The diagnosis of bipolar disorder in children remains controversial. One of the more disturbing facets of its presentation in such young patients is the presence of hypersexual behavior. How can these behaviors be differentiated from the effects of abuse and other psychiatric disorders?
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:
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).
Unlike adults with mania, multiple marriages and overt acts of sexual promiscuity will not be present in children, as they are not developmentally appropriate manifestations of hypersexuality. Rather, in children with mania, these symptoms are manifested by flirtatious or sexualized behaviors that are both age- and situation-inappropriate (Geller et al., 2002b). To assess the symptoms of prepubertal mania, including hypersexuality, it is important to separately interview parents about their children and children about themselves (Tillman et al., 2004). In addition, it is useful to observe the children for hypersexual behaviors during the interview. Examples of hypersexual behavior, as seen in children with a comprehensive research diagnosis of mania and in whom abuse and overstimulation were ruled out (Geller et al., 2000; Geller et al., 2002b), include: trying to touch private places on the examiner; rubbing themselves suggestively on table edges; imitating sexy rock stars; and touching themselves in a flirtatious manner or using highly explicit sexual act language. Areas that should be assessed include the types of magazines and movies the child seeks; their use of foul or dirty language out of proportion to peers or siblings; craving sex (in adolescents); and calling toll-free sex hotlines.
The Table compares examples of hypersexual behaviors in children with prepubertal and early adolescent bipolar disorder phenotype (as found in WASH-U-KSADS Assessments) with the behaviors of normal children and adults with BD.
There are several studies of normative sexual behaviors in children of comparable age range to the prepubertal and early adolescent bipolar disorder phenotype group (average=10.9 years, standard deviation=2.6); however, these studies did not include frequencies of the behaviors or whether the behaviors were clinically meaningful (Friedrich et al., 1998, 1992, 1991; Sandnabba et al., 2003; Schoentjes et al., 1999). Because studies of normative sexual behaviors in children did not include frequencies, it is problematic to compare these normative findings with the pathologically impairing hypersexual behaviors that occur persistently and pervasively in prepubertal and early adolescent bipolar disorder phenotype.
Furthermore, in these studies, normative sexual behaviors included items--such as "sleeps during the day" and "plays house" (Sandnabba et al., 2003)--that have uncertain relationships to pathological hypersexuality, which is usually characterized by behaviors that are sufficiently frequent and impairing to warrant clinical attention. For example, hypersexual behaviors exhibited by children with prepubertal and early adolescent bipolar disorder phenotype often resulted in being sent to the school principal or being asked not to attend church (i.e., the behaviors were impairing and led to clinical evaluation) (Geller et al., 2002b).
One of the key problems in evaluating hypersexual behaviors in children is the need to rule out child abuse or overstimulation. Comprehensive histories of home, school, latchkey after-school programs and extracurricular activities are necessary. Included must be multiple sources of independent information such as pediatric records and school reports. Also important is noting types of reported accidents and injuries and whether there are multiple or single caregivers (abusive guardians may frequently switch caretakers or use emergency departments to avoid suspicion). Whether sexual actions preceded the mania symptoms or are only present during mania symptoms is also useful information to obtain.
Temporal lobe epilepsy can present with persistent and pervasive sexual talk or actions, as can certain brain masses. These should be especially considered in children in whom other signs and symptoms of mania are not present and in those for whom there is a negative family history of mood disorders, as children with BD often have dense family histories.
Specific data comparing sexual and/or stimulatory behaviors across child psychiatric disorders are not available. Clinically, they may be distinguished by looking at the actions. Manic hypersexuality has a flirtatious, cute, funny quality. By contrast, children with pervasive developmental disorders, schizophrenia or tic disorders display behaviors such as rubbing their genital areas (self-stimulation) or stating sexual words--actions that are usually neither flirtatious nor amusing. For example, a 10-year-old boy with hypersexuality told the research nurse (a grandmother) that he "liked older women" and asked her if he could play some music so that they could dance. This child was being inappropriately sexual in an amusing way; people smile when they hear this example. In contrast are grade-school-age children who rubbed and scratched their genital areas repeatedly, sometimes until the area was scabbed; children who repeatedly poked fecal material out of their anal areas; and a 6-year-old child who drew a picture of a naked girl in a cage after the girl did not want to play with him. Children with tics or compulsions may repeatedly put their hands on and off the genital area or have coprolalia. Thus, behaviors can involve the genital area or use of sexual-organ or bathroom-function language without being sexual.
Overall management will vary with the age of the child. The main concerns for adolescents with mania revolve around unprotected sex and the risks of pregnancies and sexually transmitted diseases. Therefore, it is exceedingly important to inquire about sexual behaviors and to intervene as promptly as possible with mood-stabilizing treatments and restrictive environments. For children, one concern is that parents not be accused of abuse when none is present and when the hypersexuality has not yet been seen as part of a manic syndrome. School personnel need to be educated that