1. Pediatric Bipolar Disorder
Carlo G. Carandang, MD
IWK Health Centre
Dalhousie University Psychiatry

2. Objectives
• Learn clinical presentation of pediatric
bipolar disorder
• Differentiate pediatric bipolar disorder
from other psychiatric disorders
• Learn genetics of bipolar disorder
• Learn treatment of pediatric bipolar
disorder

3. Detailed Objectives
• What is bipolar disorder?
– How is it different in children and teens?
• Diagnostic criteria and controversy
– What is not bipolar disorder?
• Comorbid disorders
• Treatment options
– Medical
– Psychological
– Lifestyle
• Issues for children, teens and families
– School
– Social and family life
• Information sources

4. Sadness vs. Depression
• Sad is what we feel when we lose
something we love, or hope to attain.
• Depression is something more:
– Sadness that is there every day for more than
two weeks
– Interferes with life: friends, fun, family & school

5. Depression
SIGECAPSSIGECAPS for 2+ weeks (5 of 9 criteria)
Dysthymia: 1 year (3 of 9 criteria)
In addition to low moods, the following:
• Sleep Disturbance
• Irritability (core symptom in youth, not adults)
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor Agitation or Retardation
• Suicidality

6. *suspect trauma or abuse in this
age group if depressed
6
Rates of depression in children
General population:
– Pre-schoolers 0.3-0.9%*
– Latency 1.5-3% (boys > girls)
– Adolescence 1-6% (girls > boys)
• Up to 10% for all syndromes
• 10-24% by late adolescence comparable to adult:
– Men (12%)
– Women (21-24%)

7. Happiness vs. Mania
• Happiness is what we feel when close to
people we love, or our goals are met.
• Mania is something different:
– Euphoric or irritable mood that persists out of
context
– High energy, grandiose, low need for sleep
– Interferes with life
– Lasts 4-7 days

8. Mania
• DIGFASTDIGFAST 3 of 7 criteria (4 if mood only irritable
and not euphoric or expansive)
• Distractibility
• Insomnia (decreased need for sleep)
• Grandiosity
• Flight of ideas
• Activity (increase in goal-directed)
• Speech (pressured)
• Thoughtlessness (reckless behaviors)

9. Why do we care about mood
disorders?
• Duration and Course of Pediatric Unipolar
Depression:
– Duration: 3-9 months
– 10% last more than 2 years
– 60-70% risk of recurrence in adulthood
(Weller and Weller 2000)
– 20-32% develop bipolar disorder within
5 years (Geller et al., 1994; Strober and Carlson 1982; Strober et al.,
1993)

10. Risks of bipolar disorder
• Suicide:
– 50% attempt
– 15% will die
• Disrupted friendships, high divorce rates
• Family conflicts
• Lower educational attainment
• Higher unemployment or lower paid work

11. Pediatric Bipolar Disorder
• Minimal research regarding
phenomenology and course
• DSM-IV Bipolar criteria not validated for
prepubertal and early-adolescent
populations
• Late-adolescent-onset bipolar disorder is
viewed as having similar phenomenology
to adult-onset bipolar disorder

12. Diagnostic Controversy
• 2 views regarding appearance of bipolar
in children
– Conservative DSM-IV
• Strict criteria
• Higher threshold for diagnosis
– Broadly-defined Bipolar NOS
• Irritability: often misinterpreted
• Lower threshold for diagnosis

13. Clinical Manifestations of Pediatric
Bipolar Disorder
• Teen-Adult presentation:
– Distinct episodes of mania and depression
lasting >1 week
– Expansiveness, elation, grandiosity present
• Pediatric presentation:
– Brief, adult-like episodes (hours-2 days)
– Chronic course, no clear episodes
• Mixed depressive and manic symptoms
• Continuous/rapid cycling
• Irritability, mood lability, explosiveness

14. Diagnosis of Pediatric Bipolar
Disorder: Symptom Thresholds
• FIND (frequency, intensity, number,
duration)
– Frequency
• Sxs occur most days of the week
– Intensity
• Sxs cause disturbance in functioning
– Number
• Sxs occur at least 3-4 times per day
– Duration
• Sxs occur at least 4 hours per day (total)

15. (Leibenluft et al., 2003)
NIMH-Proposed Bipolar
Phenotypes in Youth
• Narrow Phenotype: Strict DSM-IV criteria
• Intermediate Phenotype-Mania NOS:
duration 1-3 days; otherwise meets full criteria
• Intermediate Phenotype-Irritable Mania:
mood irritable, not euphoric or expansive;
otherwise meets full criteria
• Broad Phenotype: chronic, non-episodic
irritability; no other hallmark symptoms of mania

