Child and Adolescent Bipolar Disorder:
A Review of the Past 10 Years

Barbara Geller, M.D. and Joan Luby, M.D.

J Am Acad Child Adoles Psychiatry 36:1168-1176, 1997


Objective: To provide a review of the epidemiology, phenomenology, natural course, comorbidity, neurobiology, and treatment of child and adolescent bipolar disorder (BP) for the past 10 years. This review is provided to prepare applicants for recertification by the American Board of Psychiatry and Neurology. Method: Literature from Medline and other searches for the past 10 years, earlier relevant articles, and the authors' experience and ongoing National Institute of Mental Health-funded project "Phenomenology and Course of Pediatric Bipolarity" were used. Results: Age-specific, developmental (child, adolescent, and adult) DSM-IV criteria manifestations; comorbidity and differential diagnoses; and episode and course features are provided. Included are age-specific examples of childhood grandiosity, hypersexuality, and delusions. Differential diagnoses (e.g. specific language disorders, sexual abuse, conduct disorder [CD], schizophrenia, substance abuse), suicidality, and BP-II are discussed. Conclusion: Available data strongly suggest that prepubertal onset BP is a nonepisodic, chronic, rapid cycling, mixed manic state that may be comorbid with attention-deficit hyperactivity disorder (ADHD) and CD or have features of ADHD and/or CD as initial manifestations. Systematic research on pediatric BP is in its infancy and will require ongoing and future studies to provide developmentally relevant diagnostic methods and treatment. J Am Acad Child Adoles Psychiatry, 1997, 36(9):1168-1176. Key Words: child, adolescent, bipolar disorder, mania, hypomania, delusions, grandiosity, hypersexuality

Developmental Considerations

As noted in a recent letter by Schneider et al. (1996), if one looks to fit children and adolescents into adult criteria for manic-depressive illness, it will be difficult except for those adolescents who have adult-type onset, i.e., individuals with good functioning until the abrupt onset of marked manic symptomatology that often requires hospitalization, is responsive to treatment, and is succeeded by interepisode well-being (McGlashan, 1988). Thus, a developmental, age-specific viewpoint needs to be considered for pediatric patients who do not have the adult-type onset.

Analogies to two other occurrences in bioscience are useful to understand the developmental perspective. The first occurrence is that different illnesses may have different neurobiological (e.g. genetic, neurotransmitter) mechanisms and thus have differences in severity with earlier age of onset (Childs and Scriver, 1986). A classic example is the comparison of juvenile to adult-onset diabetes in which genetic mechanisms and severity differ. The second situation occurs when the same causative agent can have different clinical manifestations at different times in the life cycle. An example of the second situation is when 6-OH-dopamine is given to infant versus adult rats. Infant rats given this compound develop hyperactivity, whereas geriatric rats develop parkinsonian symptomatology.

On the basis of the occurrence of either (or both) of the neurobiological mechanisms noted above, it is developmentally possible for childhood-onset manic-depressive illness to be more severe; to have a chronic, nonepisodic course; and to have mixed, rapid-cycling features similar to the clinical picture reported for severely ill, treatment-resistant adults (Geller et al., 1995; Himmelhoch and Garfinkel, 1986; Hsu, 1986; Hsu and Starzynski, 1986; Stancer and Persad, 1982). A possibility also exists that only the most severe manic-depressive children receive clinical attention because manic episodes that last a few weeks might be tolerated by parents as a phase of growing up, especially if these do not interfere with school performance. Our experience of colleagues requesting "hallway" consultations suggests that this may be the case.

The following review assumes that future data will support continuities across the age span.


As yet, no national or international epidemiological study of bipolar disorder (BP) during the pediatric years is available. However, data from Carlson and Kashani (1988) and Lewinsohn et al. (1995) suggest that prevalence during the adolescent years is at least that of the adult population.

