Recognizing Pediatric Bipolar Disorder: A Clinician’s Responsibility
By Alina Dillahunt
Bipolar disorder is characterized by cycling between at least one depressive episode and one manic/hypomanic episode. A manic episode is described by the Diagnostic and Statistical Manual of Mental Disorder, as a period of about 7 days of heightened energy that decreases need for sleep while increasing distractibility, self-esteem, and pursuit of pleasurable and goal-directed activities. Hypomania differs in that it is may be a shorter time span, about 4 days, and is less intense in severity . In the United States, about 2.6% of adults have bipolar disorder with over 80% of those cases being classified as “severe” . The prevalence among children is not agreed upon because there is not consensus among researchers and clinicians on boundaries of diagnosis. It is important to know the current research in the field regarding pediatric bipolar disorder (PBD) because many children with mania or PBD diagnosis become adults with bipolar disorder and may have better health outcomes if the condition is identified and treated earlier . Additionally, in misdiagnosing children who have PBD, the wrong treatment or medication may actually worsen symptoms . Misdiagnosis occurs when there is a lack of knowledge about the different presentations of symptoms and comorbidities that can occur in children, that may be unlike adults with the same disorder.
Once the child enters the office, the first job of the clinician is to investigate symptoms and family situations. Clinicians can assess symptoms using a proven screening tool, The Child Behavior Checklist . Other helpful tools are the General Behavior Inventory, used to help discriminate between bipolar and non-bipolar children, and the Young Mania Rating Scale used to track mania throughout treatment . Additionally, family history should be collected during the diagnostic interview stage as it can be important information to determine the course of the child’s PBD . While depressive episodes are more easily diagnosed in children, manic episodes are less clear. It is thought that mania is hard to diagnose in children, because children have unique comorbid childhood disorders and they respond to treatments targeting mania in a different way than adults with mania . Once PBD is suspected, clinicians should consider what subtype the child will fit in, to tailor treatment responses. There are broad and narrow phenotypes of PBD, the broad phenotypes may not have the classic manic symptoms but instead chronic irritability may be seen. Whereas, narrow phenotypes of PBD have classic manic symptoms and cycles in predictable episodes and may benefit from traditional mania treatment. Before the 1990s, it was thought that only the narrow phenotype should be classified as PBD, and the broad phenotype was being treated as various other similar or comorbid conditions like Attention Deficit Disorder, Oppositional Defiant Disorder and Disruptive Mood Dysregulation Disorder . However, the children falling under the broad phenotype of PBD benefit most from treatment of the manic symptoms before treatment of any comorbid disorders or symptoms, and have an increased risk of adult bipolar disorder compared to children with other mental disorders .
The reason controversy exists about PBD is due to the atypical manic symptoms exhibited in children as compared to adults with bipolar disorder . Conventional manic symptoms will appear in up to 85% of PBD cases, however, they may be missed due to more obvious external symptoms of behavioral disturbances. Additionally, there exists a population of 15% or more of children with non-conventional manic symptoms who may be misdiagnosed or mistreated . Some of these behavioral disturbances that may be seen in children with PBD are intense temper tantrums with inability to self-soothe (calm oneself down), rapid mood cycling throughout the day, and nightmares. While these may be disturbances in the behavior caused by mania, the clinician must look closer to investigate if these symptoms could be caused by a different disorder entirely or the result of severe childhood trauma or abuse . Some clinicians believe that these temper tantrums seen in kids with PBD could be the equivalent to the adult manic symptoms of grandiosity (unrealistic sense of superiority) . Manic symptoms and their differential manifestations in children are often a source of confusion for clinicians when distinguishing between diagnoses among children.
The most common comorbid (or co-occurring) disorders are also those most often confused with PBD as well. They are Oppositional Defiant Disorder (ODD), characterized by irritable mood and defiant or vindictive behavior, Disruptive Mood Dysregulation Disorder (DMDD), characterized by irritability and frequent temper tantrums, and ADHD, characterized by inattention and can include hyperactivity symptoms as well . Irritability which can be symptom of mania, is also seen in ODD, DMDD and depression . Clinicians should pay attention to mood patterns to distinguish between these . Additionally, grandiosity is a common symptoms of mania, but can be seen in ODD if exhibited without change in mood. The increased energy that is another traditional symptom of mania associated with bipolar disorder, is also a common symptoms of ADHD, however, if occurring in episodic periods, then this would indicate it is mania.
The next step for the clinician after settling on a diagnosis should be determining a course of treatment to reach the goal of reduction of symptoms and eventual remission. It is recommended that if the child has PBD and a comorbid disorder, that the clinician treat the bipolar symptoms before the others. In children with comorbid PBD and ADHD, the clinician may prescribe stimulants if the ADHD symptoms are still impairing the child after the PBD symptoms are treated. Clinicians should be cautious and monitor the effect of stimulants on the child’s manic symptoms, as some children experience increase in manic symptoms with the use of stimulants . Similarly, if the child has a comorbid behavioral disorder, this can be combated secondary, after the mania is treated, and this treatment of behavioral problems can forego the use of pharmaceuticals by utilizing parent behavioral management training, psychotherapeutic techniques and a multisystemic approach. The treatment of manic symptoms is usually a mood stabilizer, many have been shown to be efficacious in the treatment of PBD, such as: Lithium, Lamotrigine, Clozapine, and Aripiprazole. However, Lithium requires frequent blood monitoring; Lamotrigine and Clozapine, which come with many severe side effects, may be useful for those with resistant mania that does not respond to other pharmaceuticals, and Aripiprazole may cause weight gain . Additionally, much research should be done about the pubertal effects that may change pharmaceutical needs and treatment needs of a child with PBD. Many clinicians believe in tapering medications to try and minimize the reliance on pharmaceuticals, this is suggested to take place 18 months after remission of symptoms, barring there is no relapse.
Currently, much more is known about the diagnosis and treatment of PBD than even a decade ago, but more research is still needed as the remission rates among children are anywhere between 30-50% depending on the drug study and severity of initial symptoms . Specifically, by better understanding the physiology behind the disorder and the different subtypes, novel pharmaceuticals and therapeutics can be the created to improve the outcomes and target the individual rather than the disorder. With bipolar disorder being associated with 10x increase in suicidality and being the 6th leading cause of disability among adults, surely this disorder needs to be better understood and treated efficiently as early as possible.
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