16. Pediatric Bipolar Disorder
• Uncommon condition
– 1% prevalence in adolescents
• (Lewinsohn et al., 1995)
– 0.5% prevalence in prepubertal youth (est.)
• Duration and course:
– 93 outpatients, 7 to 16 years of age
(mean age = 11 years) with bipolar I or II
– Mean age onset: 7 years of age
– Mean episode duration: 3.5 years of age
• (Geller et al., 2000)

17. (presented by Axelson 2003)
Pediatric Bipolar Disorder:
Comorbidity (Referred Samples)
• ADHD: 60-90%
• ODD/Conduct Disorder: 40-90%
• Anxiety Disorders: 22-56%
• Substance Abuse: 10-22%

18. (Geller et al., 1998)
Differentiating Bipolar Disorder from
ADHD
• Findings
– Bipolar disorder group > ADHD group
• Elevated mood
• Grandiosity
• Hypersexuality
• Decreased need for sleep
• Racing thoughts

19. Over- and Under-Diagnosis of
Pediatric Bipolar Disorder
• Over-Diagnosis is the main problem
– Some families and clinicians have interpreted
irritability as a pathognomonic symptom of
mania.
– Irritability a very frequent symptom of
numerous child psychiatric disorders (ADHD,
ODD, Conduct, Autism, Major Depression,
Schizophrenia)

20. Over- and Under-Diagnosis of
Pediatric Bipolar Disorder
• Under-diagnosis may occur if mania is not
considered in the differential diagnosis of
ADHD.
• Knowledge of pediatric presentation of
mania vs. adult presentation can help with
the differential diagnosis of irritability and
ADHD, and thus help avoid over- or
under-diagnosis.

21. Clinical Pearls for Diagnosis of
Pediatric Bipolar Disorder
• Family History
• Presence of elation/euphoria or
grandiosity
• Hypersexuality
• Acute onset of depression
• Psychotic depression
• History of medication-induced mania

22. Kindling TheorySeverityofSymptoms
Time
Full Disorder Threshold

23. Molecular Genetic Studies
• Strongest evidence of linkage to date for
“Bipolar Genes:” 18p, 18q, 21q
• Polygenic
• Linkages have not been replicated
• Mood Genes: Hunting for Origins of Mania
and Depression by Samuel Barondes

24. Onset of Bipolar Disorder
• Gene by environment interaction
• Genetic vulnerability combined with
environmental stressor produces
phenotype
• Risk if one affected first-degree relative :
ranges from 6.5%-25% (compared to 1%
in general population)
• Depression most common in relatives

25. Unipolar and Bipolar Affective
Disorder
• Bipolar Affective Disorder
– Greater genetic contribution
– Treated with mood stabilizer first line
– Psychotherapy alone not a reasonable
treatment approach
• Unipolar Affective Disorder
– Genetic contribution, but greater
environmental contribution
– Psychotherapy alone first line for mild to
moderate unipolar depression
– Psychotherapy with antidepressants for
moderate to severe unipolar depression

26. What might Bipolar Disorder look like?
• Amy is 12 years old. For the past 3 months she has felt
sad almost every day. She has been crying several a
times week, at times for no reason at all. Her appetite
has gone down and she has lost about 7 pounds. She
also hasn’t been sleeping well and said that she takes
about 2 hours to fall asleep and then wakes up several
times at night.
• During the day, Amy said that she is tired and has no
energy. Although she said that she thinks that life is not
worth living, she does not have a plan to end her life. As
a result of her difficulties, Amy stopped calling friends
and does not talk as much with her parents. She also
stopped playing piano and guitar, which she used to
enjoy.

27. What might Bipolar Disorder look like?
• Over the next few days Amy seems to be feeling a bit better. She
has started to call her friends again and seems to have more
energy. She is also more talkative when around others. She has
started to play piano and guitar again and her parents noticed that
she seemed to giggle a lot, which was unusual for Amy.
• On Friday night she called about 10 of her friends to come over and
“hang out.” Most of them came over to the house and they began
playing a game. Throughout the game Amy giggled uncontrollably
and began telling jokes, most of which her friends didn’t find funny.
Amy laughed at all of the jokes, however. She also put socks on her
ears and began dancing around. Her friends did not laugh at this, so
Amy kicked them out of the house.

28. What might Bipolar Disorder look like?
• That weekend was difficult. Amy’s parents were awakened at 2AM
on Saturday, as Amy was up playing piano and singing out loud.
When they questioned Amy about playing music so late at night,
she said she was practicing to be the best musician ever, and
wanted to go on tour with her music. She said that these and other
thoughts raced through her head.
• Her parents tried to talk to her, but noted she was talking so fast and
was giggling, so her parents had trouble following her. Her parents
tried to discipline her but nothing seemed to work. Amy only became
irritable or laughed at her parents.
• On Monday her parents received a call from school saying that Amy
was laughing uncontrollably in class and acting childish. She was
sent home as a result. She was closely watched for one week by
her parents and slowly began to unwind as she became more
depressed and withdrawn, much like she was before.

