Bipolar disorder in children

This article is an expansion of a section entitled Children from within the main article: Bipolar disorder

Bipolar Disorder (BPD), formerly known as "Manic Depression", is characterized by extreme changes in mood that range from depressive "lows" to manic "highs" (typified by feelings of excessive happiness or rage). It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities --- for instance, in getting along with family, friends and teachers, or in completing schoolwork.[1]

Depressive symptoms of BPD often include sadness, irritability, an inability to enjoy one's usual activities, changes in appetite or weight, and/or sleeping more than normal or having difficulty falling/staying asleep even when tired.

Manic symptoms of BPD may include the following: inflated or unrealistic self-esteem; needing less sleep than normal and still feeling energetic; talking more/faster than normal; changing the topic of conversation so quickly/often that it interferes with communication; feeling that one's thoughts are "racing"; increased distractibility; difficulty sitting still; an unusual drive to engage in activities or pursue goals (e.g., excessive cleaning, making clearly unrealistic plans); and engaging in risky or dangerous behaviors (e.g., riding a bike on the highway; inappropriate sexual behaviors).

Identifying BPD in youth is challenging. While adults with BPD often have distinct periods of depression and mania that last for weeks, months, or longer, youth with BPD frequently have depressive and manic symptoms that occur daily, sometimes even simultaneously. As co-occurring disorders are common, determining what symptoms are signs of BPD and which are due to other disorders (e.g., depression, ADHD, disruptive behavior problems) is critical.

Diagnosis of bipolar disorder in children is controversial. While some believe the DSM-IV criteria should be followed others have proposed other behavioral markers specific for children BD. Another origin for controversy is the rise in the number of diagnosis in the last years, specially in the USA, with several possible causes for this increase. When following DSM criteria prevalence of BD in children is around 2% of the population [2]

Management usually consist in pharmacological and psychological therapy. Drugs most commonly used are mood stabilizers and atypical antipsychotics. Psychological treatment usually combines education on the disease, group therapy and cognitive behavioral therapy. Both kind of treatments are in many cases chronic.

Cases of BD in children have been known for long, although they were thought to be rare. This view changed in the last part of the twentieth century. Future research directions include improving treatments, diagnostic criteria and the knowledge of BD in children.

Contents

Signs and symptoms

Pediatric bipolar disorder (PBD) causes a significant impairment in the ability of children to function normally, especially in academics and psychosocial areas, and it is a chronic disorder that persists throughout the lifetime.[3][4] Children with PBD experience chronic periods of mania, characterized by elevated and irritable moods, or depression. PBD patients are ten times more likely to commit suicide than healthy children.[5][6] Severe manic and depressive symptoms are associated with early age of diagnosis, meaning children often display more acute symptoms than adults.[6] In children, mania often presents with psychotic symptoms and mixed manic depressive episodes.[7] Such a presentation of mania often differs from classic descriptions of mania in adults, yet children who are diagnosed with bipolar disorder show the same brain abnormalities as adults, further complicating diagnosis.[7] Children with PBD display anger, dysphoria, irritability, belligerence, and mixed-manic depressive symptoms more commonly and for more erratic time periods than adults.[4][7]

Diagnosis

The diagnosis of childhood BD is controversial,[8] although it is not under discussion that BD typical symptoms are dysfunctional and have negative consequences for minors suffering them.[9] Main discussion is centered on whether what is called BD in children refers to the same disorder than when diagnosing adults,[9] and the related question on whether adults criteria for diagnosis are useful and accurate when applied to children.[8] More specifically main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.[8] For the diagnosis of mania the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV-TR) requires a "distinct period of abnormally and persistently elevated, expansive or irritable mood" during at least four days, and a number of extra behavioral and cognitive symptoms such as grandiosity, reduced sleep need and risk seeking behaviors.[8] Regarding diagnosis of children some experts recommend to follow the same DSM criteria than for adults, although taking into account the age of the individual and the normal behavior of those of his age.[8] Others believe that these criteria do not separate correctly children with BD from other problems such as ADHD, and emphasize fast mood cycles.[8] Still others argue that what accurately differentiates children with BD is the distinct irritability with which it courses.[8] The practice parameters of the American Academy of Child and Adolescent Psychiatry encourage the first strategy.[8][9]

