Bipolar Disorder in Children
and Adolescents
James H. Johnson, PhD,
University of Florida
*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)
Bipolar Disorder: General Introduction
Bipolar disorder is a biologically based disorder
that causes unusual shifts in a person's mood,
energy, and impairs their ability to function.
It causes dramatic mood swings - from overly
"high" and/or irritable mood to sad and hopeless
mood, and then back again.
In older adolescents and adults there are often
periods of normal mood in between.
These mood related changes are accompanied by
severe changes in energy and behavior.
The periods of highs and lows are called episodes
of mania and depression.
Symptoms of Bipolar Disorder:
Mania or Manic Episode
Increased energy, activity, and restlessness
Excessively "high,“ euphoric mood
Extreme irritability
Racing thoughts, talking very fast, jumping from
one idea to another
Distractibility, inability to concentrate
Decreased need for sleep
Unrealistic beliefs in one's abilities and powers
Symptoms of Bipolar Disorder:
Manic Episode
Poor judgment
Spending sprees
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and
sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with three
or more of the other symptoms most of the day, nearly every day,
for 1 week or longer. If the mood is irritable, four additional
symptoms must be present.
Symptoms of Bipolar Disorder:
Hypomania
A mild to moderate level of mania is called
“hypomania”.
Hypomania may feel good to the person who
experiences it and may be associated with good
functioning and enhanced productivity.
Without proper treatment, however, hypomania
can become more severe in some people or can
switch into depression.
Symptoms of Bipolar Disorder:
Depressive Episode
Sad, anxious, or empty mood
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in activities once
enjoyed, including sex
Decreased energy, a feeling of fatigue or of
being "slowed down"
Difficulty concentrating, remembering, making
decisions
Restlessness or irritability
Symptoms of Bipolar Disorder:
Depressive Episode
Sleeping too much, or can't sleep
Change in appetite and/or unintended weight
loss or gain
Chronic pain or other persistent bodily
symptoms that are not caused by physical
illness or injury
Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if five or more of these
symptoms last most of the day, nearly every day, for a period of 2
weeks or longer.
Mood Swings & Symptoms of
Psychosis
Severe episodes of mania or depression can include
symptoms of psychosis (or psychotic symptoms).
Common psychotic symptoms are hallucinations and
delusions.
Psychotic symptoms in bipolar disorder tend to reflect
the extreme mood state at the time (are mood
congruent.
People with bipolar disorder who have these
symptoms are sometimes incorrectly diagnosed as
having schizophrenia.
Bipolar Disorder and Suicide
Bipolar disorder can result in an increased
risk of suicide.
This increased risk seems to be higher
earlier in the course of the illness.
Recognizing bipolar disorder early and
learning how best to manage it may
decrease the suicidal risk.
Suggestions of Suicidal Risk
talking about feeling suicidal or wanting to die
feeling hopeless - nothing will ever change or get better
feeling helpless - nothing I do makes any difference
feeling like a burden to family and friends
alcohol or drug abuse
putting affairs in order or giving away possessions to
prepare for one's death
suicide note
putting oneself in situations where there is a danger of
being killed
Bipolar Spectrum Disorders
It may be helpful to think of the various mood
states in bipolar disorder as a spectrum or
continuous range.
At one end is severe depression, above which is
moderate depression and then mild low mood.
This mild low mood is often short-lived (it is
termed "dysthymia" when it is chronic.
Then there is normal or balanced mood, above
which comes hypomania (mild to moderate
mania), and then severe mania.
Bipolar Spectrum Disorders
Bipolar Disorder: Mixed States
Symptoms of mania and depression may occur
together in what is called a mixed state.
Symptoms of a mixed state often include
agitation, trouble sleeping, significant change in
appetite, psychosis, and suicidal thinking.
This may be accompanied by a sad, hopeless
mood while feeling extremely energized.