29. So, what signs in Amy make us
think bipolar disorder?
• Symptoms of
depression lasting
over 2 weeks:
– Sad mood (crying)
– Sleep disturbance
– Appetite change
– Low energy
– Withdrawn & little
interest in activities
– Suicidal thoughts
• Symptoms of mania
lasting 4 or more days
– Euphoric mood
– More talkative &
pressured speech
– Racing thoughts
– No need for sleep
– Grandiosity (singer)
These symptoms also affected her relationships with friends, with her family and her
functioning at school.

30. What do we do?
• Comprehensive assessments
• Treatment
• Monitoring
• Support
• Case Management

31. Supports and their roles
• Therapist
• Family doctor
• Psychiatrist
• School professionals
• Community supports:
– Laing House
– Phoenix Prevention Program
• Family!

32. Family functioning
• Acknowledge problems
• Seek evaluation and treatment
• “Take the illness out of it”
• Be consistent about expectations and
consequences
• Review warning signs with your child
– Card with signs and plans of action signed by
both. Include support contacts.

33. What can youth and family do?
Mood card:
• A card that contains information on how to
recognize and cope with mood episodes
• Parents, youth and clinician together
• Agree on “warning signs” of moods
• List contact information of clinicians
• Confidential relationships issue: right to inform?
• Agree on plan of action
• Can help adherence and acceptance

34. Mood Chart

35. What are the school
challenges?
• Inability to screen out environmental stimuli
– Sounds, sights, smells
– Decrease stimuli, find quiet study/work area, change seating
arrangement
• Inability to concentrate
– Restless, short attention span, easily distracted, hard time
following directions
– Break large projects into smaller tasks, short frequent
breaks, help with study skills, assignments one task at time
or in writing, tape recorder or notetaker, photocopy notes,
textbooks on tape

36. School challenges
• Lack of stamina
– Not enough energy for day or course load
– Discuss part-time options, take tests or assignments in
sections, beverages (juice, water) in class
• Difficulty handling time pressures and multiple
tasks
– Trouble managing assignments, setting priorities,
meeting deadlines, writing tests
– Break larger tasks into smaller pieces, get syllabus, use
calendar/day planner, extended time, change format,
segmented tests

37. School challenges
• Difficulty interacting with others
– Difficult to talk to others, get notes, discuss
assignments, participate in class, chat with others,
make friends
– Mentor/buddy
• Difficulty handling negative feedback
– Hard time understanding and interpreting criticisms
– Ask teacher to talk with you about performance and
specific ways to improve, alternative assignments/extra
credits, problem solve together

38. School Challenges
• Difficulty responding to change
– Change may be stressful
– Advanced warnings, social stories, guidance counsellor

39. Parent and Teacher Roles
• Be aware of changes in performance and abilities
at school (academics, social, affect)
• Assist by:
– Educating yourself
– Listening
– Problem solving
– Communicating
– Supporting (relaxation, coping, etc.)
– Accommodating (identify and reduce stressors)
– Being flexible

40. Can a healthy lifestyle help?
Lifestyle changes can include:
• Sleep
• Diet
• Exercise
• Routines

41. Sleep
• Lack of sleep or too much can impact moods
• Needed sleep (16hrs for infants, 9hrs for teens, 7-8
for adults)
• Keep regular sleep schedule
– Go to bed and get up same time every day
– Avoid naps through day
– Adopt bedtime ritual to wind down (e.g. warm bath, reading,
soft music, etc.)
– Decrease distractions in room (no t.v., video games,
computer, etc.)
– Avoid caffeine

42. How do I get a healthy sleep?
– Get regular exercise
– Eat well balanced diet
– Change time of day you take medication (Consult
doctor)
– Avoid late night shifts at work
– If you wake up early in am and can’t get back to sleep
get up and do quiet activity (e.g. reading)
– Be aware of changes in routine

43. Diet
• Nutrition can affect your health, energy, and
sometimes your mood
• If your body is nourished properly, your brain can
function more effectively
• Excessive amounts of sugar, caffeine, alcohol, or
chocolate may be more likely to contribute to
mood disturbances
• Vegetables, fruit, oil-rich fish, and whole grains
may be more likely to help with stability

44. What is a balanced diet?
• Best advice is to limit the things you know
can impact your mood and ensure you
have a well balanced diet including foods
from all the 4 major food groups and lots
of water

45. Exercise
• Exercise releases endorphins which are
associated with good moods
• Exercise can help reduce the stress
hormone cortisol, often elevated in
depressed people.
• Exercise can help restore sleep and
eating patterns

46. What if I hate to exercise?
• Choose a method of physical activity you enjoy
• Focus on making the experience as pleasant as
possible
• Start slowly and work up
• A good goal to work towards is 30 minutes a day,
3 times a week

47. Routines
• Keeping life structured may help with
manageability
• Could use
– Day planners
– Calendars
– Sticky notes

48. Medical and Psychological
Treatments
• Medication management required to
stabilize mood
• Psychotherapy can address lifestyle
changes, coping strategies, improve
relationship skills and help with
compliance with medication.

