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Section 22
Comorbidity and Early Intervention in Pediatric Bipolar Disorder

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Many children with bipolar disorder exhibit symptoms associated with ADHD, such as distractibility, motor hyperactivity, and overtalkativeness (Hazell, Carr, Lewin, & Sly). It is not known whether these disorders may coexist, if hyperactivity precludes mania, or if there is symptom overlap (State et al.). Faraone et al. suggested that, in some cases, ADHD may be an early marker of early-onset bipolar disorder. Geller and Luby reported that 90 percent of children and 30 percent of adolescents with bipolar disorder also may have ADHD. Biederman et al. found that the lifetime prevalence of bipolar disorder in a sample of children and adolescents with ADHD doubled over a 4-year period, increasing from 11 percent to 23 percent. Thus, it is important to note that although symptoms or a diagnosis of ADHD are present, something more than ADHD may be going on.

Children with early-onset bipolar disorder may exhibit symptoms associated with ODD or CD, such as defiance, refusal to comply with adults’ requests, and deliberately annoying people (Kovacs & Pollock). Frequent lying and manipulation of others may be another comorbid symptom of bipolar disorder and ODD/CD (Papolos & Papolos). GeIler and Luby found that approximately 22 percent of children and 18 percent of adolescents with bipolar disorder demonstrated features of CD, such as poor judgment and grandiose behaviors, as initial manifestations of early-onset bipolar disorder.

Substance abuse also may become a comorbid condition during the teenage years (Geller & Luby). Children with bipolar disorder also may experience intense cravings for carbohydrates and sweets. Many females suffering from bipolar disorder also suffer from coexisting eating disorders such as anorexia (self-­induced starvation) or bulimia (bingeing and purging) (Bock).

Some children with bipolar disorder may have difficulty with peers because they are unable to respond appropriately to social clues or boundaries. Parents may describe their bipolar children as “bossy,” “intrusive,” “has to have his or her own way or the game is over,” or “too overwhelming and aggressive” (Papolos & Papoplos, p. 18). Some children with bipolar disorder may rake their arms with razors, pins, or other sharp objects, hit themselves, or bang their heads against a wall in an attempt to self-mutilate (Papolos & Papolos). Probably the most dangerous symptom of bipolar disorder is suicidal ideation, even in children as young as 4 years of age (Papolos & Papolos). There is a higher risk of suicidality among bipolar adolescents compared to adolescents with other diagnoses (Brent et al.). Hospitalization may need to be considered if a child is so out of control that he or she is unable to stop raging, experiencing delusions or hallucinations, threatening to harm others, harming himself or herself, or threatening suicide. The high prevalence of suicidality combined with the rapidity of cycling means that serious suicidal risk may appear without warning (Geller et al.).

The above-noted behaviors may be setting-specific. A child may act one way at home and another way at school, causing confusion for parents and teachers. The wide range of behavioral and mood-related symptoms associated with early-onset bipolar disorder, as discussed above, serves to complicate making an accurate diagnosis.

Early Intervention
Early intervention can help to stabilize children who experience overwhelming mood changes and rages as well as to provide hope for their future. As well, it is important to prevent other difficulties associated with adolescent bipolar disorder, such as engaging in risky behaviors, hypersexual behavior leading to unwanted pregnancy and/or sexually transmitted diseases, reckless driving, and the possibility of substance abuse (Papolos & Papolos). Early intervention helps families to obtain appropriate services and supports and to make plans for the future. Early intervention may lead to a diagnosis that explains much of the behavioral and emotional experiences of the child as well as guides treatment.

As an example of the importance of early intervention, a case study of a child recently diagnosed with early-onset bipolar disorder is examined.

Case Study Of A 9-Year-Old Male
This male child was born after a full-term pregnancy and delivery by vacuum extraction. He was always at the 50th percentile for height and weight and met all developmental milestones within normal time limits. Behavior difficulties were first noted between the ages of 2 and 3, when he would yell and bang his head at day care, aggressively hit, kick, and bite others, and thrash around in a tantrum over something simple. Most of the time, he was enthusiastic, helpful, and constantly on the move, but he would fly into a rage over nothing within minutes.

This child continuously complained of headaches, stomach problems, and difficulty swallowing, and he had frequent diarrhea. At age 5, his family doctor referred him to a psychiatrist because of his behavior, who found that he met the criteria for ADHD and ODD. His school referred him for psychological testing, where it was found he was of average intelligence, with a giftedness in math. The psychologist also found that he had many symptoms associated with ADHD, impulsivity disorder, and severe ODD. His mother chose not to start him on Ritalin because of the risk of side effects.

His Individual Program Plans (individualized educational programs designed for students identified with cognitive or behavioral difficulties in Canadian schools) from kindergarten to Grade 3 consisted of strategies to work on anger management, cooperation, behavior, and reading, as well as enrichment activities for math. His teachers reported that his behavior gradually improved, but that he would become very anxious when completing timed math facts. At one time before completing timed math facts, he became so anxious that he began screaming and banging his head against the wall. He continuously worried about getting good grades, was often bossy on the playground, did not have many friends, and would become explosive in group activities. His stories were creative and consisted of dragons, blowing up the world, sea monsters, and constant conflict. He talked incessantly and with great detail.

He reported to the school counselor, and later to a social worker, that he had been spanked, threatened, yelled at, sworn at, and made to stay up all night doing hours of homework. In referring to living at home, he said that sometimes it was as bad as “Frankenstein having his head cut off and sewn back on and being brought back to life. Do that 100 times and that’s how bad it is.” As a result, he was taken into custody by a child protection worker because of concerns about physical and emotional abuse.

While in custody, he repeatedly ran away and exhibited more extreme behaviors. He threatened to kill the foster family’s dog and to throw himself in front of a van, and he stated that if he had a knife or a gun he would “kill everyone then kill himself.” His behavior became so extreme that he was hospitalized. After being released, he continued making threats to harm himself and others, banging his head against the wall, and needed to be restrained. He again was taken to the hospital but was refused admission because they would not deal with a child with behavioral problems, stating that he “needed some discipline,” and that one could not take threats of suicide seriously from a 9-year-old child.

The mother voluntarily underwent a full parenting assessment, and none of the physical or emotional abuse concerns were substantiated. In response to her child’s reports of physical abuse, she reported that he would punch and kick her, and she would restrain him and send him to his room. In response to his reports of being made to “stay up all night to do homework,” she reported that she knew he was gifted in math, so she saw no reason for him to have difficulty with timed math facts and had him practice for a half hour each night.

It is understandable that this child’s behaviors initially were attributed to ADHD and ODD; however, several clues were missed during the assessment and observation of this child. Despite his hyperactivity, he was able to focus on a project for I to 2 hours at a time. As well, he demonstrated extreme variety and vacillation of moods, or rapid cycling. His father was reported to have been diagnosed with bipolar disorder, and his mother had been diagnosed with major depression, which points to a bilateral transmission of the disorder. His ability to focus, rapid mood changes, and family history combined with years of behavior problems narrowed the diagnosis down to early-onset bipolar disorder. Fortunately for this child, appropriate pharmacological and psychotherapeutic treatment stabilized his moods and behaviors, allowing him to do well at school and at home.

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Personal Reflection Exercise #8
The preceding section contained information about comorbidity and early intervention in pediatric bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 22
According to Bardick, what percentage of children and adolescents with bipolar disorder exhibit symptoms common to Conduct Disorder as the first manifestation of their bipolar disorder? Record the letter of the correct answer the Answer Booklet.