Bipolar disorder is a mood disorder that
affects between 1 and 2.6% of all adults around the world (Corner 213; Giedd 32; Kessler
et al. 617). Leonhard first used the term bipolar in 1957 for disorders
comprised of both the lows of depression and the highs of mania (Leibenluft “Mood”
130). In 1980, the Diagnostic and Statistical Manual for Mental Disorders (DSM)
adopted the name bipolar disorder to replace the term manic depression
(Phillips and Kupfer 1663). Persons having a depressive episode may feel sad,
down, empty, or hopeless, have decreased energy levels, decreased or increased need
for sleep, have trouble concentrating, decreased or increased appetite, and/or
absence of or decreased pleasure. On the opposite end of the spectrum, someone
having a manic episode may experience grandiosity or overblown self esteem,
reduced sleep need, increased talkativeness, agitation or irritability, rapidly
shifting ideas, and/or excessive pursuit of risky and potentially problematic
activities (Corner 184-186,212; “Bipolar Disorder”). If a manic episode experienced by one is less severe, it is defined as
being a hypomanic episode.
There
are four main types of bipolar disorder: Bipolar I Disorder, Bipolar II
Disorder, Cyclothymic Disorder, and bipolar disorder not otherwise specified (Phillips
and Kupfer 1663). Bipolar I disorder is defined as having an
occurrence of a manic episode, plus a hypomanic or major depressive episode
that either follows or precedes the manic episode (Purse “Differences”). Ronald
J. Comer stated in the textbook Fundamentals
of Abnormal Psychology that “some have mixed features, in which they
display both manic and depressive symptoms within the same episode- for
example, having racing thoughts amidst feelings of extreme sadness” (212). A person may also experience rapid cycling.
Rapid cycling is when, “a person with the disorder experiences four or more episodes of mania or
depression in
one year” (“Rapid Cycling”). It can occur at any point during one’s
disorder, and can come and go over many years. People with bipolar II disorder and women are
at increased risk to experience periods of rapid cycling during their life. Ultra-rapid
cycling is when episodes last between a few days to a few weeks. Lastly,
ultradian cycling refers to variations within a 24-hour period (Miller and
Barnett 172; Geller “Prepubertal” 81). Bipolar
II disorder is characterized by the presence or history of major depressive
episode(s), presence or history of hypomanic episode(s), and no history of a
manic episode (DSM-5 154; Corner 212). The National Institute of Health defines
cyclothymic disorder, or cyclothymia, as, “numerous periods of hypomanic symptoms as well as numerous
periods of depressive symptoms lasting for at least 2 years (1 year in children
and adolescents). However, the symptoms do not meet the diagnostic requirements
for a hypomanic episode and a depressive episode” (“Bipolar Disorder”). Lastly, bipolar not otherwise specified (NOS)
displays depressive and hympomanic-like symptoms that do not meet the
diagnostic criteria for any of the previously mentioned disorders. It should be
noted that most children with bipolar disorder fall under the category of
bipolar not otherwise specified.
One area that has come into focus with
increasing interest in bipolar research within the past 20-30 years is the
existence of bipolar disorder in children and adolescents, also called
pediatric bipolar disorder, early onset bipolar disorder, or childhood onset
bipolar disorder (Arabind and Krishnaram 88;
Findling et al. 202; Perlis et al. 875; Leibenluft “Pediatric” 1122; Birmaher et al. 175).
Although this is a relatively new area of focus, Elizabeth B. Weller wrote
that:
There have been case reports of mania in
preschool children and prepubertal school-age children dating back to Esquirol
in the mid-19th century (1845). Kraepelin (1921), Kasanin (1931),
Barrett (1931), Bleuler (1934), Olsen (1961), and Campbell (1952) have also
reported cases of mania in this group. Kraepelin believed that mania existed in
prepubertal children and that the occurrence of mania increased with the onset
of puberty (709).
Studies
of adults with bipolar disorder have reported a childhood onset in as many as
59% of cases (Geller “One-Year” 303; Lish et al. 281). However, the
characteristics and clinical prevalence of bipolar disorder in children and
adolescents remains a highly controversial topic (Kowatch et al. 483; Soutullo et al. 479; Aravind
and Krishnaram 88). One thing that holds
back researchers and clinicians are the challenges that come with recognizing
and diagnosing bipolar disorder in children and adolescents. Those difficulties
include the difference in symptoms compared to adults, course of treatment, and
the symptomatic similarity to attention-deficient/ hyperactivity disorder
(ADHD) among other psychiatric illnesses including panic disorder, conduct
disorder, oppositional defiant disorder, schizophrenia, and substance use
disorders (Aravind and Krishnaram 88; Findling et al. 202; Giedd 31; McGlashan 221; Soutullo et al.
