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Researchers identify bipolar disorder in preschoolers

By Jim Dryden

Child psychiatry researchers at Washington University School of Medicine in St. Louis have identified a small group of preschoolers who appear to suffer from bipolar disorder, also known as manic-depressive illness. The findings, presented this fall at the annual meeting of the American Academy of Child and Adolescent Psychiatry, highlight symptoms that distinguish bipolar disorder from other mental health problems in very young children.

Mania can be confused with attention deficit hyperactivity disorder.

Mania can be confused with attention deficit hyperactivity disorder.

Diagnosing bipolar disorder in children is difficult because the manic phase of the illness can be confused with the more common attention deficit hyperactivity disorder (ADHD). The confusion arises because mania and ADHD both involve hyperactivity, irritability and distractibility. These issues may be even more difficult in young children who display some of these behaviors and emotions normally. However, Joan Luby, M.D., an associate professor of child psychiatry, found mania symptoms, as defined by psychiatry's Diagnostic and Statistical Manual (DSM-IV), did not occur in healthy preschoolers and that three main symptoms distinguished bipolar disorder from ADHD in preschoolers: elation, grandiosity and hypersexuality.

Similar to the mania symptoms in older bipolar children — first outlined by Barbara Geller, M.D., professor of child psychiatry at Washington University School of Medicine — young children who manifested elation, grandiosity and hypersexuality had dramatically higher odds of having bipolar disorder when compared to children with ADHD.

"This is different than the ordinary, energetic state of young children, even children with ADHD," Luby explains. "When you ask healthy young children what they're capable of doing, they are known to inflate their capabilities and say they can run very fast or jump very high or even fly like Superman. What's different about grandiose children is that they become delusional and actually believe they can do things like run the preschool. An extreme example that I've seen involved a manic preschooler who believed that she made the sun rise and set."

This chart compares levels of impairment in young children. The purple bar represents bipolar children. The red bar shows impairment in young children with clinical depression. The white bar shows children with attention deficit hyperactivity disorder. Finally, the blue bar indicates children with no psychiatric symptoms.

This chart compares levels of impairment in young children. The purple bar represents bipolar children. The red bar shows impairment in young children with clinical depression. The white bar shows children with attention deficit hyperactivity disorder. Finally, the blue bar indicates children with no psychiatric symptoms.

During the manic phase of the illness children may experience exceedingly high self-esteem, an inflated sense of power or ability or may act as though they are in charge at home or school. They may act extremely happy, silly and giddy, but their moods can change rapidly. A decreased need for sleep and excessive chatter also are common. Some bipolar children even experience depression at the same time.

In 2003, Luby and colleagues were the first to identify clinical depression in preschoolers. In this new study, Luby's team attempted to distinguish children with bipolar disorder from those who were clinically depressed by looking for evidence of mania. They studied a community sample of 305 children between the ages of 3 and 6.

The researchers used a preschool age psychiatric interview developed at Duke University, called the PAPA, (Preschool Age Psychiatric Assessment) and added a mania module based on their experiences both with older bipolar children and with younger depressed preschoolers.

"We put together what we thought the symptoms of bipolar disorder would look like in younger children hoping both to learn whether very young children could actually have bipolar disorder and if so, whether we could distinguish it from other psychiatric disorders, particularly ADHD," Luby explains.

They also used a parent questionnaire and took advantage of special interview techniques, designed for young children, to identify signs and symptoms of depression and mania.

"One of the reasons this area of research has been slow to develop is that we've only recently learned how to ask very young children about their feelings," Luby says. "We use an age-appropriate puppet interview, in which we have two puppets converse with one another about how they feel and then ask the child to point to the puppet that best expresses his or her own emotion."

The team also observed children in various play schemes designed to induce a range of emotions — from joyful responses to frustration — and videotaped the children to obtain objective measures of their behavior. They also used story stems, in which children were given a scenario that presents some type of an emotional conflict. The researchers then asked the children to play out the story to its completion.

In all, 26 of the 305 children in the study met all DSM-IV diagnostic criteria for bipolar disorder, but because the sample was put together in such a way that depressed children and others with symptoms of disruptive disorders were much more likely to be studied than healthy children, Luby says the prevalence of bipolar disorder in preschoolers certainly is much lower than was reflected in this sample.

The study also had higher numbers of children with depression and ADHD than would be found in the general population so that the researchers could compare the disorders and detect differences that allow for more precise diagnosis. The ability to distinguish a problem like bipolar disorder from ADHD is critical because although the disorders share some symptoms and some children meet the diagnostic criteria for both disorders, Luby says treatment with stimulant medications that can help kids with ADHD can be problematic for children with bipolar disorder.

Joan Luby

Joan Luby

How best to treat bipolar disorder remains an open question, not just for preschoolers but for older children, too. Although several effective treatments exist for adults, children often respond to medications differently. A National Institute of Mental Health (NIMH)-funded study called the TEAM (Treatment of Early Age Mania) treatment study currently is comparing the effectiveness of treatments in older children. At the national level, the multi-center TEAM study is being led by Barbara Geller, M.D., a pioneer in the recognition of bipolar disorder in children.

Washington University School of Medicine's Early Emotional Development Program is one of five sites participating in the TEAM study. Luby is the study's principal investigator at the St. Louis site.

Researchers are comparing how well different medications and medication combinations work in making bipolar children between the ages of 6 and 15 feel better. Qualified participants are randomly selected to receive either lithium, a drug commonly prescribed for adults with bipolar disorder; valproate, an anticonvulsant drug that has been related to improvement of manic symptoms in a few smaller studies; or risperidone, an antipsychotic medication used in adults with schizophrenia that also is being tested in children with autism.

"We hope that by comparing these drugs and drug combinations, we might be able to find better ways to control this severe illness in older, affected children, and as those results become available, we can look at whether these treatments also might help younger children." Luby says.

In another study, Washington University investigators are part of an international team zeroing in on the genetic causes of bipolar disorder. Following analysis of DNA from more than 5,000 people from more than 1,000 families, that study has found evidence suggesting a genetic linkage to regions on chromosomes 6 and 8. Those researchers are continuing to enroll bipolar adults 18 and older to further isolate the genes that may contribute to the debilitating disorder.

Someday, those findings may make it easier to identify adults and children at risk for bipolar disorder and to begin treatment sooner.


The Treatment of Early Age Mania (TEAM) study at Washington University is ongoing and currently recruiting children ages 6-15 with a diagnosis or symptoms of bipolar disorder to participate. For more information, please call study coordinator Samantha Blankenship, at (314) 286-2783.

For more information on the adult genetic study, call program manager Caroline Drain at (314) 286-1345 or toll-free at (866) 289-1378.

Luby JL, et al. Preschool bipolar disorder: assessment and validation. Presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Oct. 21, 2005.

(related article)

Luby JL, Heffelfinger AK, Mrakotsky C, Brown KM, Hessler MJ, Wallis JM, Spitznagel EL. The clinical picture of depression in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 42:3, pp. 340-348, March 1, 2003.

This research was supported by a grant from the National Institute of Mental Health of the National Institutes of Health to Dr. Luby

The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

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Jim Dryden
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