Harvard Mental Health Letter 

May  2007

"Bipolar disorder in children."

Childhood bipolar disorder made unwanted headlines in December 2006 when

a four-year-old child in Massachusetts died as a result of a drug

reaction. Given a diagnosis of bipolar disorder and attention deficit

hyperactivity disorder (ADHD) at age 2, she was taking an antipsychotic

drug, an anticonvulsant, and clonidine, a blood pressure medication that

is sometimes used to treat complex behaviors that include agitation and

hyperactivity. The cause of the death may have been an overdose of

clonidine, and the girl's parents have been charged with homicide. This

tragedy has given wider publicity to a continuing controversy about the

diagnosis and treatment of bipolar disorder in children.

The disorder was once thought to be rare -- according to a 1997 estimate,

occurring in only one out of 20,000 children. Now, though, it's believed

that at least a third of the time, the symptoms of bipolar disorder

appear first in childhood or adolescence -- at a rate that may be closer

to one in 200. Some believe this indicates belated recognition of a

previously neglected condition. Nearly two-thirds of children and

adolescents with mood disorders of all kinds, they say, are still not

diagnosed or are inadequately treated. Others suspect that the diagnosis

of bipolar disorder is being overused. As a result, they say, drugs are

dispensed too freely and not enough attention is paid to social and

psychological issues that may include abuse and trauma or simply family

conflict and inadequate parenting skills.

Symptoms

The main reason for the past neglect of this diagnosis and the present

concern about it is that the symptoms rarely follow a discrete pattern.

Children, especially young children, usually do not show the adult cycle

of distinct mood swings from mania to depression lasting for several

months, with intervals of normal mood in between. Many symptoms that may

be a result of bipolar disorder also occur in other childhood disorders:

moods fluctuating in very rapid cycles, even sometimes from hour to

hour; irritability and agitation instead of euphoria; or bursts of rage.

Children can become dangerous to themselves and others. There are

reports of three-year-olds so violent that their parents fear for their

own safety and four-year-olds who throw hour-long tantrums on being

asked to tie their shoes.

Children may also have more classic and unmistakable manic symptoms,

which include racing thoughts, compulsive volubility, decreased need for

sleep, unwanted sexual touching, and inappropriate giddiness or clowning

(for example, after being suspended from school). Another symptom is

extreme bossiness and defiance of authority; one 12-year-old told his

soccer coach and teachers how to do their jobs.

Mania may alternate with depressive states in which the child is

listless, withdrawn, unable to enjoy life, and plagued by physical

complaints and morbid thoughts. Suicide is a danger for adolescents and

can occur even in younger children. To add to the difficulty of

diagnosing childhood bipolar disorder, irritability is probably the most

common symptom of depression as well as mania in children.

These children's symptoms can take so many different forms that they are

often assigned a diagnosis of bipolar disorder "not otherwise

specified." This term is used in the American Psychiatric Association's

manual to describe severe mood fluctuations that for various reasons

don't easily fit into any of the standard categories.

The National Institute of Mental Health-funded Course and Outcome of

Bipolar Illness in Youth (COBY) Study followed 263 children ages 7 to 17

for two years. The results, published in 2006, showed a continuum of

symptoms from mild to severe. About 70% of the children eventually

recovered from their first episode of mania or depression (meaning two

months without symptoms). But during the two years of the study, they

relapsed an average of three times. The children had some symptoms 60%

of the time, but enough to warrant a diagnosis of bipolar disorder only

20% of the time. Even during the symptom-free periods, most had other

problems, especially ADHD. Many children who were originally diagnosed

with bipolar disorder not otherwise specified eventually developed more

typical bipolar symptoms that resembled the adult disorder.

The Child Bipolar Questionnaire

The Child Bipolar Questionnaire, an automatically scored 65-item

questionnaire for parents that helps to identify bipolar symptoms in

children, is available on the Internet at the Web site of the Juvenile

Bipolar Research Foundation, www.jbrf.org.

