Bipolar Affective Disorder in Children and Adolescents
Bipolar affective disorder expresses itself differently in children and teens than in adults. This article discusses Western and Oriental medicine approaches to treatment. DSM4 definitions have limited applicability. Children have special side effects. Bipolar disease is frequently confused with ADHD and stimulants can make bipolar disease worse. Includes a review of TCM patterns to bipolar disease and points and herbal formulas used for treatment.

March 25th 2006 - Bipolar Affective Disorder in Children and Adolescents
Copyright by Karen S. Vaughan, MSTOM, Licensed Acupuncturist

Bipolar affective disorder, formerly known as mania depression and related mood disorders, affects approximately 3% of people and 1% of children in the United States. Males and females seem equally receptive to the spectrum of diseases and there is a hereditary component. Bipolar disease has been described with accuracy since Arataeus of Cappodocia in the first century combined melancholia and mania (viewed as a more severe form of melancholia) into a single disease. It was recognized early in Chinese and Ayurvedic medicine as well. This spectrum has broadened over the years and includes Type 1 and Type 2 Bipolar disorder, Cyclothemia, Rapid cycling and new diagnostic categories continue to be formed since patients fall through the diagnostic cracks. (1) Although the overall mood disorder category is reasonably clear, distinguishing subcategories can be difficult because there is significant overlap with these forms and other disorders. This is particularly true when diagnosing children.

Approximately 30% to 55% of patients with major depression suffer from bipolar spectrum disorder. Rapid cycling, defined as switching from manic or hypomanic states at least 4 times per year, is more often related to bipolar II disorder than bipolar I. In a study by Perugi and colleagues,(2) 72% of 86 patients with major depression with atypical features as delineated by the DSM-IV met the researchers' criteria for bipolar II and associated soft subtypes of the bipolar spectrum disorders. All patients, by the atypical depression criteria, showed mood reactivity. Interpersonal sensitivity was present in 94%. Approximately 60% had pre-existing cyclothymic or hyperthymic temperaments. If the threshold criteria for hypomania in bipolar type II in patients with bipolar II is considered to be 4 days, as outlined in the DSM-IV, 32.6% of the sample met criteria for bipolar II. This rate is approximately 3 times the rate noted for atypical depression noted in the literature. There was a high rate of comorbidity (coexisting illnesses) in this study, as follows: social phobia, 30%; body dysmorphic disorder, 42%; obsessive-compulsive disorder (OCD), 20%; and panic disorder, 64%. There was also a high rate of both cluster A (anxious personality) disorders and cluster B (borderline and histrionic) disorders.

Using DSM4 definitions which express bipolar behavior in terms of adult experiences like spending sprees, children were traditionally not diagnosed with bipolar disease. Current research, clinical experience, and family accounts provide substantial evidence that bipolar affective disorder can occur in children and adolescents. Bipolar affective disorder is difficult to recognize and diagnose in youth, however, because it does not fit the DSM4 symptom criteria established for adults, and because its symptoms can resemble or occur with those of other common childhood-onset mental disorders like ADHD, Borderline disorder, Asperger’s syndrome, PSTD, substance abuse and normal adolescence. But unlike normal mood changes, bipolar affective disorder significantly impairs functioning in school, with friends, and with family. There is now pressure to substantially change the definition for DSM5.
The DSM4 definition of Bipolar Disease is summarized in the appended chart (3)
Table 1. Comparison of Diagnostic Characteristics and Associated Features Among Bipolar Disorder Subtypes*

Bipolar I Pure manic or mixed manic episode(s) required (1 week†) Depression may occur ( at least 2 weeks) Recurrent in 90% of individuals, completed suicide in 10% to 15%, violent behavior, school/occupational failure, divorce, episodic antisocial behavior. Comorbidity:Anorexia nervosa, bulimia nervosa, attention deficit/hyperactivity disorder (ADHD), panic disorder, social phobia, substance-related disorder

Bipolar II Hypomania (4 days) One or more major depressive episodes required (2 weeks) Completed suicide in 10% to 15%, school/occupational failure, divorce Comorbidity:Substance abuse or dependence, anorexia nervosa, bulimia nervosa, ADHD, panic disorder, social phobia, borderline personality disorder

Cyclothymia Hypomania cycling with depressive symptoms, without manic, mixed, or major depressive episodes (2 years‡ with symptom-free intervals less than 2 months) 15% to 50% risk of developing bipolar I or II disorder Substance-related and sleep disorders

Bipolar not otherwise specified Rapid (days) alternation between manic and depressive symptoms without manic, mixed, or major depressive episodes; may include hypomanic episodes (but less than 4 days) without intercurrent depression; may be diagnosed when clinician determines a bipolar disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

*From Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, 2000.
†Shorter duration allowed if hospitalization is required.
‡One-year minimum duration for children/adolescents.

