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1 JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY Volume 12, Number 1, 2002 Mary Ann Liebert, Inc. Pp. 3 9 Phenomenology of Prepubertal and Early Adolescent Bipolar Disorder: Examples of Elated Mood, Grandiose Behaviors, Decreased Need for Sleep, Racing Thoughts and Hypersexuality BARBARA GELLER, M.D., 1 BETSY ZIMERMAN, M.A., 1 MARLENE WILLIAMS, R.N., 1 MELISSA P. DELBELLO, M.D., 2 JEANNE FRAZIER, B.S.N., 1 and LINDA BERINGER, R.N. 1 ABSTRACT Objective: Children are developmentally incapable of many manifestations of bipolar symptoms described in adults (e.g., children do not max out credit cards or have four marriages). To address this issue, our group investigated prepubertal and early adolescent age equivalents of adult mania behaviors. Methods: Details of the methods appear in the companion article in this issue (Geller et al. 2002a). Subjects had a prepubertal and early adolescent bipolar disorder phenotype (PEA- BP) that was validated by reliable assessment (Geller et al. 2001b), 6-month stability (Geller et al. 2000c), and 1- and 2-year longitudinal diagnostic outcome (Geller et al. 2001a, 2002b). Results: Examples of elation, grandiosity, decreased need for sleep, racing thoughts, and hypersexuality in PEA-BP subjects were compared to examples in prepubertal normal controls and to examples in late teenage/adult-onset mania. Because it is not intuitive that children can be pathologically happy or expansive, sections on guidelines for differentiating normal versus impairing elation and grandiosity are provided. Conclusion: Due to the high comorbidity of PEA-BP and attention deficit hyperactivity disorder (ADHD), recognition of mania symptoms that do not overlap with those for ADHD may aid in avoiding both under- and overdiagnosis of child bipolar disorder. A discussion of how nonoverlapping with ADHD Diagnostic and Statistical Manual of Mental Disorders (4th ed.) mania symptoms can be useful in the differential diagnosis of irritability is also provided. 1Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri. 2Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio. This study was supported by National Institute of Mental Health Grant R01 MH to Dr. Geller. 3

2 GELLER ET AL. INTRODUCTION BOTH CLINICAL DIAGNOSIS AND INVESTIGATIONS of child bipolar disorders have been beset by substantial controversy over the differentiation of mania from attention-deficit hyperactivity disorder (ADHD) (Fristad et al. 1992; Geller et al. 1995, 1998a, 1998b, 2000b, 2002a). Unlike late-teenage and adult-onset bipolar disorders, in which schizophrenia was one of the main differential diagnoses (Goodwin and Jamison 1990), ADHD has been the major differential problem in prepubertal and early adolescent subjects. This child-age specific differential diagnostic problem stems from the very high prevalence of comorbid ADHD among child-onset bipolar disorder subjects and from the overlap of certain Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association 1994) criteria for mania and ADHD (e.g., hyperactivity, distractibility) (Fristad et al. 1992; Geller et al. 1995, 1998a, 1998b, 2000c, 2002a, 2002b). Our group has addressed the issue of differentiating child-onset mania from ADHD through the use of the following definition (Geller et al. 2000a, 2000b, 2000c, 2001a, 2001b, 2002a). A prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) was defined by a current episode of DSM-IV mania/hypomania with grandiosity and/or elation as one inclusion criterion. The latter criterion was selected to ensure that subjects were not diagnosed just by criteria that overlapped with those for ADHD and that they had at least one of the two cardinal features of mania (i.e., elation and/or grandiosity). The PEA- BP has been validated by reliable assessment (Geller et al. 2001b), 6-month stability (Geller et al. 2000c) and 1- and 2-year longitudinal diagnostic outcome (Geller et al. 2001a, 2002b). An important research question in investigating PEA-BP was what were pediatric age equivalents of adult symptoms of mania (Geller et al. 1995; Geller and Luby 1997; Geller et al. 2001a). Manifestations of DSM-IV mania criteria in adults have been widely accepted for decades (Goodwin and Jamison 1990), but include behaviors that do not occur during the prepubertal and early adolescent years. For example, children will not have had four marriages and will not have maxed out credit cards. To investigate pediatric manifestations of bipolar disorders, Geller et al. (1996, 1998b, 2001b) developed an instrument specifically for research interview assessment of PEA-BP symptoms. This tool, the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al. 1996), which has been described in detail elsewhere (Geller et al. 2001b), has excellent reliability (Geller et al. 2001b) and has been validated against parent and teacher reports (Geller et al. 1998a). It is a semistructured interview given to mothers about their children and separately to children about themselves by experienced research nurses who have established interrater reliability. As noted in the recent National Institute of Mental Health (NIMH) Research