Diagnosis of Bipolar Disorder
Subtypes
The classic form of the disorder involves recurrent
episodes of both mania and depression (Bipolar I).
In some cases the person never develops severe
mania, but experiences milder episodes of
hypomania that alternate with depression (Bipolar II).
When four or more episodes of illness occur within a
12-month period, a person is said to have rapidcycling bipolar disorder.
Some people experience multiple episodes within a
single week, or even within a single day.
Rapid cycling tends to develop later in the course of
illness and is more common among women than
among men.
Child/Adolescent Bipolar Disorder
Until recently, the diagnosis of Bipolar
Disorder was viewed as only appropriate
for adults.
Indeed, few clinicians would have even
considered using this diagnostic category
with children.
Despite continuing controversy, it is
increasingly common to find clinicians
using this diagnosis with children
displaying certain types of symptoms.
Child/Adolescent Bipolar Disorder
It is now believed that symptoms of bipolar
disorder can emerge in early childhood.
Mothers often report that children, later
diagnosed with early-onset bipolar disorder,
were extremely difficult to soothe and slept
erratically.
They seemed extraordinarily clingy and, from
a very young age, often displayed
uncontrollable, seizure-like tantrums or rages
out of proportion to any event.
These severe tantrums often appear to be
without provocation.
Frequency of Child Bipolar Disorder
Prevalence is largely unknown as there are no well
accepted criteria for the diagnosis of Child Bipolar
disorder.
This is because DSM IV criteria are generally
viewed as inadequate for use with younger
children.
The best guess is that the disorder occurs at least
as often as adult bipolar disorder (e.g., about 1%)
However, many believe that this disorder is
significantly under diagnosed in children.
Frequency of Child Bipolar Disorder
It is suspected that a significant number of
children diagnosed with ADHD at an early age
actually have early-onset bipolar disorder instead
of (or along with) ADHD.
According to the American Academy of Child and
Adolescent Psychiatry, up to one-third of children
and adolescents with depressive disorders may
actually have early onset of bipolar disorder.
 20 to 40 % of adults with Bipolar Disorder report
a childhood onset of symptoms.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
As with adults, Bipolar disorder in children is
viewed a serious mental disorder
Characterized by recurrent episodes of
depression, mania, and/or mixed symptom
states.
Some evidence suggests that child bipolar
disorder may be a different and possibly more
severe form of the illness than older adolescent
and adult-onset bipolar disorder.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
While older adolescents often have a clinical
presentation that is somewhat similar to that
seen with adults.
The clinical presentation of early-onset bipolar
disorder in children can look quite different than
that seen in older individuals.
Clinicians may fail to diagnose this disorder
when using DSM IV criteria for the diagnosis of
this condition.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
Most cases of child bipolar disorder do
not present with the sudden or acute
onset often found with adults.
Most do not show the improvement
between episodes, often found with adult
bipolar disorder.
With children the symptom onset may be
more insidious.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
With children,
– initial symptoms of the disorder can be depressive in
nature
With these being confused with and treated as MDD.
– In other cases, ADHD like symptoms appear first
with these symptoms being followed later by a full manic
episode.
Unlike adults - children in a manic state are
more likely to be irritable and prone to
destructive outbursts than to be elated or
euphoric.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
Children, more often show
– rapid cycling and mixed states rather than clear
manic or clear depressive episodes, and
– an “ongoing and continuous mood disturbance that
is a mix of mania (or hypomania) and depression”.
The rapid and severe cycling between moods
produces chronic irritability and few clear
periods of wellness between episodes.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
Depression and dysphoria are an almost constant part
of pediatric bipolar disorder.
As noted earlier, hyperactivity is often the first
manifestation of early-onset bipolar disorder.
When children are initially seen because of bipolar
symptoms,
– approximately 90% of early-onset, and
– 30 % of adolescents with bipolar disorder meet criteria for a
diagnosis of ADHD.
Comorbid conduct disorder is also quite common.
