Bipolar disorder (or manic depressive illness) often can be
severely impairing and disruptive to families.
In the manic phase, individuals show excessively poor judgment (e.g., spend
large amounts of money, unprotected sex, and other risk-taking behaviors), and
disregard school and work. In the
depressive phase, individuals meet criteria for major depressive episode.
Bipolar in adults has been well known since at least the
1850’s, and is considered rare in children.
However, many patients have been incorrectly diagnosed with bipolar disorder
beginning in the mid-1990’s (Liebenluft and Rich, 2008) when they presented
with symptoms of irritability and outbursts of aggression and agitation that
did not fit any existing diagnostic categories.
It appears that some doctors had been influenced to widen their concept
of bipolar disorder by a series of research papers that came out of a group at
Harvard Medical School who believed that pediatric bipolar had been underrecognized
(Biederman 1998, Wozniak et al., 1995), with some even claiming to have diagnosed
bipolar in preschoolers (Pavuluri et al., 2002). The group at Harvard argued that the
traditional symptoms required for bipolar, including grandiosity and discrete
cycles of mania and depression that exist for periods of days, were not
applicable to children. Although this
idiosyncratic interpretation of bipolar has been debunked by longitudinal
research (AACAP Practice Parameter, 2007), the practice of over-diagnosing bipolar
has persisted to this day.
During the manic phase, the symptoms include:
- Grandiosity or inflated self-esteem
- Decreased need for sleep
- Pressure to keep talking
- Flight of ideas; thoughts feel like they are racing
- Increased activity in one or more areas (work, school, socially, or sexually)
- Psychomotor agitation
- Involvement in activities that are very likely to have harmful consequences (e.g., buying sprees, sexual recklessness, or foolish business investments)
(American Psychiatric Association, 2013. Diagnostic and Statistical Manual, 5th Edition).
A hypomanic phase is seen in some individuals. The types of symptoms are the same as in a manic phase but they are less severe.
During the depressive phase, individuals meet criteria for depression.
Screening for bipolar tends to be inaccurate because the symptoms of mania, grandiosity, pressured talking, flight of ideas, and harmful activities require clinical training and experience to detect accurately. There has been little research on the accuracy of screening measures for bipolar disorder. The Swanson, Nolan, and Pelham scale (SNAP) contains seven screen questions for bipolar (questions #59-65) and can be downloaded below.
When to Refer
Bipolar disorder is a serious, impairing condition that tends to be life-long. Suspected cases need to be referred to child and adolescent psychiatrists as soon as possible as there are effective treatments.
Standard treatment includes pharmacotherapy, usually involving lithium, valproate, or the atypical antipsychotic medications. After the acute manic phase is controlled, medication often needs to be ongoing to prevent relapse, and frequently needs to be life-long. For severely impaired adolescents for whom medication is not effective or tolerated, electroconvulsive therapy may be used. Psychotherapy is also an important part of treatment to deal with many related psychosocial issues.
On the Find A
Provider page of the Kid Catch Directory, you can use the Issues filter box to search for local
experts on bipolar. Clicking on this
filter selection will return results of clinicians who advertise themselves as
working with this problem. Kid Catch
cannot guarantee that clinicians who advertise themselves this way are truly
AACAP Practice Parameter (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46(1), 107-125.
Biederman J (1998). Resolved: Mania is Mistaken for ADHD in
Prepubertal Children. Journal of the American Academy of Child & Adolescent
Leibenluft E, Rich BA (2008). Pediatric bipolar disorder. Annual Review of Clinical Psychology 4, 163-187, doi: 10.1146/annurev.clinpsy.4.022007.141216
Pavuluri MN, Janicak PG, Carbray J (2002). Topiramate plus risperidone for controlling weight gain and symptoms in preschool mania. Journal of Child and Adolescent Psychopharmacology 12(3), 271-273.
Wozniak J, Biederman J, Kiely K, Ablon JS, Faraone SV,
Mundy E, Mennin D (1995). Mania-like symptoms suggestive of childhood-onset
bipolar disorder in clinically referred children. Journal of the American
Academy of Child & Adolescent Psychiatry 34(7):867-876, doi: 10.1097/00004583-199507000-00010
- Updated October 17, 2019