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Bipolar Disorder in Children and Adolescents:
Diagnostic Issues and Clinical Case Follow-up
James H. Johnson, PhD, ABPP/CAP
University of Florida
*Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)
Bipolar Disorder: General Introduction
Bipolar disorder is a largely biologically based
disorder that causes extreme variations in a
person's mood and energy and impairs their ability
to function.
It causes dramatic mood swings - from an overly
"high" and/or irritable mood to sad and hopeless
mood, and back.
In older adolescents and adults there are often
periods of normal mood in between.
Mood related changes are accompanied by severe
variations in energy and behavior.
The periods of highs and lows are called episodes
of mania and depression.
Symptoms of Bipolar Disorder:
Mania/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 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)
Bipolar Spectrum
It’s helpful to think of various mood states in
bipolar disorder as a spectrum or continuous
range.
At one end is severe depression, then moderate
depression and then mild low mood.
This mild low mood is often short-lived (it’s
termed "dysthymia" when 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 a mixed state.
Symptoms of a mixed state often include
agitation, trouble sleeping, change in
appetite, psychosis, and suicidal thinking.
This may be accompanied by a sad,
hopeless mood while also feeling highly
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 episodes of hypomania that
alternate with depression (Bipolar II).
When four or more episodes occur within a 12-month
period, a person is said to have rapid-cycling 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 seen as only appropriate for
adults.
Indeed, few clinicians would have
considered using this diagnostic category
with children.
Despite continued controversy, it is
increasingly common to find clinicians
using this diagnosis with both children and
adolescents.
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
– rage reactions.
These often appear to be without obvious
provocation.
Prevalence of Child Bipolar Disorder
Prevalence of Bipolar Disorder in children is
largely unknown as there are no well accepted
criteria for the diagnosis of Child Bipolar
disorder.
This is because DSM IV criteria are often
viewed as inadequate for use with younger
children, due to a different clinical presentation
in childhood.
The best guess is that the disorder occurs at
least as often as adult bipolar disorder (e.g.,
~1.2 %)
Many believe that this disorder is significantly
under diagnosed in in younger individuals.
Clinical Presentation of Child Bipolar
Disorder
It has been suggested that a significant number
of children diagnosed with ADHD at a very early
age may 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.
 Approximately 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 and chronic mental
disorder.
It is characterized by recurrent episodes
of depression, mania, and/or mixed
symptom states.
It has been suggested that child bipolar
disorder may be a 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 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 can be depressive in nature
With these being confused with and treated as MDD
– In other cases, ADHD like symptoms may appear first
with these symptoms being followed by a 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 clearly depressive episodes, and
– an “ongoing and continuous mood disturbance that
is a mix of mania (or hypomania) and depression”.
There may be few clear periods of wellness
between episodes.
Child/Adolescent Bipolar Disorder:
Clinical Presentation
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 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 30 (adolescents) - 90% (children) display
symptoms
Oppositional Defiant Disorder (ODD) & Conduct
Disorder (CD)
– 70 - 75%
Substance Abuse (adolescents)
– 40 - 50%
Anxiety Disorders
– 35- 40%
Treatment of Child Bipolar Disorder
Treatment of children with bipolar disorder is
generally similar to adults with this disorder.
– Although, 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 antiaggressive qualities.
– Other anti-convulsants (Neurontin, Lamictal, Topamax)
Sometimes these are used in combination with Lithium.
Abilify is another relatively new drug which is being used in the
treatment of bipolar disorder in children and adults
– Developed as an add-on treatment to antidepressants for
Major Depressive Disorder in adults but seems to also
have anti-manic effects.
– Not FDA approved for children under 18 but is currently
being prescribed for children.
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 seems to be a somewhat 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.
Must be aware that bipolar disorder can mimic
conditions like ADHD and Depression due to
symptom overlap
Additional Treatment Approaches
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.
Case Presentation: ADHD or
Bipolar Disorder
Bobby – A 12 year – 8 month old male in the 7th Grade was
seen in Clinic during 2002
– Brought to the clinic by his guardians (paternal
grandparents)
– Always had problems with attention and hyperactivity (from
birth) as well as oppositional and socially inappropriate
behavior
– These and other difficulties had worsened during the months
preceding the evaluation.
– Diagnosed with ADHD in first grade and has been
medicated since then.
– Grandparents and school wonder if there may be some
disorder in addition to ADHD that my contribute to his
problems.
Developmental/School History
Mom thought to have used drugs and alcohol
during first three months of pregnancy
Pregnancy with no complications
Reached all milestones on time or early
Low grade fevers (undetermined causes) from 1
½ to 4 years.
Hospitalized at age 6 for pneumonia.
Diagnosed with ADHD at age 6
Behavioral difficulties in school but average
academic performance in most subjects
Recent Behavioral Difficulties
During the six months preceding the
evaluation had shown a wide range of
behavioral variations including
Increased oppositional behavior and significant
depression
Refusal to bathe, brush teeth and
Had lost interest in friends and activities
Had often stayed bed for several days at a time
and was easily irritated
More recently has had difficulty sleeping,
sometimes going two to three days without
sleeping.
