar Support Alliance have reported that they first exhibited signs of bipolar illness before age 19, with distribution by age as follows:
- 5% before age 5
- 12% at ages 5 to 9
- 14% at ages 10 to 14
- 28% at ages 15 to 19.5
HOW LIKELY ARE YOU TO SEE PEDIATRIC BIPOLAR DISORDER?
Pediatric bipolar disorder is seen much more commonly in specialized psychiatric settings than in general practice.
Overall prevalence. A large, well-designed population study of mood disorders in adolescents reported a lifetime prevalence of 1% for bipolar spectrum disorders, including bipolar I, bipolar II, and cyclothymia.1 Most adolescents in the bipolar group (84%) reported a distinct period of elevated, expansive, or irritable mood that best fit DSM-IV criteria for bipolar disorder not otherwise specified (NOS). These adolescents—who represented an overall prevalence of 5.7%—had extremely high rates of psychosocial impairment and use of mental health services, similar to those with bipolar I disorder.
In specialized settings. Bipolar disorder is seen much more frequently in specialized settings, such as a pediatric psychopharmacology clinic, than in general psychiatric practice. For example:
- Among 262 children referred consecutively to a specialty pediatric psychopharmacology clinic, 16% met DSM-III-R criteria for mania.3
- In a special education class, 8 of 12 students met DSM-III-R criteria for a bipolar disorder.4
- In child and adolescent psychiatry inpatient units, it is not uncommon to find 30 to 40% of patients with a bipolar disorder.
Table 1
COMMON PRESENTING SYMPTOMS OF PEDIATRIC BIPOLAR DISORDER
| Episodes of depressed mood/hopelessness |
| Excessive mood lability |
| Periods of increased or decreased energy |
| Episodes of decreased need for sleep |
| Anger dyscontrol |
| Markedly irritable moods |
| Frequent argumentativeness |
| Bold/intrusive/demanding behaviors |
In a similar study,6 58 adult patients with bipolar I disorder reported an average interval of 9 to 12 years between the emergence of bipolar symptoms and the onset of a major affective disorder.
Common initial symptoms of pediatric bipolar disorder are listed in Table 1. Most of these symptoms occur in discrete episodes and represent a change from the child’s normal functioning.
Many children and adolescents are labeled “bipolar” without careful consideration of this disorder’s diagnostic complexities and subtypes. Bipolarity in young patients can be difficult to establish because of:
- variability of symptom expression, depending on the illness’ context and phase
- effects of development on symptom expression
- mood and behavioral effects of psychotropic medications the patient is taking.
Pediatric bipolar patients often present with a mixed or “dysphoric” picture characterized by frequent short periods of intense mood lability and irritability rather than classic euphoric mania.3,7 Clinicians who evaluate children with pediatric bipolar disorders often try to fit them into the DSM-IV “rapid cycling” subtype. This subtype does not fit bipolar children very well, however, because they often lack clear episodes of mania. Rather, researchers are reporting that bipolar children cycle far more frequently than the four episodes/year in DSM-IV’s diagnostic criteria:
- Continuous, daily cycling from mania or hypomania to euthymia or depression was seen in 81% of a well-defined group of pediatric bipolar patients.7,8
- A high rate of rapid cycling and onset of a first manic episode at mean age 7 was reported in 90 children and adolescents (mean age 11) with bipolar I disorder.9
The picture that emerges from independent research groups is that multiple daily mood swings and irritability are much more common than euphoria in prepubertal children with bipolar disorder.8,10
Making the diagnosis
DSM-IV’s diagnostic classification system for bipolar disorders is complex, involving: