Bipolar Disorders in Children and Adolescents

INTRODUCTION

Symptoms of bipolar disorders (BPDs) in younger age groups were first recognised by the formidable German Psychiatrist Kraepelin nearly a century ago. Today, bipolar disorders reaching adult diagnostic criteria affect adolescents, the percentage of children affected is unknown. The illness unfortunately is often overlooked, misdiagnosed and mismanaged. For most in these age groups, the BPDs are unremitting. They commonly co - occur with another psychiatric diagnosis and compromise the life of the sufferer and their family. Those with BPDs have historically been seen as naughty. They are not. The BPDs are clearly neurobiological illnesses stemming from structural pathology in the brain; a finding supported using neuro-imaging studies particularly MRI scans. Genetic factors are also involved, in that, where a child has a BPD, a parent may also have a similar illness.

THE DIAGNOSIS

Adult criteria for BPDs are used to diagnose BPDs in children and adolescents. Four types of BPDs are now specified, all of which may occur in children and adolescents.

Bipolar I Disorder (BPI) is characterised by one or more manic episodes or mixed episodes. A mixed episode is defined when rapid altering moods occur accompanied by symptoms of a manic episode.

Bipolar II Disorder (BPII) is diagnosed when an episode of major depression is accompanied by a hypomanic episode. A hypomanic episode is a distinct period of a persistently elated, expansive or irritable mood, which is clearly different from the usual non - depressed mood.

Cyclothymia is a chronic fluctuating mood disorder involving symptoms of hypomania.

Bipolar Disorder Not Otherwise Specified (BDNOS) is diagnosed when there are bipolar symptoms that do not fulfil the criteria for a specific bipolar disorder. Those with BDNOS often progress to BPI. Each type of BPD may occur in children and adolescents. The core features of bipolar disorders are listed in Table 1.

THE ILLNESS

Childhood onset may occur as young as age four and adolescent onset occurs in early pubescence; insidious onset is the norm. One study of children has shown that 70% experienced their first manic episode by 4.4 years of age. Prior to the diagnosis of BPDs, mothers often perceive their child as different, noting exceptional activity in utero, greater activity during infancy, a dislike of transition, decrease in sleep time, separation anxiety and appearing advanced for their age.

MOOD CHANGES

Irritability and a rapid cycling of moods with little inter - episode recovery is characteristic in childhood BPDs. One recent study in children has shown that 64% presented with irritability, 32% presented with irritability and euphoria and 4% presented with euphoria alone. Irritability is less but inter - episode recovery is longer in adolescent BPDs. Elated mood and mixed episodes occur in both age groups. Mood shifts may be rapid; at times, the sufferer becomes trapped in depression and mania, a switch process known as a mixed state. Mania or an elated mood may present as excitability, silly behaviour or laughing fits. Depressive or dysphoric episodes that can be extremely distressing may manifest as crabbiness, whining, unhappiness or excessive crying. Outbursts of agitation, hostility and explosive outbursts occur, at times with damage to property, self and others. These explosive outbursts are difficult to control, may last for an hour or longer, might not be recalled and occasionally occur without reason.

ASSOCIATED SYMPTOMS

Claims of being outstanding, invincible, having remarkable abilities and knowing all in the absence of evidence are examples of grandiosity. There is often a belief that they know better than adults resulting in a refusal to comply. Sleep time is decreased, wakening is often hindered and there is difficulty getting going. Refusal to retire to bed is common as are nightmares and night terrors with a theme of gore. Talking may be pressured, loud, domineering and incessant. Goal directed behaviours include the constant performing of routine activities and the pursuit of grandiose ideas, often in a frenzy. Sexual precociousness and hyper - sexuality are exhibited in 43% and an early awareness of gender differences is common. Psychotic symptoms (hallucinations and delusions) may feature in any phase of bipolar disorder. The hallucinations may be visual, auditory, tactile or olfactory. Delusions vary with the mood state; in mania, they may be grandiose and in depression morbid. Suicidal behaviour occurs in 24% of children and nearly half of adolescents. The most dangerous time for suicide attempts is in the mixed state.

BIPOLAR DOES NOT OCCUR ALONE

Most with child or adolescent BPDs have another psychiatrist illness, the disruptive behavioural disorders being the most common. Seventy five percent to 92% of children present with attention deficit hyperactivity disorder (ADHD) characterised by hyperactivity, impulsiveness and inattentiveness, 75% present with oppositional defiant disorder (ODD) see Table 2 and 37% with conduct disorder (CD) see Table 3. The disruptive behavioural disorders have been postulated as an early precursor to BPDs in certain children. Comorbid ADHD, ODD and CD are less common in adolescent onset; anxiety symptoms and substance abuse however are more common.

DIAGNOSTIC CONFUSION

That distractibility and hyper - energy are characteristic of both BPDs and ADHD has led to diagnostic confusion and the under - diagnosis of childhood BPDs. Five common symptoms that discriminate BPDs from ADHD are listed in Table 4. Other discriminating symptoms include the presence of learning difficulties in ADHD children but not in BPD children, and the expression of giftedness in BPD children but not in ADHD children. ADHD sufferers undertake risk - taking behaviours often unaware of danger whereas those with BPDs are risk seekers. Moreover, depression is more common in those with BPDs than ADHD.

RISK FACTORS AND COURSE

Up to 30% of children and adolescents who develop major depression will develop BPDs. Predictive factors include the rapid onset of depression, the occurrence of manic symptoms, psychomotor retardation and psychotic features. Eighty percent of those who develop BP1 have at least one parent diagnosed with a mood disorder. A study of high - risk children has shown that 39% of the offspring of parents with BPDs will also develop the disorder. For many, BPD symptoms in children and adolescents are chronic. Manic episodes are often long and severe, rapid cycling, mixed states and psychosis occurs in a significant number of children. The duration of episodes is often longer than occurs in adults.

THOROUGH ASSESSMENT

The diagnosis of bipolar disorders in children and adolescents is only possible after careful history taking from the sufferer, parents, educators and observation over time. No one symptom identifies BPDs, yet a correct diagnosis is vital for the sufferer’s well-being. When there are high levels of irritability, shifting moods, prolonged temper tantrums, hyperactivity, family history of a mood disorder and functional impairment, an early referral to a child & adolescent psychiatrist or paediatrician is warranted.

Click here for Treatments