These reports and those below taken together -- i.e. epidemiological data, secular trends, high switch rates, data from inpatient services, and reports from chart reviews -- support that the prevalence of child and adolescent manic-depressive illness is at least that in the adult population and may be increasing. A secular trend, i.e., earlier age of onset of BP with successively later years of birth, has also been reported (Rice et al., 1987).

Underdiagnosis of childhood bipolarity has been noted by several authors who have described a high prevalence on inpatient services (Gammon et al., 1983; Isaac, 1995) and a high prevalence of both diagnosed and undiagnosed cases on chart reviews (Weller et al., 1986; Wozniak et al., 1995). Another source of underdiagnosis during childhood and adolescence is that many parents who are bipolar, and thus at higher risk of having bipolar offspring, remain underdiagnosed themselves (Geller, 1996). These parents may not recognize the pathological implications of their children's manic behaviors.

Literature on adult samples has noted that 20% to 40% of adults report that their onset was during childhood (Joyce, 1984; Lish et al., 1994). Adults with childhood onset by history often also report that the initial episode was depressive (Lish et al., 1994). The latter is consistent with the high rate of switching of prepubertal depression to prepubertal mania (32%) reported by Geller et al (1994b) and of depressed adolescents switching to adolescent-onset mania (20%) (Strober and Carlson, 1982). These rates of switching may be conservative because of the probable underdiagnosis of childhood mania discussed above.

Clinical Characteristics

At all ages, manic subjects in the cross-section appear to be the happiest of people because of their infectious, amusing, elated affect. This is also true of children, and it can be very misleading to see a happy child laughing in the office in the context of a miserable history (e.g., school suspensions, family fights). This contrasts with sad, depressed children who everyone thinks are ill because it is more difficult to acknowledge conceptually that happy children have serious psychopathology. Thus, it is important to evaluate children's affect in relationship to historical features in exactly the way one evaluates the incongruity between the infectious elation of manic adult patients in the context of histories that include loss of family, unemployment, and jail sentences.

Across the life span, grandiose delusions must be judged by failure to follow the laws of logic and by a firm belief (often to an extent that action is taken). A common presentation for bipolar children is to harass teachers about how to teach the class; this harrassment is often so intense that teachers telephone parents, begging them to ask their children to desist. These children may fail subjects intentionally because they believe the courses are taught incorrectly. Therefore, their thinking bypasses laws of logic (i.e. that children can choose what to fail or pass), and the beliefs are acted upon by purposely failing courses. Another common grandiose manifestation in children as young as seven is to steal expensive items and be impervious to police officers who attempt to make them understand that what they have done is wrong and illegal. Similar to grandiose adults, grandiose children believe that stealing may be illegal for other people but not for them. Unlike patients with pure conduct disorder, manic children and adolescents, similar to bipolar adults, frequently know that stealing is a bad thing to do, but they believe that they are "above" the law. Common adolescent grandiose delusions are that they will achieve a prominent profession (e.g. lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic. Asked how he or she will become a lawyer, an adolescent will answer is "I just know I will". Similarly, a manic adolescent, even in the absence of musical talent or ability to carry a tune, might practice all day with the belief that he or she can become a rock star.

Dissimilar to depressed patients who have trouble falling asleep and lie in bed brooding, manic children have high activity levels in the bedroom prior to sleep, e.g. rearranging furniture for several hours. Manic adolescents will wait until parents are asleep and then go out "partying," whereas manic adults will party and work around the clock.

Pressured speech is relatively similar at all ages in that the individual can be difficult or impossible to interrupt. Racing thoughts are frequently described by children and adolescents in very concrete terms. For example, children state that they are not able to get anything done because their thoughts keep interrupting. An adolescent wished she had a button on her forehead to turn off her thoughts. Flight of ideas in children is similar to that in adults except for age-specific content, e.g., "Do you live in Nashville? Some people have hogs for Thanksgiving. Do you have a key to that door?"

