# Bipolar disorder in children

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time (i.e. days, weeks, or years) and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.
Since 1980, the DSMTooltip Diagnostic and Statistical Manual of Mental Disorders has specified that the criteria for bipolar disorder in adults can also be applied to children with some adjustments based on developmental differences. Genetics and environment are considered risk factors for the development of bipolar disorder with the exact cause unknown at this time. Therefore, diagnosis of bipolar disorder requires evaluation by a professional and diagnosis of PBD typically requires more in depth observation due to children's inability to properly report symptoms.

## Causes

While there is limited understanding regarding the development of bipolar disorder, research shows that there are many environmental and biological risk factors. Family history is a strong predictor of childhood development of bipolar disorder, with genetics contributing to risk by up to 50%. With this in mind, it is important to understand that family history does not lead to absolute diagnosis of PBD in the child. Only 6% of children with parents diagnosed with bipolar disorder also have bipolar disorder. Still, children of parents with bipolar disorder should be monitored for possible development of bipolar disorder especially if they exhibit sleep disturbances and symptoms of anxiety disorders early on. Other factors that can contribute to pediatric bipolar disorder include substance use disorder and childhood adversity such as abuse or school trauma.

## Diagnosis

Diagnosis is made based on a clinical interview by a licensed mental health professional. There are no blood tests or imaging to diagnose bipolar disorder. Pediatric bipolar disorder can be difficult to diagnose, especially in children under 11–12 years as they may be unable to properly self-assess and communicate any possible symptoms. Therefore, it is helpful to obtain information from multiple sources, such as family members and teachers, and use questionnaires and checklists for a more accurate diagnosis. Commonly used assessment tools include the K-SADS (Kiddie Schedule for Affective Disorders and Schizophrenia), the Diagnostic Interview Schedule for Children (DISC), and the Child Mania Rating Scale (CMRS). It is important to assess the child's baseline mood and behavior and determine if the symptoms present episodically. Often, parents are encouraged to keep mood logs to assist with this. Family history is also important to obtain as bipolar disorder is heritable. Medication, substance use, or other medical problems should be ruled out to appropriately diagnose bipolar disorder.
Early diagnosis is important for children to start treatment soon and leads to better outcomes. Often, anxiety disorders and sleep disturbances precede the mood symptoms of PBD. If a child presents with symptoms of anxiety and changes in sleep pattern with major changes in energy and deterioration of function, especially in school, this may warrant evaluation for PBD.
It can be difficult to distinguish pediatric bipolar disorder due to overlapping symptoms with other conditions such as ADHD, OCD, autism spectrum disorder, depression, anxiety, or conduct disorders. For example, irritability, distractibility, and poor judgment are symptoms commonly seen in pediatric bipolar disorder and ADHD. Elated mood and decreased need for sleep can be specifically diagnostic of PBD.

### Signs and symptoms

The American Psychiatric Association's DSM-5Tooltip Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the World Health Organization's ICD-10Tooltip International Classification of Diseases (ICD-10), use the same criteria to diagnose bipolar disorder in adults and children with some adjustments to account for differences in age and developmental stage, particularly with depressive episodes. For example, the DSM-5 specifies that children may exhibit persistently irritable moods instead of a depressed mood. Additionally, children will more than likely fail to meet their expected body weight instead of presenting with weight loss.
In diagnosing manic episodes, it is important to compare the changes in mood and behavior to the child's normal mood and behaviors at baseline instead of to other children or adults. For example, grandiosity (i.e., unrealistic overestimation of one's intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child's normal self-view in between episodes.
It is important to distinguish if irritability is related to bipolar disorder or another condition as it is commonly in other childhood disorders. If irritability is persistent, it is important to differentiate from chronic irritability seen in disruptive mood dysregulation disorder (DMDD).
In particular, PBD and ADHD have many overlapping symptoms at the surface, such as the hyperactivity characteristic of the manic episodes that occur in PBD. As a result, many children and adolescents with PBD are instead diagnosed with ADHD. Misdiagnosis of PBD can lead to complications in youth and adolescents as different disorders require different types of medications that may make symptoms of PBD more severe.

#### Manic episodes include

* Elevated mood (or increased silliness in children)
* Rapid speech that is difficult to interrupt
* Decreased need for sleep
* Racing thoughts
* Increased interests/participation in activities (especially those considered more reckless)
* Inflated sense of ability

#### Depressive episodes include

* Frequent and unprovoked sadness
* Physical pain (stomach aches, headaches)
* Sleeping more
* Difficulty concentrating
* Worthlessness/hopelessness
* Changes in eating habits

### Subtypes

According to the DSM-5 there are 3 major categories of bipolar disorder: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). Just as in adults, bipolar I is the most severe form of PBD in children and adolescents, and can impair sleep, general function, and lead to hospitalization. Bipolar NOS is the mildest form of PBD in children and adolescents. The criteria for distinguishing is the same as that of bipolar disorder (BD) in adults.

### Controversy

The diagnosis of childhood bipolar disorder has been heavily debated. It is recognized that the typical symptoms of bipolar disorder are dysfunctional and have negative consequences for minors with the condition. The main discussion is centered on whether what is called bipolar disorder in children refers to the same disorder in adults, and the related question on whether the criteria for adult diagnosis is useful and accurate when applied to children. More specifically, regarding the symptomatology of mania and its differences between children and adults.
There are significant differences in how commonly PBD is diagnosed across clinics and in different countries. In the United States, there were concerns about over diagnosis and misdiagnosis of PBD. More understanding and research lead to a decrease in PBD diagnosis from mid-2000s to 2010. This is likely due to the various challenges that come with identifying bipolar disorder in youth. PBD has many overlapping symptoms with other childhood conditions.

