Evidence-Based Reviews

Not all mood swings are bipolar disorder

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The clinical picture of a child with BD that emerges from the COBY study is:

  • a fairly young child with the onset of mood symptoms between age 5 to 12
  • subsyndromal and less frequently clear syndromal episodes
  • primarily mixed and depressed symptoms with rapid mood cycles during these episodes.22

It is clear that there is a spectrum of bipolar disorders in children and adolescents with varying degrees of symptom expression and children differ from adolescents and adults in their initial presentation of BD.

Table 2

COBY criteria for bipolar disorder, not otherwise specified

Presence of clinically relevant bipolar symptoms that do not fulfill DSM-IV criteria for BDI or BDII
In addition, patients are required to have elevated mood plus 2 associated DSM-IV symptoms or irritable mood plus 3 DSM-IV associated symptoms, along with a change in level of functioning
Duration of a minimum of 4 hours within a 24-hour period
At least 4 cumulative lifetime days meeting the criteria
BDI: bipolar I disorder; BDII: bipolar II disorder; COBY: Course and Outcome of Bipolar Youth study
Source: Reference 18

Related Resources

  • Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2009.
  • Goodwin FK, Jamison KR. Manic-depressive illness. 2nd ed. Oxford, United Kingdom: Oxford University Press; 2007.
  • Miklowitz DJ, Cicchetti D, eds. Understanding bipolar disorder: a developmental perspective. New York, NY: Guilford Press; 2010.

Drug Brand Name

  • Methylphenidate • Ritalin, Concerta, others


Dr. Kowatch receives grant/research support from the National Institute of Child Health and Human Development and the National Institute of Mental Health and is a consultant to AstraZeneca, Forest Pharmaceuticals, Merck, and the REACH Foundation.

Dr. Delgado and Ms. Monroe report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


FIND criteria of disorders found to cause mood swings

Frequency of symptoms/week7 days (more days than not in an average week)2 to 3 days/weekDaily (chronic) irritability and mood swings precipitated by ‘not getting their way’Greatest during times of change/stressDaily
Intensity of symptomsSevere—parents often are afraid to take the child out in public because of mood symptomsModerateMild/moderateMild/moderate when stressedMild/moderate
Number of mood cycles/dayDaily cycles of euphoria and depression3 to 45 to 102 to 38 to 10
Duration of symptoms/dayEuphoria: 30 to 60 minutes Depression: 30 minutes to 6 hours4 hours total/day of mood symptomsShort; 5 to 10 minutesShort; 5 to 10 minutesShort; 5 to 10 minutes
ARND: alcohol-related neurodevelopmental disorder; BDI: bipolar I disorder; BD-NOS: bipolar disorder, not otherwise specified; GAD: generalized anxiety disorder; ODD: oppositional defiant disorder
Source: Kowatch RA, Fristad MA, Findling RL, et al. Clinical manual for the management of bipolar disorder in children and adolescents. Arlington, VA: American Psychiatric Publishing, Inc.; 2008


The lasting effects of alcohol use during pregnancy

Even small amounts of alcohol use by a pregnant woman can impact her child’s development. In a controlled study examining drinking behavior of 12,678 pregnant women and the effect this had on their children, Sayel et ala found that <1 drink per week during the first trimester was clinically significant for mental health problems in girls, measured at age 4 and 8, when using parent or teacher report.

Fetal alcohol spectrum disorder describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These disorders include fetal alcohol syndrome (FAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD).

FAS. Individuals with FAS have a distinct pattern of facial abnormalities, growth deficiency, and evidence of CNS dysfunction. Characteristic facial abnormalities may include a smooth philtrum, thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, small palpebral fissures, and small head circumference. Growth deficiency begins in-utero and continues throughout childhood and into adulthood. CNS abnormalities can include impaired brain growth or abnormal structure, manifested differently depending on age.

ARND. Many individuals affected by alcohol exposure before birth do not have the characteristic facial abnormalities and growth retardation identified with full FAS, yet have significant brain and behavioral impairments. Individuals with ARND have either the facial anomalies, growth retardation, and other physical abnormalities, or a complex pattern of behavioral or cognitive abnormalities inconsistent with developmental level and unexplained by genetic background or environmental conditions (ie, poor impulse control, language deficits, problems with abstraction, mathematical and social perception deficits, learning problems, and impairment in attention, memory, or judgment).b

ARBD. Persons with ARBD have malformations of the skeletal and major organ systems, such as cardiac or renal abnormalities.

Comorbid psychiatric conditions in children with prenatal alcohol exposure are 5 to 16 times more prevalent than in the general population; these children are 38% more likely to have an anger disorder.c O’Connor and Paleyd found that “…mood disorder symptoms were significantly higher for children with parental alcohol exposure compared to children without exposure.” Children with ARND are treated symptomatically depending upon which deficits and behaviors they exhibit.e


a. Sayal K, Heron J, Golding J, et al. Binge pattern of alcohol consumption during pregnancy and childhood mental health outcomes: longitudinal population-based study. Pediatrics. 2009;123(2):e289-296.
b. Warren KR, Foudin LL. Alcohol-related birth defects—the past, present, and future. Alcohol Res Health. 2001;25(3):153-158.
c. Burd L, Klug MG, Martsolf JT, et al. Fetal alcohol syndrome: neuropsychiatric phenomics. Neurotoxicol Teratol. 2003;25(6):697-705.
d. O’Connor MJ, Paley B. Psychiatric conditions associated with prenatal alcohol exposure. Dev Disabil Res Rev. 2009;15(3):225-234.
e. Paley B, O’Connor MJ. Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management. Dev Disabil Res Rev. 2009;15(3):258-267.

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