Bipolar Disorder in Children

Prepubertal Compared to Adult-Onset Bipolar Disorder

One topic of interest in the study of prepubertal BP is the differing presentations of child and adult-onset BP. Children with BP do not usually present with the reportedly typical adult presentation of discrete episodes of mania or depression with intervening relatively well periods (Goodwin & Jamison, 1990; NIMH, 2001). By contrast, prepubertal BP is typically characterized by long episode duration in years, mixed mania, psychosis, and ultradian (continuous) rapid cycling (Geller, Zimerman, Williams, DelBello, Bolhofner, et al., 2002; Geller, Tillman, Craney, & Bolhofner, 2004; Tillman & Geller, 2003).

The entire duration of illness is called an episode, whereas mood switches within an episode are called cycles (Tillman & Geller, 2003). For example, an 8-year-old boy was ill for 2 years, during which time he cycled twice daily. He is said to have an episode lasting 2 years, characterized by ultradian (continuous daily) cycling. A similarly severe presentation with continuous rapid cycling is observed in fewer than 20% of adults with BP (Goodwin & Jamison, 1990).

Assessment of Prepubertal Mania

To address the need for a prepubertal age-specific instrument for assessing mania, Geller, Williams, Zimmerman, and Frazier (1996) developed the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-UKSADS). The WASH-U-KSADS was developed from the KSADS by adding items specifically to assess prepubertal mania, a section on rapid cycling, items for current and lifetime occurrences of symptoms and syndromes, items for specific timing of onsets and offsets for all symptoms and syndromes, and expanded items for assessment of ADHD and multiple other DSM-IV diagnoses (Geller et al., 1996; Geller et al., 2000a; Geller, Zimerman, Williams, DelBello, Bolhofner, et al., 2002; Geller, Zimerman, Williams, DelBello, Frazier, et al., 2002; Geller et al., 2003).

The WASH-U-KSADS allowed for the assessment of prepubertal manifestations of mania, because unlike adults with BP, children will not have “maxed out” credit cards or have had four or more marriages. It is not intuitive that children can have impairing, pathological happiness or be pathologically too expansive and grandiose (Geller, Zimerman, Williams, DelBello, Frazier, et al., 2002). The following examples differentiate normal from pathological elation and grandiosity. Normal children show elation when they go to Disneyland, on Christmas, and when grandparents are visiting. The excited mood is appropriate to context, is expected, and is nonimpairing (Geller, Zimerman, Williams, DelBello, Frazier, et al., 2002). By contrast, a manic child may act “Jim Carrey–like” daily in class, resulting in repeated trips to the principal's office. The happiness is inappropriate to context and is impairing. In addition, normal children may play at being fire-fighters, rescuing victims with friends. The behavior is appropriate to the context of after-school play and is expected and nonimpairing (Geller, Zimerman, Williams, DelBello, Frazier, et al., 2002). A child suffering from grandiose delusions, however, may believe that he is Superman and attempt to fly from a second-story window, resulting in multiple fractures.

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