## Management

A combination of medication and psychosocial intervention is recommended for most pediatric populations with PBD and has been proven to lead to improved prognosis. In order to choose the best medication and therapy, it is important to consider the child's age, their psychosocial environment, presentation and severity of symptoms, and their family history.

### Medication

Mood stabilizers, which help manage manic episodes, and atypical antipsychotics, which help manage both manic and depressive episodes, have been demonstrated to be the safest and most effective in pediatric populations for the treatment of PBD. Mood stabilizers used for the treatment of PBD include: lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine. Lithium is FDA approved for those 12 years and older appears to be particularly effective in children with a family history of mood disorders especially if the family members have been successfully treated with lithium. Atypical antipsychotics that have been approved for use by the FDA for treatment of PBD include risperidone, cariprazine, lurasidone, olanzapine-fluoxetine combination, and quetiapine. Risperidone has been approved for use in children 10 and older. Medications have also been proven effective when used in combination whether that is multiple mood stabilizers or a mood stabilizer with an atypical antipsychotic.
Medications for the treatment of PBD can produce significant side effects, so it is recommended that families of patients be informed of the different possible issues that can arise. Although atypical antipsychotics are more effective in treating PBD than mood stabilizers, they can lead to more side effects. Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidemia. Extrapyramidal secondary effects may occur with the use of these medications, including tardive dyskinesia, a difficult-to-treat movement disorder. Liver and kidney damage may occur as a result of the use of mood stabilizers. Lithium overdose can also occur in individuals with low sodium levels. Pediatric populations often struggle with medication adherence for PBD, which can be improved with motivational interviewing techniques.

### Psychotherapy

Psychological treatment for PBD can take on several different forms such as psychoeducation, psychotherapy, and alternative treatments. One form of psychotherapy is psychoeducation, in which children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments. Similarly, family-focused therapy (FFT) is therapy for both individuals with PBD and their caregivers, in which families take part in communication improvement training and problem-solving skills training. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Another type of therapy used in individuals with PBD is chronotherapy, which helps children and adolescents form a healthy sleep pattern, as sleep is often disrupted by PBD symptoms. Finally, cognitive-behavioral therapy (CBT) aims to make participants have a better understanding and control over their emotions and behaviors.
Psychotherapy can be tailored to each individual and address needs that medication alone cannot to help improve lifestyle and functionality. Additionally, psychotherapy improves medication adherence.
Alternative treatments are currently being developed for pediatric populations with PBD in which medication and psychotherapy has proven to be ineffective. Currently, interventions involving dialectical behavioral therapy (DBT) are being explored due to the focus on mindfulness and distress tolerance skill building. According to the APA, studies have shown that DBT may lead to decreased suicidal ideation compared to typical psychosocial treatments. Nutritional interventions are also currently undergoing further research along with other lifestyle modifications including exercise and proper sleep habits.

## Prognosis

Bipolar disorder is a chronic condition that requires lifelong care and treatment. Without proper treatment, PBD oftentimes has a poor prognosis in children and adolescents. Chronic adherence to medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost 40% in those complying with medication regimens in some studies. Other risk factors for poor outcomes of PBD and increased severity of symptoms are comorbid pathologies and early onset of disease.
Children with PBD, especially early onset, are more likely to commit suicide than other children, as well as misuse alcohol and/or other drugs. Studies have shown that among adolescents with PBD, 44% report a lifetime suicide rate, twice as much compared to teens diagnosed major depressive disorder. Children and adolescents with PBD are also at an increased risk for behavior that can result in incarceration.
Hypomanic episodes in adolescents have been shown to not always progress into adult bipolar disorder. However, research surrounding PBD emphasizes the importance of early diagnosis of PBD for improved prognosis.

## Comorbid conditions

The most common comorbidities seen with PBD is ADHD (80%) and oppositional defiant disorder (47%). Anywhere between 13.2% and 29% of patients with bipolar disorder are diagnosed with conduct disorder, substance use disorders, anxiety disorders, or borderline personality disorder.
Comorbid ADHD can be diagnosed if symptoms such as hyperactivity and distractibility are present persistently. If they are purely related to mood episodes, this is likely a symptom of PBD. Therefore, it is important to carefully evaluate onset of symptoms and course of time present. While difficulty with sleep can be present in both, patients with bipolar disorder will typically have a decreased need for sleep during manic episodes while children with ADHD will have sleep problems with increased fatigue. Grandiosity is also a distinguishing factor as mania typically presents with increased self-esteem and in ADHD children may actually have lower self esteem.

## Epidemiology

Globally, the prevalence of PBD in children and adolescents under the age of 18 is estimated at 3.9% as of 2019. However, 5 surveys (from Brazil, England, Turkey, and the United States) have reported pre-adolescence rates of PBD as zero or close to zero.
The increase in PBD in children in the United States is attributed to the cohort effect (shared circumstances of more recently born children) as well as the anticipation effect (the earlier onset of genetic conditions in later generations).

## History

Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger's criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.
In Emil Kraepelin's descriptions of bipolar disorder in the 1920s, which he called "manic depressive insanity", he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.
Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.