Also at all ages, minor perturbations in the environment can produce marked amounts of distractibility. Increased motor activity and goal-directed behaviors in children and adolescents frequently look like normal activities done in a profuse amount. The manic child may in a brief period of time make curtains, begin an illustrated book, rearrange furniture, and make multiple phone calls, compared with the manic adult, who may start many businesses and join many social groups.

Involvement in pleasurable activities with a high level of danger is manifested in age-specific behaviors. Hypersexuality in children frequently begins when a child brought up in a conservative home without any history of sexual abuse or excessive exposure to sexual situations begins to use profanity and may tell a teacher to "f--- herself" and "gives her the finger." Children may masturbate frequently, initially openly, and then when told not to do it publicly will simply make frequent trips to the bathroom to continue the stimulation. Children will begin to proposition teachers and make overt sexual comments to classmates. Adolescents develop romantic fantasies and delusions about teachers (see vignette in Geller et al. 1995). Older children and adolescents will call the 1-900 sex telephone lines, which the family discovers when the telephone bill arrives. Older adolescents and adults will have multiple partners with unprotected sexual behaviors and frequently will have an urgency to have sex, e.g., an adolescent wrote to her boyfriend, starting the letter with a sentence that said "When are we going to f---?" Adults will have multiple partners; males may be womanizers; and often there are multiple marriages.

Interest in money appears in young children when they start their own businesses in school and when they begin to order multiple items, trips, and plane tickets from advertised 1-800 and 1-900 telephone numbers. Again, the family frequently does not discover this until items arrive at the house and telephone bills arrive. Adults may overdraw on bank accounts and "top out" on multiple credit cards.

Across the age span, taking more dares is common. In older adolescents and adults, this frequently appears as wild driving, eventuating in many speed and "driving under the influence" tickets. In children it manifests as grandiose delusions that they can fly out the window because they believe that they have that ability or in exaggerations of usual childhood hopping around on trees or between roof tops, based on beliefs that they are above the possibility of danger.

To further exemplify pediatric features, characteristic vignettes of children and adolescents with BP can be reviewed in Geller et al. (1995). Characterization of preschool-age BP is an important avenue for future investigation.

Differential Diagnosis and Comorbidity

Table 1 provides a list of differential diagnoses and/or comorbid conditions by age group.

Sexual abuse is especially important as a differential diagnosis during the childhood years because manic hypersexuality is often manifested in children by self-stimulatory behaviors including frequent masturbation. Thus, it is useful to obtain a careful history of whether the child could have been abused or exposed to adult sexual behaviors.

Specific language disorders need to be differentiated from flight of ideas because children and adolescents with language disabilities can sound as though they have a thought disorder when they partake in conversation without actual comprehension of the content and/or the ability to find the appropriate words to use.

At present, data suggest that for some prepubertal-onset bipolar children, hyperactivity manifestations begin at preschool age and are followed by a full manic syndrome during the early grade-school years (Geller, 1997b). In these children, it is possible that hyperactivity is the first developmentally age-specific manifestation of prepubertal-onset BP. This hypothesis is consistent with the higher prevalence of attention-deficit hyperactivity disorder (ADHD) in prepubertal- versus adolescent-onset BP. For other bipolar children, ADHD and BP may be comorbid, i.e., hyperactivity is a separate disorder that coexists. Numerous authors (Biederman et al., 1995; Borchardt and Bernstein, 1995; Fristad et al., 1992; Geller et al., 1995; Strober et al., 1988; West et al., 1995) have noted the high prevalence of symptoms of hyperactivity among children and adolescents with bipolarity. When subjects are seen initially because of bipolar symptomatology, approximately 90% of prepubertal and 30% of adolescent bipolars have ADHD (Geller et al., 1995). Manifestations of ADHD overlap with those of multiple other DSM-IV diagnoses (e.g., BP, major depressive disorder [MDD]). Thus, validation of the distinctness of coexistent ADHD versus similar symptom clusters but dissimilar pathogenesis must await future naturalistic course, family genetic, and other neurobiological studies (Biederman et al. 1991; Geller, 1997b).

