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Barbara Geller, MD; Rebecca Tillman, MS; James L. Craney, MPH, JD; Kristine Bolhofner, BS

Arch Gen Psychiatry. 2004;61:459-467.

Background  Diagnosis of child mania has been contentious.

Objective  To investigate natural history and prospective validation of the existence and long-episode duration of mania in children.

Design  Four-year prospective longitudinal study of 86 subjects with intake episode mania who were all assessed at 6, 12, 18, 24, 36, and 48 months. The phenotype was defined as DSM-IV bipolar I disorder (manic or mixed) with at least 1 cardinal symptom (elation and/or grandiosity) to ensure differentiation from attention-deficit/hyperactivity disorder. Parent and child informants were separately interviewed, by highly experienced research nurses, using the Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). A Children's Global Assessment Scale score of 60 or less was needed to establish definite impairment. Treatment was by subjects' community practitioners.

Setting  Research unit in a university medical school.

Participants  Subjects were obtained from psychiatric and pediatric sites by consecutive new case ascertainment, and their baseline age was 10.8 ± 2.7 years. Onset of the baseline episode was 7.4 ± 3.5 years. (Data are given as mean ± SD.)

Main Outcome Measures  Episode duration, weeks ill, recovery/relapse rates, and outcome predictors.

Results  Prospective episode duration of manic diagnoses, using onset of mania as baseline date, was 79.2 ± 66.7 consecutive weeks. Any bipolar disorder diagnosis occurred during 67.1% ± 28.5% of total weeks, during the 209.4 ± 3.3 weeks of follow-up. Subjects spent 56.9% ± 28.8% of total weeks with mania or hypomania (unipolar or mixed), and 38.7% ± 28.8% of these were with mania. Major or minor depression and dysthymia (unipolar or mixed) occurred during 47.1% ± 30.4% of total weeks. Polarity switches occurred 1.1 ± 0.7 times per year. Low maternal warmth predicted faster relapse after recovery from mania (² = 13.6, P = .0002), and psychosis predicted more weeks ill with mania or hypomania (F_1,80 = 12.2, P = .0008). Pubertal status and sex were not predictive. (Data are given as mean ± SD.)

Conclusions  These findings validate the existence, long-episode duration, and chronicity of child mania. Differences from the natural history of adult bipolar disorder are discussed.

From the Department of Psychiatry, Washington University in St Louis, St Louis, Mo.