Increase

Number of American children and adolescents diagnosed of BD in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the current century, while in outpatient clinics it doubled reaching the 6%.[8] Outpatient office visits for children and adolescents with bipolar disorder in the United States increased from 20,000 in 1994–95 to 800,000 in 2002–03.[10] The data suggest that doctors had been more aggressively applying the diagnosis to children, rather than that the incidence of the disorder has increased.[citation needed]

The reasons for this increase in diagnosis are unclear. On the one hand, the recent consensus from the scientific community (see above) will have educated clinicians about the nature of the disorder and the methods for diagnosis and treatment in children. That, in turn, should increase the rate of diagnosis. On the other hand, assumptions regarding behavior, particularly in regard to the differential diagnosis of bipolar disorder, ADHD, and conduct disorder in children and adolescents, may also play a role. In addition, some argue that the rise in diagnosis of pediatric bipolar disorder is the result of the influence of the pharmaceutical industry on psychiatry, especially with regard to big pharma's recent push to expand the market of atypical antipsychotics to children and the elderly.[11]

National differences

Another factor is that the "consensus" regarding the diagnosis in the pediatric age group seems to apply only to the USA.[citation needed] The British National Institute on Health and Clinical Excellence (NICE) guidelines on bipolar disorder in 2006 [12] specifically described the broadened criteria used in the USA to diagnose bipolar disorder in children as suitable "only for research" and "were not convinced that evidence currently exists to support the everyday clinical use of (pediatric bipolar phenotype) diagnoses" which increase the "risk that medicines may be used to inappropriately treat a bipolar diathesis that does not exist."(p526). A 2002 German survey [13] of 251 child and adolescent psychiatrists (average 15 years clinical experience) found only 8% had ever diagnosed a pre-pubertal case of bipolar disorder in their careers. A similar survey of 199 child & adolescent psychiatrists (av 15 years clinical experience) in Australia and New Zealand [14] also found much lower rates of diagnosis than in the USA and a consensus that bipolar disorder was overdiagnosed in children and youth in the USA. Concerns about overdiagnosis in the USA have also been expressed by American child & adolescent psychiatrists [15][16][17][18] and a series of essays in the book "Bipolar children: Cutting-edge controversy, insights and research" [19] highlight several controversies and suggest the science still lacks consensus with regard to bipolar disorder diagnosis in the pediatric age group.

Epidemiology

Studies using DSM criteria show that up to 2% of youth may have bipolar disorder.[2][9]

Studies in clinics using these criteria show that up to 20% of youth referred to psychiatric clinics have bipolar disorder.[20][21]

Treatment

Lithium carbonate. Lithium is the only drug approved for children with BD by the FDA

Usual treatment involves medication and psychotherapy.[8] Nevertheless studies on the treatment of BD in children are scarce and of low quality, and many times approaches are directly derived from studies and practice with adults.[8]

Drug prescription is commonly used as the initial treatment.[8] It aims to reduce symptomatology and maximize the positive effect of psychotherapeutic interventions that may come afterwards.[8] It usually consists in mood stabilizers, atypical antipsychotics, or a combination of both.[8] Among the formers lithium is the only compound approved by the Food and Drug Administration for children with BD (above 12 years old).[9] Combined therapy has been recommended for cases with partial or no response to a single medication and for individuals with psychosis.[8]

Medications can produce important side effects so interventions have been recommended to be closely monitored and families of patients be informed of the different possible problems that can arise.[9] Atypical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidemia.[9] Extrapyramidal secondary effects may appear with these medications. These include tardive dyskinesia, a difficult-to-treat movement disorder (dyskinesia) that can appear after long-term use of antipsychotics.[9] Liver and kidney damage are a possibility with mood stabilizers.[9]

Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioral therapy.[8] Children with BD and their families are informed, in ways accordingly to their age and family role, about the different aspects of BD and its management including causes, signs and symptoms and treatments.[8] Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool.[8] Finally cognitive-behavioral training is directed towards the participants having a better understanding and control over their emotions and behaviors.[8]

Family therapy has strong support for treatment of pediatric bipolar disorder. Family Therapy is a branch of psychotherapy that works with families. It tends to view change in terms of the systems of interactions between family members. Families are seen as an interconnected force where the actions of the family members affect the health or dysfunction of each individual and the family as a whole. Family therapists focus on relationship patterns and are generally more interested in what goes on between family members rather than within one or more individuals. One family member may have a problem and the family relationships may be contributing to or maintaining that problem. For example, when a child has a behavior problem, family therapists may see the child as a 'scapegoat' and view the problem as actually residing within the family system. Family therapists avoid blaming any family member for the problem, and instead help the family interact in different ways that may solve the problem. There are both general, historical models of Family therapy (i.e., Structural, Strategic, Bowenian) and more specific, evidence-based approaches that are based on the earlier models. Strong research evidence suggests that both general and specific family therapy approaches are effective with a wide variety of clinical problems, including the treatment of bipolar spectrum disorders.[22]