Bipolar patients manifest manic or hypomanic symptoms. Mania may be may be straightforwardly diagnosed in Type 1 Bipolar disease, but in Type 2 Bipolar and other associated disorders hypomanic symptoms are recognized by contrast to depression and may include dysphoria and anger, in addition to grandiosity and decreased need for sleep. Anger is specifically attributed to bipolar disease in young adults but is unaccountably missing from the list of adult manic symptoms. Manic symptoms for adults include (4):
• Severe changes in mood—either extremely irritable or overly silly and elated
• Overly-inflated self-esteem; grandiosity
• Increased energy
• Decreased need for sleep—ability to go with very little or no sleep for days without tiring
• Increased talking—talks too much, too fast; changes topics too quickly; cannot be interrupted
• Distractibility—attention moves constantly from one thing to the next
• Hypersexuality—increased sexual thoughts, feelings, or behaviors; use of explicit sexual language
• Increased goal-directed activity or physical agitation
• Disregard of risk—excessive involvement in risky behaviors or activities
Depressive symptoms include(5):
• Persistent sad or irritable mood
• Loss of interest in activities once enjoyed
• Significant change in appetite or body weight
• Difficulty sleeping or oversleeping
• Physical agitation or slowing
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Difficulty concentrating
• Recurrent thoughts of death or suicide
Children experience bipolar affective disorders differently than adults. Children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be euphoric. When depressed, they may have headaches, muscle aches, stomachaches or fatigue, frequent absences from school or poor school performance, talk of or plans to run away from home, irritability, complaining, unexplained crying, social isolation, poor communication, and extreme sensitivity to rejection or failure. Other ways manic and depressive states are manifested include alcohol or substance abuse and relationship difficulties.(6)
Bipolar disorder beginning in childhood or early adolescence may be a different, more severe form of the illness than when it shows up in older adolescents and adults. When the illness begins around puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may occur with disruptive behavior disorders, especially attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) or conduct disorder (CD), or may have features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and has a more episodic pattern with relatively stable periods between episodes. There is also less co-occurring ADHD, ODD or CD among those with later onset illness.(7)
A child or adolescent who appears to be depressed and exhibits ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes, should be evaluated by a psychiatrist experienced in bipolar disorder, particularly if there is a family history of the illness. (Psychiatrists without bipolar experience may misdiagnose by excessive reliance on DSM4 which is out of date for both adult and children’s disorders.) This evaluation is especially important since psychostimulant medications like Ritalin, often prescribed for ADHD, may worsen manic symptoms. There is also limited evidence suggesting that some of the symptoms of ADHD may be a forerunner of full-blown mania, but it is not certain.(8)
Cycling is also not as discrete and ranges outside of DSM4 criteria for adults cited above. All those with bipolar affective disorder experience mood swings that alternate from periods of severe highs (mania) to severe lows (depression). However, while these abnormally intense moods usually last for weeks or months in adults with the illness, children with bipolar disorder can experience such rapid mood swings that they commonly cycle many times within a day. The most typical pattern of cycling among those with childhood bipolar affective disorder, called ultra-ultra rapid or ultradian, is most often associated with low arousal states in the mornings followed by increases in energy towards late afternoon or evening. (9)
It is not uncommon for the initial episode of childhood or adolescent bipolar affective disorder to present itself as major depression. But clinical investigators have observed a significant rate of transition from depression into bipolar states in children.
One of the most important factors in establishing the diagnosis is family history. According to several recent studies, a history of mood disorders (particularly bipolar disorder) and/or alcoholism on both the maternal and paternal sides of a family appears to be commonly associated with childhood and adolescent onset bipolar disease. (9)
The root of the mood disorder appears in infancy, although there is nothing that would be described as the full blown childhood form of this disorder. Parents report that their children have seemed different with difficulty settling down, and they note that their children are easily over-responsive to sensory stimulation. They may have unusual tastes, be unusually articulate although performing at below average levels on reading, writing and small motor skills. Sleep disturbances, late enuresis and night terrors are also commonly reported. (10)
Later stages in a child's development show hyperactivity, fidgetiness, difficulties making changes, and high levels of anxiety (particularly in response to separation from the mother) are commonly seen. Additionally, being easily frustrated, having difficulty controlling anger, and impulsiveness (difficulty waiting one's turn, interrupting others) often result in prolonged and violent temper tantrums.
Bipolar affective disorder in children rarely occurs by itself. Rather, it is often accompanied by symptoms that, when observed at points of the child's life, suggest other psychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder, and conduct disorder (CD). An estimated 50 percent to 80 percent also have ADHD as a co-occuring diagnosis. Since stimulant medications often prescribed for ADHD (Dexedrine, Adderall, Ritalin, Cylert) have been known to escalate the mood and behavioral fluctuations in those with bipolar affective disorder, it is important to address the bipolar disorder before the attention-deficit disorder in such cases. Some clinicians suggest that the prescription of a stimulant for a child genetically predisposed to develop bipolar disorder may induce an earlier onset or negatively influence the cycling pattern of the illness. (11)