479; Leibenluft “Mood” 130; Geller “Two-Year” 927; Miller and Barnett 171).
These disorders may also be comorbid with bipolar disorder in children and
adolescents.
Most
researchers on the topic of bipolar disorder in children and adolescents agree
that there are some major differences in the way that bipolar disorder
manifests itself in children compared to adults. This has been one of the
leading challenges in diagnosing the disorder in children. Diagnostic criteria
in the DSM was developed for adults, and children with bipolar do not always
meet that criteria (Aravind
and Krishnaram 88). The most prominent
difference between adults with bipolar disorder and children or adolescents, is
that adult-onset forms are commonly characterized by distinct, lengthy mood
states with inter-episode recovery. On the other hand, initial data suggests
that children and adolescents with the disorder display brief mood episodes,
rapid cycling, mixed states, and an absence of inter-episode recovery (Findling et al. 202; Geller et al. “Complex” 265; Geller
and Luby “Child” 1168; Weller and Weller 711). Simply put, this means that
adults with bipolar disorder have clear-cut, longer lasting depressive and/or
manic episodes. Adults also experience a recovery-period between depressive or
manic episodes. Children with this disorder lack those clear-cut episodes,
making it extremely difficult to get an accurate diagnosis of bipolar disorder.
Chang writes, “As you get younger and younger, you start to lose those
distinctions around the edges, and it's harder to discern discrete episodes. In
other words, very often a child is rapidly moving from one mood to another, and
so it's difficult to tell exactly when the mania starts and when the mania
ends.” In one study, it was found that 57.7% of children and adolescents
reported having ‘mixed-mania’ (coexistent mania and depression), also known as
a mixed state, compared to 30% prevalence in adults (Geller et al “Complex”
265). Also, adolescents that were hospitalized
for bipolar disorder were found to experience mixed states more frequently and
experience psychosis less frequently than do adults who are hospitalized with
the same disorder (Findling et al. 202; McElroy et al. 44). Children and adolescents may also display
different signs and symptoms during manic and depressive episodes than do
adults. One distinguishing characteristic of bipolar disorder in those under
the age of 18 is irritability. Findling et al. writes in the article “Rapid,
Continuous Cycling and Psychiatric Co-Morbidity in Pediatric Bipolar I Disorder”
that, “periods of mania, hypomania, or mixed states can be characterized
by irritability. Similarly, youths may appear more irritable than sad during
periods of depression” (207). Children and
adolescents with bipolar disorder may also display behavioral problems, which
may include school problems like fighting, substance abuse, and sexual behavior
(Aravind and Krishnaram 88). Lastly, family studies suggest that youth with
bipolar disorder may have a greater genetic load, or presence of unfavorable
genetic material in the genes of a population, for bipolar disorder than do
adults with the disorder (Soutullo et al 479; Todd 141).
You can also find a variation in symptoms
within children and adolescents. Elizabeth B. and Ronald A. Weller noted that, “a
literature review by Carlson (1983) reported irritability and emotional
lability were more common in manic children who were younger then 9 years of
age, while euphoria, elation, paranoia, and grandiose delusions were more
common in children older than 9 years” (Weller and Weller 711; Carlson)
Before moving on to the similarities
between bipolar disorder in children and adolescents and other psychiatric
illness, and also comorbidity, let’s discuss the signs and symptoms most
prominent in children and adolescents with bipolar disorder. Varanka et al.
performed a study of 10 6- to 12-yeard-old children who were diagnosed to have
mania by DSM-III-criteria (1557-1559). Miller and Miller reported the results
of the above study:
All of these children reported mood
disturbances. However, 50% reported a primarily elated mood and 50% reported a
primarily irritable mood. All were restless; 90% reported decreased sleep; 70%
reported visual hallucinations and persecutory delusions; 60% reported
increased sexual activity, pressured speech, and racing thoughts; 50% reported
increased talkativeness, increased distractibility, flight of ideas, and
auditory hallucinations. Grandiose delusions were reported by 20% (711).
