Bipolar disorders in children

INVITED EDITORIAL

Bipolar disorders in children

Gibsi Possapp Rocha^I; Paulo de Tarso da Luz Fontes Neto^II

^IChild psychiatrist and MSc in Health Sciences, Mount Sinai School of Medicine of New York, New York, USA. Professor, Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

^IIPsychiatrist. MSc. in Health Sciences: Pediatrician, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

In 1845, Esquirol published an article about 5-year-old children who had mood changes, being the first to study child psychiatry in the medical literature. Despite being associated with alarming suicide rates, high risk behaviors and school problems, only over the past decades bipolar disorder (BD) in childhood has been given proper attention. There are many ongoing investigations and lines of research; among them, two major issues are trying to be answered by researchers:

- Can explosive and uncontrolled behavior and emotional lability in children and adolescents be diagnosed as BD?

- Is BD in this age group the same disease described in adults?

Lately, there has been an increase in number of children and adolescents diagnosed with BD. Such fact has also generated several debates in the scientific community, raising other questions about the reason for that increase. Would it be due to increase in identification of cases or has this disorder actually become more frequent? That type of question is placing BD phenomenology in the foreground, with interesting consequences related to its identification. BD diagnosis is doubtlessly progressing as information about symptoms of cases throughout life is investigated, and as new diagnostic criteria characterizing possible subtypes are developed, capacitating practitioners about this theme and enhancing assessment instruments.¹

Mood changes in young children and adolescents are often associated with characteristics of borderline personality disorder or with behavior disorders, raising questions as to diagnostic specificity, overlapping between mood and personality disorders and validity of diagnosis of personality disorders in this age group.¹

Evidence has demonstrated that BD diagnosis in young children and adolescents is still controversial, although it is considered similar to adult diagnosis when its onset is in the middle or late adolescence. Early clinical presentation of mania, for example, can be manifested only as worsening of some improper behaviors, such as exacerbation of an emotional lability, more frequent impulsive behaviors, concentration difficulties, sleep changes and worsening in social relationships. Since these behaviors are preexisting, but less intense, they are often not easily perceived by parents. On the other hand, there are reports in the literature showing more important behavioral changes, such as well behaved children who suddenly became wild children.² The National Institute of Mental Health reached a consensus in 2001 that BD in children can have wide or circumscribed phenotypical presentation.

Children and adolescents with circumscribed presentation have periods of major depression and mania or hypomania, belonging to traditional definitions of type I or II BD according to the Diagnostic and Statistical Manual of Mental Disorders. Most youths have multiple episodes with fast cycles and brief duration (< 4-7 days) of mania and hypomania episodes. Wide spectrum represents most cases in offices and clinics. Common states are great irritability, behavioral storms, "wreath attacks," mood lability, depressive symptoms, anxiety, hyperactivity, concentration problems and impulsiveness, and there may or not be periodicity.³ In 2003, Leibenluft et al. suggested inclusion of an intermediate type, with two subcategories: a group with short-duration symptoms (1-3 days) and a group with symptoms of hypomania or mania with irritability and no elation.⁴ Regarding the occurrence of symptoms characteristic of BD in children, Kowatch et al., in 2005, performed a meta-analysis and found data that demonstrate diversity of symptoms.⁵ With regard to euphoria, they found rates ranging between 14-89.5 in their studies.^6,7 As to occurrence of irritability, rates were 22-97.7.^7,8 For grandiosity, their findings showed rates between 61.1-86.^7,9 As to existence of flight of ideas, they report findings between 44-69.^8-10 Accelerated thinking was found in 46.5-87.8.7-10 Reduction in need of sleep was found in 61.1-95.1.^9-11 Reduced criticism reported by the researchers was 33.3-89.5.^7,9 Hypersexuality ranged between 32.3-45.3.^7,10 Pressure of speech was found in 67-96.5.^7,8 Distractibility had values between 61.1-93^7,9 and increased energy was 81.1-100.^7,10

Another fact that draws attention is the quantity and importance of differential diagnosis and comorbidities in BD. Anxiety disorders, conduct disorders, attention deficit hyperactivity disorder (ADHD), psychotic disorders, among others, stand out for having symptoms in common with BD and point to the need of detailed screening and identification. BD can be distinguished from ADHD due to presence of grandiosity, elation, flight of ideas, hypersexuality and reduced sleep.¹²

As to the second question, trying to understand whether BD in children is the same disease described in adults, there is still no conclusive evidence that pediatric BD is the same pathology found in adults, although psychotic manic states in adolescence seem to be similar to BD observed in adults.¹³

BD in children was for a long time underdiagnosed and poorly recognized, being mistaken for other psychopathological states. This is due to widely variable clinical manifestations, with symptoms overlapping those of other diseases, and to variation of symptoms according to developmental stage of these small patients. We do not aim at raising all issues involved in such a complex theme, but would like to motivate our colleagues to keep searching for theoretical substrates that can help managing their small patients.

References

• 1. Lee Fu-I. Transtorno bipolar na infância e na adolescência. São Paulo: Segmento Frama; 2007.
• 2. Carlson GA, Jensen PS, Findling RL, Meyer RE, Calabrese J, DelBello MP, et al. Methodological issues and controversies in clinical trials with child and adolescent patients with bipolar disorder: report of a consensus conference. J Child Adolesc Psychopharmacol. 2003;13(1):13-27.
• 3. National Institute of Mental Health research roundtable on prepubertal bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2001;40(8):871-8.
• 4. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS. Defining clinical phenotypes of juvenile mania. Am J Psychiatry. 2003;160(3):430-7.
• 5. Kowatch RA, Youngstrom E A, Danielyan A, Findling RL. Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disord. 2005;7(6)483-96.
• 6. Wozniak J, Biederman J, Faraone SV, Frazier J, Kim J, Millstein R, et al. Mania in children with pervasive developmental disorder revisited. J Am Acad Child Adolesc Psychiatry. 1997;36(11):1552-9.
• 7. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, Delbello MP, et al. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol. 2000;10(3):157-64.
• 8. Ballenger JC, Reus VI, Post RM. The "atypical" picture of adolescent mania. Am J Psychiatry. 1982;139(5):602-6.
• 9. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry. 1995;34(4):454-63.
• 10. Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA, et al. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder. Bipolar Disord. 2001;3(4):202-10.
• 11. Faedda GL, Baldessarini RJ, Suppes T, Tondo L, Becker I, Lipschitz DS. Pediatric - onset bipolar disorder; a neglected clinical and public health problem. Harv Rev Psychiatry. 1995;3(4):171-95.
• 12. Geller B, Warner K, Williams M, Zimmermann B. Prepubertal and Young adolescent bipolarity versus ADHD: assessment and validity using the WASH-U-KSADS, CBCL and TRF. J Affect Disord. 1998;51(2):93-100.
• 13. McClellan J, McCurry C, Snell J, DuBose A. Early-onset psychotic disorders: course and outcome over a 2-year period. J Am Acad Child Adolesc Psychiatry. 1999;38:1380-8.

Publication Dates

• Publication in this collection
  31 Mar 2008
• Date of issue
  Dec 2007