Hypersexuality in Children With Mania: Differential Diagnosis and Clinical Presentation

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.

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.

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).

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.

As the Figures (Figure 1, Figure 2 and Figure3) demonstrate, hypersexuality is one of the items that count toward the poor judgment mania criterion (Craney and Geller, 2003).