Evidence-Based Reviews

Not all mood swings are bipolar disorder

Current Psychiatry. 2011 February;10(2):38-B

References

1. Axelson D, Birmaher BJ, Brent D, et al. A preliminary study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children mania rating scale for children and adolescents. J Child Adolesc Psychopharmacol. 2003;13(4):463-470.

2. Youngstrom EA, Birmaher B, Findling RL. Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis. Bipolar Disord. 2008;10(1 Pt 2):194-214.

3. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

4. Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for the management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2008.

5. Conners CK. Conners’ Parent Rating Scale Long Form (CPRS-R:L) North Tonawanda, NY: Multi-Health Systems, Inc.; 1997.

6. Martel MM. Research review: a new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry. 2009;50(9):1042-1051.

7. Steiner H, Remsing L. and the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(1):126-141.

8. Dodge KA, Cole JD. Social-information-processing factors in reactive and proactive aggression in children’s peer groups. J Pers Soc Psychol. 1987;53(6):1146-1158.

9. Connor DF, Steingard RJ, Cunningham JA, et al. Proactive and reactive aggression in referred children and adolescents. Am J Orthopsychiatry. 2004;74(2):129-136.

10. Connor DF, Chartier KG, Preen EC, et al. Impulsive aggression in attention-deficit/hyperactivity disorder: symptom severity, co-morbidity, and attention-deficit/hyperactivity disorder subtype. J Child Adolesc Psychopharmacol. 2010;20(2):119-126.

11. Mick E, Spencer T, Wozniak J, et al. Heterogeneity of irritability in attention-deficit/hyperactivity disorder subjects with and without mood disorders. Biol Psychiatry. 2005;58(7):576-582.

12. Orvaschel H. Schizophrenia and Affective Disorders Schedule for children—Epidemiological Version (KSADS-E). Fort Lauderdale, FL: Nova Southeastern University; 1995.

13. Pappadopulos E, Woolston S, Chait A, et al. Pharmacotherapy of aggression in children and adolescents: efficacy and effect size. J Can Acad Child Adolesc Psychiatry. 2006;15(1):27-39.

14. Achenbach TM, Howell CT, McConaughy SH, et al. Six-year predictors of problems in a national sample: IV. Young adult signs of disturbance. J Am Acad Child Adolesc Psychiatry. 1998;37(7):718-727.

15. Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36:545-553.

16. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989.

17. Youngstrom EA, Duax J. Evidence-based assessment of pediatric bipolar disorder, part I: base rate and family history. J Am Acad Child Adolesc Psychiatry. 2005;44(7):712-717.

18. Birmaher B, Axelson D, Strober M, et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(2):175-183.

19. Kaufman J, Birmaher B, Brent D, et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980-988.

20. Birmaher B, Axelson D. Course and outcome of bipolar spectrum disorder in children and adolescents: a review of the existing literature. Dev Psychopathol. 2006;18(4):1023-1035.

21. Birmaher B, Axelson D, Strober M, et al. Comparison of manic and depressive symptoms between children and adolescents with bipolar spectrum disorders. Bipolar Disord. 2009;11(1):52-62.

22. Birmaher B, Axelson D, Goldstein B, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. Am J Psychiatry. 2009;166(7):795-804.

Clinical Point

In the COBY study, onset of mood symptoms preceded onset of clear bipolar episodes by 1±1.7 years

The clinical picture of a child with BD that emerges from the COBY study is:

a fairly young child with the onset of mood symptoms between age 5 to 12
subsyndromal and less frequently clear syndromal episodes
primarily mixed and depressed symptoms with rapid mood cycles during these episodes.²²

It is clear that there is a spectrum of bipolar disorders in children and adolescents with varying degrees of symptom expression and children differ from adolescents and adults in their initial presentation of BD.

Table 2

COBY criteria for bipolar disorder, not otherwise specified

Presence of clinically relevant bipolar symptoms that do not fulfill DSM-IV criteria for BDI or BDII
In addition, patients are required to have elevated mood plus 2 associated DSM-IV symptoms or irritable mood plus 3 DSM-IV associated symptoms, along with a change in level of functioning
Duration of a minimum of 4 hours within a 24-hour period
At least 4 cumulative lifetime days meeting the criteria
BDI: bipolar I disorder; BDII: bipolar II disorder; COBY: Course and Outcome of Bipolar Youth study
Source: Reference 18

Related Resources

Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2009.
Goodwin FK, Jamison KR. Manic-depressive illness. 2nd ed. Oxford, United Kingdom: Oxford University Press; 2007.
Miklowitz DJ, Cicchetti D, eds. Understanding bipolar disorder: a developmental perspective. New York, NY: Guilford Press; 2010.