Several studies have shown that more than 80 percent of children who go on to develop bipolar affective disorder have five or more of the primary symptoms of ADHD-distractibility, lack of attention to details, difficulty following through on tasks or instructions, motor restlessness, difficulty waiting one's turn, and interrupting or intruding upon others. In fact, difficulties with attention are so common in children that ADHD is often diagnosed instead of bipolar disease.
But the way symptoms common to bipolar affective disorder and ADHD are expressed and the triggers may differ. For instance, destructiveness and misbehavior are seen in both disorders, but these behaviors often seem intentional in bipolar children and caused more by carelessness in ADHD. Physical outbursts and temper tantrums are triggered by sensory or emotional over-stimulation in ADHD but can be caused by a simple "No" from a parent for bipolar children. Duration differs too: those with ADHD seem to calm down within 15 to 30 minutes, while those with bipolar often continue to feel angry for hours. Bipolar children often feel bad afterwards and say that they were unable to control their anger when the tantrum subsides.
Other symptoms are only seen often with bipolar disease but not ADHD. These include dream disturbed sleep and night terrors with life-threatening content like nuclear war, terrorism, replays of the Trade Center attack or attacking animals. Distractibility, daydreaming, impulsiveness, mischievous bursts of energy that are difficult for the child to control, and sudden intrusions and interruptions in the classroom are also common features of the bipolar child.
Between six and eight bipolar children often exhibit stubborn, oppositional, and bossy behavior. Risk-taking, rejection of authority, and drug use are not uncommon. Many bipolar children have comorbid (simultaneously occurring) learning disabilities.
Treating children and young people with bipolar disorder carries specific challenges not found in adult bipolar disorder. While children may not discuss their disorder in the same terms as adults, they generally know something is going on and will be able to express that it is happening to them. A six year old might describe her irritable mania as "feeling like a wasp buzzing around the room ready to sting somebody," not liking that feeling. Without articulating a mood state in literal terms, young children express the discomfort and distress they feel in other ways.
Teens are faced with the stigma of a psychiatric diagnosis at a time when the pressure to be like one's peers is intense, and they may rebel against the very concept. Similarly they may not distinguish their own mood swings from the normal mood swings of their fellow adolescents. They may resist prescribed medication and seek to self medicate through illegal drug use. A diagnosis of bipolar disorder during adolescence makes everything more complex and difficult.
Girls get bipolar disease at the same rate as boys, but there are special considerations in their manifestation and medications. Child sexual abuse is more frequently reported by females than by males (12)(13% of females vs. 4% of males) and thus depressive episodes may be more pronounced. Teenage girls in defiant, authority-defying modes may be more likely to act out sexually, resulting in increased rates of abuse, rape, sexual disease and pregnancy, all contributing to symptoms and associated conditions. PSTD may be more common as a comorbid factor since girls acting outside of normative modes may be considered “acceptable” targets of abuse. It appears that not only do girls experience more violence than boys but that they may be more vulnerable to psychological effects of abuse. Biologically there may be more interference with the hypothalamic and corticotropin (ACTH) regulation and increased hypothalamic-pituitary-adrenal responsiveness to stress in females.(13) Factors that affect it may include the frequency, severity, and duration of the abuse, the relationship to the perpetrator, poverty, and family dysfunction.
Finally, medication may have different issues on boys and girls. A number of mood stabilizers cause weight gain as a side effect, which may cause higher rates of noncompliance among girls. Depakote, Tegretol, Neurontin, Lamictal and Topamax should not be used during pregnancy due to associations with spina bifida or other birth defects. Antipsychotics like Thoraxine, Haldol Prolixin and Clozaril should not be used while breastfeeding. (14) According to studies conducted in Finland in patients with epilepsy, valproate (Depakote, Tegretol) may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. (15) Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician
There is no one bipolar pill and probably there will never be. The market segment is small, the disease manifests in different ways at different times and symptoms vary significantly between patients, especially patients of different ages. For the most part, drugs are developed for other more common forms of mental and physical illnesses and are adapted to use for the treatment of bipolar disease. So typical and atypical antipsychotics, anticonvulsants, antidepressants and antiepileptic drugs are adapted, in addition to lithium which was actually developed in 1949 for bipolar disease. Frequently patients do better on a combination therapy.
Once the diagnosis of bipolar disorder is made, the treatment of children and adolescents is based mainly on experience with adults, since there is very limited data on the usefulness and safety of mood stabilizing medications in youth(16) . The essential treatment for this disorder in adults involves the use of appropriate doses of mood stabilizers, most typically lithium and/or valproate (Depakote), which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Antidepressants are not given until mood stabilization has taken place with children but may sometimes be given with adults. Research on these medications in children and adolescents with bipolar disorder is only now being done. In addition, studies are investigating various forms of non-drug therapy to complement medication for bipolar affective disorder in young people.(17)