Roundtable on Prepubertal Bipolar Disorder (2001), the WASH-U-KSADS is used in the large majority of NIMH-funded studies of child bipolar disorders. This widespread use of the WASH-U-KSADS supports the increasing consensus on the existence of child mania and the usefulness of the WASH-U-KSADS in the assessment of child mania. To our knowledge, this is the first report of examples of DSM-IV mania symptoms in PEA-BP and of their comparison to manifestations in adults with bipolar disorder. METHODS The methodology of ascertaining and assessing the 268 participants (93 PEA-BP, 81 ADHD, and 94 normal community controls) in the ongoing Phenomenology and Course of Pediatric Bipolar Disorders study has been detailed in the companion article in this issue and elsewhere (Geller et al. 1998a, 1998b, 2000a, 2000b, 2000c, 2001a, 2001b, 2002a, 2002b). The five DSM-IV mania symptoms presented in this article are euphoric mood, grandiosity, decreased need for sleep, racing thoughts, and hypersexuality. These were selected as examples because they were excellent discriminators between PEA-BP and ADHD subjects as reported by Geller et al. (2002a) in the companion article in this issue. 4

3 PHENOMENOLOGY OF PREPUBERTAL MANIA It can be noted that the examples presented in this article were only a small part of the comprehensive diagnostic process, which included multiple informants, school and medical records, videotaped observations, and consensus conferences. These are described in the companion article and elsewhere (e.g., Geller et al. 2000a, 2000b, 2000c, 2001a, 2001b, 2002a, 2002b). Detailed instructions on how DSM-IV symptoms on the WASH-U-KSADS were rated on a severity scale appear in the WASH-U-KSADS instrument (Geller et al. 1996, 2001b). These instructions take numerous relevant factors into account (e.g., frequency, duration, context, intensity, functional impairment, occurrence in multiple settings, noticed by peers and adults). Representative, typical examples of mania symptoms were taken from WASH-U-KSADS research interviews and from other settings. Although the WASH-U-KSADS was administered to mothers about their children and to children about themselves, the examples discussed in this article are largely from the children s interviews about themselves. Examples for bipolar adults were taken from the clinical experience of the authors. Tables 1 5 were constructed to provide examples of mania symptoms in PEA-BP subjects, normal children, and bipolar adults. Because it is not intuitive that children can be pathologically happy or expansive, sections on guidelines for differentiating normal versus functionally impairing elation and grandiosity are provided. After complete description of the study to parents and children, written informed consent was obtained from parents and written assent was obtained from children. Guidelines for differentiating normal from pathological manic euphoria Normal children were extremely elated when going to Disneyland, when grandparents were visiting, and on Christmas morning. This mood was appropriate to context, expected by the adults, and nonimpairing. This can be compared to a child who was elated and giggling in the classroom, when others were not, and who got sent to the principal and suspended from school for this behavior. In this example, the elated mood was inappropriate to context and impairing and thus was pathological. This example demonstrates that the guideline for pathological elated mood was inappropriateness to context and association with impairment. Guidelines for differentiating normal expansive play from manic grandiosity Normal children were expansive and grandiose when playing. For example, a child played at being a fire fighter after school and directed the other fire fighters on what to do. Another child played at being the teacher after school and directed an imaginary group of students. In these examples, the context is appropriate (i.e., play after school hours), and the grandiose idea that they were teachers and fire fighters was developmentally expected. Because it was after school and only in an imaginary play situation, it was nonimpairing. Compare the above to a child who got up during the class and began instructing the teacher on how to educate and began telling the students what they should learn or the child who went to the principal demanding that his teacher be fired. Both of these students received school suspensions. In these examples, the grandiosity was not in play after school but was acted upon in real-life situations. It was impairing in that it disrupted the class and led to punishment. Thus, similar to pathological elated mood, pathological grandiosity is inappropriate to context and functionally impairing. RESULTS Tables 1 5 present examples for each of the five mania symptoms. Flight of ideas was also an excellent discriminator between subjects with PEA-BP and ADHD (Geller et al. 2002a), but manifestations of flight of ideas were similar to those of adults with bipolar disorder, so these were not provided in the tables. 5

