Vol. 21 Issue 20
Bipolar Disorder in Children
Diagnostic and Treatment Issues
Pediatric bipolar disorder is a severe, recurrent and chronic mental illness that is associated with periods of mania and depression. Multiple factors contribute to the disorder, including genetic, biological, environmental and psychosocial stressors. At least one author has proposed that bipolar disorder is a complex set of diseases rather than a single disease entity.1
Until recently, the mental health community was skeptical that bipolar disorder existed in children and adolescents at all.1 Experts now know that bipolar disorder affects children and adolescents but presents differently from the disease in adults.2 Despite this growing understanding, bipolar disorder remains underdiagnosed in the pediatric population.3
Without prompt diagnosis and treatment, bipolar disorder can disrupt normal emotional, social and cognitive development and lead to risky behaviors such as drug and alcohol use as well as attempted suicide.4
The lifetime prevalence rate of suicide in people with bipolar disorder is 2 percent, and the lifetime risk of making at least one suicide attempt is between 25 and 50 percent.4 Of patients who attempt suicide, approximately 10 to 25 percent succeed.2 Suicide in children with bipolar disorder usually occurs during a mixed state of the disease. Children as young as 4 to 7 years old can have thoughts of suicide and have been known to act on their impulses.5
The course of bipolar disorder can be unpredictable, and there are many obstacles to its appropriate diagnosis and treatment in children and adolescents. Children often have an atypical presentation that includes co-occurring mania and depression, as well as chronic irritability, rapid mood cycling and other comorbid psychiatric diagnoses.6
No test can diagnose pediatric bipolar disorder.5 In addition, the neurobiology of pediatric bipolar disorder is still unknown. According to the American Academy of Child and Adolescent Psychiatry, an estimated one-third of the 3.4 million children who experience depression go on to manifest the bipolar form of a mood disorder.7 More than 50 percent of bipolar patients experienced major depressive disorder prior to their mania.3
Many symptoms of ADHD and bipolar disorder overlap, including distractibility, physical hyperactivity and talkativeness. A study of 677 children with bipolar disorder found that 88 percent also met the criteria for ADHD.6 Children with pediatric bipolar disorder may also develop ADHD-like symptoms later in life, and the symptoms are more abrupt. Another clue that a child may not have ADHD alone is an initial good response to stimulants followed by a return to symptom severity. The supposed ADHD symptoms may also come and go with mood changes.4
Children with bipolar disorder tend to have comorbid psychiatric disorders in addition to ADHD, such as anxiety, conduct disorder, substance abuse disorder, oppositional defiant disorder, eating disorders and impulse control disorders.
Fifty-eight percent of people with bipolar disorder report at least one psychotic symptom during the course of their illness. In patient self-reports, 90 percent of patients reported experiencing psychosis on a periodic basis.7 The presence of psychotic symptoms in bipolar disorder may be significantly underreported.8
Most people with bipolar disorder go undiagnosed for more than 10 years and receive up to 3.5 misdiagnoses.9 Fewer than 6,300 psychiatrists are available to treat children with bipolar disorder. Since access to psychiatric care is limited, the primary care provider's role in early identification is paramount.
Several studies have examined a genetic link for bipolar disorder.10,11 The European Collaborative on Affective Disorders found that bipolar disorder had related "hot spots" on chromosomes 11 and 17. The ultimate goal of genetic studies is to better predict variation in treatment response and thus better individualize psychopharmacologic care.1 The lifetime risk of developing bipolar disorder when a first-degree relative is affected is 8 percent. The concordance rate with monozygotic twins is 57 percent, and with dizygotic twins, it is 14 percent. Twenty percent of children with two parents affected by bipolar disorder have a higher-than-normal risk of developing it.3 One of every four of these children may also develop some other form of a mood disorder.
Scientists have attempted to delineate neuroanatomical changes in children with bipolar disorder using imaging studies.12,13 A study of 12 boys with bipolar disorder who were between 9 and 18 years old documented greater activation in the bilateral anterior cingulated cortex, left putamen, left thalamus, left dorsolateral prefrontal cortex and right inferior frontal gyrus.12,13 An underlying abnormality may also exist in the regulation of prefrontal-subcortical circuits.
Because many comorbid diagnoses are associated with pediatric bipolar disorder, certain target symptoms in the child's mood and aggression may resolve with treatment while others persist. These problems, such as anxiety or ADHD, may not respond to pharmacologic treatment due to worsening symptoms of mania. This requires other creative strategies, such as cognitive behavioral therapy (CBT), behavioral programs at school and possibly a more therapeutic academic program outside the regular school system.
Several medical conditions can mimic mood disorders. These include hormonal and metabolic disorders (Wilson's disease, hypothyroidism, hypoglycemia, Cushing's disease, diabetes, hyperthyroidism and hyperparathyroidism); tumors of the central nervous system; genetic disorders (velo-cardiofacial syndrome and Asperger's syndrome); nutritional disorders (pellagra and pernicious anemia); metal intoxications (manganese, mercury, thallium F); blood disorders (acute intermittent porphyria and iron-deficiency anemia); infectious diseases (AIDS, hepatitis, influenzas, mononucleosis, syphilis and viral pneumonia); and neurological disorders (Kleine-Levin syndrome and temporal lobe epilepsy). Other disorders, such as Lyme disease and chronic fatigue syndrome, should also be ruled out.