Before consulting a mental health professional, parents may find it

helpful to keep daily logs for a couple of weeks to track the child's

mood, energy, sleep, and behavior. Mood charts can be found at

www.manicdepressive.org.

Making the diagnosis

Children can be sad or silly or irritable or agitated for many reasons.

It's important to be sure that a child's mood changes are not better

understood as a reaction to events and circumstances, including child

abuse, other forms of trauma, or stress in the home. Longer-lasting and

more severe symptoms could have other causes, including temporal lobe

epilepsy, intermittent explosive disorder, fetal alcohol syndrome,

oppositional defiant disorder, and post-traumatic stress disorder.

Bipolar disorder in children is especially difficult to distinguish from

ADHD, since many of the symptoms -- impulsiveness, distractibility, and

hyperactivity -- are similar. Up to 30% of children originally diagnosed

with ADHD are eventually given a diagnosis of bipolar disorder. Up to

50% or more of children and adolescents with bipolar disorder also fit

the criteria for a diagnosis of ADHD. The two conditions may also

overlap genetically, since children with a bipolar parent have a higher

than average rate of ADHD.

Some preliminary research suggests that many children diagnosed with

bipolar disorder, especially bipolar disorder not otherwise specified,

actually have a condition that has recently been labeled severe mood

dysregulation. Its symptoms are periodic irritability and hyperactivity,

and it is often associated with oppositional defiant disorder and ADHD.

In an experiment that involved the performance of a mildly frustrating

task, the EEGs (brain electrical signals) of children supposed to be

suffering from severe mood dysregulation differed from the EEGs of

children with bipolar disorder. One implication is that the treatment

might also be different.

Drug treatment

Bipolar disorder in adults is treated with mood stabilizers -- frequently

several drugs in combination -- and the same drugs are increasingly

prescribed for children. Lithium, the favored drug treatment for adult

bipolar disorder, is also the only medication that has been proved

effective in controlled studies and granted FDA approval for bipolar

disorder in children. But other drugs are also commonly used. These

include the anticonvulsant valproate (Depakote) and several second-

generation antipsychotic drugs.

Experts working with the Child and Adolescent Bipolar Foundation have

published treatment guidelines for mania in children. They recommend

starting with a single drug, usually lithium or valproate, then

substituting or adding other drugs in various combinations depending on

the response. For depression, lithium and antipsychotic drugs are

sometimes prescribed, along with the anticonvulsant lamotrigine

(Lamictal). Fluoxetine (Prozac) and other antidepressants may also be

helpful, but some believe they raise the risk of switching from

depression to mania. Once mood swings are damped down, a treatment for

ADHD can be added -- usually a stimulant, either methylphenidate

(Ritalin) or dextroamphetamine (Dexedrine).

Most mood stabilizers have the potential for uncomfortable or worrisome

side effects. Antipsychotic medications can cause irregular heart

rhythms, movement disorders, weight gain, and a rise in cholesterol and

blood sugar. Lithium has a long list of potential side effects,

including weight gain, nausea, acne, and excessive thirst and urination.

It requires periodic blood tests, including tests of thyroid and kidney

function. Valproate may cause an upset stomach, and lamotrigine can

produce a hypersensitivity reaction that appears as a rash. Most of

these drugs can be sedating, making a child sleepy or sluggish. Children

often drop out of treatment because of side effects. Adolescents in

particular may reject lithium because it causes weight gain and acne.

Psychosocial treatment

Whether children with bipolar disorder take drugs or not, psychotherapy

can help them in the same way it helps adults with the disorder.

Supportive therapy provides sympathy, reassurance, and strategies for

managing everyday problems. Psychodynamic therapy may help older

children and adolescents explore their present and past personal

relationships, their psychological development, and how they defend

against uncomfortable feelings. With cognitive therapy, they can examine

and re-examine their thoughts and ways of interpreting experience.