Cognitive behavioral therapy (CBT) is also effective in treating bipolar disorder in young people. CBT is the term used for a group of psychological treatments that are based on scientific evidence. These treatments have been proven to be effective in treating many psychological disorders among children and adolescents, as well as adults.[23]

When all treatment options are ineffective clozapine and electroconvulsive therapy have been proposed as last choice possibilities.[8]

Prognosis

Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies.[8] Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis.[9] A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.[9]

History

Emil Kraepelin

Emil Kraepelin in the 1920s noted that mania episodes were rare before puberty.[9] In general BD in children was not recognized in the first half of the XX century with first reviews of cases being published in the 60s.[9][24] True recognition came twenty years after, with epidemiological studies showing that in approximately 20% of adults with BD already had symptoms in childhood or adolescence.[9] Nevertheless onset before age 10 was thought to be rare, below 0.5% of the cases.[9] During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the XXth century.[9]

Research directions

Current research directions for BD in children include optimizing treatments for this population through well designed clinical trials, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder, finding out why so many pediatric cases are among boys whereas many adult cases are in women, and improving diagnostic criteria.[8] Regarding the latter the mental health professionals charged with forming the new Diagnostic and Statistical Manual for Mental Disorders (the DSM-V) have proposed a new diagnosis, Disruptive Mood Dysregulation Disorder, which (though it is still a biologically based mental illness requiring drug and psychotherapeutic treatment) is considered to cover some presentations involving behavioral outbursts in different settings and locations that is as of now currently thought of as simple childhood-onset bipolar disorder occurring before puberty.[25][26]