Even with the relatively conservative DSM-IV criteria, conduct disorder occurs in approximately 22% of bipolar children and 18% of bipolar adolescents (Geller et al., 1995). Conduct disorder, similar to ADHD, may be an initial manifestation of prepubertal-onset BP (Geller, 1997b; Kovacs and Pollock, 1995). These comorbid conduct disorders appear related to poor judgment and grandiosity. As an example, a 7-year-old child stole a go-cart, an item that costs several hundred dollars, and was completely unfazed when the police appeared and tried to admonish him, thus demonstrating the grandiosity of stealing such a large object and of being impervious to legal intervention. Conduct disorders during adolescence (which may include driving under the influence, running away for sexual adventures, and stealing large amounts of jewelry) frequently lead to placement of these youngsters in juvenile facilities. Adult antisocial equivalents are well known (e.g., buying new television sets for every room in the hospital; obtaining real estate that the individual cannot afford).

During the teenage years, because of greater perceptual distortions seen in bipolar illness during adolescence, schizophrenia is a major differential (Horowitz, 1975). Differentiation is greatly aided by a family history of mania, which is more probable for BP than schizophrenic adolescents (Strober et al., 1988).

Substance abuse begins to be an important comorbid condition during the teenage years and is an important differential (Horowitz, 1975; 1977). For example, laughing fits may be due to smoking marijuana as a differential from the laughing fits that occur during the pediatric years as a manifestation of elation. Furthermore, very rapid cycling (Table 2) that is a hallmark of child and adolescent bipolarity (Geller et al., 1995) can easily be mimicked by amphetamine highs followed by withdrawal "crashes." Hallucinogens can mimic bipolar perceptual distortions (Horowitz, 1975; 1977).

Similar to the multiple comorbid anxiety conditions seen with MDD, bipolar patients also manifest multiple comorbid anxiety conditions (approximately 33% of bipolar prepubertal patients and 12% of bipolar adolescent patients ) (Geller et al., 1995).

Naturalistic Course

Table 2 provides a comparison between pubertal-onset versus adult-onset episode and course features.

As noted in the beginning of this article, prepubertal onset manic-depressive disorder may not present with the sudden or acute onset and improved interepisode functioning characteristic of the disorder in older adolescents and adults. Rather, it may present with a picture of continuous, mixed manic, rapid cycling of multiple brief episodes described in detail by Geller et al. (1995). Thus, children may be having a laughing fit and happily doing an arts and crafts project when, without any environmental prompt, they will suddenly become miserable and acutely suicidal, talking about wanting to shoot themselves. Parents frequently describe their frustration at not being able to convince practitioners that their children rapidly cycle, sometimes numerous times in each day. Because this history has been given independently by parents (including those from many parts of the United States who have received Dr. Geller's name from the National Institutes of Health) who have no idea that this cycling pattern has been described by other parents, there is no reason to disbelieve these parental observations. Adults with mixed manic, rapid-cycling BP have a poorer prognosis than those with discrete episodes (Keller et al., 1993). Therefore, future studies of the adult course of BP children will be crucial for developing long-term, prophylactic treatments for implementation during the prepubertal years. Naturalistic follow-up of bipolar adolescent inpatients has evidenced a poor prognosis (Strober et al., 1995).

One of the issues that arises for child and adolescent manic-depressive individuals is whether or not BP-II disorder has the same implications as it does in the adult population (Coryell et al.,1995; Geller et al., 1994b). The switch rate from BP-II to BP-I in adults has been estimated by Coryell et al. (1989, 1995) to be similar to the low rate reported by Geller et al. (1994b) for switching from BP-II to BP-I among prepubertal subjects who switched during the prepubertal period. However, it remains possible that BP-II in children and adolescents may be an age-specific, developmental precursor to BP-I (Geller et al., 1994b). If the latter were established, then treatment for BP children might differ from that for BP adults in whom BP-II is often treated with the same regimen as MDD (Frank and Kupfer, 1985). Treatment for MDD in potentially BP pediatric patients may be contraindicated because there is evidence, albeit controversial, that antidepressant therapy may precipitate or worsen rapid cycling (Akiskal et al., 1985, 1995; Geller et al., 1993; Wehr and Goodwin, 1979; Wehr et al., 1988).

