Childhood Bipolar Disorder: Diagnosis, Traits & Education

Introduction to Juvenile-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 its "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 considerable leeway when assessing the child. Research on child-onset bipolar disorder has evolved, however, 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" remains more common than an official bipolar diagnosis. Educators need not concern themselves with the minutiae of psychiatric diagnoses, because best practices in instruction, classroom design, educational philosophy, and pedagogy will naturally reflect the needs of individual students.

Definitions and Diagnostic 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 such as the American Psychiatric Association, which publishes and updates the Diagnostic and Statistical Manual (DSM) to offer evidence-based diagnostic criteria for formally assessing individuals. Diagnostic criteria are both rigid and flexible, allowing for significant clinical judgment. They 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 as "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; 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, which is also characterized by the opposite polarity of mania: depression.

The disorder is named for its representing two poles — mania and depression — and was once commonly known as manic depression. Definitions must therefore 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 shown during the manic stage. For example, the child may be fatigued, listless, or withdrawn, showing little interest even in activities once found enjoyable or pleasurable. The inability to concentrate is a feature of depression as well as of mania, 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 a child experiencing rapid and sudden mood swings resulting in behavioral, attitudinal, or psychological changes throughout the day.

Furthermore, children exhibit different symptoms, behaviors, and characteristics than adults. Children also differ in their symptom expression according to factors such as age, gender, and environmental influences 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 among subtypes of bipolar disorder — including Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS) — each of which has further subtypes to aid in diagnosis and treatment planning.

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, the diagnosis may be Bipolar I Disorder. If no manic episode but only hypomania was evident, 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 rapid cycling and an unclear etiology or prognosis (Geller & Luby, 1997).

Age, Gender, and Symptom Variation

Regardless of age cohort, most children with BPSD will be characterized more by their mania, which is differentiated 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). Child-onset bipolar disorder also tends to differ from adult bipolar disorder in that manic episodes are characterized more by irritability or aggressive behavior than by the "euphoria" adults report during a manic episode (Wozniak, Biederman, Kiely, et al., 1995). Research further shows that children with bipolar disorder 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 a task; they are 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 their younger counterparts, including hypersexuality, without any significant differences related to gender (Geller, Zimerman, Williams, et al., 2000).

References

American Academy of Child and Adolescent Psychiatry (2018). Bipolar disorder resource center. https://www.aacap.org/aacap/families_and_youth/resource_centers/bipolar_disorder_resource_center/home.aspx

Bauer, I. E., Ramakrishnan, N., Saxena, K., et al. (2017). 7.4 Functional activation during an implicit emotional face processing task in children and adolescents with bipolar disorder and unaffected offspring of bipolar parents. Journal of the American Academy of Child & Adolescent Psychiatry, 56(10), S311–S312. doi:10.1016/j.jaac.2017.07.615

Blader, J. C., & Carlson, G. A. (2007). Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996–2004. Biological Psychiatry, 62(2), 107–114. doi:10.1016/j.biopsych.2006.11.006

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Johnson, C., Eva, A. L., Johnson, L., & Walker, B. (2010). Don't turn away: Empowering teachers to support students' mental health. The Clearing House: A Journal of Educational Strategies, Issues and Ideas, 84(1), 9–14. doi:10.1080/00098655.2010.484441

Juvenile Bipolar Research Foundation (2018). The bipolar disorder classification as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). https://www.jbrf.org/diagnosis-by-the-dsm/

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Post, R. M., Altshuler, L. L., Kupka, R., et al. (2014). Verbal abuse, like physical and sexual abuse, in childhood is associated with an earlier onset and more difficult course of bipolar disorder. Bipolar Disorders, 17(3), 323–330. doi:10.1111/bdi.12268

Stahlberg, O., Soderstrom, H., Rastam, M., et al. (2004). Bipolar disorder, schizophrenia, and other psychotic disorders in adults with childhood onset AD/HD and/or autism spectrum disorders. Journal of Neural Transmission, 111(7), 891. https://doi.org/10.1007/s00702-004-0115-1

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