Behavioral treatment helps them observe and change their behavior. They

can be taught social skills and problem-solving and rehearse what to do

when threatened with relapse. Sleep hygiene -- rising and going to bed at

the same time every day -- may help to prevent mania. Some bipolar

children need tutoring and special education for learning disabilities.

Parents often need help to cope with a child whose erratic behavior,

defiance, agitation, or withdrawal is causing family chaos and conflict.

They can be educated about the illness, provided with training in stress

management and communication skills, and shown how to avoid words and

actions that exacerbate a child's symptoms. Family therapy and support

groups may improve the lives of both parents and children. Information

on support groups is available at the Child and Adolescent Bipolar

Foundation (see Resources).

Critics continue to worry about the sometimes frustrating and confusing

symptoms of childhood bipolar disorder and about the increasing use of

drugs to treat those symptoms. The complaint is often heard that

physicians and mental health professionals turn to pharmacological

solutions because of cost-cutting pressure from insurers and HMOs.

It's true that the relationship between childhood symptoms labeled

bipolar and the adult form of the disorder is still uncertain. Until we

understand the underlying causes of these illnesses, treatment of an

individual child will depend less on making the "right" diagnosis than

on identifying problems and symptoms that may respond to psychotherapy

and medication.

Diagnosing psychiatric disorders in children has always been difficult,

and many illnesses have different symptoms in children and adults. We

need to learn more about the long-term risks and benefits of drugs and

drug combinations, especially their influence on emotional and social

development. We also need more definite information about how to treat

different forms of childhood bipolar symptoms, and about the

relationship between those symptoms and other childhood disorders,

including ADHD. Genetic and neuroscience research is beginning to

provide some answers. Meanwhile, it's important to understand that

despite uncertainties surrounding the diagnosis, childhood bipolar

disorder is a real and serious illness that should be recognized and

treated as early as possible.

Resources

Child and Adolescent Bipolar Foundation

847-256-8525

www.bpkids.org

American Academy of Child and Adolescent Psychiatry

202-966-7300

www.aacap.org

Juvenile Bipolar Research Foundation

866-333-JBRF (toll free)

www.jbrf.org

References

American Academy of Child and Adolescent Psychiatry. "Practice Parameter

for the Assessment and Treatment of Children and Adolescents with

Bipolar Disorder," Journal of the American Academy of Child and

Adolescent Psychiatry (January 2007): Vol. 46, No. 1, pp. 107-25.

Axelson D, et al. "Phenomenology of Children and Adolescents with

Bipolar Spectrum Disorders," Archives of General Psychiatry (October

2006): Vol. 63, No. 10, pp. 1139-48.

Birmaher B, et al. "Clinical Course of Children and Adolescents with

Bipolar Spectrum Disorders," Archives of General Psychiatry (February

2006): Vol. 63, No. 2, pp. 175-83.

Ghaemi SN. "Defining the Boundaries of Childhood Bipolar Disorder,"

American Journal of Psychiatry (February 2007): Vol. 164, No. 2, pp. 185-88.

Henin A, et al. "Childhood Antecedent Disorders to Bipolar Disorder in

Adults: A Controlled Study," Journal of Affective Disorders (April

2007): Vol. 99, Nos. 1-3, pp. 51-57.

Kowatch RA, et al. "Treatment Guidelines for Children and Adolescents

with Bipolar Disorder," Journal of the American Academy of Child and

Adolescent Psychiatry (March 2005): Vol. 44, No. 3, pp. 213-35.

Papolos D, et al. The Bipolar Child, Third Edition. Broadway Books, 2006.

Soutullo CA , et al. "Bipolar Disorder in Children and Adolescents:

International Perspective on Epidemiology and Phenomenology," Bipolar

Disorders (December 2005): Vol. 7, No. 6, pp. 497-506.

West AE , et al. "Maintenance Model of Integrated Psychosocial Treatment

in Pediatric Bipolar Disorder: A Pilot Feasibility Study," Journal of

the American Academy of Child and Adolescent Psychiatry (February 2007):

Vol. 46, No. 2, pp. 205-12.