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

Coexisting Conditions

The main diagnostic dilemmas in mood disorders involve distinguishing BPD from unipolar depression or anxiety disorders, ADHD, and/or conduct disorder (Carlson, 1998). An additional quandary is whether the child has BPD only or has BPD in addition to coexisting conditions. The significance of these overlapping diagnoses will be clearer in the discussion of treatment below, because medications commonly used to treat anxiety disorders may precipitate manic episodes in children with undiagnosed BPD, and antiepileptic drugs are sometimes used as mood stabilizers.

Between 30% and 50% of children with anxiety disorders also have a depressive disorder, either unipolar or bipolar (Varley & Smith, 2003). In a study of 2025 youths referred to an anxiety and mood disorders clinic, 19% of children with panic disorder also had BPD (Birmaher, Kennah, Brent, Ehmann, Bridge, et al., 2002). In one Italian study of children and adolescents at a tertiary care psychiatric center, about 45% of youths with diagnoses of either obsessive compulsive disorder or BPD showed a lifetime history of comorbidity (Masi, Perugi, Toni, Millepiedi, Mucci, et al., 2004). Up to 40% of hospitalized manic adolescents in one study had a substance use disorder (West, Strakowski, Sax, McElroy, Keck, et al., 1996).

A preliminary survey of persons with epilepsy found that 8% had symptoms consistent with bipolar spectrum (Barry, 2003), and the author speculates that interictal mania may be more prevalent.

Attention-Deficit Hyperactivity Disorder

Clinical descriptions and diagnostic criteria for ADHD have changed over time, from the hyperkinetic child of the 1970s in whom emotional variability was a hallmark (Carlson, 1998) to the current definition of the DSM-IV-TR , which focuses entirely on inattention and hyperactivity/impulsivity (American Psychiatric Association, 2000). Kim and Miklowitz (2002) found that, depending on the studies they reviewed, 57% to 98% of children with mania also had a diagnosis of ADHD, while 20% to 23% of children with ADHD also had a diagnosis of bipolar disorder. Faraone and colleagues suggest two different models to explanation this overlap. In one model, the combination of ADHD with BPD represents a distinct subtype, with higher rates of both ADHD and early onset BPD in the relatives of children with both diagnoses, compared with children with ADHD alone and with children who have no mental health diagnoses (Faraone, Biederman, Mennin, Wozniak, & Spencer, 1997). Another model posits that ADHD is a developmental marker for early-childhood onset BPD, with higher rates of ADHD noted among children with earlier appearance of manic symptoms (Faraone, Biederman, Wozniak, Mundy, Mennin, et al., 1997).

Conduct Disorder

The DSM-IV-TR defines conduct disorder as "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated" (American Psychiatric Association, 2000, p. 93). Irritability in manic children is often violent, similar to the irritability in conduct disorder (Kim & Miklowitz, 2002; Weckerly, 2002). However, one distinguishing clinical characteristic is the often rapid onset of irritable, impulsive outbursts in BPD, contrasting with a lengthy prodromal period in conduct disorder, progressing from less severe to more severe rule-breaking. Two other characteristics specific to BPD are the episodic nature of the violent outburst, as well as the guilt and remorse the child generally exhibits when the outburst is over (Kusumakar, Lazier, MacMaster, & Santor, 2002). In one study of children referred to a psychopharmacology clinic in Boston, 41% of children with mania met criteria for conduct disorder, and 40% of children with conduct disorder had symptoms of mania (Biederman, Faraone, Chu, & Wozniak, 1999).

Other symptoms common to both disorders are inappropriate sexual behavior, disinhibited social interactions, and displays of poor judgment. More empiric studies are required to distinguish age of onset, quality of mood disturbance, and the clinical course of children with mania alone, conduct disorder alone, and both diagnoses (Kim & Miklowitz, 2002).

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