Medications based upon adult experience for mood stabilization include: lithium carbonate (Lithobid, Lithane, Eskalith), divalproex sodium or valporate (Depakote, Depakene), and carbamazepine (Tegretol). A new atypical antipsychotic drug, Aripiprazole (Abilify) which was designed for use with schizophrenics shows promise for its ability to loosely bind with dopamine 2 receptors. Newer agents such as gabapentin (Neurontin), lamotrigine (Lamictal), and topirimate (Topomax) are currently under clinical investigation and are being used in children. (Lamictal is not recommended for those under the age of 16.) (18)
Several studies have reported very high rates of inducing mania or hypomania in children with bipolar affective disorder who are exposed to antidepressant drugs of all types (SSRIs, and trycyclics are most common). In addition, a child may experience a marked increase in irritability and aggression. The course of the disorder may be altered if antidepressants are prescribed without mood stabilizers like lithium or valporate.
For the treatment of psychotic symptoms and aggressive behavior, risperidone (Risperdal) and olanzapine (Zyprexa) are commonly used newer agents, while thioridazine (Mellaril), trifluperazine (Trilafon), and haloperidol (Haldol) are old standbys. Clonazepam (Klonopin) and lorezapam (Ativan) are also used to treat anxiety states, induce sleep, and put a brake on rapid-cycling swings in activity and energy. (19)
Amino acid treatment has been used for manic stages. Dopamine appears to be a key neurotransmitter involved in mania and may relate to the degree of agitation. Amphetamine releases both dopamine and norepinepherine. Although psychosis can be induced with amphetamines, it is much more common to observe increased energy, increased arousal, and elated mood, all symptoms of mania. Lowering tyrosine and phenylalanine (the precursor to tyrosine) result in lower dopamine but not norepinepherine. By employing a tyrosine and phenylalanine-free amino acid drink, dopamine-sensitive prolactin levels were decreased within 6 hours.(20) The mixture also was effective in diminishing manic symptoms in 20 inpatients during a manic episode. Use of an amino acid drink as a supplemental treatment in acute mania is being developed.(21)
For many children who have bipolar illness, antidepressant pharmacotherapy is not necessary, according to Findling.(22) "In our first series of about 100 youngsters whom we treated with the combination of lithium and divalproex, fewer than 5 percent had persistent enough dysphoria or depression to necessitate treatment with an antidepressant," he says. (22)
When treating a child or adolescent with bipolar affective disorder, the doctor should focus on adequate mood stabilization, improved functioning, and the cyclicity of the illness, not necessarily the specific moods that the child presents. If moods are stabilized and cycling decreased, often the depression no longer remains a problem. Unfortunately, the elevated mood or mixed presentation often does.
Most of the studies have focused on adjunctive therapy for the typical and atypical antipsychotics, In clinical practice, Findling has found that these treatments are effective as combination therapy, but not as the sole therapy. The main shortcoming of the atypical antipsychotics in the area of side effects is weight gain, which is especially a problem with teenaged girls.
Another class of medication, the psychostimulants, can be used to treat residual symptoms of ADHD, and may be useful in patients with simultaneous bipolar disorder and ADHD whose moods are reasonably stabilized.
The novel anticonvulsants appear to have the most promise as mood-stabilizing medications. In this class, lamotrigine has produced the most evidence from random trials in adults for effectness in acute bipolar depression and preventing bipolar depression as well as some evidence for efficacy in rapid cycling.
The side effect profile of mood stabilizers in late adolescence and young adults is quite similar. The most important side effects are weight gain, cognitive side effects, and, if neuroleptics are used, extrapyramidal symptoms like akathisia. It is important to respect the patient’s feelings about side effects and to work hard to improve the side effect profile, or children will stop taking drugs as soon as they obtain a measure of independence.
Medications alone do not treat bipolar affective disorders adequately, especially with children. Cognitive therapy, social rhythm therapy, family interventions and substance abuse treatment, if indicated, are useful adjunctive treatments to medication.
Cognitive therapy has been shown to be effective in treating unipolar depression and is now being used in bipolar disorder. Specific cognitive therapy strategies include learning to identify automatic thought processes, challenging negative thought patterns, and confronting barriers to treatment. Scott compared patients treated with cognitive therapy with controls who were on a waiting list. At the 6-month follow-up period, patients treated with cognitive therapy had less depression as measured on the Beck Depression Scale and improved Global Assessment of Functioning scores. Patients on the waiting list got cognitive therapy after 18 months. Relapse rates decreased by 60% in these individuals during the therapy period, and 70% of the sample viewed the intervention as "highly acceptable." Although the treatment appears to be effective, the techniques are more complex than for unipolar depression. Therapy focuses on identification of links between mood symptoms and episodes and life events. (23)
