The importance of recognizing a child with bipolar disorder

February 1, 2005

Too often, confusion clouds the diagnosis of bipolar disorder in pediatric patients. To help ensure that these children get the treatment they desperately need, pediatricians must understand the unique way that this illness manifests in the young.

Contrary to thinking in the not-so-distant past, bipolar disorder-also known as manic depression-does occur in prepubertal children and adolescents. Research findings and clinical experience now strongly support this fact. The prevalence of manic depression in children and adolescents is at least equal to that in the adult population, and it may be rising.1 It is estimated that 1% of youth are affected, with equal rates among boys and girls.

The highest rate of onset of bipolar disorder has been reported to be between 15 and 19 years of age.2 Prodromal symptoms may begin many years before: According to one report, emerging bipolar disorder was characterized by early episodic shifts in mood, energy, and behavior over a period of 10 years or more.3

Diagnosing bipolar disorder in youth is often difficult because the symptoms and course of illness are different in young people than in adults.4 The criteria for bipolar disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition (DSM-IV) largely reflect the condition as it looks in adults-one reason that bipolar disorder in children often goes undiagnosed. In addition, symptoms overlap with several more common childhood disorders, such as attention deficit hyperactivity disorder (ADHD). Frequent comorbidity also clouds the picture. Moreover, many symptoms of bipolar disorder can be viewed as extreme but nonetheless "normal" childhood behaviors and emotional reactions.

What bipolar disorder looks like in a child Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania, or both simultaneously (a mixed-symptom state). The expression of these symptoms-extreme shifts in mood, activity level, and behavior-significantly interferes with the child's functioning at home and school and with peer interactions.

As many as 80% of children and adolescents who have bipolar disorder show complex cycling patterns marked by brief manic episodes lasting four hours or more.7 Children switch in and out of depression, irritable mania with extreme and prolonged tantrums (so-called affective storms), and euphoric "silly" mania unpredictably throughout the day, almost every day, with little time spent in a normal, age-appropriate mood state. Despite the chronicity of symptoms, these children may exhibit the abnormal moods differently in different settings. Irritability and feelings of hopelessness may be accompanied by increased recklessness and agitated thoughts and behavior.