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Bipolar disorder in children and adolescents
Boris Birmaher and David Axelson
University of Pittsburgh Medical Center, Pittsburgh, PA, USA

There is no doubt that children and adolescents may experience classical
Kraepelinian (1921) or Diagnostic and Statistical Manual of Mental Disorders
(DSM)-type bipolar disorder (BP-I, II, mixed, rapid-cycling; American
Psychiatric Association, 1994). However, as discussed in detail below, many BP
children and adolescents have very short and frequent periods of mania, hypo-
mania, or depression and, more controversially, some have continuous mood
lability and irritability (Nottelman et al., 2001). Children and adolescents with
BP disorder usually have poor psychosocial outcome, increased risk for suicide,
substance abuse, and psychosis (Lewinsohn et al., 1995, 2000; Strober et al., 1995;
Geller et al., 1998a, b, 2000a, b, 2001; Birmaher, 2001), indicating the need for
accurate diagnosis and prompt treatment of this illness.
Since the research on BP disorder in children and adolescents is in its earlier stages,
below we present the extant literature following in most part the criteria described by
Robins and Guze (1970) to validate a psychiatric disorder, including the presence of
a reliable diagnosis that can be differentiated from other psychiatric disorders,
specific course, family history, response to treatment, and biological characteristics.
Because of their scarcity, no biological studies are presented in this chapter.

A large adolescent community study, using the Schedule for Affective Disorders
and Schizophrenia for School-Aged Children (6“18) epidemiologic version (K-
SADS) (Chambers et al., 1985), found that, similar to adult epidemiological
studies, DSM-IV bipolar disorder was approximately 1% (Lewinsohn et al.,
1995). However, most adolescents had BP-II (periods of major depression and
hypomania) and cyclothymic disorders. Another 6% of the sample showed
Cambridge University Press, 2005.
238 B. Birmaher and D. Axelson

Table 10.1 Clinical manifestations of bipolar disorder in children and

Typical phenotype (DSM-IV) (bipolar I and bipolar II)
Many of these children have rapid-cycling and mixed bipolar presentations
Typical phenotype but for a short time (DSM-IV BP NOS)
Many have rapid-cycling and mixed episodes
Broad phenotype
Continuous mood lability, mood swings, affective storms, irritability,
anger, aggressiveness, periodic agitation, explosiveness, recurrent severe
temper tantrums, ADHD-like symptoms

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edn;
BP NOS, bipolar not otherwise specified;
ADHD, attention-deficit hyperactivity disorder.

subsyndromal BP symptoms, defined in the study as the presence of a distinct
period of abnormally and persistently elevated, expansive, or irritable mood. In
clinical samples the incidence of BP disorder in children and adolescents has
ranged from 2% to 15% depending on the nomenclature system, assessment
instruments, and methodology used to diagnose patients™ psychiatric disorders
and sample origin (e.g., inpatient versus outpatient; Geller et al., 1995; 1998a, b;
Wozniak et al., 1995; Axelson et al., 1998).

Clinical diagnoses
Based on the literature and our clinical experience, the following three types of BP
presentations in youth can be identified (Nottelmann et al., 2001) (Table 10.1):
(1) patients with typical DSM-IV BP characteristics
(2) patients with DSM-IV BP characteristics but whose symptoms are of short
(3) children and adolescents with continuous mood lability, irritability, and
severe temper outbursts
Patients with Kraepelinian or DSM-IV classical BP disorder display the cognitive,
emotional, and behavioral BP symptomatology described in adult BP populations,
with a great proportion having mixed and rapid cycles. These youths usually
represent the minority of BP disorder cases seen at the clinics. In contrast, most
BP children and adolescents do not have the time duration (7 days for mania and
4 days for hypomania) required by the DSM nomenclature and are usually
diagnosed as BP-not otherwise specified (NOS). These patients usually display
mixed or very-rapid-cycling presentations but it is not clear whether they can be
239 Bipolar disorder in children and adolescents

Mixed mania
50% Rapid cycling
Suicidal (plan and intent)

Mean age = 10.9 ± 2.6 years

Fig. 10.1 Prepubertal bipolar disorder.

