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Facts About Childhood-Onset Bipolar Disorder
What is childhood-onset bipolar disorder (COBPD), and how does it
differ from bipolar disorder (manic-depression) in adults?
All those with bipolar disorder experience mood swings that alternate from
periods of severe highs (mania) to severe lows (depression). However, while
these abnormally intense moods usually last for weeks or months in adults
with the illness, children with bipolar disorder can experience such rapid
mood swings that they commonly cycle many times within a day. The most
typical pattern of cycling among those with COBPD, called ultra-ultra rapid
or ultradian, is most often associated with low arousal states in the mornings
followed by increases in energy towards late afternoon or evening.
It is not uncommon for the initial episode of COBPD to present itself as
major depression. But as clinical investigators have followed the course of the
disorder in children, they have observed a significant rate of transition from
depression into bipolar mood states.
Is COBPD usually inherited?
Yes. One of the most important factors in establishing the diagnosis is family
history. According to several recent studies, a history of mood disorders
(particularly bipolar disorder) and/or alcoholism on both the maternal and
paternal sides of a family appears to be commonly associated with COBPD.
How early in childhood does the disorder start? What are some
common early symptoms?
Many parents report that their children have seemed different since early
infancy. They describe difficulty settling their babies, and they note that their
children are easily over-responsive to sensory stimulation. Sleep disturbances
and night terrors are also commonly reported.
Later in a child's development, hyperactivity, fidgetiness, difficulties making
changes, and high levels of anxiety (particularly in response to separation
from the child's mother) are commonly seen. Additionally, being easily
frustrated, having difficulty controlling anger, and impulsiveness (difficulty
waiting one's turn, interrupting others) often result in prolonged and violent
Are there other childhood
psychiatric conditions that can
co-occur with bipolar disorder?
Yes. Rarely does bipolar disorder in children occur by itself. Rather, it is
often accompanied by clusters of symptoms that, when observed at certain
points of the child's life, suggest other psychiatric disorders such as
attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive
disorder (OCD), oppositional defiant disorder, and conduct disorder.
An estimated 50 percent to 80 percent of those with COBPD have ADHD
as a co-occuring diagnosis. Since stimulant medications often prescribed for
ADHD (Dexedrine, Adderall, Ritalin, Cylert) have been known to escalate
the mood and behavioral fluctuations in those with COBPD, it is important to
address the bipolar disorder before the attention-deficit disorder in such
cases. Some clinicians suggest that the prescription of a stimulant for a child
genetically predisposed to develop bipolar disorder may induce an earlier
onset or negatively influence the cycling pattern of the illness.
What is the difference between ADHD and COBPD?
Several studies have reported that more than 80 percent of children who go
on to develop COBPD have five or more of the primary symptoms of
ADHD-distractibility, lack of attention to details, difficulty following through
on tasks or instructions, motor restlessness, difficulty waiting one's turn, and
interrupting or intruding upon others. In fact, difficulties with attention are so
common in children that ADHD is often diagnosed instead of bipolar
disorder. Actually, ADHD often appears before a clear development of the
frequent alternating mood swings and prolonged temper tantrums associated
While the symptoms of COBPD and ADHD may be similar, their origins
differ. For instance, destructiveness and misbehavior are seen in both
disorders, but these behaviors often seem intentional in those with COBPD
and caused more by carelessness or inattention in those with ADHD.
Physical outbursts and temper tantrums, also features of both disorders, are
triggered by sensory and emotional overstimulation in those with ADHD but
can be caused by limit-setting (e.g., a simple "No" from a parent) in
those with COBPD. Furthermore, while those with ADHD seem to calm
down after such outbursts within 15 to 30 minutes, those with COBPD often
continue to feel angry, sometimes for hours. It is important to note that
children with COBPD are often remorseful following temper tantrums and
express that they are unable to control their anger.
Other symptoms, such as irritability and sleep disturbances often
accompanied by night terrors with morbid, life-threatening content (e.g.,
nuclear war or attacking animals), are commonly seen in those with COBPD
but are rarely associated with ADHD.
How does the illness affect
school performance and social
Deficits in shifting and sustaining attention, as well as difficulties inhibiting
motor activity once initiated, can strongly influence both classroom behavior
and the establishment of stable peer relationships. Distractibility,
daydreaming, impulsiveness, mischievous bursts of energy that are difficult for
the child to control, and sudden intrusions and interruptions in the classroom
are also common features of the COBPD.
Stubborn, oppositional, and bossy behavior, usually appearing between the
ages of six to eight, pose significant problems for parents, educators, and
peers. Risk-taking, disobedience to authority figures, and the likelihood of
becoming addicted to psychoactive drugs such as marijuana and cocaine also
present serious concerns to those affected by a child with COBPD.
Furthermore, a high percentage of children with COBPD have co-occurring
learning disabilities, a problem that can negatively affect school performance
Should parents tell teachers?
Teachers need to be educated about the common behaviors, symptoms, and
nature of COBPD. Most families have found that many teachers can be
sympathetic allies when they fully understand the day-to-day problems of the
child. A teacher's view of a child is limited to the period of day when most
bipolar children are less easily aroused and can tolerate and be responsive to
social rules set by the teacher. Teachers often see only the child's attention
problems, fidgetiness, and occasional abundance of mischievous energy, not
the explosive tantrums.
How is COBPD treated?
The first line of treatment is to stabilize the child's mood and to treat sleep
disturbances and psychotic symptoms if present. Once the child is stable,
therapy that helps him or her understand the nature of the illness and how it
affects his or her emotions and behavior is a critical component of a
comprehensive treatment plan.
Some medications have also proved useful. Since few treatment studies have
been conducted in children, though, most clinicians use drugs that have been
tested and proved successful in adult forms of bipolar disorder. For mood
stabilization these include: lithium carbonate (Lithobid, Lithane, Eskalith),
divalproex sodium (Depakote, Depakene), and carbamazepine (Tegretol).
Newer agents such as gabapentin (Neurontin), lamotrigine (Lamictal), and
topirimate (Topomax) are currently under clinical investigation and are being
used in children. (Lamictal is not recommended for those under the age of
For the treatment of psychotic symptoms and aggressive behavior,
risperidone (Risperdal) and olanzapine (Zyprexa) are commonly used newer
agents, while thioridazine (Mellaril), trifluperazine (Trilafon), and haloperidol
(Haldol) are old standbys. Clonazepam (Klonopin) and lorezapam (Ativan)
are also used to treat anxiety states, induce sleep, and put a brake on
rapid-cycling swings in activity and energy.
What about the use of antidepressant drugs?
It's very risky. Several studies have reported very high rates of the induction
of mania or hypomania (rapid-cycling) in children with bipolar disorder who
are exposed to antidepressant drugs of all classes. In addition, the child may
experience a marked increase in irritability and aggression. The course of the
disorder may be altered if antidepressants are prescribed without mood
Papolos, D.F. and J.D. Papolos. The Bipolar Child. New York City:
Broadway Books, in press (pub. date fall, 1999).
Papolos, D.F. and J.D. Papolos. Overcoming Depression. New York City:
Reviewed by Demitri F. Papolos, M.D., associate professor of psychiatry
and co-director of the Program in Behavioral Genetics, Albert Einstein
College of Medicine/Montefiore Medical Center, New York City
Source: NAMI at www.nami.org