The answers to the following questions do not represent the views of all mental health professionals; they reflect the academic, clinical and professional expertise of investigators supported by JBRF and other like-minded experts.
Please note: although you will read much on this site about how bipolar disorder per se is just an idea which is losing credibility, we will nevertheless use the term here as a shortcut because it is one which has a familiar meaning and because it fits with the nature of the questions.
What is “early-onset”/ “pediatric”/ “juvenile” bipolar disorder and why are we suddenly hearing so much about it?
Although the terms “early-onset”, “pediatric” and “juvenile” bipolar disorder actually mean slightly different things, they are often used interchangeably as labels for a manic-depressive disorder that appears early –very early—in life. For many years it was assumed that children could not suffer the mood swings of mania or depression, but researchers are now reporting that bipolar disorder (or early temperamental features of it) can occur in very young children, and that it is much more common than previously thought.
Is bipolar disorder in children the same thing as bipolar disorder in adults?
Adults diagnosed with bipolar disorder seem to experience abnormally intense moods for weeks or months at a time, but children appear to experience such rapid shifts of mood that they commonly cycle many times within the day. This cycling pattern is called ultra-ultra rapid or ultradian cycling and it is most often associated with low arousal states in the mornings (these children find it almost impossible to get up in the morning) followed by afternoons and evenings of increased energy.
It is not uncommon for the first episode of the disorder to be a depressive one. But as clinical investigators have followed the course of the disorder in children, they have reported a significant rate of transition from depression into bipolar mood states.
It is important to note that there are many adults whose symptom profiles look much more similar to the pediatric profile. However, just like those children, they would not qualify for a bipolar I or II diagnosis. Additionally, even those people who do qualify for a bipolar I or II diagnosis spend most of their time in a sub-syndromal state; that is, their symptoms do not meet criteria.
What are the symptoms in childhood, and how early can they begin?
We have interviewed many parents who report that their children seemed different from birth, or that they noticed that something was wrong as early as 18 months. Their babies were often extremely difficult to settle, rarely slept, experienced separation anxiety, and seemed overly responsive to sensory stimulation.
In early childhood, the youngster may appear hyperactive, inattentive, fidgety, easily frustrated and prone to terrible temper tantrums (especially if the word “no” appears in the parental vocabulary). These explosions can go on for prolonged periods of time and the child can become quite aggressive or even violent. (Rarely does the child show this side to the outside world.)
A child with bipolar disorder may be bossy, overbearing, extremely oppositional, and have difficulty making transitions. His or her mood can veer from morbid and hopeless to silly, giddy and goofy within very short periods of time. Some children experience social phobia, while others are extremely charismatic and risk-taking.
If the child is fidgety and inattentive and hyperactive, isn’t the correct diagnosis attention-deficit disorder with hyperactivity (ADHD)? Or, if the child is oppositional, wouldn’t oppositional-defiant disorder (ODD) be the correct diagnosis?
Several studies have reported that over 80 percent of children who have early-onset bipolar disorder will meet full criteria for ADHD. It is possible that the disorders are co-morbid–appearing together–or that ADHD-like symptoms are a part of the bipolar picture. JBRF sponsored investigators identified measures on several neurocognitive tests which are able to differentiate between ADHD and bipolar disorder. The published study can be seen here: Neuropsychological factors differentiating treated children with pediatric bipolar disorder from those with attention-deficit:hyperactivity disorder.
In addition to these subtle neurocognitive differences, children with bipolar disorder exhibit more irritability, labile mood, grandiose behavior, and sleep disturbances– often accompanied by night terrors (nightmares filled with gore and life-threatening content)–than do children with ADHD.
Because stimulant medications may exacerbate an underlying mood disorder, bipolar disorder should be ruled out before a stimulant is prescribed.
In another JBRF sponsored study, almost all of the 120 boys and girls diagnosed with bipolar disorder met criteria for oppositional defiant disorder (ODD). You will find extensive information about how oppositional behaviors fit into the mood disorder called Fear of Harm in the following postings: Fear of harm, a possible phenotype of pediatric bipolar disorder: A dimensional approach to diagnosis for genotyping psychiatric syndromes and More About Fear, Aggression, Anxiety. The child should be evaluated for a possible bipolar disorder.
So how would a doctor diagnose early-onset bipolar disorder?
The family history is an important clue in the diagnostic process. If the family history reveals mood disorders or substance abuse coming down one or both sides of the family tree, red flags should appear in the mind of the diagnostician. The illness has a strong genetic component, although it can skip a generation.
