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Child-Onset Bipolar Disorder:
An Executive Summary
Larry Fisher, Ph.D., UHS Neurobehavioral Systems, Austin, Texas


The prevalence of Child-Onset Bipolar Disorder (COBD) is the topic of hot debate in recent years. In clinics throughout the country there appears to be an epidemic of COBD. The research is unclear as to the actual prevalence of COBD. One epidemiological study shows a prevalence rate of 0.58 (Lewinsohn et al., 1995). However, in a clinic sample (Wozniak et al., 1995) the rate reported was 16% of all consecutively referred preadolescent children (using DSM-III-R criteria for mania). Since COBD is not infectious, but is basically a genetic disorder, there cannot be a real epidemic. But, we are certainly seeing an exponential increase in the use of this diagnostic label in preadolescent children. In fact, there is debate as to whether pediatric bipolar disorder is a valid diagnosis at all (Biederman et al., 2003). It is possible that this label is simply being applied to all irritable children, since there are no widely accepted criteria for COBD, other than the adult criteria in DSM-IV.

Some publications (Biederman, 1998, Klein et al., 1998, Faraone et al., 1997) debate whether COBD is being overlooked, or misdiagnosed as Attention Deficit Hyperactivity Disorder (ADHD). The exact relationship between COBD and ADHD is not well understood, and most children diagnosed with COBD have a comorbid diagnosis of ADHD (Biederman et al., 1998). Rates of comorbidity with ADHD range from 60% to 90% (Wozniak et al., 1995, Borchardt & Bernestein, 1995, and Geller et al., 1995). In fact, COBD has been reported to be comorbid with Conduct Disorder at a rate of 69% (Kovacs and Pollack, 1995).

There is also controversy over the symptoms of COBD, since the presentation is more chronic than episodic, irritability is more common than euphoria, and the picture is usually mixed and characterized as rapid cycling (Wozniak et al., 1995, Carlson, 1984, Davis, 1979). While there are some adult cases of Bipolar Disorder that also present as a chronic, rapid cycling, mixed state, this is certainly an atypical picture in adults. However, this type of atypical syndrome is very characteristic of COBD (Geller & Luby, 1997). Recent studies have supported the diagnosis of COBD (Wozniak et al., 2001, 2003), suggesting that while most COBD patients present with atypical symptoms, the population does exhibit a variety of classic bipolar symptoms. So, while the validity of COBD is still controversial, there is some evidence to support its clinical utility (Faedda et al., 1995; Geller et al., 1994; Kovacs, 1989; Weller et al., 1995).

 

References

Biederman, J., 1998. Resolved: mania is mistaken for ADHD in prepubertal children: Affirmative. J. Am. Acad. Child Adolesc. Psychiatry. 37: 1091-1093.

Biederman, J., Russell, R., Soriano, J., Wozniak, J., Faraone, S., 1998. Clinical features of children with both ADHD and mania: does ascertainment source make a difference? J. Affect. Disord. 51:101-112.

Biederman, J., Mick, E., Faraone, S.V., Spenser, T., Wilens, T.E., Wozniak, J., 2003. Current concepts in the validity, diagnosis, and treatment of pediatric bipolar disorder. Int. J. Neuropsychopharmacol. 6: 293-300.

Borchardt, C.M., Bernestein, G.A., 1995. Comorbid disorders in hospitalized bipolar adolescents compared with unipolar depressed adolescents. Child Psychiatry Hum. Dev. 26: 11-18.

Carlson, G.A., 1984. Classification issues in bipolar disorders in childhood. Psychiat. Dev. 2: 73-285.

Davis, R.E., 1979. Manic depressive variant syndrome of childhood: a preliminary report. Am. J. Psychiatry. 136: 702-706.

Faedda, G., Baldessarini, R., Suppes, T., Tondo, L., Becker, I., Lipschitz, D., 1995. Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harvard Rev. Psychiatry. 3: 171-195.

Faraone, S.V., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., O’Donnell, D., 1997. Is comorbidity with ADHD a marker for juvenile onset mania? J. Am. Acad. Child Adolesc. Psychiatry. 37: 1046-1055.

Geller, B., Sun, K., Zimmerman, B., Luby, J., Frazier, J., Williams, M., 1995. Complex and rapid-cycling in bipolar children and adolescents: a preliminary study. J. Affect. Disord. 34: 259-268.

Geller, B., Luby, J., 1997. Child and adolescent bipolar disorder: a review of the past 10 years. J. Am. Acad. Child Adolesc. Psychiatry. 36: 1168-1176.

Klein, R.G., Pine, D.S., Klein, D.F., 1998. Resolved: mania is mistaken for ADHD in prepubertal children: Negative. J. Am. Acad. Child Adolesc. Psychiatry. 37: 1093-1095.

Kovacs, M. & Pollack, M., 1995. Bipolar disorder and comorbid conduct disorder in childhood and adolescence. J. Am. Acad. Child Adolesc. Psychiatry. 4: 715-723.

Lewinsohn, P., Klein, D., Seeley, J., 1995. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J. Am. Acad., Child Adolesc. Psychiatry. 42: 454-463.

Weller, E., Weller, R., Fristad, M., 1995. Bipolar disorder children: misdiagnosis, under diagnosis, and future directions. J. Am. Acad. Child Adolesc. Psychiatry. 34: 709-714.

Wozniak, J., Biederman, J., Mundy, E., Mennin, D., Faraone, S.V., 1995. A pilot family study of childhood-onset mania. J. Am. Acad. Child Adolesc. Psychiatry. 34: 1577-1583.

Wozniak, J., Biederman, J., Richards, J.A., 2001. Diagnostic and therapeutic dilemmas in the management of pediatric-onset bipolar disorder. J. Clin. Psychiatry. 62 (supp. 14); 10-15.

Wozniak, J., Monuteaux, M., Richard, J., Lail, K.E., Faraone, S.V., and Biederman, J., 2003. Convergence between structured diagnostic interviews and clinical assessment on the diagnosis of pediatric-onset mania. Biol. Psychiatry. 53: 938-944.