4 GELLER ET AL. TABLE 1. EXAMPLES OF ELATED MOOD IN PREPUBERTAL AND EARLY ADOLESCENT BIPOLAR DISORDER SUBJECTS, NORMAL CHILDREN, AND BIPIOLAR ADULTS Child was super happy on days A 7-year-old boy was repeatedly A 40-year-old man giggled family went to Disneyland, on taken to the principal for clowning infectiously while being placed in Christmas morning, and during and giggling in class (when no one restraints in the emergency room. A grandparents visits. Child s joy else was) and was suspended from 50-year-old man in the emergency was appropriate to context. school. He had to leave church with room was infectiously amusing as he Child s behavior was not his family for similar behaviors. described multiple hospitalizations, impairing. A 9-year-old girl continually danced losing jobs, and losing family ties. around at home stating, I m high, over the mountain high after suspension from school. TABLE 2. EXAMPLES OF GRANDIOSE BEHAVIORS IN PREPUBERTAL AND EARLY ADOLESCENT BIPOLAR DISORDER SUBJECTS, NORMAL CHILDREN, AND BIPOLAR ADULTS A 7-year-old boy played at being A 7-year-old boy stole a go-cart An adult man kept his family in a fire fighter, directing other fire because he just wanted to have it, increasing debt due to multiple fighters and rescuing victims. The even though he knew stealing was unrealistic business ventures. A child was not calling the fire station wrong. He did not, however, believe 21-year-old man believed he to tell them what to do. Play was it was wrong for him to steal. When could commit a homicide and during afterschool hours; it was the police arrived, the child thought not be arrested because the age appropriate and not impairing. the officers were there to play with laws would not pertain to him. him. An 8-year-old girl opened a An 18-year-old woman rang the paper flower store in her classroom mayor s home doorbell because and was annoyed and refused to do she knew they were engaged. classwork when asked by the teacher. When asked if she had ever An 8-year-old girl, failing at school, met the mayor, she stated that spent her evenings practicing for did not matter. when she would be the first female president. She was also planning how to train her husband to be the First Gentleman. When asked how she could fail school and still be president, she said she just knew. TABLE 3. EXAMPLES OF DECREASED NEED FOR SLEEP IN PREPUBERTAL AND EARLY ADOLESCENT BIPOLAR DISORDER SUBJECTS, NORMAL CHILDREN, AND BIPOLAR ADULTS Normal children sleep approximately An 8-year-old boy chronically A 25-year-old woman worked both 8 to 10 hours a night and are tired stayed up until 2 a.m. rearranging the day and evening full-time jobs the next day if they sleep fewer furniture or playing games. Then he seemingly without fatigue. A hours than usual. awoke at 6 a.m. for school and was father described his wife as she energetic during the day without parties for days in a row and evident tiredness or fatigue. A 7-year- then sleeps for days in a row. old girl, daily, knocked on a friend s door at 6 a.m. ready to play. 6

5 PHENOMENOLOGY OF PREPUBERTAL MANIA TABLE 4. EXAMPLES OF HYPERSEXUAL BEHAVIORS IN PREPUBERTAL AND EARLY ADOLESCENT BIPOLAR DISORDER SUBJECTS, NORMAL CHILDREN, AND BIPOLAR ADULTS A 7-year-old child played doctor An 8-year-old boy imitated a rock Numerous adults who had four or with a same-aged friend. A star by gyrating his hips and more marriages not due to death of 12-year-old boy looked at his rubbing his crotch during a research spouses or who had multiple father s pornographic interview. A 9-year-old boy drew extramarital affairs. magazines. pictures of naked ladies in public, stating they were drawings of his future wife. A 14-year-old girl passed notes to boys in class asking them to f her. Another girl faxed a similar note to the local police station. A 7-year-old girl touched the teacher s breasts and propositioned boys in class. A 10-year-old boy used explicit sexual act language in restaurants and other public places. Another child called sex lines, which his parents discovered when the phone bill arrived at the end of the month. TABLE 5. EXAMPLES OF RACING THOUGHTS IN PREPUBERTAL AND EARLY ADOLESCENT BIPOLAR DISORDER SUBJECTS, NORMAL CHILDREN, AND BIPOLAR ADULTS Normal subjects did not give Unlike manic adults, children gave Adults conceptually understand affirmative responses to concrete answers to describe their racing thoughts and can describe inquiries about racing racing thoughts. Examples are: A girl them using the word racing. thoughts. pointed to the middle of her forehead and stated, I need a stoplight up there. Other children noted the following: It s like an energizer bunny in my head. Too much stuff is flying around up there. I don t know what to think first. My thoughts broke the speed limit. My thoughts broke the sound barrier of my mind. DISCUSSION Recognition of mania symptoms that do not overlap with those for ADHD may be useful to avoid both under- and overdiagnosis of child bipolar disorder. Over diagnosis may be occurring because of the complex differential diagnosis of irritability in children. The importance of the symptom of irritability was observed by Biederman (2000) and in the very popular book by Papolos and Papolos (1999). These authors noted that, in their work, irritability was the most common symptom of child mania. Some families and practitioners may have misinterpreted most common to mean that irritability was a pathognomonic symptom of mania. A comparison to strep throat may be useful to put irritability in proper perspective. Sore throat is the most common symptom of strep throat, but only 5% or fewer of children who present with a sore throat actually 7