49. Somatic Treatments
• Lithium
• Valproate
• Carbamazepine
• Atypical Antipsychotics
• Third-Generation Anticonvulsants
• ECT

50. (Pediatric Bipolar Disorder,
JAACAP, 44:9, Sept. 2005)
What do studies show regarding medications for
pediatric bipolar disorder?
• Combination of atypical antipsychotics and mood
stabilizers appears effective for acute treatment
and stabilization of pediatric bipolar disorder
• Combination of mood stabilizer and stimulant
appears promising for youth with ADHD and
bipolar disorder
• Antidepressants may worsen mania
• Monotherapy with mood stabilizer alone may not
maintain moods for longer than 4 months
• Lamotrigine promising for bipolar depression

51. Treatment of Pediatric
Manic Episode
• Taper stimulant or antidepressant medications
– Reevaluate mood & behavior
• Still with mood symptoms?
– Euphoric → lithium
– Mixed → valproate
– Psychosis/impulsive aggression → atypical
• Non/partial response → lithium + valproate
– Or mood stabilizer + atypical
– Once stable - reevaluate ADHD
• Still with ADHD symptoms?
– Add low-dose stimulants

52. Treatment of Pediatric Bipolar
Depression
• Lithium monotherapy
• If treatment refractory, consider adding
lamotrigine (adjunctive or monotherapy)
– Lithium + lamotrigine
– LTG monotherapy
• Adding SSRI to mood stabilizer needs
close supervision, observing for rapid
cycling

53. Psychosocial Treatments
• Psychoeducation
• Circadian Rhythm Hygiene (structured
sleep/wake cycle)
• Case management/wraparound services
• CBT (especially for depression and
anxiety)
• Multifamily Psychoeducational Groups

54. Is adherence with treatment
important?
YES!

55. Adherence issues
• Why take it?
– Effective treatment can reduce number and
severity of episodes and limit their effects.
• Why do some not take it?
– Stigma
– Side-effects
– Misunderstanding of its effects
– Allure of mania
– Cost
– Poor relationship with therapist or doctor

56. Stigma
• Overlap with denial of symptoms
• Personal views of mental illness
• Others’ experiences
• Fear of criticism of others
• Fear of misinterpretation of need for
medication: “pathologized”

57. Allure of Mania
• It can feel good…for a while.
– Faster thinking
– Creativity
– Decreased need for sleep
– Euphoria
– Over-optimism
• Decreased awareness of consequences
• Over-confidence
• Forget past depressions, negative effects.

58. Fear
• “I won’t be me.”
• “I will be controlled by medication. I need
to deal with this myself.”
• “It will damage my brain and my body.”

59. Side-effects
• Sedation
• Weight gain
• Diabetes
• Acne
• Slower thinking
• Loss of manic and hypomanic highs
• Aim is to balance risks and benefits
• Several options available!

60. Cost
• Teens often acutely aware of family financial
problems
• First-line treatments are less expensive
• Newer medications cost more but are covered by
all plans.
• Samples often available
• Long-term costs of no treatment far greater

61. Why does a relationship
matter?
• Doctors’ and therapists’ role is to help with the
problems that prevent adherence
• Need to listen and actively address fears and
side-effects
• Informed consent requires good, clear
information
• Anger or frustration with treatment or clinician can
show up as non-compliance.

62. How to tell if treatment is
working?
• Feeling better
• Living better
• Tolerating medication and side-effects: the
balancing act

63. Pediatric Bipolar Summary
• Difficult to manage
• Currently overdiagnosed
– KSADS-PL and/or WASH-U-KSADS often necessary
• No “magic bullets” exist
• Much more research is needed
– Single agents
– Combination pharmacotherapy
– Pharmacotherapy + CBT
– Multifamily Psychoeducation Groups

64. Internet Resources
• Depression and Bipolar Support Alliance:
– www.dbsalliance.org
• Child and Adolescent Bipolar Foundation:
– www.bpkids.org

65. Suggested Reading
Parents and youth:
• New Hope for Children and Teens with Bipolar
Disorder, Boris Birmaher, MD. Three Rivers
Press, NY, 2004.
Clinicians:
• Pediatric Bipolar Disorder: A Review of the Last
10 Years. Journal of the American Academy of
Child and Adolescent Psychiatry 44(9): Sept.
2005.