Recent Behavioral Difficulties
Grandparents noted that some of his
behaviors seem to have been the result of
medication that did not work as expected
Put on hospital homebound school
program due to development of tics,
secondary to medication change (shouting
extreme obscenities at girls – school can’t
protect)
Recent Behavioral Difficulties
Had been on multiple medications in multiple
doses which had not been effective in controlling
his behavior (Examples of Medication).
Medications typically seemed to work for a while
and then stop working or make him much worse
Off-meds grandparents described his behavior
as sometimes “silly, elated, giddy, happy, and
crazy, as if in another world.”
On several occasions has taken off all of his
clothes and “run into the streets howling”
Family History
Mother had been adopted
– Little info on her family background
– Described as wild, impulsive with multiple
monogamous relationships – never married
– Began using tobacco, drugs, and alcohol at 13
– Was killed in car accident (when pt was 9)
Little information about biological father
Paternal GM hospitalized for “Mood Swings”
Paternal GF on meds into his 60’s for “activity and
attention problems”
Paternal Uncle with ADHD.
Bobby has lived with Maternal Grandparents most of his
life
Behavioral Observations
Had not slept for two days prior to
evaluation; did not report being tired
Flat affect through the evaluation
Cooperative throughout the testing but not
forthcoming when talking about feelings or
responding to personality questionnaires
(e.g., leaving out items, refusing to answer
some questions)
Test Results
WASI: FSIQ = 107 (Verbal 102; Performance 109)
WIAT: Reading GE = 8 – 3; Math GE = 5 – 8;
Spelling GE = 8 – 6 (Note. In 7th Grade)
Attention Measures
– Conner’s CPT (Confidence Index = 99.9)
– TEA-CH Selective Attention (Above Average)’ Attentional
Control (Low Average); Sustained Attention (Significantly
Impaired on 4 or 5 tests)
– Conner’s: Clinically significant elevations on:
– DSM IV Hyperactive/impulsive, DSM IV inattention, DSM
IV Total, ADHD index, Social Problems, Oppositional,
Restless-Impulsive, and Emotional Lability (High ranging
profie)
Test Results (Cont)
Personality Inventory for Children
Clinically significant elevations on multiple
scales:
–
–
–
–
–
–
–
Psychosis
Withdrawal
Hyperactivity
Social Skills Deficits
Depression
Delinquency (Behavioral Problems)
Anxiety
PIC PROFILE
Child Test Measures
Administered child anxiety and depression
scales as well as the Roberts Apperception
Test and the Incomplete Sentence
Schedule
Due to patients response set and lack of
motivation and involvement, this data is of
questionable validity
DIAGNOSIS ?
DIAGNOSES
ADHD, Combined type (314.01)
– Long standing history of hyperactiveimpulsive, and inattentive behavior – Poorly
Controlled with Medication
– Highly significant elevations of Conner’s
Parent Report Measure
– Significant Confidence Index on CPT
– Impairments in Sustained Attention on TeaCh
Diagnoses
Major Depressive Disorder (296.2)
Grandparents report of symptoms of
depression, including:
– Highly significant elevations on Personality
Inventory for Children
– Irritable mood
– Anhedonia
– Decreased energy
– Difficulty sleeping
– Problems concentrating
Diagnoses
Bipolar Disorder R/O (296)
Question? Should this be the superordinate diagnosis?
– Grandparents describe the patient’s behavior off of medication as “Crazy,
wild, hyperactive” and note that he becomes “silly, elated, and giddy, as if
in another world”.
– Has taken clothes off and run into the street howling on multiple
occasions; this behavior has occurred as far back as 6 years of age and
as recently as the past year when medications stop working.
– Patient has a history of depression, decreased need for sleep, irritable
mood, and severely disinhibited behavior.
– This is combined with a paternal grandmother who was hospitalization for
“mood swings”, a paternal grandfather who was medicated into his 60’ for
attention problems and activity level.
– Taken together it is believed that he should be further evaluated for
bipolar disorder.
– While a definitive diagnosis is difficult at this time because core
psychopathology has been clouded over time by multiple doses and
combinations of numerous prescription and over-the-counter medications,
it appears that this disorder may well account for his erratic and highly
impairing and behavior
Six Year Follow-up
Patient seen for reevaluation this past year
As an adult (18) wanted an evaluation to
reconsider the “diagnosis” of bipolar
disorder.
Was accompanied to the evaluation by his
Grandfather and his 25 year old fiancé,
with whom he lives.
Clinical Status Update
Significant change in treatment since last
evaluation, although still under the care of
a psychiatrist
Changed from stimulants and
antidepressants + to mood stabilizers +
Some positive effects of mood stabilizers
over the years were described but they
seemed to have not helped with continuing
“major attention problems”.
