James H. Johnson, PhD,
University of Florida
*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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
(Youngstrom, 2007).
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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.
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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.
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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.
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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.
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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.
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Unlike adults - children in a manic state are
more likely to be irritable and prone to
destructive outbursts than to be elated or
euphoric.
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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”.
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The rapid and severe cycling between
moods produces chronic irritability and
few clear periods of wellness between
episodes.
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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.
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Comorbid conduct disorder is also quite
common.
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)
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Attention Deficit Hyperactivity Disorder (ADHD)
◦ Between 60 - 80% display symptoms
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Oppositional Defiant Disorder (ODD) & Conduct
Disorder (CD)
◦ 70 - 75%
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Substance Abuse (adolescents)
◦ 40 - 50%
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Anxiety Disorders
◦ 35- 40%
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Bipolar Disorder has a heavy genetic loading
More than two-thirds of those with bipolar
disorder have at least one close relative with
the disorder or with unipolar major
depression
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 %
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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.
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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.
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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.
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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.
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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.
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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.
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.
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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.
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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.
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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.
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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.
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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)
James H. Johnson, PhD, ABPP
University of Florida
*Some material for this presentation provided by NIMH Publication No. 00-5124,(2003)
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Childhood Schizophrenia is a severe
neurodevelopmental disorder of childhood
that is usually manifest in a range of
symptoms including:
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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.
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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,
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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.
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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.
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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.
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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.
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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.
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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
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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.
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“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.
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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).”
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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.
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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.