Family interventions are also useful. Family stress may be a significant factor in making symptoms worse, and family support may be helpful in stabilizing bipolar children. Communication skills, including expressing positive feelings, using active listening techniques, and providing feedback about specific negative behaviors are useful. Miklowitz found that family interventions were more effective than crisis management, which generally depends upon drugs. The therapy was helpful in decreasing depressive but not manic symptoms. The treatment was particularly useful in families with high levels of expressed emotion. Another study found that family interventions were helpful in the treatment of female patients with bipolar disorder, probably since female adolescents are especially dependent upon social cues.(24)
Abnormal circadian rhythms, sleep-wake cycles, and lifestyle patterns are common in bipolar disorders. As daily rhythms become more disorderly, the risk of relapse increases. Patients need to identify these signs and symptoms as a warning sign of a relapse. Morning activities in particular are delayed in patients who are depressed compared with patients manifesting hypomania or normal behavior. Social rhythm therapy has been designed to address life difficulties that disturb the normal rhythms. Interpersonal and social rhythm therapy can be effective in normalizing these negative patterns which might induce a relapse. Children and adolescents can benefit as much as adults.
Problems with substance abuse make bipolar disorder much more difficult to treat. It has been found that more than 60% of patients with bipolar I and nearly 50% of patients with bipolar II had problems with substance abuse. (25) These patients tend to have an earlier onset of the disease, are more likely to experience irritable or angry states, are more treatment resistant, and are hospitalized more frequently. It is very important to integrate substance abuse treatment along with the treatment of the psychiatric illness. Bipolar children often exhibit earlier abuse of substances than other children.
There are different personality factors that are associated with bipolar spectrum disorders compared with unipolar depression disorders including depressive and hyperthymic temperaments. Those with high depressive or low hyperthymic scores on a personality test have more major depressive episodes. Alternately, higher hyperthymic scores were associated with a higher rate of manic episodes. Temperament may also predict the tendency to engage in suicidal behaviors. Suicide attempters and completers have increased cyclic and mixed bipolar characteristics as well as impulsivity. Impulsivity and assertiveness were the best predictors of suicidal behavior beyond 12 months. The sensitivity level for these two factors was 74% and the specificity level was 82%. (26)
Anxiety disorders are also common among individuals with bipolar type II disorder. Perugi and associates found that social phobia (exaggerated shyness) tended to precede hypomanic episodes and to go away after the hypomania started. Alternatively, panic disorder and OCD tend to occur during the hypomanic episodes, and in approximately one third of patients, panic symptoms began during episodes of hypomania. (27)In another study, the rate of bipolar disorder was 15.7% in patients with OCD. Most of these patients suffered from bipolar type II. Obsessions in this subgroup were more likely to include sexual or religious content, and checking rituals tended to be less frequent. A total of 34.8% of the OCD had unipolar depression. The disease tended to be more chronic in these individuals, with more hospitalizations and suicide attempts. These individuals were more likely to manifest aggressive obsessions as well as philosophical, superstitious, or bizarre content.
Bipolar affective disorder is generally considered a disorder with a relatively good prognosis. It has however been shown to have a wide range of negative effects on psychological and social functioning. A variety of drug and therapy techniques are therefore required to address the many complex and clinically challenging issues. New drugs are helpful in extending the therapeutic reach of the clinician, yet coordination of the multiple medical interventions often requires an integrated treatment team.
There are several features of bipolar spectrum disorders that have value. Individuals may have a type of "driven" personality that may be predisposed to bipolar spectrum disorders. These individuals tend to be very achievement oriented, resulting in personal success. An optimistic outlook may be present and is related to perseverance and adaptations under adverse conditions. Coryell and associates (29) found that a segment of patients with bipolar I and II disorders had higher levels of achievement compared with nonbipolar controls, even though educational levels were similar.
The creative process has been associated with bipolar disorder. Mental flexibility, increased drive, heightened perceptual capacities, as well as the intense emotional states are some of the reasons that have been posited for this association. Andreasen compared 30 creative writers with 30 controls matched for demographics and IQ. There was a significantly higher rate of bipolar affective disorders among the writers. In addition, close relatives of the writers had higher levels of various affective disorders as well as creativity, suggesting a possible genetic link between affective disorders and the creative trait. (30)
Up to now, bipolar disorders have been confined to two types. However, there is now substantial evidence that "softer" clinical disorders may form part of the bipolar affective spectrum. Included are personality temperaments such as hyperthymia and personality disorders such as borderline personality. Yet there is an association between these disorders and characteristics and bipolar spectrum disorders. Some of these links include inheritance patterns, presentation of traits, psychopharmacologic response, and patterns of the diseases over time. This is especially apparent with children and adolescents whose characteristics seem to fit first one then another pattern. By expanding the definition of bipolar affective disorders, we may reach patients who would fall between the cracks of of the current more specific definitions.