References

  1. ^ Information about Bipolar Disorder
  2. ^ a b Van Meter, A., Moreira, A. L., & Youngstrom, E. (2011). Meta-analysis of Epidemiological Studies of Pediatric Bipolar Disorder. Journal of Clinical Psychiatry.
  3. ^ Scheffer RE, Tripathi A, Kirkpatrick FG, Schultz T (2010) Rapid Quetiapine Loading in Youths with Bipolar Disorder J. Child Adol. Psychop 20:441-445
  4. ^ a b Mana S, Martinot MLP, Martinot JL (2010) Brain Imaging Findings in Children and Adolescents with Mental Disorders: A Cross-sectional Review J Eurpsy 25: 345-354
  5. ^ Nandagopal JJ and DelBello MP (2010) Pharmacotherapy for Pediatric Bipolar Disorder Psychiatric Annals 4:221-230
  6. ^ a b Wagner KD, Redden L, Kowatch RA, Willens T, Segal S, et al. (2009) A double-blind, randomized, placebo-controlled trial of divalproex extended-release in the treatment of bipolar disorder in children and adolescents J Am Acad Child Adolesc Psychiatry 48: 519-532
  7. ^ a b c McClellan J, Kowatch R, Findling R (2008) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder J Am Acad Child Adolesc Psychiatry 1: 107-125
  8. ^ a b c d e f g h i j k l m n o p q r s t u v Leibenluft E, Rich BA (2008). "Pediatric bipolar disorder". Annu Rev Clin Psychol 4: 163–87. doi:10.1146/annurev.clinpsy.4.022007.141216. PMID 17716034. 
  9. ^ a b c d e f g h i j k l m n o p McClellan J, Kowatch R, Findling RL (January 2007). "Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder". J Am Acad Child Adolesc Psychiatry 46 (1): 107–25. doi:10.1097/01.chi.0000242240.69678.c4. PMID 17195735. 
  10. ^ Kaplan, Stuart L. (2011-06-19). "Mommy, Am I Really Bipolar?". Newsweek. http://www.newsweek.com/2011/06/19/mommy-am-i-really-bipolar.html. Retrieved 2011-06-19. 
  11. ^ Robbins, Brent D.; Higgins, Meghan; Fisher, Maureen; Over, Katie (2011-01). "Conflicts of interest in research on antipsychotic treatment of pediatric bipolar disorder, temper dysregulation disorder, and attenuated psychotic symptoms syndrome: Exploring the unholy alliance between big pharma and psychiatry". Journal of Psychological Issues in Organizational Culture (Journal of Psychological Issues in Organizational Culture) 1 (4): 32. doi:10.1002/jpoc.20039. 
  12. ^ National Institute of Health and Clinical Excellence (2006). National clinical practice guidelines number 38: Bipolar disorder: the management of bipolar disorder in adults, children and adolescents in primary and secondary care. London: National Collaborating Centre for Mental Health.
  13. ^ Meyer TD, Koßmann-Böhm S, Schlottke PF. Do child psychiatrists in Germany diagnose bipolar disorders in children and adolescents? Result from a survey. Bipolar Disorders, 2004; 6: 426 – 431
  14. ^ Parry P, Furber G, Allison S. The paediatric bipolar hypothesis: the view from Australia and New Zealand. Child and Adolescent Mental Health. (in press)
  15. ^ Carlson, G; Meyer, S. (2006). "Phenomenology and diagnosis of bipolar disorder in children, adolescents, and adults: Complexities and developmental issues". Development and Psychopathology 18 (4): 939–969. doi:10.1017/S0954579406060470. PMID 17064424. 
  16. ^ Harris J. Child & adolescent psychiatry: the increased diagnosis of “juvenile bipolar disorder”: what are we treating? Psychiatr Serv 2005; 56: 529 – 531
  17. ^ McClellan, J. (2005). "Commentary: treatment guidelines for child and adolescent bipolar disorder". Journal of the American Academy of Child and Adolescent Psychiatry 44 (3): 236–239. doi:10.1097/00004583-200503000-00007. PMID 15725967. 
  18. ^ Laurel Williams. Mental health and children: Too often the system conspires to treat behavioural problems with pills. Los Angeles Times 14 Dec 2008 available at: http://www.latimes.com/news/opinion/commentary/la-oe-williams14-2008dec14,0,3774809.story
  19. ^ Bipolar Children: Cutting-edge controversy, insights and research. Childhood in America series. editor Sharna Olfman. 2007. Praeger press. Westport CT. http://www.amazon.com/dp/0275997308
  20. ^ Weller, Weller; Tucker, EB; Fristad, SG; Fristad, MA (1986). "Mania in prepubertal children: Has it been underdiagnosed". Journal of Affective Disorders 11 (2): 151–154. doi:10.1016/0165-0327(86)90022-4. PMID 2948989. 
  21. ^ Wozniak, Biederman; Kiely, Ablon; Faraone, Mundy; Mennin, JS; Faraone, SV; Mundy, E; Mennin, D (1995). "Mania-like symptoms suggestive of childhood onset bipolar disorder in clinically referred children". Journal of the American Academy of Child and Adolescent Psychiatry 34 (7): 867–876. doi:10.1097/00004583-199507000-00010. PMID 7649957. 
  22. ^ http://www.abct.org/sccap/?m=sPublic&fa=pub_WhatIsFT%7C | What is Family Therapy?
  23. ^ http://www.abct.org/sccap/?m=sPublic&fa=pub_WhatIsCBT | What is Cognitive Behavioral Therapy?
  24. ^ Anthony, James; Scott, Peter (1960). "Manic-depressive psychosis in childhood". Journal of Child Psychology and Psychiatry 1: 53–72. doi:10.1111/j.1469-7610.1960.tb01979.x. 
  25. ^ http://www.dsm5.org/Proposed%20Revision%20Attachments/Justification%20for%20Temper%20Dysregulation%20Disorder%20with%20Dysphoria.pdf
  26. ^ http://www.dsm5.org/Newsroom/Documents/Diag%20%20Criteria%20General%20FINAL%202.05.pdf

Further reading

Handbooks for researchers and clinicians

Bipolar Disorder in Childhood ad Early Adolescence. Gellar, B., & BelBello, M. (ed)

Resources for parents

  • The Ups and Downs of Raising a Bipolar Child: A Survival Guide for Parents‎ by Judith Lederman, Candida Fink - 2003 - 320 pages
  • Understanding the Mind of Your Bipolar Child: The Complete Guide to the Development Treatment and Parenting of Children with Bipolar Disorder. by Gregory Thomas Lombardo - 2006 - 364 pages
  • Straight Talk about Your Child's Mental Health: What to Do When Something Seems Wrong by Stephen V. Faraone - 2003 - 390 pages
  • Parenting a bipolar child: what to do & why by Gianni Faedda, Nancy B. Austin - 2006 - 278 pages

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