Further research will also be needed to provide better differentiation of whether the Akiskal et al. (1995) concept of temperamental issues (i.e., that there is essentially a constant temperamental modulation in some patients) is only semantically different from the mixed manic picture of BP-I and BP-II children, adolescents, and adults (Geller et al., 1995; Keller et al., 1993).

The role of comorbid personality disorders as prognostic and course features of adolescent BP remains a poorly studied but important area based on reported interepisode personality trait impairments in BP adults (Solomon et al. 1996). Johnson et al. (1995) have noted cluster II personality disorders were more prominent among BP adolescents. Other work in the area of personality disorders among pediatric BP individuals is not yet available, in part because of the need for further work on instrumentation (Brent et al., 1990).

Data support a higher risk of suicidality among BP adolescents compared to adolescents with other diagnoses (Brent et al., 1988, 1993). In addition, comorbidity of mood and substance use disorders has been correlated with higher suicide risk in older adolescents and young adults (Rich et al., 1986, 1990). The well known high comorbidity of substance dependency and BP in adults is especially notable because data suggest that "secondary" substance use is more amenable to treatment and has a better prognosis (Geller, 1997a; Winokur et al. 1995).


In their classic 1986 paper, Childs and Scriver describe different genetic mechanisms for medical illnesses that have both an early- and late-onset form, e.g., diabetes mellitus. In 1988 and 1992, Strober et al. described this phenomenon for pediatric bipolarity, noting that prepubertal-onset bipolarity was more likely to be associated with early aggressive hyperactivity, lithium resistance, and greater familial loading. Thus, clinically it is useful to identify parents who may have undiagnosed bipolarity (Geller, 1996). This is best done by asking way-of-life questions (e.g. how relatives manage money; driving histories; relatives with more than four marriages) because patients with undiagnosed mania are unlikely to think of themselves as ill. Vignettes of relatives with undiagnosed mania appear in Geller (1996). Also, possible relationships of genomic imprinting (preferential maternal or parental transmission) and mitochondrial inheritance (maternal transmission) to pediatric age of onset of BP remain intriguing issues for future research (Grigoroiu-Serbanescu et al. 1995; McMahon et al. 1995).

Familial aggregation of alcoholism among bipolar adults has been noted to be greater than among subjects with other diagnoses (Winokur et al., 1995, 1996). A similar high prevalence of alcoholism among first-degree relatives of prepubertal and adolescent subjects with mood disorders has been reported (Geller, 1997a; Geller et al., 1990, 1992; Puig-Antich et al., 1989; Todd et al., 1996). Further research on prognostic implications of familial alcoholism among pediatric BP cases is warranted. Another promising line of investigation includes genetically based malformation syndromes that include BP behavioral manifestations (Papolos et al., 1996).

The few available neurobiological studies include a single case study of a hypomanic child who had significantly different urinary methoxyhydroxyphenylglycol level from those of normal controls (McKnew et al., 1974), a report of enlarged ventricles and increased number of hyperintensities in a small open pilot study of bipolar children and adolescents (Botteron et al., 1995), and a report comparing sleep and neuroendocrine parameters in depressed adolescents with BP outcomes and those who remain depressed (Rao, 1994).

Available work on cognitive characteristics of child and adolescent bipolarity is sparse but includes the work of Decina et al. (1983). That report noted a significant discrepancy between Verbal and Performance IQ scores in offspring of bipolar parents but not in the normal control group. This is consistent with neurobiological data in adult samples that support right-sided brain impairments in manic individuals (Sackeim and Decina, 1983). Fristad (personal communication, November, 1993) noted that bipolar subjects had higher IQs than an ADHD control group. Also Kutcher (1993) reported a decrease in math performance based on school records among prebipolar adolescents. This finding may be consistent with the Decina et al. (1983) findings on lower performance IQ. It is clear that further work on cognitive impairments and their prognostic and treatment implications is needed.

