It is clinically well established that adults can be hypersexual and that promiscuity and multiple marriages (without spousal death) are common manifestations of mania in adults. Some practitioners may be somewhat uncomfortable asking about these areas, but hopefully they are aware of the usefulness of covering these issues in psychiatric evaluations of adults. By contrast, hypersexuality is often not covered in psychiatric evaluations of children unless abuse is suspected, and it is likely that mental health care professionals are less comfortable covering this area with children than with adults.
Can Non-Abused Children Be Hypersexual?
Available data, however, show that hypersexuality can be a manifestation of pediatric bipolar disorder (BD). Specifically, in a controlled, blinded study of 93 children with a prepubertal and early adolescent bipolar disorder phenotype, approximately 1% had a history of abuse but 43% were hypersexual (Geller et al., 2000). These data were based upon separate mother and child interviews using the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) to obtain hypersexuality ratings (Geller et al., 2001). Histories of abuse were obtained separately from parents and children using a comprehensive psychosocial battery (Geller et al., 2000). In addition, reports from pediatricians, family doctors, after-school personnel, school educators and guidance counselors were obtained. This sample of children provides strong support that hypersexuality in child mania occurs in the absence of abuse.
Is Child Mania a Validated Diagnosis?
Part of the problem with accepting hypersexual behaviors in children as a mania symptom has been the overall contentiousness in the field about whether child mania exists. However, prepubertal and early adolescent bipolar disorder phenotype has been validated and is defined as DSM-IV bipolar I disorder (BD-I) (manic or mixed phase) with elation and/or grandiosity as one criterion (to avoid diagnosis only by criteria that overlap with those of attention-deficit/hyperactivity disorder). Specifically, using the Robins and Guze (1970) criteria, prepubertal and early adolescent bipolar disorder phenotype has the following validators:
- unique symptoms (Geller et al., 2002a, 2002b);
- longitudinal stability over four-year prospective follow-up (i.e., did not become only ADHD) (Geller et al., 2004b);
- significantly higher familial aggregation of bipolar disorders in first-degree relatives than control groups (children with ADHD and children without psychiatric disorders) (Geller, 2002); and
- a significant molecular genetic finding (Geller et al., 2004a).
Non-BD-I types of child mania or BD-I types that do not include the cardinal symptoms of mania have yet to be validated (National Institute of Mental Health research roundtable, 2001).
Hypersexuality in Differential Diagnosis
Data on children with prepubertal and early adolescent bipolar disorder phenotype have shown that these young children can be differentiated from those with ADHD by four main criteria of mania: euphoric mood, grandiose behaviors, flight of ideas/racing thoughts and decreased sleep need. In addition, hypersexuality occurred almost exclusively in the prepubertal and early adolescent bipolar disorder phenotype group compared to the ADHD group (Geller et al., 2002a, 2002b). Characterizing hypersexuality in children with BD is therefore of differential diagnostic importance.
sexual behaviors are part of a manic picture.
Craney JL, Geller B (2003), A prepubertal and early adolescent bipolar disorder-I phenotype: review of phenomenology and longitudinal course. Bipolar Disord 5(4):243-256.
Friedrich WN, Fisher J, Broughton D et al. (1998), Normative sexual behavior in children: a contemporary sample. Pediatrics 101(4):E9.
Friedrich WN, Grambsch P, Broughton D et al. (1991), Normative sexual behavior in children. Pediatrics 88(3):456-464.
Friedrich WN, Grambsch P, Damon L et al. (1992), Child Sexual Behavior Inventory: normative and clinical comparisons. Psychol Assess 4(3):303-311.
Geller B (2002), Longitudinal and family study validators of a prepubertal and early adolescent bipolar disorder phenotype. Bipolar disorder in children and adolescents. Conference 3-7. Presented at the 41st Annual Meeting of the American College of Neuropsychopharmacology. San Juan, Puerto Rico; Dec. 9.
Geller B, Badner JA, Tillman R et al. (2004a), Linkage disequilibrium of the brain-derived neurotrophic factor val66met polymorphism in children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 161(9):1698-1700.
Geller B, Bolhofner K, Craney JL et al. (2000), Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. J Am Acad Child Adolesc Psychiatry 39 (12):1543-1548.
Geller B, Tillman R, Craney JL, Bolhofner K (2004b), Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Arch Gen Psychiatry 61(5):459-467.
Geller B, Zimerman B, Williams M et al. (2001), Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. J Am Acad Child Adolesc Psychiatry 40(4):450-455.
Geller B, Zimerman B, Williams M et al. (2002a), DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. J Child Adolesc Psychopharmacol 12(1):11-25.
Geller B, Zimerman B, Williams M et al. (2002b), Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality. J Child Adolesc Psychopharmacol 12(1):3-9.
National Institute of Mental Health research roundtable on prepubertal bipolar disorder (2001), J Am Acad Child Adolesc Psychiatry 40(8):871-878.
Robins E, Guze SB (1970), Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 126(7):983-987.
Sandnabba NK, Santtila P, Wannas M, Krook K (2003), Age and gender specific sexual behaviors in children. Child Abuse Negl 27(6):579-605.
Schoentjes E, Deboutte D, Friedrich W (1999), Child sexual behavior inventory: a Dutch-speaking normative sample. Pediatrics 104(4 pt 1):885-893.
Tillman R, Geller B, Craney JL et al. (2004), Relationship of parent and child informants to prevalence of mania symptoms in children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 161(7):1278-1284.