“The little children that we see have the most severe form of the illness,” says Dr. Barbara Geller, one of the nation’s acknowledged pioneers in research on bipolar children.

By contrast, she says, only 20 percent of adults with the disorder have the severest form.

A typical bipolar adult has high or low periods that last for a few months, she explains, but can feel and behave normally in between, free of the disorder’s telltale mood swings.

“But the children do not have well periods,” Geller, a psychiatry professor at Washington University School of Medicine in St. Louis, says. Rather, they have manic and depressive episodes almost simultaneously, her research shows.

“A child can be absolutely manic and amusing and, just a few minutes later, can be suicidal and talk about stabbing themselves in the heart,” Geller says.

Since 1995, Geller and her colleagues have been following 93 bipolar children, comparing them to 81 hyperactive children and 94 healthy children. The children were all around 7 years old when the study began, she says.

The idea was “to characterize systematically what this illness looks like in prepubertal children,” Geller says.

Bipolar disorder is a serious brain disease that causes extreme changes in a person’s mood, energy and ability to function. It afflicts about 2.3 million adults in the United States, according to the National Institute of Mental Health. About 1 million children are bipolar, reports the Child & Adolescent Bipolar Foundation, based in Wilmette, Ill.

Some experts, however, suspect that far more children have the disorder than many doctors believe.

“We think that it’s vastly underdiagnosed,” says Ruth Field, president of the foundation’s board of directors. “Vastly.”

That’s because, experts say, children with bipolar disorder may appear instead to be hyperactive or have attention deficit hyperactivity disorder, commonly known as ADHD.

Or doctors may think some of them have conduct disorder, oppositional defiant disorder or even attachment disorder, which is the inability to bond with other people, Field says.

“It would be a real shame to diagnose young people with a condition for which there is no treatment and let them suffer when, if they had the correct medical diagnosis, there’s adequate treatment,” she adds. “Bipolar disorder is a medical illness that responds to treatment,” usually medications that control sufferers’ mood swings.

Recent research also has shown that almost half the children who doctors first believe are depressed are eventually diagnosed as bipolar, Field says.

But researchers like Geller say they’re making progress in identifying the extent and severity of the disease in children.

“We now can tell who’s [hyperactive] and who isn’t,” Geller says.

“Hyperactivity, irritability, distractibility, aggression — those symptoms don’t tell you anything because they’re so common,” she says. Children who are hyperactive, autistic or manic, for instance, all could have these symptoms.

“But elation and grandiose behavior occur only in the manic kids,” Geller says. “[They’re] the cardinal symptoms of mania. They’re unique to [bipolar disorder], and don’t occur in ADHD.”

To understand the world of the bipolar child, picture this:

“A normal child is told they’re going to Disneyland and goes absolutely bananas. And that’s completely appropriate,”

Geller says. But a bipolar child “will be just that happy and excited for no reason at all in the middle of the classroom every day,” she explains. That’s what she calls inappropriate elation.

As for the grandiose behavior, again imagine a child in school, but this time the child “tells the teacher how to teach, tells other students what to learn, generally takes over the classroom,” Geller says.

That’s like an adult “who calls the president, calls the mayor and advises them on what to do,” she says, something a bipolar adult might do.

Finding these “childhood equivalents of adult symptoms of mania” has been groundbreaking and critical, Geller says.

“This was important because many of the [warning signs] in adults could not possibly occur in children,” she says. “They aren’t going to max out credit cards, have four marriages [or] call the president and tell him how to run the country.”

But now, she says, we know that children with this disorder behave much the same as bipolar adults, just in a more childlike way.

In the months and years ahead, Geller says, she and her researchers “want to see if the children stay the way they are, having the most severe form [of bipolar disorder], or if, later on, they’ll look like the more typical [bipolar] adult.”

What To Do

Field says, “What organizations like ours need to do is get the word out to the medical profession, especially pediatricians, who are on the front lines of medical care for children and adolescents, that bipolar disorder can occur in all age ranges.”

“So don’t rule it out,” she advises doctors. “Consider it along with all the other things you’re considering, so you don’t accidentally make a mistake.”