In
a different study conducted by Kowatch et al, they analyzed the clinical
characteristics of mania in children and adolescents. Hypersexuality, appearing
in 31-45% of cases, and flight of ideas, appearing in 46-66% of cases, were
less common than any other symptoms or feature of mania. Occurring in around
70% of children and adolescents with bipolar disorder was racing thoughts,
decreased need for sleep, and poor judgment. Increased energy was one of the
most commonly presented symptoms, appearing in 76-96% of cases (489-490). Weller
and Weller reported that the clinical presentation in young children usually
includes a worsening of disruptive behavior, difficulty sleeping at night,
moodiness, hyperactivity, an inability to concentrate, and impulsivity. Explosive
anger, low frustration tolerance, and episodic short attention span that are
followed by depression, guilt, sulkiness, and poor school performance have been
reported (711). There have also been reports of ‘model children’ who
dramatically change and become ‘wild’ (Carlson and Cantwell).
There are numerous disorders that have
symptomatic similarity to and/or are comorbid with bipolar disorder in children
and adolescents. The disorder most prominently misdiagnosed with, or comorbid
with bipolar disorder is attention-deficit/hyperactivity disorder (ADHD). Jay
N. Giedd writes that the “DSM-IV diagnostic criteria for bipolar disorder and
ADHD directly overlap for symptoms of talkativeness, distractibility, and
psychomotor agitation” (31). Giedd goes on to say that other criteria, while
not directly overlapping, can be difficult to discern clinically. These include
decreased need for sleep (BPD) versus sleep difficulties (ADHD), flight of
ideas versus difficult sustaining attention, and excessive involvement in
pleasurable activities that have a high potential for painful consequences
versus impulsivity. There are also overlaps between the two disorders present
in school performance, self-esteem, and social and family relationships.
However, there are some distinguishing characteristics that set bipolar disorder
apart from attention-deficit/hyperactivity disorder. Barbara Geller et al.
conducted a study and found that 87% of children with bipolar disorder reported
elevated mood, compared to only 5% of children with
attention-deficit/hyperactivity disorder. Grandiosity, an unrealistic sense of
superiority, was found in 85% of children with bipolar disorder versus 7% of
those with ADHD. Decreased need for sleep, racing thoughts, and hypersexuality
were also found to be more common in children with bipolar disorder than those
with ADHD (Geller et al 81; Giedd 31). Attention-deficit/hyperactivity disorder
has also been found to be the most common comorbidity, the simultaneous
presence of two chronic diseases in a patient. In a study by Findling et al.,
ADHD was found in 70% of the youths (75% of children and 61.8% of adolescents)
(205). Where there is comorbidity between bipolar disorder and
attention-deficit/hyperactivity disorder, it is recommended to stabilize the
mania before treating ADHD symptoms to get the best results (Aravind and
Krishnaram 90). It is worth noting that the treatment of choice for
attention-deficit/hyperactivity disorder, stimulants, are ineffective in the
treatment of bipolar disorder and may actually induce mania in some individuals
with very severe consequences. In a study, of the 73 children with bipolar
disorder who were first treated with Ritalin, 65 percent were thrown into
severe manic states and had to be hospitalized (“Research”). The onset of attention-deficit/hyperactivity
disorder is also usually earlier than the onset of bipolar disorder. The onset
of ADHD occurs in their preschool years and the course of illness is more
chronic (Weller and Weller 712).
Attention-deficit/hyperactivity disorder
is not the only disorder that bipolar disorder is comorbid with or has
symptomatic similarities. Conduct disorder, anxiety disorders, substance use
disorder, and schizophrenia have been identified as possibilities. In one
study, it was found that 81.1% of youths (83.9% children and 76.5% teenagers)
met diagnostic criteria for a comorbid psychiatric condition while euthymic. Findling
et al. reported that, “the onset of bipolar disorder proceeded the development
of a substance abuse disorder in five out of six cases (83%)” (206). In
children, the mania that comes with bipolar disorder has been associated with
conduct disorder. Aravind and Krishnaram report that most patients with mania
qualify for a diagnosis of conduct disorder. However, physical restlessness and
poor judgments are more common in comorbid cases of conduct disorder, than in
mania cases alone (90). Also, children with conduct disorder’s behavior are
more hurtful and vindictive with the motive to get others in trouble, and do
not usually show any guilt or remorse. On the other hand, a manic child’s
behavior is usually more mischievous. Children with mania also display a push
of speech, psychotic symptoms, or flight of ideas that children with conduct
disorder do not (Weller and Weller 712). It also been noted that anxiety
disorders, especially panic disorder and agoraphobia, are frequently comorbid
with mania in children. Another
psychiatric disorder brought up in literature is schizophrenia. However, children
with schizophrenia usually have a family history of schizophrenia and a more
insidious onset of illness. They also do not have the push of speech, flight of
ideas, or the engaging quality that a child with mania has.