Oriental Medicine Treatment of Bipolar Affective Disorder in Children

Bipolar disease (dwan-kwan) has been recognized by Chinese medicine for many centuries and formulas and points have been used to treat it. Formulas tend to be based upon presentation of mania or depression. There are no translated accounts of dealing with bipolar diseases in children. But treatment for underlying disorders such as Liver Qi stagnation, Liver Yang rising, Phlegm heat and Heart fire, along with the root causes should be helpful at least as adjunctive therapy.

Although bipolar disease is a form of depression that combines with periods of mania, in children true mania is rarely seen. Instead irritability and ADHD behaviors follow periods of depression. Children tend to cycle faster than adults between the two states and often experience mixed episodes. A high percentage of bipolar children are initially diagnosed as ADHD. Symptoms overlap with schizophrenia in children and treatment is often similar.

With manic states and comorbid ADHD, it is very important to look at diet. Allergic reactions to food dyes and preservatives can often stimulate hyperactive behavior. Phlegm from cow’s milk, citrus, wheat and sugar can also play into this behavior. In Oriental Medicine we might seek to anchor the Yang, smooth the Liver or to reduce Phlegm Heat, depending upon presentation. Physical exercise and behavioral retraining can be helpful as well.

Oppositional Defiance Disorder is also found frequently with bipolar affective disease and can be treated similarly. It is often correlated with Liver Yang Rising or Heart Fire Conditions. Behavioral conditioning can be useful with treatment.

In naturopathic treatment, there may be emphasis on detoxification, limiting carbohydrates in the diet, ensuring adequate mineral intake, particularly calcium, magnesium and lithium which are used for cell transport and increasing Omega 3 fatty acids. Herbs such as St. John’s Wort may be mixed with skullcap, passionflower, lemon balm, black cohosh or rose petals, depending upon presentation, and may include liver tonics like dandelion and milk thistle or endocrine balancers like vitex or milky stage oats.

Oriental medicine looks for such symptoms as Liver qi constraint, which depresses emotions and may let them back up into Liver Yang Rising or Spleen qi deficiency which often manifests as fatigue goes to Phlegm Heat and may harass the Heart. For a child, an acupuncturist might use a shoni shin massaging device or needle points in the foot and hand for the former or massage points below the knee and near the belly button for the latter. Treatment is geared to the child’s age and willingness to accept different treatment methods. Herbs may be given either as individually formulated decoctions or in pill or tincture form, depending upon the child’s willingness to comply with treatment that may involve chalky or bitter tastes.

Bodywork and exercise can also be useful for children suffering from bipolar disease as it moves qi in the depression stage and drains energy in manic phases. Exercise, particularly yoga or tai chi, helps relieve stress, move qi stagnation and balance feelings.

Appendix One
Chinese Herbal Treatment for Bipolar Affective Diseases

Here are listed common patterns of bipolar disease and the standard formulas that are given to children for those patterns:

Spleen vacuity/hyperactive Liver– Yi gan san

Heart blood deficiency/Spleen vacuity-Gui pi tang with schisandra, acorus and fu xiao

Yin vacuity/ hyperactive yang -Zuo gui yin or Tian Wan Bu Xin Tang

Phlegm heat-huang lian wen dan tang

Blood Stasis-Po zhu an shen tang

Yang def- Jin gui shen qi wan w acorus and yi zhi ren

Appendix Two
Acupuncture Treatment in Chinese Medicine

Points are chosen depending upon presentation, the channels involved, and the stage of the disease being manifested (mania or depression). Needling, as opposed to shoni shin or massage, will frequently be used for children with bipolar affective disorders because they tend to be older. During manic states, oversensitivity issues may be a problem until heat is drained so initial bleeding of jingwell points in the fingertips, electrostimulation form Du 20 to 24 or use of ghost points may help. Depressed stages are less problematical for acupuncture treatment, although patients may not be motivated to take herbs regularly.

The following points are used in the treatment of bipolar affective disease. (All indications are quoted from Peter Deadman. A Manual of Acupuncture.) (31)

The Heart and Small intestine meridians are especially important because of the treatment of heart shen.

• SI-7 bipolar affective disorder, fear and fright, sadness and anxiety, restless organ disorder. Also treats disorders of the shen due to the Small Intestine's paired relationship with the Heart. The Methods of Acupuncture and Moxibustion from the Golden Mirror of Medicine, more specifically recommends SI-7 for "depression and knotting of all the seven emotions".
• H-5: groaning and sadness, fear of people, restless organ disorder1, pain and agitation of the Heart, sadness and fright, depressive disorder2, frequent yawning, fright palpitation, pounding of the heart.
• H-7: Palpitations, fright palpitations, pounding of the heart, insomnia, restless organ disorder, frequent talking during sleep, poor memory, bipolar affective disorder, epilepsy, dementia, desire to laugh, mad laughter, insulting people, sighing, sadness, fear and fright, disorientation, Heart agitation, loss of voice.
• H-8: Sadness and worry with diminished qi, fearfulness, fear of people, excessive sighing, plumpit throat, epilepsy.
• H-9: Palpitations, pounding of the heart, bipolar affective disorder, epilepsy, fright epilepsy, excessive sighing, susceptibility to anger, fright and sadness with diminished qi, febrile disease with agitation and restlessness.
• P-4: Agitated Heart, insomnia, melancholy, sadness and fear, fear of people, insufficiency of the shen qi, epilepsy.
• P-5: sudden palpitations, oppression of the chest, apprehensive, susceptibility to fright, sudden fright disorder in children, epilepsy, mania, sudden mania, manic raving, agitation and restlessness, absent-mindedness, poor memory, loss of voice, ghost evil.
• P-6: insomnia, epilepsy, mania, poor memory, fear and fright, loss of wisdom, loss of will, loss of memory following windstroke.
• P-8: epilepsy, bipolar affective disorder, fright, sadness, apprehensiveness, susceptibility to anger, restless organ disorder, ceaseless laughter at other's misfortune.

