Early Signs of Bipolar Disorder in Very Young Children:
Symtoms, Assessment, and Treatment
Ira Glovinsky, Ph.D., Lori Radner, M.S., Valerie Timko, M.S.,
Norma Wolford, M.S., Marita LaPalm, B.S.

Pediatric bipolar disorder is a highly controversial diagnosis in children. We are beginning to understand that it is not a single illness, but rather a spectrum of conditions (Findling et al. 2003). Classic manic-depression, a disorder in which there are clear episodes of mania, followed by depression, and well-periods (euthymia) between episodes is rare. Carlson (2004) states that:

Children with problems with executive functions, i.e., trouble paying attention inhibiting impulsive responding, planning, organizing, transitioning from one activity to another, and controlling emotion are relatively common and comprise the bulk of children being called bipolar (p. 15).

Greenspan and Glovinsky (2004, in unpublished) have presented a developmental bio-psychosocial model that describes “bipolar patterns” in terms of functional emotional developmental milestones. They describe a “signature” that children with bipolar patterns exhibit in the context of each of the developmental functional emotional milestones. The “signature” includes: (1) hypersensitivity and being easily overloaded by sensory information, particularly sound and touch; (2) being extremely tuned into their environments; (3) craving sensations; (4) going into “active mode” when overloaded.

When they are anxious children with bipolar patterns seeking sensory experiences, including movement in space; (5) as they become more active, craving sensations, sensory overload is increased, escalating the problem; (6) self-critical, self-blaming behaviors; (7) “all-or-nothing” thinking; (8) counterphobic defenses.

The earliest milestone includes the ability to regulate emotions in order to attend to the child’s external surroundings. Children with bipolar patterns evidence a combination of sensory over-reactivity and extreme sensory carving. Typically, when children become overloaded in their sensory systems, they tend to become more cautious. The child with a bipolar pattern, in contrast switches to a sensory craving mode, and becomes more impulsive, aggressive, over-agitated, or excited. This tends to elicit punitive limit-setting on the part of the parent who also “up-regulates” emotionally and matches the child’s emotional intensity. In this matched but maladaptive "dance," the child may then shift to self-incriminations and depressive states.

As children move to the next higher level that involves engagement and attachment, these children evidence the capacity to be purposeful and related, but appear to have difficulty sustaining long co-regulated emotional reciprocity. Themes relating to aggression or sadness and loss cannot be handled and lead to emotional dysregulation. Children seem to be unable to read and respond to parental emotional signals that would enable the child to tolerate feelings associated with these themes. Parents provide cues to either “up-regulate” the children when they are feeling sad of “down-regulate” the children when they are in a heightened or excited emotional state.

The child who evidences the “bipolar signature” seems unable to read and respond to parental emotional signaling (Greenspan and Glovinsky, unpublished). Soothing gestures and behaviors on the part of the parent increase rather than decrease agitation.

As these children reach higher stages of functional emotional development and are able to represent and symbolize emotional experiences many children with bipolar patterns can be creative and imaginative, but remain constricted in their emotional range. Now the children are able to engage in pretend play. In some themes they can sustain co-regulated emotional reciprocity, e.g., nurturance, but when they engage in aggressive themes they shift to an “action mode” marked by excitability, impulsivity, and frank aggression, e.g., throwing things, destroying property, and striking out physically at adults with whom they are engaged. Their words merely describe an event and accompany the discharge of aggression in their actions, rather than containing or representing their intense feelings in a dialogue (Greenspan and Glovinsky, unpublished).

As these children move to higher levels of logical and reflective thinking, these earlier patterns continue leaving the child with a bipolar pattern in a more polarized “all-or-nothing” verbal and behavioral pattern. These children have difficulty with "gray-area" thinking and reflective thinking, in emotionally charged areas that other children use to modulate emotional expressions. Unless there are environmental interventions or perhaps shifts in life experiences, the bipolar patterns may continue through latency, adolescence, and into adulthood.

There is presently an increased recognition that these patterns are being seen in younger children. For example, in 2003 a second international conference on Pediatric Bipolar Disorder, under the auspices of the National Institute of Mental Health, brought together close to 100 researchers, clinicians, and parents from the United States and other countries to share their work and experiences with bipolar children (Biederman, 2004). A third international conference will be held in 2005. The proceedings of the meeting included a number of papers and poster presentations on pediatric bipolar disorder including two papers on mania in preschool-aged children. Scheffer and Nikalas Apps (2004) studied 31 patients, ages 2-5 years and found that their symptom expression allowed for a diagnosis of bipolar disorder according to DSM-IV criteria. These children were effectively treated with mood stabilizers, and had significant developmental benefits.

Dilsaver and Akiskal (2004) studied a group of children presenting in a community mental health clinic over a 24-month period. The children were younger than five years of age. Using a structured clinical interview, the researchers found that there was a surprisingly high incidence of mania with classical features in this population. Mania in this population appeared to be strongly linked to the presence of familial affective illness.

Tumuluru et al (2004) reported on the case histories of 6 preschool children ages 3-5 years who were obtained from a sample of 36 consecutively hospitalized preschool children, i.e., 17% of the group were diagnosed as bipolar. All of the children had irritable moods, a strong family history of affective illness, and previous presentation with symptoms of attention deficit disorder. Wilens et al. (2004) compared 44 preschoolers and 29 consecutively ascertained school-aged children with bipolar disorder. They found that the preschool-aged children had similar rates of comorbid psychopathology when they were compared to the school-aged children. Both groups of children diagnosed with bipolar disorder manifested symptoms of mania and major depression simultaneously (mixed states). The children showed substantial problems in school as well as in social and overall functioning.

A recent study by Faedda et al.(2004) underscores the need for more education to understand the early signs of pediatric bipolar disorder. Studying 82 children (aged 10.6 ± 3.6 years) diagnosed with bipolar disorder, in 74% psychopathology was recognized before age 3 in the form of sleep disturbances, hyperactivity, aggression, and anxiety. Although the mean age of boys evidencing their first symptoms was 3.2 years (S.D.=3.5) and the girls at 2.2 (S.D.= 3.8), the former were not treated until they were over six years and the girls not until seven years. Boys were first diagnosed with bipolar disorder at 9.2 years (S.D.= 3.4) and girls received the diagnosis at 10.4 years (S.D.= 3.7). This reflects years of confusion and family turmoil associated with misdiagnoses and often mistreatment.