Clinical Status Update
At the time of evaluation was prescribed
2000 mg of Depakote, 400 mg of
Seroquel, 300 mg of Wellbutrin and .01
mg of synthroid.
Had gained weight on Seroquel; up to 250
pounds.
Said it make him irritable and that he felt
drugged
Quit taking all meds several months and
has now dropped to 140 pounds.
Interview Findings
Reports currently sleeping 7 – 8 hours per
night but reports functioning fine without
any sleep.
Describes major problem with anger
– Frequently extremely irritable – small things
set him off
– When angry he yells, hits, and breaks things
– Numerous physical altercations in and out of
school over the years
– Got drunk and beat fiancé “really bad”
Interview Findings
After previous evaluation he had returned
to school but had rough time
– Frequently suspended and expelled for
fighting and arguing with teachers
– Well known to law enforcement in his
hometown - fighting, drug use
– Feels he can’t go back without being hassled
by police
– Quit high school after middle of 11th grade
Interview Findings
Describes frequent mood changes
– Reports that a couple of times a month will be
giddy and laughing for 2 – 3 days at a time
– Mood is way beyond just being happy; people
notice and comment on his exaggerated
mood.
– Describes having extreme racing thoughts
which “he can’t keep up with” and creates
problems in concentrating
– Describes problems with hyperactivity,
impulsivity and inattention
Interview Findings
Grandfather describes him as significantly
depressed.
Patient also describes himself as “sometimes sad”.
Grandfather says he is just like his mother “overly
happy, manic and then depressed.”
Pt describes himself as self-medicating almost daily
with marijuana to help himself “calm down”
Currently has a drug possession charges pending.
Grandfather concerned over failure to meet with
probation officer for drug testing and having legal
difficulties.
Patient seemingly not concerned.
Interview Findings
Discussed living apart from Grandfather
with fiancé.
Describes good relationship with fiancé
Both unemployed
– Got mom’s inheritance when he turned 18
– Stated that he had enough money to last a
couple of years without working
– Later wants to get GED and learn
computers.
Interview
Findings
“Confidential discussion” regarding inheritance
Patient had agreed with grandfather on a
budget of $2,800 per month to live on.
Unknown to grandfather - first 6 months after
getting inheritance spent over $100,000.
– Two new cars
(both for patient – the second car to drive when he was
tired of driving the first)
– Clothes
– Jewelry
– Unconcerned about how long money will last!
Test Findings
WASI
– FSIQ = 98;
– VIQ = 97;
– PIQ = 99
WIAT II
– Word Reading >12.9 GE
– Reading Comp 12.6 GE
– Math 7.0 (NO) – 7.2 (MR) GE’s
– Written Expression 3.1 GE
(Low Written Expression due to disinterest and
impulsiveness in responding)
Test Findings
Parent Report Measures: Conner’s 3; BASC
– Clinically Significant Elevations on Conner’s Scales:
ADHD Inattentive; ADHD Hyperactive/Impulsive;
Oppositional Defiant; Aggression; Peer Relations; ADHD
Index; Global Index; and Executive Function Scale
– Extreme Elevations on Most Scales
– Clinically Significant Elevations on the BASC
Clinically Significant elevations on Hyperactivity, Conduct
Problems, Attention Problems; “At Risk elevations on
Depression, Atypicality, and Withdrawal
Also, significant impairment in Daily Living Skills, and
difficulties in social skills and functional communication
MMPI 2
MMPI FINDINGS
Clinically significant elevations on scales
reflecting
– extremely high levels of manic/hypomanic
symptomatology
– suspiciousness/distrust
– antisocial features
– a level of mental confusion that may be reflected in
poor judgment in everyday life.
Content Scales, composed of critical items
associated with depression, suggest significant
depressive symptomatology
Examples of Critical Items
DIAGNOSIS ?
Diagnoses
Attention Deficit Hyperactivity Disorder,
Combined Type (314.01)
Bipolar Disorder, Not Otherwise Specified
(296.80)
Are both warranted ??
Recommendations
Given concerns expressed by the patient and his
Grandfather regarding his current medication regimen,
along with the fact that pt is not taking his medications,
continued consultation with his psychiatrist is
important.
This consultation should include discussion of the
undesirable side effects that patient has experienced
from this current medications (weight gain, feeling
drugged), as well as concerns that his serious
attention problems continue to impair his functioning.
Hopefully, an approach can be found to optimally
address his current mood related difficulties as well as
his attention problems and impulse control.
Recommendations
It is highly recommended that the Bobby become
involved in working with a therapist who can focus
on evidence based treatment to help him deal with
issues of depression and anger management.
It would also be important for Bobby to work with a
counselor to assist him in the areas of
– financial management,
– the development of more adaptive life management
and general problem solving skills,
– assisting him in planning for the completion of the
GED and
– the subsequent development of vocational skills in an
area related to his interests.
The End