Stomach and Large Intestine meridians are strongly indicated in the treatment of disorders such as mania and bipolar affective disorder. Points of the Stomach channel are important to resolve phlegm - an important etiological factor in bipolar diseases. Large Intestine points are important to clear heat from the body, and it is the combination of phlegm and heat that underlies the most severe manifestations of psycho-emotional disorders. The Stomach Divergent channel also enters the Heart. Finally in Chinese medicine harmonious digestion is considered a precondition for a peaceful shen: "When the Stomach and Intestines are coordinated the five yin organs are peaceful, blood is harmonized and mental activity is stable. The Mind derives from the refined essence of water and food" (32)

• L.I.-5: bipolar affective disorder, febrile disease with agitated Heart, manic raving, propensity to laughter, sees ghosts, fright.

• ST-23: bipolar affective disorder, agitation, tongue thrusting, manic walking.

• ST-40: bipolar affective disorder, mad laughter, excessive happiness, desire to climb to high places and sing, desire to undress and run around, restlessness, sees ghosts, indolence, epilepsy.

• ST-41: epilepsy, spasm, mania, agitation, sadness and weeping, fright palpitations, Stomach heat with raving, sees ghosts.

• ST-42: bipolar affective disorder, desire to ascend to high places and sing, desire to undress and run around.

• ST-45: excessive dreaming, easily frightened with desire to sleep, insomnia, dizziness, bipolar affective disorder, desire to ascend to high places and sing, desire to undress and run around.

The Spleen channel connects with the Heart and its healthy function provides the basis for proper nourishment of the Heart by blood, and ensures proper transportation and transformation of body fluids, thus preventing the formation of phlegm and treating it once arisen. SP-4 is the confluent point of the Chong Mai, which spreads in the chest, and is the luo-connecting point of the Spleen channel which has important effects on psycho-emotional disorders.
• SP-1: agitation, sighing, susceptibility to melancholy, bipolar affective disorder, excessive dreaming, insomnia, chronic fright wind, corpse collapse.
• SP-4: bipolar affective disorder, manic talking with much drinking, insomnia and restlessness, Heart pain, Gall Bladder deficiency, much sighing.
• SP-5: bipolar affective disorder, agitation with thirst, excessive thinking, propensity to laughter, nightmares, melancholy Heart, chronic, childhood fright wind, childhood fright epilepsy.
• SP-6: palpitations, insomnia, Gall Bladder deficiency.
• SP-15: susceptibility to sadness, sighing.

A few points from the Lung channel are indicated, either because of their effect on the po (corporeal soul), or because their influence on the Zong Qi helps resolve blood stasis and consequent malnourishment of the Heart shen

• LU-3: somnolence, insomnia, sadness, weeping, absent-minded and forgetful, “floating corpse ghost-talk”, melancholy crying.
• LU-9: agitation with Heart pain accompanied by choppy pulse, manic raving.

Points from the Kidney channel are indicated for their ability to nourish yin and harmonize and cool Heart fire, to ground rising fire, yang and wind or to treat the will:

• K-1: agitation, insomnia, poor memory, inability to speak, susceptibility to fear, anger with desire to kill people, bipolar affective disorder, loss of voice.
• K-3: insomnia, excessive dreaming, poor memory.
• K-4: palpitations, agitation, mental idiocy, somnolence, tendency to anger, fear and fright, susceptibility to fear, desire to close the door and remain at home.
• K-6: insomnia, somnolence, night-time epilepsy, sadness, fright, nightmares.

Points of the Gall Bladder and Liver channels are indicated for psycho-emotional disorders characterized by stagnation of Qi and its subsequent transformation into heat which may rise to disturb the Heart, and for disorders of the hun (ethereal soul) like insomnia and fear. It is interesting to note that a point such as LIV-3 which is used in modern practice for treating disorders such as depression, irritability, frustration etc. has surprisingly few indications of this sort in traditional texts.

• Liv-2: tendency to anger, sadness, susceptibility to fright, madness, insomnia, palpitations, epilepsy.
• Liv-5: plumpit throat, depression, much belching, fright palpitations, fear and fright.
• Liv-13: agitation and heat with a dry mouth, tendency to anger, susceptibility to fear, insomnia, manic walking, epilepsy, depression with inability to take a satisfactory breath.