Bipolar Disorder vs. ADHD
Bipolar Disorder (Mania)
1. More talkative than usual,
or pressure to keep
talking
2. Distractibility
3. Increase in goal directed
activity or psychomotor
agitation
ADHD
1. Often talks excessively
2. Is often easily distracted
by extraneous stimuli
3. Is often “on the go” or
often acts as if “driven by
a motor”
Differentiation: Elated mood, Grandiosity, Decreased
need for sleep, Hypersexuality, and Irritable mood.
Hart (2005)
Child Bipolar Disorder: Comorbidity
Attention Deficit Hyperactivity Disorder (ADHD)
– Between 60 - 80% display symptoms
Oppositional Defiant Disorder (ODD) & Conduct
Disorder (CD)
– 70 - 75%
Substance Abuse (adolescents)
– 40 - 50%
Anxiety Disorders
– 35- 40%
Child Bipolar Disorder: Genetics
Bipolar Disorder has a heavy genetic
loading
In the general population, a conservative
estimate of an individual's risk of bipolar
disorder is about 1.2 %.
More than two-thirds of those with bipolar
disorder have at least one close relative
with the disorder or with unipolar major
depression
Child Bipolar Disorder: Genetics
When one parent has bipolar disorder, the risk
to each child is about 15 – 30 %
When both parents have bipolar disorder, the
risk increases to 50 – 75 %
The risk to siblings and fraternal twins is 15 – 27
%
The risk in identical twins is approximately 70 %
Note. Despite these figures only about 5% of
children with a parent with Bipolar disorder
would be expected to develop the disorder in
childhood.
Etiology :What is Inherited?
A significant question is What is Inherited??
The answer is not entirely clear, but …
– It's believed this condition is caused by an imbalance in
neurotransmitters.
– a low or high level of a specific neurotransmitter such
as serotonin, norepinephrine or dopamine is the likely
cause.
– Others have suggested that it is an imbalance of these
substances that may be the problem
– Here, a specific level of a neurotransmitter may not as
important as its amount in relation to the other
neurotransmitters.
– Still other studies have found evidence that a change in
the sensitivity of the receptors may be the issue.
– It seems likely that the neurotransmitter system is at
least part of the cause of bipolar disorder, but further
research is still needed to define its exact role.
Etiology of Bipolar Disorder
Environmental Factors
That more than hereditary is involved in Bipolar
Disorder is indicated by the fact that in studies
involving identical twins, raised in the same home,
one twin sometimes develops bipolar disorder
while one does not .
Here it is suggested that environmental factors
may play a role in bipolar disorder.
For some, stresses such as a death in the family,
divorce, or other traumatic events seem to trigger
a first episode of mania or depression.
Etiology of Bipolar Disorder
Environmental Factors
Puberty may trigger the disorder in adolescent
females.
Stressful life events can lead to the onset
– Once the disorder is triggered and progresses, it seems to
develop a life of its own.
– Once the cycle begins, a psychological or pathophysiological
process takes over and ensures that the disorder will
continue.
The best explanation for this disorder seems to be
reflected in the "Diathesis-Stress Model."
Genetics PLUS environmental percipients.
Treatment of Child Bipolar Disorder
Treatment of children and adults with bipolar
disorder is generally similar to adults with this
disorder.
– Less is known about the effectiveness & safety of
the medications used.
– Lithium appears to frequently have a strong
prophylactic effect against mania, and is sometimes
used with children.
– However, in very early onset bipolar disorder, with a
heavy family loading, children may not respond as
well to lithium as do adults.
Treatment of Child Bipolar Disorder
As with adults, anti-convulsants are often used to
control rapid cycling and aggressive behavior.
– Depakote – an anti-convulsant – used to control
rapid cycling.
– Tergetol – an anti-convulsant – has anti-manic and
anti-aggressive qualities.