Another highly controversial aspect of
bipolar disorder in children and adolescents is treatment. There is currently a
lack of long-term and combination studies on the topic, but there is still some
data in literature from small-scale studies. Starting with the use of
medication itself, Findling et al. found in their study of children and
adolescents with bipolar disorder that:
Over the course of their lifetime, the
average total number of psychotropic [any medication capable of affecting the
mind, emotions, behavior] medications that had been prescribed to these youths
was 3.94. The mean number that had been prescribed to the children was 4.07 and
the mean number of medications that had been prescribed to the adolescents
during their lifetime was 3.74. At the time of assessment, the youths were on
an average of 1.56 psychotropic medications with the children on 1.50 and the
adolescents on 1.65 agents (205).
Moving
on to specific treatments, psychopharmalogical interventions for childhood
mania include valproate, lithium, and/or atypical antipsychotics. Atypical, or
second generation, antipsychotics include risperidone and aripiprazole, which
have been approved to treat mania in children 10 years of age or older. Atypical
antipsychotics seem to have a favorable efficacy profile in treating mania.
Anti-consultants that were used in the past in the treatment of bipolar have
proved to have a poor efficacy profile. As mentioned before with use of
stimulants, antidepressants and SSRIs have been found to have adverse affects
in children and adolescents with bipolar disorder. Chang calls for the “need
[for] better studies of lithium, quetiapine, aripiprazole, lamotrigine, or
other agents that are not antidepressants that have been either shown or have
been thought to be effective in adults with bipolar depression.” On the
forefront of bipolar treatments for adults is lithium. Researchers have been
trying to confirm the same efficacy in children and adolescents with the
disorder. According to Aravind and Krishnaram, lithium has been fund to be therapeutically
effective in the management of pediatric bipolar disorder (90). In one
short-term study, 20 children and adolescents with mania were treated with
lithium. At a follow-up fifteen days later, there was a recovery rate of 63.5%.
Greater severity and longer duration predicted a poorer response.
First discussed in this paper were
the signs and symptoms of the mania and depression that comprise bipolar
disorder. These included the grandiosity, talkativeness, and rapidly shifting
ideas that make up mania. And then the feelings of emptiness, hopelessness, and
decreased pleasure and energy levels that make up depression. Next was the four
main types of bipolar disorder: Bipolar I disorder, bipolar II disorder,
cyclothymic disorder, and bipolar not otherwise specified. Also discussed were
the concepts of mixed episodes and rapid cycling. This brought us to the main
subject of the paper, bipolar disorder in children and adolescents. First
talked about was the history of mania in children, dating back to the 19th
century. Then we moved on to the three biggest difficulties that come up when
talking about bipolar disorder in children and adolescents: symptoms in youth
vs. adults, comorbidity and symptomatic similarities, and course of treatment.
The first obstacle discussed was the difference in symptoms displayed in
children and adolescents with bipolar disorder compared to adults with the
disorder. Adults with bipolar disorder display
clear-cut, longer lasting depressive and/or manic episodes. They also experience
a recovery-period between depressive or manic episodes. However, children with
the disorder lack those clear-cut episodes, making it extremely difficult to
get an accurate diagnosis of bipolar disorder. Children and adolescents also
have a higher prevalence of mixed states, and irritability is present more
frequently in depressive and manic episodes. Briefly discussed was the
variation of symptoms with the children and adolescent age group. Then we moved
on to the most prominent symptoms that children and adolescents with bipolar
disorder experience. The top symptom was increased energy, followed by racing
thoughts, decreased need for sleep, and poor judgment. The next big difficulty
was the comorbidity and symptomatic similarity of bipolar disorder in children
and adolescents with attention—deficit/hyperactivity disorder (ADHD), conduct
disorder, anxiety disorders, substance abuse disorder, and schizophrenia. The
last challenge discussed was treatment. Atypical antipsychotics have
shown promising efficacy in the treatment of mania in childhood bipolar.
Lithium has shown promising results in studies as well. Anti-consultants,
anti-depressants, and stimulants have been shown to be ineffective or cause
adverse reactions in the treatment of bipolar disorder in children. There is a
call for more research to be done to find treatments for the depression found
in bipolar. Now that bipolar disorder in children and adolescents is gaining
more attention, the hope is that more research and long-term studies will be
conducted to further help children and adolescents with this disorder.