There are back-shu, front-mu points, and points on the Du meridian used in the treatment of psycho-emotional disorders which may be useful for bipolar affective disorders.

• UB-15: poor memory, anxiety, weeping with grief, insomnia, excessive dreaming, not speaking for years, heart xu frightened and watchful (cautious), delayed speech development, bipolar affective disorder, epilepsy, dementia, mad walking, anxious and depressed sensation in the chest with inability to take a satisfactory breath.
• UB-18: much anger, bipolar affective disorder, epilepsy.
• UB-43: poor memory, palpitations, insomnia, phlegm-fire mania.
• DU-8: anger injures the Liver, mania, mad walking, much talking, epilepsy, fright epilepsy.
• REN-14: fright palpitations, poor memory, mania, bipolar affective disorder, aversion to fire, tendency to curse and scold others, ranting and raving, anger, epilepsy with foamy vomiting.
• REN-15: the five kinds of epilepsy, mania, mad walking, mad singing, dislikes the sound of voices.

In addition to the points listed above are points on or affecting channels which enter the brain. These are points of the Du Mai and Bladder channels, and points located on the head and neck. The points across the front of the scalp are known as”Prozac points” to contemporary practicioners:

• SI-3: epilepsy, bipolar affective disorder.
• UB-10: mania, ceaseless talking, sees ghosts, epilepsy, childhood epilepsy.
• UB-62: bipolar affective disorder, palpitations, insomnia.
• UB-9: madness, manic walking, epilepsy.
• UB-12: epilepsy, mania, mental agitation, insomnia.
• DU-16: mania, ceaseless talking, mad walking and desire to commit suicide, sadness and fear with fright palpitations.
• DU-20: fright palpitations, poor memory, lack of mental vigour, inability to choose words, absent-mindedness, much crying, sadness and crying with desire to die, wind epilepsy, mania.
• DU-24: bipolar affective disorder, ascends to high places and sings, discards clothing and runs around, mimics other people's speech, fright palpitations, insomnia, loss of consciousness, tongue thrusting8.
• DU-26: bipolar affective disorder, epilepsy, inappropriate laughter, unexpected laughter and crying, speaking without awareness of a person's high or low status, ghost attack.

Children’s Bipolar Disease References
1. Disorders now considered temperament disorders may be more appropriately viewed as part of the bipolar spectrum in future editions. The DSM5 may also include antidepressant-induced cycling as Bipolar Type 3. Akisal, H.S, Journal of Affective Disorders. Op cit.
2. Korn, M. “Across the Bipolar Spectrum: From Practice to Research” Medscape CME 2000 (3)
3. DSM4, fourth edition, summarized in chart by Bowden, C. Diagnosis of Bipolar Disorders. Medscape General Medicine 4 (3) 2002.
4. Korn, M.D., Martin L. Across the Bipolar Spectrum: From Practice to Research.
5. ibid
6. Carlson, GA, Jensen PS, Nottelmann ED, eds. Special issue: current issues in childhood bipolarity. Journal of Affective Disorders, 1998; 51: entire issue.
7. Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(9): 1168-76.
8. Childhood and Adolescent Bipolar Disorder. An Update from the National Institute of Mental Health.
9. NIMH Op. cit.
10. Discussions with parents and doctors at NAMI and MDSG meetings, Beth Israel hospital.
11. NIMH Op. cit.
12. Am J Psychiatry 160:100-104, January 2003 © 2003 American Psychiatric Association
13. 1st World Congress on Women's Mental Health How Does Women's Mental Health Differ From That of Men? 1st World Congress on Women's Mental Health; March 27-31, 2001; Lorraine Dennerstein
14. McMan’s Bipolar Weekley. Bipolar Meds-Part 1 http://www/
15. Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.
16. http:/www.nimh.nih/publication#4
17. McMann’s Depression and Bipolar Weekley, op.cit.
18. NIMH, publication 4, op cit.
19. McMann’s Depression and Bipolar Weekley, op.cit.
20. Korn, op. cit.
21. ibid.
22. The Brown University Child and Adolescent Psychopharmacology Update
23. Korn, op.cit.
24. Korn, op cit.
25. ibid.
26. ibid.
27. ibid.
28. 4McClellan J, Werry J. Practice parameters for the assessment and treatment of adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(Suppl 10): 157S-76S.
29. Korn, op.cit.
30. Carlson GA, Jensen PS, Nottelmann ED, eds. Special issue: current issues in childhood bipolarity. Journal of Affective Disorders, 1998; 51: entire issue Deadman, Peter. A Manual of Acupuncture. 1999. Also Deadman, P. Acupuncture in Psychoemotional Disorders. detail.php?sub=Diseases&category=+Psycho-emotional
31. Ling Zhu, Chapter 30

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