6 GELLER ET AL. have strep throat. By analogy, only a very small percentage of children with irritability will have mania. Irritability is also a very frequent symptom and a very common reason for clinical referral in children with numerous other child psychiatric disorders (e.g., ADHD, oppositional defiant disorder, conduct disorder, autism, Asperger s syndrome). Thus, clinicians need to be watchful for potentially overdiagnosing mania in children with irritable mood but without nonoverlapping with ADHD mania symptoms. It is also useful to be mindful that co-occurring irritability and elation was very frequent in both child and adult bipolar disorder (Geller et al. 2002a; Goodwin and Jamison 1990). Underdiagnosis may occur if mania is not considered in the differential diagnosis of children who have ADHD. Data that support the occurrence of underdiagnosis were reported by Geller et al. (2002b) in a 2- year follow-up of subjects with PEA-BP who were comprehensively assessed in our research unit at 6- month intervals. These subjects received all of their treatment from their own community practitioners. Less than half had received any antimanic medication (defined as lithium, an anticonvulsant, or a neuroleptic) from their community practitioners during the 2 years. These data may reflect that community physicians recognize ADHD but do not yet recognize symptoms of child mania or do not consider mania in their differential diagnosis of ADHD. Knowledge of examples of pediatric equivalents of adult manifestations of mania can help clinicians and investigators with the differential diagnosis of irritability and of ADHD and thus help avoid over- or underdiagnosis of child mania. REFERENCES American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington (DC), American Psychiatric Association, Biederman J: Advances in the psychopharmacology of pediatric bipolar disorder and ADHD. J Child Adolesc Psychopharmacol 10: , Fristad MA, Weller EB, Weller RA: The mania rating scale: Can it be used in children? A preliminary report. J Am Acad Child Adolesc Psychiatry 31: , Geller B, Sun K, Zimerman B, Luby J, Frazier J, Williams M: Complex and rapid-cycling in bipolar children and adolescents: A preliminary study. J Affect Disord 34: , Geller B, Williams M, Zimerman B, Frazier J: Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). St. Louis, Washington University, Geller B, Luby J: Child and adolescent bipolar disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 36: , Geller B, Warner K, Williams M, Zimerman B: Prepubertal and young adolescent bipolarity versus ADHD: Assessment and validity using the WASH-U-KSADS, CBCL and TRF. J Affect Disord 51:93 100, 1998a. Geller B, Williams M, Zimerman B, Frazier J, Beringer L, Warner KL: Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultrarapid or ultradian cycling. J Affect Disord 51:81 91, 1998b. Geller B, Bolhofner K, Craney JL, Williams M, DelBello MP, Gundersen K: Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. J Am Acad Child Adolesc Psychiatry 39: , 2000a. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, DelBello MP, Soutullo CA: Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid ADHD. J Child Adolesc Psychopharmacol 10: , 2000b. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, DelBello MP, Soutullo CA: Six-month stability and outcome of a prepubertal and early adolescent bipolar disorder phenotype. J Child Adolesc Psychopharmacol 10: , 2000c. Geller B, Craney JL, Bolhofner K, DelBello MP, Williams M, Zimerman B: One-year recovery and relapse rates of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 158: , 2001a. 8

7 PHENOMENOLOGY OF PREPUBERTAL MANIA Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, DelBello M, Soutullo C: Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. J Am Acad Child Adolesc Psychiatry 40: , 2001b. Geller B, Zimerman B, Williams M, DelBello MP, Bolhofner K, Craney JL, Frazier J, Beringer L, Nickelsburg MJ: DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attentiondeficit hyperactive and normal controls. J Child Adolesc Psychopharmacol 12:11 26, 2002a. Geller B, Craney JL, Bolhofner K, Nickelsburg MJ, Williams M, Zimerman B: Two year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 2002b (in press). Goodwin FK, Jamison KR (eds): Manic-Depressive Illness. New York, Oxford University Press, National Institute of Mental Health research roundtable on prepubertal bipolar disorder. J Am Acad Child Adolesc Psychiatry 40: , Papolos DF, Papolos J: The Bipolar Child: The Definitive and Reassuring Guide to Childhood s Most Misunderstood Disorder. New York, Broadway Books, Address reprint requests to: Barbara Geller, M.D. Washington University School of Medicine 660 South Euclid Avenue, Box 8134 St. Louis, MO gellerb@medicine.wustl.edu 9