Many parents are told that a proper diagnosis cannot be made until the child grows into the upper edges of adolescence–between 16 and 19 years old. This reflects outdated ideas. However, even among doctors who acknowledge that children can and should be diagnosed earlier; there is a reluctance to do so. The seriousness of the diagnosis, the effects of the medications used to treat the condition and the difficulty to tease out normal, albeit difficult, developmental behavior from behavior which warrants medical attention, often delays proper diagnosis.
Objective criteria or tests would be a welcome relief. Unfortunately, the field of psychiatry is not at that point.
That said, as you will read in postings under the tab “Information from JBRF Sponsored Research”, there are some very important and easily recognizable signs of the condition which JBRF investigators call Fear of Harm (FOH). Studies have shown that approximately 2/3 of children who are diagnosed with bipolar disorder or who are at risk for bipolar disorder may actually have this condition. They symptom profile of FOH is well described in this website. If you recognize your child in this description, we strongly advise you to bring the information to the attention of your child’s doctor. Several of the symptoms of FOH appear very early in life making early diagnosis and intervention more likely. To read an article which discusses those early warnings, click here .
If a child hears voices or sees things, does that mean he or she is schizophrenic?
Absolutely not. Psychotic symptoms such as delusions (fixed, irrational beliefs that could not possibly exist) and hallucinations (seeing or hearing things not seen or heard by others) can occur during both phases of bipolar disorder. In fact, they are not uncommon. Sometimes the voices and visions are compelling; often they are threatening. Quite a few children report seeing bugs or snakes or say that they see and hear satanic figures. The hallucinations can be either well formed or vague, such as a dark wind. The hallucinations often occur shortly before sleep or upon waking up.
What are the treatments for early-onset bipolar disorder?
The first line of treatment is to stabilize the child’s mood and to treat sleep disturbances and psychotic symptoms if present. Once the child is stable, a therapy that helps him or her understand the nature of the illness and how it affects his or her emotions and behaviors is a critical component of a comprehensive treatment plan.
Mood stabilizers are the mainstay of treatment for a bipolar disorder, but many of these medications have only recently begun to be used in children with the condition, so not a lot of data about their use in childhood bipolar disorder exists. (However, the anticonvulsant mood stabilizers such as Depakote and Tegretol, etc. have been used to treat young children with epilepsy for quite some time, so there is a literature about these drugs in the pediatric population.)
Many psychiatrists simply adapt what they know about the treatment of adults to the pediatric and adolescent population. Our experience tells us that, because they are treating children and there is not much literature on the subject, many psychiatrists prescribe the drugs very cautiously. This often causes them to discount the efficacy of the treatment before it is able to reach a therapeutic dose. The result is to either pass-up an effective treatment or to question the diagnosis altogether.
Commonly prescribed mood stabilizers include lithium carbonate (Lithobid, Lithane, Eskalith), divalproex sodium (Depakote, Depakene), carbamazapine (Tegretol), and Oxcarbazapine (Trilepta). Newer agents such as gabapentin (Neurontin), lamotrigine (Lamictal), topirimate (Topomax), and tiagabine (Gabitril) are currently under clinical investigation for the treatment of bipolar disorder and are being used in children. (Lamictal is Black Label for those under the age of 16.)
If a child is experiencing psychotic symptoms and/or aggressive behavior, the newer antipsychotic drugs, risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and Aripiprazole (Abilify) are commonly prescribed. Older antipsychotics such as thioridazine (Mellaril), haloperidol (Haldol), and molindone (Moban) are old standbys. Clonazepam (Klonopin) and lorezapam (Ativan) are also used to treat anxiety states, induce sleep, and put a break on rapid-cycling swings in activity and energy.
Research pursued by JBRF-sponsored investigators has accumulated impressive results by treating children characterized by Fear of Harm with intranasal ketamine. To the best of our knowledge there is nobody else in the country using this treatment regimen at this time. Upon conclusion of the Ketamine Clinical Study, we will prioritize distributing this information.
Should antidepressants be used?
It’s very risky. Several studies have reported high rates of the induction of mania or hypomania and rapid-cycling in children with bipolar disorder who are exposed to antidepressant drugs of all classes. In addition, the child may experience a marked increase in irritability and aggression. Many parents on the BPParents listserv (an on-line community of parents who communicate with each other from all over the world via E-mail) reported that their children experienced psychosis and were hospitalized subsequent to their treatment with antidepressants. Some children did well for weeks or even for three months before a switch into mania and ultra-rapid mood shifts began.
Can a child take antidepressants for the depressive periods after he or she is stabilized on a mood stabilizer?
Maybe. Some children may be able to take an antidepressant for a brief period if it is opposed by a mood stabilizer. More studies need to be done so that treatment recommendations can be made.