Drug Brand Name

Methylphenidate • Ritalin, Concerta, others

Disclosures

Dr. Kowatch receives grant/research support from the National Institute of Child Health and Human Development and the National Institute of Mental Health and is a consultant to AstraZeneca, Forest Pharmaceuticals, Merck, and the REACH Foundation.

Dr. Delgado and Ms. Monroe report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table

FIND criteria of disorders found to cause mood swings

Criteria	BDI	BP-NOS	ODD	GAD	ARND
Frequency of symptoms/week	7 days (more days than not in an average week)	2 to 3 days/week	Daily (chronic) irritability and mood swings precipitated by ‘not getting their way’	Greatest during times of change/stress	Daily
Intensity of symptoms	Severe—parents often are afraid to take the child out in public because of mood symptoms	Moderate	Mild/moderate	Mild/moderate when stressed	Mild/moderate
Number of mood cycles/day	Daily cycles of euphoria and depression	3 to 4	5 to 10	2 to 3	8 to 10
Duration of symptoms/day	Euphoria: 30 to 60 minutes Depression: 30 minutes to 6 hours	4 hours total/day of mood symptoms	Short; 5 to 10 minutes	Short; 5 to 10 minutes	Short; 5 to 10 minutes
ARND: alcohol-related neurodevelopmental disorder; BDI: bipolar I disorder; BD-NOS: bipolar disorder, not otherwise specified; GAD: generalized anxiety disorder; ODD: oppositional defiant disorder
Source: Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for the management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2008

Box

The lasting effects of alcohol use during pregnancy

Even small amounts of alcohol use by a pregnant woman can impact her child’s development. In a controlled study examining drinking behavior of 12,678 pregnant women and the effect this had on their children, Sayel et al^a found that <1 drink per week during the first trimester was clinically significant for mental health problems in girls, measured at age 4 and 8, when using parent or teacher report.

Fetal alcohol spectrum disorder describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These disorders include fetal alcohol syndrome (FAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD).

FAS. Individuals with FAS have a distinct pattern of facial abnormalities, growth deficiency, and evidence of CNS dysfunction. Characteristic facial abnormalities may include a smooth philtrum, thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, small palpebral fissures, and small head circumference. Growth deficiency begins in-utero and continues throughout childhood and into adulthood. CNS abnormalities can include impaired brain growth or abnormal structure, manifested differently depending on age.

ARND. Many individuals affected by alcohol exposure before birth do not have the characteristic facial abnormalities and growth retardation identified with full FAS, yet have significant brain and behavioral impairments. Individuals with ARND have either the facial anomalies, growth retardation, and other physical abnormalities, or a complex pattern of behavioral or cognitive abnormalities inconsistent with developmental level and unexplained by genetic background or environmental conditions (ie, poor impulse control, language deficits, problems with abstraction, mathematical and social perception deficits, learning problems, and impairment in attention, memory, or judgment).^b

ARBD. Persons with ARBD have malformations of the skeletal and major organ systems, such as cardiac or renal abnormalities.

Comorbid psychiatric conditions in children with prenatal alcohol exposure are 5 to 16 times more prevalent than in the general population; these children are 38% more likely to have an anger disorder.^c O’Connor and Paley^d found that “…mood disorder symptoms were significantly higher for children with parental alcohol exposure compared to children without exposure.” Children with ARND are treated symptomatically depending upon which deficits and behaviors they exhibit.^e

References

a. Sayal K, Heron J, Golding J, et al. Binge pattern of alcohol consumption during pregnancy and childhood mental health outcomes: longitudinal population-based study. Pediatrics. 2009;123(2):e289-296.
b. Warren KR, Foudin LL. Alcohol-related birth defects—the past, present, and future. Alcohol Res Health. 2001;25(3):153-158.
c. Burd L, Klug MG, Martsolf JT, et al. Fetal alcohol syndrome: neuropsychiatric phenomics. Neurotoxicol Teratol. 2003;25(6):697-705.
d. O’Connor MJ, Paley B. Psychiatric conditions associated with prenatal alcohol exposure. Dev Disabil Res Rev. 2009;15(3):225-234.
e. Paley B, O’Connor MJ. Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management. Dev Disabil Res Rev. 2009;15(3):258-267.