Psychopharmacological Treatment

Treatment of childhood bipolarity remains a remarkably understudied area in spite of voluminous literature comprising more than 400 case reports, studies with small numbers, and investigations with populations that were not diagnosed with DSM-III or higher criteria (Botteron and Geller, 1995; Fetner and Geller, 1992; Kafantaris, 1995; Youngerman and Canino, 1978). Thus, unless there is an expectation that childhood bipolarity completely mimics the adult treatment considerations, separate study is warranted. Compelling arguments, however, against the similarity of treatment of bipolarity across age groups can be constructed by analogy to the treatment differences between childhood and adult MDD (Geller et al., 1996). Because there is as yet only one completed double-blind, placebo-controlled study of any medication for child or adolescent mania using rigorous methodology and design (Geller, 1997a), the clinician will be tempted to extrapolate from studies of adults. However, extrapolation from treatment of MDD in adults did not prove useful, i.e., tricyclic antidepressants have never been shown to work better than placebo in any study of a child and adolescent population (Geller et al., 1996).

The pharmacokinetics of lithium in children has been studied (Vitiello et al., 1988), and, as expected, lithium has a shorter half-life in children than in adults. The latter is expected because of the more efficient renal system of children. More recently, in a completed double-blind, placebo-controlled study of lithium for adolescents who were bipolar and substance dependent, lithium was significantly more effective than placebo by both completer and intent to treat analyses (Geller, 1997a). Literature on lithium suggests that it can be given to children with the same safety precautions used in adults and with similar monitoring at 6-month intervals for renal, thyroid, calcium and phosphorus indices (Fetner and Geller, 1992; Khandelwal et al., 1984). Further, a double-blind, placebo-controlled study of lithium for aggressive children has highlighted that there may be some children who will develop cognitive impairment at low plasma levels (Silva et al., 1992). This was also noted in a double-blind, placebo-controlled study of lithium for depressed children who had predictors of future bipolarity (Geller et al., 1994a).

The safest, most rapid method of prescribing lithium is to do so pharmacokinetically using a nomogram (Cooper et al., 1973; Fetner and Geller, 1992; Geller and Fetner, 1989). Alternately, if obtaining a serum lithium level 24 hours after a single dose is impractical, a 300-mg total daily dose can be administered until steady state is reached (Fetner and Geller, 1992). If the lithium level at the 300-mg daily dose is not between 0.8 and 1.2 mEq/L, then a linear proportion can be made to estimate the dose needed to reach the desired level (Geller and Fetner, 1989). Because of genetic variation in rate of elimination of lithium, slow eliminators can develop unacceptably high serum lithium levels and adverse effects if nonpharmacokinetic administration such as milligram-per-kilogram dosing is used (Hagino et al. 1995). Tactical problems and side effects with lithium are discussed in detail in Fetner and Geller (1992).

Lithium, however, is not a drug that can be given either to chaotic families or families who are unable to keep multiple appointments for monitoring of lithium levels and renal and thyroid functioning. Many young bipolar patients have at least one bipolar parent and some (Gaensbauer et al., 1984; Grigoroiu-Serbanescu et al., 1989), but not all (Anderson and Hammen, 1993), offspring studies attest to the negative impact bipolar parenting can produce. Therefore, it is imperative to have choices of medications that can safely and effectively be given in chaotic environments. Furthermore, because of the cycling and abrupt onset of suicidality, it is also important to have medications that would be safer than lithium if taken in overdose.

