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Child and Adolescent Bipolar Disorder:
An Update from the National Institute of Mental Health
Research findings, clinical experience, and family accounts provide
substantial evidence that bipolar disorder, also called manic-depressive
illness, can occur in children and adolescents. Bipolar disorder is difficult to
recognize and diagnose in youth, however, because it does not fit precisely the
symptom criteria established for adults, and because its symptoms can resemble
or co-occur with those of other common childhood-onset mental disorders. In
addition, symptoms of bipolar disorder may be initially mistaken for normal
emotions and behaviors of children and adolescents. But unlike normal mood
changes, bipolar disorder significantly impairs functioning in school, with
peers, and at home with family. Better understanding of the diagnosis and
treatment of bipolar disorder in youth is urgently needed. In pursuit of this
goal, the National Institute of Mental Health (NIMH) is conducting and
supporting research on child and adolescent bipolar disorder.
A Cautionary Note
Effective treatment depends on appropriate diagnosis of bipolar disorder in
children and adolescents. There is some evidence that using antidepressant
medication to treat depression in a person who has bipolar disorder may induce
manic symptoms if it is taken without a mood stabilizer. In addition, using
stimulant medications to treat attention deficit hyperactivity disorder (ADHD)
or ADHD-like symptoms in a child with bipolar disorder may worsen manic
symptoms. While it can be hard to determine which young patients will become
manic, there is a greater likelihood among children and adolescents who have a
family history of bipolar disorder. If manic symptoms develop or markedly worsen
during antidepressant or stimulant use, a physician should be consulted
immediately, and diagnosis and treatment for bipolar disorder should be
considered.
Symptoms and Diagnosis
Bipolar disorder is a serious mental illness characterized by recurrent
episodes of depression, mania, and/or mixed symptom states. These episodes cause
unusual and extreme shifts in mood, energy, and behavior that interfere
significantly with normal, healthy functioning.
Manic symptoms include:
- Severe changes in mood, either extremely irritable or overly silly and
elated
- Overly-inflated self-esteem; grandiosity
- Increased energy
- Decreased need for sleep, ability to go with very little or no sleep for
days without tiring
- Increased talking, talks too much, too fast; changes topics too quickly;
cannot be interrupted
- Distractibility, attention moves constantly from one thing to the next
- Hypersexuality, increased sexual thoughts, feelings, or behaviors; use of
explicit sexual language
- Increased goal-directed activity or physical agitation
- Disregard of risk, excessive involvement in risky behaviors or activities
Depressive symptoms include:
- Persistent sad or irritable mood
- Loss of interest in activities once enjoyed
- Significant change in appetite or body weight
- Difficulty sleeping or oversleeping
- Physical agitation or slowing
- Loss of energy
- Feelings of worthlessness or inappropriate guilt
- Difficulty concentrating
- Recurrent thoughts of death or suicide
Symptoms of mania and depression in children and adolescents may manifest
themselves through a variety of different behaviors.1,2 When manic, children and
adolescents, in contrast to adults, are more likely to be irritable and prone to
destructive outbursts than to be elated or euphoric. When depressed, there may
be many physical complaints such as headaches, muscle aches, stomachaches or
tiredness, frequent absences from school or poor performance in school, talk of
or efforts to run away from home, irritability, complaining, unexplained crying,
social isolation, poor communication, and extreme sensitivity to rejection or
failure. Other manifestations of manic and depressive states may include alcohol
or substance abuse and difficulty with relationships.
Existing evidence indicates that bipolar disorder beginning in childhood or
early adolescence may be a different, possibly more severe form of the illness
than older adolescent- and adult-onset bipolar disorder.1,2 When the illness
begins before or soon after puberty, it is often characterized by a continuous,
rapid-cycling, irritable, and mixed symptom state that may co-occur with
disruptive behavior disorders, particularly attention deficit hyperactivity
disorder (ADHD) or conduct disorder (CD), or may have features of these
disorders as initial symptoms. In contrast, later adolescent- or adult-onset
bipolar disorder tends to begin suddenly, often with a classic manic episode,
and to have a more episodic pattern with relatively stable periods between
episodes. There is also less co-occurring ADHD or CD among those with later
onset illness.