– Other anti-convulsants (Neurontin, Lamictal,
Topamax)
Sometimes these are used in combination with
Lithium.
Treatment of Child Bipolar Disorder
As with adults, certain antipsychotic drugs may
also be used to control symptoms.
Included here are atypical antipsychotic
medications such as Clozaril®, Zyprexa®,
Risperdal®, and Seroquel®.
Such drugs have been shown to sometimes
function as mood stabilizers in cases were drugs
like lithium and anticonvulsants may not work
They are used to deal with acute mania, and/or
to treat psychotic depression.
Issues in the Pharmacological
Treatment of Child Bipolar Disorder
Bipolar youth often require multiple medications
for mood stabilization, treatment of attention
problems, depression, and sometimes psychotic
symptoms.
There can, however, be risks with drug treatments
Problems can arise in cases of misdiagnosis.
Sometimes children with undiagnosed bipolar
disorder are mistakenly treated for MDD with
antidepressants.
Issues in the Pharmacological
Treatment of Child Bipolar Disorder
Treating such children with antidepressants (in
the absence of a mood stabilizer) can actually
precipitate or exacerbate manic symptoms.
In children with ADHD symptoms, treatment
with stimulant drugs (in the absence of a mood
stabilizer) can result in manic symptoms and/or
worsen symptoms.
Issues in Pharmacological
Treatment of Child Bipolar Disorder
It is difficult to determine which children will
become manic or experience a worsening of
symptoms
There is a greater likelihood among children
with a strong family history of bipolar disorder.
It has been suggested that
– if manic symptoms develop or markedly worsen
during antidepressant or stimulant use, the diagnosis
and treatment for bipolar disorder should be
considered.
Proper diagnosis of Child Bipolar Disorder is
necessary to avoid these problems.
Additional Treatment Approaches
As with adults, treatments in addition to medication
are often necessary to assist children with bipolar
disorder and their families.
These interventions may involve
– Educating the family about the nature of childhood
bipolar disorder and involving the family in treatment.
– Insuring that children receive the special educational
services necessary to prevent them from falling
behind academically
– Appropriate classroom accommodations to help
them function effectively in the academic
environment.
– Family and individual approaches to therapy should
be provided as necessary.
Examples of Educational
Accommodations
Provide student with a safe place and person to go
to when feeling overwhelmed or stressed
Shortened day (permit late start as needed)
Prior notice of transitions
Consistent schedule
Scheduling the student’s most challenging tasks at a
time of day when the child is best able to perform
Modified or shortened assignments
Adjust for medication needs, dispensing, as well as
plans for addressing side effects (e.g., sedation)
Hart (2005)
THE END
Childhood Schizophrenia
Lite*
James H. Johnson, PhD, ABPP
University of Florida
*Some material for this presentation provided by NIMH Publication No. 00-5124,(2003)
Child Schizophrenia: Symptoms
Childhood Schizophrenia is a severe
neurodevelopmental disorder of childhood
that is usually manifest in a range of
symptoms including:
–
–
–
–
–
–
Disturbed though processes
psychotic symptoms (hallucinations, delusions)
social withdrawal
flattened emotions
loss of social and personal care skills
increased risk of suicide
Schizophrenia in children is rare, affecting
only about 1 in 40,000 compared to 1 in 100
in adults.
Child Schizophrenia: Symptoms
Children with schizophrenia often see or hear things
that do not exist. and harbor paranoid and bizarre
beliefs.
They may think people are plotting against them or
can read their minds.
Other symptoms of the disorder include
– problems paying attention,
–
–
–
–
–
impaired memory and reasoning,
speech impairments,
inappropriate or flattened expression of emotion,
poor social skills, and
depressed mood.
Such children may laugh at a sad event, make poor
eye contact, and show little body language or facial
expression.
Child Schizophrenia: Overview
While schizophrenia sometimes begins as an
acute psychotic episode in young adults, it
emerges gradually in children.
