pediatric bipolar disorder ( pbd ) is among the most active and controversial areas of child and adolescent psychiatry research , particularly with regard to appropriate limits of diagnosis .
bipolar disorder has been recognized in children since 1990s ; even then , there was intense debate whether it could occur prior to the age of 12 years .
the 3 diagnostic dilemmas in pediatric pbd are 1 ) whether elevated mood vs. irritable mood is essential for diagnosis , 2 ) minimum duration of manic episode and 3 ) comorbid diagnosis .
phenomenology of childhood mania , especially in younger children , can vary from the classic description of bipolar disorder in adults .
diagnostic criteria in dsm - iv was developed for adults ; children with bipolar disorder do not always meet these criteria .
manic episode in children is characterized by the presence of an elated , expansive or irritable mood , which represents a change from baseline , lasting for more than 7 days for manic episode or more than 4 days for hypomanic episode and the presence of neurovegetative symptoms . in children ,
compared to the elated mood , irritability is a fairly more ubiquitous feature  that the irritability should follow an episodic course and be accompanied with other neurovegetative symptoms such as decreased need for sleep , grandiosity , flight of ideas , etc
. moreover , irritability must be noticeable to others for a diagnosis of hypomania ; and impairing , for a diagnosis of mania .
it can be noted that most of the pediatric pbds fall under the category of bipolar disorder not otherwise specified ( nos ) . in general many children
typically present with atypical or mixed features like irritability ; labile mood ; rapid cycling course ; and behavioral problems , which include school problems like fighting , substance abuse and sexual behavior .
normal imaginatory play , boastfulness , overactivity and grandiosity may be mistaken for symptoms of bipolar disorder
schneiderian first - rank symptoms occur in 20% of cases ; early - onset bipolar disorder may be missed in 50% .
it is difficult to diagnose bipolar disorder in children because many of the symptoms can be caused by other disorders such as adhd , panic disorder , conduct disorder and substance use disorder , or in fact these disorders may be comorbid with bipolar disorder in children .
a 13-year - old male , class viii student , was brought by his parents with symptoms of scholastic backwardness ; sleep disturbances ; running away from school ; spending his time mostly in drawing , painting , scribbling in notebook ; and with increased communication .
he refused to do school assignment , homework and was relatively slow in completing them .
his symptoms started when he was in class vi , and they became gradually worse . while in class vi , he attended classes for hardly 3 months and ran away from school , leaving his school bag at his uncle 's place 15 km away from his school . within 20 days of this incident , he got rs .
300 from his father to pay for school fees and wandered away to madurai to worship at meenakshi temple and then returned home .
a month later , he repeated this behavior of absenting from school ; and this time , he again went to his uncle 's home .
however , he attributed his behavior of absconding from school to the torture by school teachers , their compelling him to do homework and his dislike towards schooling .
parents changed the school ; and for his class viii , he was put in a school that followed the state syllabus . in this school also , he started spending most of his time scribbling and drawing various pictures in his notebook .
he had projected his wild imagination and fantasy in the colorful drawings [ figures 14 ] .
his drawings included all things associated with an imaginary magic kingdom and utopia  a magic fort ; flag ; magic soul ; rivers ; weapons ; paleological buildings ; sorcery ; and demons , whose functions were to provide security and safety .
he titled this as  dream world and kavithai ulagam ( world of poems )  .
he felt this dream world was a separate country and was to come into existence in the near future .
since he depicted these in almost all the class tests and examinations in schools , he was referred for psychiatric assessment and management .
magic soul and weapons palleological buildings imaginary magic kingdom at the time of consultation , besides the above , his parents reported that he was very irritable most of the time ; aggressive at times ; and when controlled , he was prone to tantrum behaviors .
he had a tendency to become aggressive when enquired about studies , school or home assignment .
he detailed his drawings he had made on the dream world and he had difficulty in distinguishing fantasy from reality .
he spoke in a soft tone , and racing of thoughts was evident . at times , he was prone to distraction too .
he attributed his behavior of absconding from school to his urge for exploration and discovery .
he did not manifest hallucinations or had thought alienation , thought broadcasting , passivity or depersonalization .
prior to the onset of illness , he was a boy of timid nature  shy , reserved , having no intimacy with others in school , having very few friends .
he had good faith and belief in god and used to offer daily prayers and visit temples often .
there was no history of delinquent behavior , bed - wetting , sleep talking , seizure , substance abuse and head trauma .
he was submitted for psychometric investigation with binet - kamat test of mental ability , wechsler intelligence scale for children ( wisc ) , rorschach inkblot test .
based on the clinical and psychometric assessment , a diagnosis of pediatric bipolar disorder ( pbd ) was made , and he was started on lithium therapy .
his response to lithium was good , and he was maintained with lithium therapy and follow - up .
it is difficult to diagnose bipolar disorder in children because many of the symptoms can be caused by other disorders such as adhd , panic disorder , conduct disorder and substance use disorder , or in fact these disorders may be comorbid with bipolar disorder in children .
the present case clearly meets the diagnostic criteria of dsm - iv for a diagnosis of pediatric bipolar disorder .
the interesting observation is that the illness manifested by the age of 11 years and was continuous , not episodic to the core of cycling  rapid , ultra or ultradian .
the presence of wild imaginations that manifested in the drawings and scribbling was not due to childhood psychosis , and there was lack of schneiderian first - rank symptoms or other schizophrenic symptoms .
his running away from school on 3 occasions was not due to comorbid conduct disorder but was part of illness itself .
conduct disorder according to icd-10 should start before the age of 6 ; and according to dsm - iv , before the age of 7 . in children
it has been estimated that over half of the patients with pediatric mania also have adhd .
the diagnostic symptoms of distractibility , motor hyperactivity and talkativeness overlap with both mania and adhd and are also due to true comorbidity . in such patients , it is necessary to stabilize the mania before treating adhd symptoms to get the best results and also to combine mood stabilizers with adhd treatment . in children , conduct disorder
it is to be noted that physical restlessness and poor judgments are more common in comorbid cases of conduct disorder , rather than in cases of mania alone .
finally anxiety disorders , especially panic disorder and agoraphobia , are frequently comorbid with mania in children .
it is well known among clinicians that if a child is treated with stimulant or antidepressant medication and if there is an underlying bipolar disorder , the medication can induce mania with very severe consequences .
all mood stabilizers and antipsychotic agents are commonly used for early - onset bipolar disorder in clinical settings .
lithium has been found to be therapeutically effective in the management of pediatric bipolar disorder . in a short - term study , 20 children and adolescents ( mean age , 14 - 1 year ) with mania
were treated with lithium ( mean dose , 1125 + 106 mg ) . at follow - up
( age , < 16 years ) and found that 96% of them recovered from the index episode ; 90% were on a mood stabilizer ( usually lithium or valproate ) .
 clinicians are less sensitive in considering the diagnosis of mania in children because of the variations in clinical presentation and because of the high comorbidity with other psychiatric disorders 
 . more often than the elated and expansive mood , irritability and significant aggression may be the presenting symptoms in these cases . 
 one such case report is discussed highlighting the clinical aspects of pediatric bipolar disorder . 
INTRODUCTION
CASE REPORT
DISCUSSION