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This chapter will primarily focus on the manic/hypomanic phase of bipolar disorder. The clinical features of bipolar depression have yet to be addressed in the paediatric population. Despite the acceptance of a child and adolescent variant of bipolar disorder, the diagnosis continues to be controversial. Experts have not yet agreed on all diagnostic criteria and treatment methods. There are questions about the presence and duration of episodes and the hallmark symptoms of mania and hypomania.

The most common type of adult-onset bipolar disorder (classic presentation), with discrete episodes of depression and mania having a clear-cut onset and offset, appears to be less commonly seen in children. However, children and adolescents with full-blown bipolar illness have been described [11,25-30]. Children who exhibit discrete episodes of depression and mania respond well to lithium [31]. However, the natural course of paediatric bipolar disorder tends to be chronic and continuous rather than episodic and acute [32-35], and early onset bipolar disorder is associated with lithium resistance [36].

In a recent review of the past ten years of research on paediatric mania, Geller and Luby [37] concluded that childhood-onset mania is non-episodic, chronic, rapid-cycling and presents as mixed manic state. They emphasized, however, that the classic symptoms of mania remain the hallmark of the disorder and can be diagnosed even in children. Geller et al. [38] described developmental variants of five DSM-IV mania symptoms: euphoric mood, grandiosity, decreased need for sleep, racing thoughts and hypersexuality. They compared presentations of four of the five symptoms (manifestations of racing thoughts were similar in all age groups) in normal children, manic children and manic adults in an attempt to describe ''paediatric age equivalents of adult symptoms of mania''. At all ages, manic subjects appear to be the happiest of people, because of their infectious, amusing, elated affect. The authors recommend 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. A common presentation for bipolar children is to harass teachers about how to teach the class; this harassment is often so intense that teachers telephone parents, begging them to ask their children to desist. These children may fail intentionally at school because they believe the courses are taught incorrectly. 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. Another example is that of a manic adolescent who, even in the absence of musical talent or ability to carry a tune, might practise all day with the belief that he or she can become a rock star. Unlike 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. Children and adolescents frequently describe racing thoughts in very concrete terms. For example, children state that they are not able to get anything done because their thoughts keep interrupting. Geller et al. [38] describe an adolescent who wished she had a button on her forehead to turn off her thoughts.

Also at all ages, minor perturbations in the environment can produce marked amounts of distractibility. Increased motor activity and goal-directed behaviours 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. Involvement in pleasurable activities with a high level of danger is manifested in age-specific behaviours. Hyper-sexuality 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 ''give 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. Older children and adolescents will call the premium rate sex telephone lines, which the family discovers when the telephone bill arrives. Older adolescents will have multiple partners with unprotected sexual behaviours and frequently will feel an urgency to have sex. Geller et al. [38] give an example of an adolescent who wrote to her boyfriend, starting the letter with the sentence, ''When are we going to f***?''.

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 premium rate telephone numbers. Again, the family frequently does not discover this until items arrive at the house or telephone bills arrive. Across the age span, taking more dares is common. In older adolescents and adults, this frequently appears as wild driving, resulting in many speed and ''driving under the influence'' tickets. In children it manifests as grandiose delusions that they can fly out of the window.

Many investigators contend that irritability or prolonged aggressive temper outbursts rather than euphoria are the hallmarks of the disorder in children and adolescents [39]. However, episodic irritability can also be seen in depressed children and chronic irritability is common in attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder and some variants of pervasive developmental disorder. Other investigators have suggested the episodic decreased need for sleep being a hallmark of bipolar disorder. Of all the symptoms of mania, decreased need for sleep is the one that has been shown to have pathophysiological significance [40,41]. Decreased need for sleep characteristic of mania should be distinguished from nonspecific insomnia (which is generally accompanied by feeling tired) or chronically decreased need for sleep that may be seen in ADHD. Also, stimulant-induced insomnia (generally early insomnia) needs to be ruled out.

Several investigators have implied that even relatively mild forms of bipolar disorder in adolescents are serious conditions that are associated with substantial impairment and comorbidity [42-45]. Although most of the bipolar cases only met criteria for bipolar II disorder or cyclothymia in Lewinsohn et al.'s study [22], they exhibited considerable impairment. During their most recent episode, a majority of these subjects reported impaired functioning in social situations, with family and at school, as well as a high degree of comorbidity. In particular, the bipolar subjects exhibited significantly elevated rates of comorbid anxiety disorders (especially separation anxiety and panic) and disruptive behaviour (especially ADHD). Moreover, the bipolar subjects were at least as impaired as the major depressive comparison group on every variable examined. Indeed, a greater proportion of bipolar subjects had attempted suicide compared to major depressive subjects. Also, bipolar subjects exhibited significantly greater impairment than the major depressive subjects on the Global Assessment of Functioning (GAF) at the second assessment and during the previous year. Finally, the bipolar subjects exhibited a relatively chronic course. The median duration of illness in this group was more than 4 years and these adolescents had already spent a median total of 28 months in an affective episode. Although more than half of these subjects had received some form of mental health treatment, only one had been treated with lithium. Many of these cases were not recognized as having a bipolar disorder by the mental health professionals with whom they had contact [22].

Akiskal [46] examined prodromal symptoms of childhood bipolar disorder and suggested that subtle presentations of mood regulation difficulties could be warning signs. He reported that many children diagnosed with bipolar disorder are described by their parents as having a difficult temperament since infancy. During childhood many of these behaviours may be ascribed to difficult temperaments, thus making it hard to conceptualize more severe difficulties as part of a potentially treatable disorder.

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