classified as such because the DSM-IV definitions of rapid-cycling or mixed state
require that the periods of mania or hypomania last 7 or 4 days respectively.
There are few phenomenological studies of BP disorder in children and adoles-
cents. These studies include one or more of the BP presentations described above.
Geller et al. (1998b, 2002b) studied 93 children (mean age: 11 years) diagnosed
with BP disorder and compared them with 81 children with attention-deficit
hyperactivity disorder (ADHD) and no mood disorders, and 94 normal controls.
To enter the study children needed to have grandiose ideation and/or elated mood.
Compared to ADHD and normal control children, the BP group had an increased
incidence of psychosis and suicidality (Fig. 10.1). Most children (80%) had very
rapid fluctuations in their mood with very short periods of mania, sometimes
lasting for only a few hours. Irritability, hyperactivity, and short attention span did
not differentiate children with BP disorder from those with ADHD. Only symp-
toms specific for BP disorder, including grandiosity, elation, flight of ideas, and
hypersexuality, differentiated the two groups.
Data from our own outpatient clinical population at Western Psychiatric
Institute and Clinic (WPIC) indicate that child and adolescent BP disorder pre-
sents predominantly with brief episodes of manic symptoms that reach the DSM-
IV threshold for severity. In examining a database of KSADS-P intake interviews of
1926 pediatric patients referred to the WPIC child mood and anxiety outpatient
services from 1985 to 1995, we identified 120 patients (6.2% of the sample) who
met the DSM-IV symptom criteria for a manic episode. The median episode
duration of manic symptoms was found to be 1“2 days. Only 19% of the manic
patients had episodes of manic symptoms that lasted the 1 week or longer which is
the DSM-IV duration criterion for a manic or mixed episode.
240 B. Birmaher and D. Axelson

BP-spectrum MDD Other Axis I D/O

% of patients




Suicide attempt Psychosis Conduct D/O
BP > other axis I (P = 0.01) BP > other axis I (P < 0.001) BP > MDD (P = 0.003)
BP > MDD (P < 0.001)

Fig. 10.2 Western Psychiatric Institute and Clinic (WPIC) mood and anxiety disorder outpatients.
BP, bipolar; MDD, major depressive disorder; D/O, disorder.

Similar to other studies, the youth presenting with manic symptoms to the
WPIC outpatient services had severe psychopathology that was often more serious
than other children and adolescents presenting for clinical treatment (Fig. 10.2).
Compared to non-BP youth presenting with a major depressive disorder (MDD,
n ¼ 916), children and adolescents with manic symptoms had significantly higher
rates of psychosis (20% versus 7%) and conduct disorder (18% versus 11%).
Youth presenting with manic symptoms also had higher rates of psychosis (20%
versus 3%) and suicide attempts (25% versus 16%) compared with youth who met
criteria for other non-MDD, non-BP Axis I disorders (n ¼ 679).
Depression during the current psychiatric episode was a pervasive feature of
children and adolescents who presented to our outpatient services with manic
symptoms. Approximately 66% of these patients had moderate or worse depressed
mood and 78% of them met three or more DSM-IV criteria for MDD during the
current psychiatric episode. Forty-five (38%) of the children and adolescents who
presented with manic symptoms were also given a clinical diagnosis of MDD
during the current psychiatric episode. The high rates of mixed states and cycling
between depression and manic symptoms were similar to the ones reported in
Geller and colleagues™ study, reported above. Also, as in the study by Geller et al.
(1998b), irritability was a non-specific symptom that did not differentiate BP
youth from youth with other disorders. Irritability was present in 93% of youth
presenting with manic symptoms, while irritability was present in 89% of youth
with MDD and 60% of youth with other Axis I disorders.
In addition to the BP presentations described above, there is a more contro-
versial group of children who have been diagnosed as BP (Table 10.1). These
children do not have typical manic/depressive symptoms but ongoing mood
lability, very low frustration tolerance, agitation, frequent severe temper outbursts,
241 Bipolar disorder in children and adolescents

Table 10.2 Consequences of bipolar disorder

Poor academic functioning

Interpersonal and family difficulties

Increased risk for suicide

Increased use of tobacco, alcohol, and other substances

Behavior problems

Legal difficulties

Increased health services utilization (e.g., hospitalizations)

irritability, ADHD-like symptomatology, sometimes silliness, and short periods of
dysphoria (Wozniak et al., 1995; Biederman, 1998). Since these children have
˜˜continuous manic symptoms™™ without accompanying elation or grandiosity, it is
difficult to differentiate them from other psychiatric disorders and in particular
ADHD or oppositional defiant disorder (ODD).
This last group of children represents the majority of patients currently referred
to our clinics to rule out BP disorder. They usually have heterogeneous psychiatric
disorders (e.g., ADHD, ODD, Asperger™s disorder, recurrent MDD) accompanied


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