Juvenile/Child Onset Bipolar Disorder Diagnoses of bipolar disorder in childhood are rare, even among adolescent populations. One of the reasons why bipolar disorder is infrequently diagnosed is the “symptomatic overlap with attention deficit hyperactivity disorder (ADHD),” (Wozniak, Biederman, Kiely, et al., 1995). Diagnoses are likely dependent on contextual variables, as the psychologist or psychiatrist has leeway when assessing the child. Research on child onset bipolar disorder has evolved, though, to offer the clinical community more cogent guidelines for age-appropriate symptom assessment and diagnosis. Preliminary research demonstrates unique features of prepubescent-onset bipolar disorder as being, compared with adult-onset bipolar disorder, “nonepisodic, chronic, rapid-cycling,” characterized by a “mixed manic state that may be comorbid with ADHD and conduct disorder (CD),” (Geller & Luby, 1997, p. 1168). Other possible comorbidities and symptom overlap have been found with autism spectrum disorders, warranting future research on improving the exclusion criteria used to diagnose one or more of these clinical psychiatric disorders (Stahlberg, Soderstrom, Rastam, et al., 2004). Recent neurobiological research has yielded evidence supporting a construct known as bipolar spectrum disorders (BPSD), based on findings of structural abnormalities in cortical, subcortical, and limbic brain systems in youth who may therefore be labeled as at high risk for developing full-fledged bipolar disorder as adults (Bauer, Ramakrishnan, Saxena, et al., 2017). The designation of “high-risk” students remains more common than official bipolar diagnoses. Educators need not concern themselves with the minutia of psychiatric diagnoses, because best practices in instruction, classroom design, educational philosophy, and pedagogy will reflect the needs of individual students.

Definitions and Characteristics

Bipolar disorder is defined not legally, as through legislation like the Individuals with Disabilities Education Act (IDEA), but clinically. The most established, reliable evidence-based definitions are provided by professional organizations like the American Psychiatric Association. The American Psychiatric Association publishes and updates the Diagnostic and Statistical Manual (DSM), to offer the evidence-based diagnostic criteria for formally assessing individuals. Diagnostic criteria are both rigid and flexible, allowing for significant clinical judgment, and also include exclusionary criteria so that psychologists, psychiatrists, and other clinicians can ensure accurate diagnoses for conditions with considerable symptom convergence. For example, one of the key characteristics of bipolar disorder is the expression of manic symptoms or mania: defined by “a period of at least one week during which the person is in an abnormally and persistently elevated or irritable mood,” (Juvenile Bipolar Research Foundation, 2018, p. 1). Mania is considered a “cardinal symptom” of the disorder, for without the presence of mania in the child’s behavioral presentation, the child would be more likely to be diagnosed with a depressive disorder (Juvenile Bipolar Research Foundation, 2018, p. 1). Manic behaviors can, however, resemble those found in ADHD such as “intensified speech,” “distractibility,” and “psychomotor agitation,” (Juvenile Bipolar Research Foundation, 2018, p. 1). These are only a few of the behavioral features of bipolar disorder, though, which is also characterized by the opposite polarity of mania: depression.

The disorder is thus named because of its representing two poles: mania and depression, and was once commonly known as manic depression. Definitions of the disorder therefore must include the presence of a “major depressive episode,” in addition to exhibitions of mania for a specific duration and time frame (Juvenile Bipolar Research Foundation, 2018, p. 1). Depressive episodes can be more difficult to observe, with internalizing behaviors and characteristics that differ sharply from the externalizing ones...

For example, the child may be fatigued, listless, or withdrawn, showing little interest even in activities that were once found enjoyable or pleasurable. The inability to concentrate is a feature of depression as well as of mania, though, which challenges clinicians to differentiate bipolar symptoms from those of ADHD. Other characteristics of children with bipolar disorder include sleep problems—both insomnia and hypersomnia—changes in eating habits, irritability, and expressing feelings of “worthlessness or excessive, inappropriate, or delusional guilt nearly every day,” (Juvenile Bipolar Research Foundation, 2018, p. 1). Research on child onset bipolar disorder shows that rather than experiencing longer episodes of manic and depressive states, young people cycle rather rapidly (Geller & Luby, 1997). In other words, teachers may notice the child experiencing rapid and sudden mood swings resulting in behavioral, attitudinal, or psychological changes throughout the day.
Furthermore, children do exhibit different symptoms, behaviors, and characteristics than adults. Children also differ in their symptom expression according to factors like age, gender, and environmental factors that increase or exacerbate risk. For example, trauma and child abuse are persistent and severe risk factors, with almost half of individuals diagnosed with BPSD having experienced childhood trauma (Garno, Goldberg, Ramirez, et al., 2018). It is also important to differentiate between subtypes of bipolar disorder: including Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS), each of which has further subtypes to help with diagnosis and treatment interventions. Bipolar I Disorder is characterized by the child having a full manic episode. A full manic episode is differentiated from a “hypomanic” episode in both intensity and duration, with hypomania being less severe than, full-fledged mania (Juvenile Bipolar Research Foundation, 2018, p. 1). If the child has demonstrated a manic episode, then the diagnosis may be Bipolar I Disorder. If no manic episode but only hypomania was evident, then the child is more likely to be diagnosed with Bipolar II Disorder. Most children who have been diagnosed with clinical BPSD will, however, receive the Bipolar NOS diagnosis, which is characterized more by the rapid cycling, and an unclear etiology or prognosis (Geller & Luby, 1997).

Regardless of age cohort, most children with BPSD will be characterized more by their mania, which is differential from ADHD in that it is accompanied by depressive episodes as well. Research shows that there are no significant differences between children at different age levels or even different genders in that all exhibited similar mania criteria and behaviors—even though male children of all ages were more likely to be diagnosed with comorbid ADHD (Geller, Zimerman, Williams, et al., 2000). Also, child onset bipolar disorder tends to be different from adult bipolar disorder in that the manic episodes are characterized more by irritability or aggressive behavior than by the “euphoria” that adults report when experiencing a manic episode (Wozniak, Biederman, Kiely, et al., 1995). Research also shows that children with bipolar do not exhibit the “intense mission-driven efforts” to complete tasks or the seemingly obsessive behaviors that characterize adult bipolar disorder (Blader & Carlson, 2007). Therefore, teachers will not necessarily notice students becoming overly absorbed in something and more likely to witness “vigorous and hurried activity...without much goal direction,” (Blader & Carlson, 2007, p. 107).

One of the main age-related issues in childhood bipolar disorder is the role that puberty plays in behavior and symptom expression. Research shows that prepubertal children with bipolar disorder are “more hyperactive” than their postpubertal counterparts and therefore more likely to receive a comorbid diagnosis of ADHD (Geller, Zimerman, Williams, et al., 2000). Moreover, postpubertal adolescents exhibit different manic symptoms than…