Bipolar disorder is difficult to recognize and diagnose
in youth, however, because it does not fit precisely the symptom
criteria established for adults, and because its symptoms can
resemble or co-occur with those of other common childhood-onset
mental disorders. In addition, symptoms of bipolar disorder may be
initially mistaken for normal emotions and behaviors of children and
adolescents. But unlike normal mood changes, bipolar disorder
significantly impairs functioning in school, with peers, and at home
with family. Better understanding of the diagnosis and treatment of
bipolar disorder in youth is urgently needed. In pursuit of this
goal, the National Institute of Mental Health (NIMH) is conducting
and supporting research on child and adolescent bipolar disorder.
Symptoms of mania and depression in children and adolescents may manifest
themselves through a variety of different behaviors. When manic,
children and adolescents, in contrast to adults, are more likely to be
irritable and prone to destructive outbursts than to be elated or
euphoric. When depressed, there may be many physical complaints such as
headaches, muscle aches, stomachaches or tiredness, frequent absences from
school or poor performance in school, talk of or efforts to run away from
home, irritability, complaining, unexplained crying, social isolation,
poor communication, and extreme sensitivity to rejection or failure. Other
manifestations of manic and depressive states may include alcohol or
substance abuse and difficulty with relationships.
Existing evidence indicates that bipolar disorder beginning in childhood
or early adolescence may be a different, possibly more severe form of the
illness than older adolescent- and adult-onset bipolar disorder. When
the illness begins before or soon after puberty, it is often characterized
by a continuous, rapid-cycling, irritable, and mixed symptom state that
may co-occur with disruptive behavior disorders, particularly attention
deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may
have features of these disorders as initial symptoms. In contrast, later
adolescent- or adult-onset bipolar disorder tends to begin suddenly, often
with a classic manic episode, and to have a more episodic pattern with
relatively stable periods between episodes. There is also less
co-occurring ADHD or CD among those with later onset illness.
A child or adolescent who appears to be depressed and exhibits ADHD-like
symptoms that are very severe, with excessive temper outbursts and mood
changes, should be evaluated by a psychiatrist or psychologist with
experience in bipolar disorder, particularly if there is a family history
of the illness. This evaluation is especially important since
psychostimulant medications, often prescribed for ADHD, may worsen manic
symptoms. There is also limited evidence suggesting that some of the
symptoms of ADHD may be a forerunner of full-blown mania.
Findings from an NIMH-supported study suggest:
The illness may be at least as common among youth as among adults.
one percent of adolescents ages 14 to 18 were found to have met criteria for bipolar
disorder or cyclothymia, a similar but milder illness, in their lifetime.
Close to six percent of adolescents in the study had
experienced a distinct period of abnormally and persistently elevated,
expansive, or irritable mood even though they never met full criteria for
bipolar disorder or cyclothymia.
Compared to adolescents with a history of major depressive disorder and to a never-mentally-ill group, both the teens with bipolar disorder and those with subclinical symptoms had greater functional impairment and higher rates of co-occurring illnesses
(especially anxiety and disruptive behavior disorders), suicide attempts,
and mental health services utilization. The study highlights the need for
improved recognition, treatment, and prevention of even the milder and
subclinical cases of bipolar disorder in adolescence.
(NIH Publication No. 00-4778, Printed August 2000)
Given the challenging nature of the problem, it is usually advisable to
involve a child psychiatrist or psychologist in the evaluation, diagnosis,
and treatment of a child or adolescent in whom depression is suspected.
A number of epidemiological studies have reported that up to 2.5 percent
of children and up to 8.3 percent of adolescents in the U.S. suffer from
depression.
An NIMH-sponsored study of 9- to 17-year-olds estimates that
the prevalence of any depression is more than 6 percent in a 6-month
period, with 4.9 percent having major depression.
Depression onset is occurring earlier in life today than in
past decades.
A recently published longitudinal prospective study found
that early-onset depression often persists, recurs, and continues into
adulthood, and indicates that depression in youth may also predict more
severe illness in adult life.
Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, and with physical illnesses, such as diabetes.
Depression in children and adolescents is associated with an
increased risk of suicidal behaviors. This risk may rise, particularly
among adolescent boys, if the depression is accompanied by conduct
disorder and alcohol or other substance abuse. In 1997, suicide was the
third leading cause of death in 10- to 24-year-olds. NIMH-supported
researchers found that among adolescents who develop major depressive
disorder, as many as 7 percent may commit suicide in the young adult years. Consequently, it is important for doctors and parents to take all
threats of suicide seriously.
( NIH Publication No. 00-4744, Printed September 2000)