A child or adolescent who appears to be depressed and exhibits ADHD-like
symptoms that are very severe, with excessive temper outbursts and mood changes,
should be evaluated by a psychiatrist or psychologist with experience in bipolar
disorder, particularly if there is a family history of the illness. This
evaluation is especially important since psychostimulant medications, often
prescribed for ADHD, may worsen manic symptoms. There is also limited evidence
suggesting that some of the symptoms of ADHD may be a forerunner of full-blown
mania.
Findings from an NIMH-supported study suggest that the illness may be at
least as common among youth as among adults. In this study, one percent of
adolescents ages 14 to 18 were found to have met criteria for bipolar disorder
or cyclothymia, a similar but milder illness, in their lifetime.3 In addition,
close to six percent of adolescents in the study had experienced a distinct
period of abnormally and persistently elevated, expansive, or irritable mood
even though they never met full criteria for bipolar disorder or cyclothymia.
Compared to adolescents with a history of major depressive disorder and to a
never-mentally-ill group, both the teens with bipolar disorder and those with
subclinical symptoms had greater functional impairment and higher rates of
co-occurring illnesses (especially anxiety and disruptive behavior disorders),
suicide attempts, and mental health services utilization. The study highlights
the need for improved recognition, treatment, and prevention of even the milder
and subclinical cases of bipolar disorder in adolescence.
Treatment
Once the diagnosis of bipolar disorder is made, the treatment of children and
adolescents is based mainly on experience with adults, since as yet there is
very limited data on the efficacy and safety of mood stabilizing medications in
youth.4 The essential treatment for this disorder in adults involves the use of
appropriate doses of mood stabilizers, most typically lithium and/or valproate,
which are often very effective for controlling mania and preventing recurrences
of manic and depressive episodes. Research on the effectiveness of these and
other medications in children and adolescents with bipolar disorder is ongoing.
In addition, studies are investigating various forms of psychotherapy, including
cognitive-behavioral therapy, to complement medication treatment for this
illness in young people.
Valproate Use
According to studies conducted in Finland in patients with epilepsy,
valproate may increase testosterone levels in teenage girls and produce
polycystic ovary syndrome in women who began taking the medication before age
20.5 Increased testosterone can lead to polycystic ovary syndrome with irregular
or absent menses, obesity, and abnormal growth of hair. Therefore, young female
patients taking valproate should be monitored carefully by a physician.
NIMH is attempting to fill the current gaps in treatment knowledge with
carefully designed studies involving children and adolescents with bipolar
disorder. Data from adults do not necessarily apply to younger patients, because
the differences in development may have implications for treatment efficacy and
safety.4 Current multi-site studies funded by NIMH are investigating the value
of long-term treatment with lithium and other mood stabilizers in preventing
recurrence of bipolar disorder in adolescents. Specifically, these studies aim
to determine how well lithium and other mood stabilizers prevent recurrences of
mania or depression and control subclinical symptoms in adolescents; to identify
factors that predict outcome; and to assess side effects and overall adherence
to treatment. Another NIMH-funded study is evaluating the safety and efficacy of
valproate for treatment of acute mania in children and adolescents, and also is
investigating the biological correlates of treatment response. Other NIMH-supported
investigators are studying the effects of antidepressant medications added to
mood stabilizers in the treatment of the depressive phase of bipolar disorder in
adolescents.
References
1Carlson GA, Jensen PS, Nottelmann ED, eds. Special issue: current issues in
childhood bipolarity. Journal of Affective Disorders, 1998; 51: entire issue.
2Geller B, Luby J. Child and adolescent bipolar disorder: a review of the
past 10 years. Journal of the American Academy of Child and Adolescent
Psychiatry, 1997; 36(9): 1168-76.
3Lewinsohn PM, Klein DN, Seely JR. Bipolar disorders in a community sample of
older adolescents: prevalence, phenomenology, comorbidity, and course. Journal
of the American Academy of Child and Adolescent Psychiatry, 1995; 34(4): 454-63.
4McClellan J, Werry J. Practice parameters for the assessment and treatment
of adolescents with bipolar disorder. Journal of the American Academy of Child
and Adolescent Psychiatry, 1997; 36(Suppl 10): 157S-76S.
5Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism
during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999;
45(4): 444-50.
NIH Publication No. 00-4778
Printed 2000
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