Recognizing Pediatric Bipolar Disorder: A Clinician’s Responsibility
By Alina Dillahunt
Bipolar disorder is characterized by a cycle 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 among researchers and clinicians because they lack consensus on the boundaries of diagnosis.
It is important to know the current research in the field regarding pediatric bipolar disorder (PBD), which suggests many children with mania or with a PBD diagnosis become adults with bipolar disorder and may have a better prognosis if identified and treated earlier . Additionally, by 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 co-occurring disorders that can occur in children, that may be distinct from adults with the same disorder. Therefore, in the best interest of the patient, PBD must be diagnosed correctly and treated early, and it is the clinician’s job to accomplish this.
Once the child enters the office, the clinician must 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 .
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, it is thought that around 15% or more of all children with non-conventional manic symptoms 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 cause 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 the source of confusion for clinicians when distinguishing between diagnoses among children.
The most common co-occurring disorders are also those most often confused with PBD. 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 Attention Deficit Hyperactivity Disorder (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 .
Additionally, grandiosity is a common symptom 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 symptom 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 clinician’s goal of reduction of symptoms and eventual remission. The current research recommends 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 multisystem approach.
The primary treatment of manic symptoms is usually a mood stabilizer, many of which have been shown to be effective in 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 most useful for those with resistant mania that does not respond to other pharmaceuticals, and Aripiprazole may cause weight gain .
Moreover, further 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 information 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 achieving a better understanding of 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 a 10x increase in suicidality and being the 6th leading cause of disability among adults , surely this disorder needs to be better understood, differentiated from other diagnoses, and treated efficiently as early as possible.
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