It is often preceded by developmental
disturbances, such as lags in motor and
speech/language development.
The diagnostic criteria for childhood
schizophrenia are the same as for adults,
except that symptoms appear prior to age 12,
instead of in the late teens or early 20s..
It is seldom diagnosed before the age of 7.
Child Schizophrenia: Differential
Diagnoses
Misdiagnosis of schizophrenia in
children is common.
It is distinguished from autism by the
persistence of hallucinations and
delusions for at least 6 months, and a
later age of onset - 7 years or older.
Autism is usually diagnosed by age
3.
Child Schizophrenia: Differential
Diagnoses
Some children who later develop
schizophrenia may have a history of
some Pervasive Development
Disorder symptoms.
In adolescents, schizophrenia is also
to be distinguished from bipolar
disorder.
Child Schizophrenia: Differential
Diagnoses
Sometimes an acute onset manic episode may
be mistaken for schizophrenia, as
hallucinations and delusions may be present
(usually mood congruent).
Symptoms of schizophrenia characteristically
pervade the child's life, and are not limited to
specific situations.
Since impairment in social relationships are
central, if the child shows a strong interest in
friendships (even if they fail at maintaining
them) it is unlikely that they have
schizophrenia.
Child Schizophrenia: Presumed
Etiology
Evidence suggests that Childhood Schizophrenia is
a neurodevelopmental disorder likely involving;
– a genetic predisposition,
– a prenatal insult to the developing brain, and
– stressful life events.
The role of genetics has long been established;
– the risk of schizophrenia rises from 1 percent with no
family history of the illness,
– to 10 percent if a first degree relative has it,
– to 50 percent if an identical twin has it..
Prenatal insults may include viral infections, such
as maternal influenza in the second trimester,
starvation, lack of oxygen at birth, and untreated
blood type incompatibility
Child Schizophrenia: Etiology
Studies find that children with schizophrenia
display many of the same abnormal brain
features (structural, physiological, and
neuropsychological) that are found in adults.
The children seem to have more severe
symptoms than adults, with more
pronounced neurological abnormalities.
Unlike most adult-onset patients, children
who become psychotic prior to puberty show
conspicuous evidence of progressively
abnormal brain development.
Child Schizophrenia: Neurology
“In the first longitudinal brain imaging
study of adolescents (Giedd, et al 1999;
Rapoport, et al, 1999), MRI scans revealed
fluid filled cavities in the middle of the
brain, enlarging abnormally between ages
14 and 18, in teens with early-onset
schizophrenia, suggesting a shrinkage in
brain tissue volume.
These children lost four times as much
gray matter, neurons and their branchlike
extensions, in their frontal lobes as
normally occurs in teens.
Child Schizophrenia: Neurology
This gray matter loss engulfs the brain in a
progressive wave from back to front over 5
years, beginning in rear structures involved
in attention and perception, eventually
spreading to frontal areas responsible for
organizing, planning, and other "executive"
functions impaired in schizophrenia. (NIMH,
2000).”
Child Schizophrenia: Treatment
Early diagnosis and treatment is important in
dealing with childhood schizophrenia.
Children with this disorder must have a complete
evaluation in order to develop a comprehensive
individual treatment plan to address their
difficulties.
A combination of medication and individual
therapy, family therapy, and specialized programs
(school, activities, etc.) is often necessary.
Medication can be helpful for many of the
symptoms and problems identified.
Child Schizophrenia: Treatment
Standard antipsychotic drugs appear to be effective
for many schizophrenic children and adolescents.
And the atypical drug clozapine is helpful for at least
half of those who do not respond to other drugs.
In a few cases psychotic symptoms seem to
disappear entirely.
Unfortunately, children may be more susceptible
than adults to the toxic effects of clozapine; about
one third of them have to stop taking it because of
the side effects.
Newer antipsychotic drugs that may be safer and
just as effective are now being tested.
The End