Bipolar Disorders in Children and Adolescents

Naomi A. Schapiro, RN, MS, CPNP

Disclosures

J Pediatr Health Care. 2005;19(3):131-141. 

In This Article

Mania in Children and Adolescents

Melancholia and mania were two of the three forms of mental illness described by ancient Greek physicians (Glovinsky, 2002), and the connection between melancholia and mania was noted as early as the second century CE. Case reports connecting melancholy and mania were published in the 18th century, but it was not until the 19th century that European physicians began to describe a circular madness, or one that alternated between periods of mania and depression.

Systematic studies of young children with mania started in the 1920s, although the prevailing belief was that pre-adolescent children did not have the higher level cognitive structures that were necessary to exhibit grandiose delusions (Glovinksy, 2002; Weller, Calvert, & Weller, 2003). During the 1970s, there were published reports of the use of lithium in young children, and Davis (1979) published a landmark paper that described hyperactivity and emotional upheavals in children without grandiosity or psychotic symptoms. Controversy over the prevalence and quality of mania in childhood continues to this day (Carlson, 1998; NIMH, 2001), primarily over age-appropriate descriptions of manic behavior and whether a child can be manic without grandiosity or elation.

It can be difficult to distinguish between age-appropriate restlessness, the fidgeting of children with ADHD, and the purposeful busy activity of mania (Harrington & Myatt, 2003). Looking at another behavior, the rapid speech of a child with a language disorder or ADHD may not appear different from the "pressured speech" of mania. In children younger than 7 years with limited ability to test reality, grandiosity is difficult to confirm (Carlson, 1998). In addition, in young children the primary historian is the parent, and parents do not necessarily represent their children's thought processes accurately (Tillman, Geller, Craney, Bolhofner, Williams, et al., 2004).

According to some researchers (Biederman, Faraone, Mick, Wozniak, Chen, et al., 1996), irritability is a hallmark of pediatric mania, especially when presenting children have a coexisting diagnosis of ADHD. The irritability of manic children has been described as severe, persistent, and violent, often involving explosive outbursts of physical or verbal aggression (Weckerly, 2002), as in the case of Marina. Children whose primary symptoms include irritability and disruptive behavior may be diagnosed with ADHD and/or conduct disorder without adequate exploration of their moods (Kim & Miklowitz, 2002), resulting in underdiagnosis of BPD.

However, irritability is also a symptom of many psychiatric disorders, including ADHD, depression, anxiety disorders, and conduct disorder (Kim & Miklowitz, 2002; see Table 1 ). If irritable children can be labeled as manic without grandiosity or elation, then the possibility exists of overdiagnosis, as suggested by Kim and Miklowitz in reviewing longitudinal studies of adolescents with a BPD diagnosis and no recurrences in adulthood.

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