There are a few open, uncontrolled studies addressing anticonvulsant treatment of BP. Papatheodorou and Kutcher (1993) reported that valproate showed promising results. Himmelhoch and Garfinkel (1986) reported on the use of carbamazepine for lithium resistant adolescents. A report by Isojarvi et al. (1993) in the New England Journal of Medicine showed that polycystic ovarian disease developed in 89% of young females receiving valproic acid for epilepsy compared with 27% of epileptic females who were not receiving this preparation. In a 1996 article, Isojarvi et al. noted that valproate was associated with onset of obesity in more than half of the women and that these individuals also developed polycystic ovarian disease. Obviously, these would be prohibitive side effects for most female children with manic-depressive illness. Further work on whether or not this side effect appears only when the medication is given for epilepsy and independent replication of these findings are warranted. Details of valproate and carbamazepine administration are provided in Botteron and Geller (1995). Low dose chlorpromazine may be another alternative (Botteron and Geller, 1995).

Methylphenidate has been reported, in case studies, both to worsen (Koehler-Troy et al., 1986) and to be a first line of medication (Max et al., 1995) for bipolar children and adolescents. At present, there is a need to use trial and error to judge which patients benefit and which might be made worse by stimulant medication.

Due to the chronic course of childhood manic-depressive illness and because of rapid cycling, mixed features which are known to predict poor response in older populations (Geller et al., 1995; Himmelhoch and Garfinkel, 1986; Hsu, 1986; Keller et al., 1993), duration of antimanic treatments is complex. Further, literature on adults suggest that intermittent lithium therapy is worse for outcome than continuous, noninterrupted therapy and that it can be difficult to restabilize patients on lithium after interruptions (Ahrens et al., 1995; Muller-Oerlinghausen et al., 1992, 1994; Schou, 1995; Schou et al., 1989). Of note, Strober et al. (1990, 1995) keep adolescents on antimanic treatments throughout the teenage years. Strober et al. (1990) have also reported an open, uncontrolled naturalistic follow-up study of adolescents on lithium. These data strongly support long term maintenance lithium because subjects who discontinued lithium had a significantly higher relapse rate.

Psychosocial Treatments

As yet, this area has not been investigated for children and adolescents with BP. It may, however, be especially important because of the known increased significance of nonshared environmental factors during the early childhood years (Pike and Plomin, 1996). Studies showing the relationship of negative expressed emotion to poorer outcome among bipolar adults argue for similar investigation of nonshared environmental factors among childhood populations (Miklowitz et al., 1988).

Among adults, impairment in psychosocial functioning between BP episodes has been reported (Coryell et al., 1993; Gitlin et al., 1995). The latter is relevant to an ongoing controlled study of adults who, after stabilization on medication, are randomly assigned to either a family-focused or a combined interpersonal and social rhythm (e.g., sleep) intervention (Miklowitz et al., 1996). It is clear that similar studies of psychosocial therapies among younger populations will be warranted when medication maintenance studies for pediatric BP become available.


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Differential Diagnoses and/or Comorbid Conditions




Specific language disorders




Attention-deficit hyperactivity disorder




Oppositional defiant disorder




Conduct disorder




Sexual abuse







Substance abuse




Antisocial personality




Hypothesized Clinical Course by Age of Onset

Prepubertal and Young Adolescent

Older Adeolescent and Adult

Initial episode

Major depressive disorder


Episode type

Rapid-cycling, mixed

Discrete with sudden onsets and clear offsets


Chronic, continuous cycling


Interepisode functioning


Improved functioning

© 1997 by the American Academy of Child and Adolescent Psychiatry. This article is reproduced here with permission of the Academy.

Dr. Geller is Professor of Psychiatry and Dr. Luby is Assistant Professor of Psychiatry, Department of Psychiatry, Washington University School of Medicine, St. Louis.

Reprint requests to Dr. Geller
Washington University School of Medicine
4940 Children's Place
St. Louis, MO 63110

This work was supported by NIMH Grant R01 MH53063 "Phenomenology and Course of Pediatric Bipolarity" to Dr. Geller.

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