The typical presentation of children with bipolar disorder is outlined in Table 1.6 Other symptoms of pediatric bipolar disorder include a history of social and separation anxiety, lethargy and low self-esteem, oversensitivity to emotional and environmental triggers, increased carbohydrate cravings, trouble with morning awakening and manipulative behavior (most common), enuresis (especially in boys), obsessive and compulsive behavior, motor or vocal tics, learning disabilities, poor short-term memory, fascination with gore and morbid topics, lying and paranoia. Bingeing, self-mutilation, migraines and cruelty to animals are less common.5
The psychiatric evaluation for a child or adolescent who presents with the described symptoms should encompass a careful history of the child and family's report of current behavior as well as the clinical course of the disorder, observed behavior of the child, sleep changes, medication trials and responses, medical history, family history of bipolar disorder, and prior hospitalizations or suicide attempts.5 Laboratory monitoring and an electroencephalogram may be appropriate.
It is helpful to have parents keep a mood diary to better understand what precipitates tantrums, how long they are, and what occurs during and after them. It is also crucial to speak with other members of the child's treatment team, such as therapists and teachers. A complete battery of neuropsychological testing is recommended because many children with bipolar disorder have significant learning disabilities. Auditory processing testing is helpful when issues with processing speed are suspected.
Other helpful diagnostic tools include the Young Mania Rating Scale, the Children's Depression Scale, the Mood Disorder Questionnaire and the Kiddie SADS (Schedule for Affective Disorders-Schizophrenia).
Consequences of Improper Diagnosis
When bipolar disorder is not treated, children can have significant difficulties in overall functioning. They tend to have trouble keeping and making friends as well as difficulty reading social cues. They may have academic problems exacerbated by comorbidities such as anxiety and ADHD.
Whether treated or untreated, children with bipolar disorder can also get into trouble with the law, be labeled at school as a result of behavioral issues, and are at greater risk for smoking, drug and alcohol use (self-medicating behaviors) and indiscriminate sexual behavior. In addition, drug and alcohol use can worsen the underlying disorder and medication response. Children with bipolar disorder are also at risk for suicide.
Long before a child is diagnosed with bipolar disorder, parents know that something is not quite right but tend to deny the possibility of a mental health disorder. They often report years of chaos in the household due to their child's behavior. Parents try to rationalize that the child is bright and that the behaviors represent a developmental phase. As the symptoms worsen, people begin to judge the parents for their inability to control their child. Parents often blame themselves for failing to set limits.
When parents finally seek professional help and get a definitive diagnosis, they experience relief as well as grief. Most become experts on their child's disorder and seek pertinent references on pediatric bipolar disorder and its treatment.3,5,14 They realize that their child's life will never be normal and worry about his or her future (college, marriage). They can become overwhelmed with the long-term financial costs of treatment.10
Parents become exhausted as a result of tiptoeing through life to adjust to their child's moods. Because of their focus on the ill child, they have little energy for themselves or their relationships. Chronic marital discord is common. Parents are often called to school to address behavioral issues, disrupting work schedules and potentially impacting job security. Homework time can be a source of stress and meltdowns. Siblings often feel resentful, jealous and neglected because the child with bipolar disorder is treated differently. As the demands of school increase, often around the fourth grade, the child may begin to have explosive outbursts at school. The typical child with bipolar disorder has such mood instability that he or she may not be able to see or respond to parental consequences. As one researcher noted, "A child needs to be in a state of mind to appreciate the meaning of consequences."15
Research about pharmacologic therapy for pediatric bipolar disorder is limited, thus many treatments are prescribed off label. The most effective way to prevent recurrences of mania and depression is mood stabilization. This is a trial-and-error process. Multiple medication trials may be required before a patient feels mood improvement. Some medications may not demonstrate effectiveness for 3 weeks. It can take up to a year to fully stabilize a pediatric patient with bipolar disorder.
The treatment of children with several co-morbid disorders can be complicated because combined pharmacotherapy is often needed. The mania and psychosis should be treated first, followed by the depression and then the anxiety and ADHD.6 Treatment can be further complicated if the child is improperly diagnosed with ADHD or depression and is first treated with a stimulant or antidepressant. This may cause a switch to a manic state and can also accelerate mania cycles. Not all pharmacologically-induced symptoms of mania are necessarily indicative of bipolar disorder, however.
Despite limited research, it is clear that evidence-based psychopharmacologic approaches are associated with better outcomes.16,17 Combination therapy may yield a better response than monotherapy. Children treated with a combination of medications may still achieve only partial response. If children do not receive an adequate trial period and the appropriate dosage of medication, they may be prematurely removed from medications that could be useful to address target symptoms. It is important to identify evidence-based maintenance treatment that will be both well-tolerated and efficacious.
Despite the available medications and recent advances in the pharmacologic management of pediatric bipolar disorder, relapse rates remain high. Improvement with mood stabilizers such as lithium, carbamazepine (Tegretol) and divalproex (Depakote) have been documented, but relapse rates were higher than 50 percent over 2 to 3 years.6
A combination of medications and evidence-based psychotherapy (such as CBT) is the most beneficial approach to managing bipolar disorder in children. One study of this two-part approach documented a significant decrease in severity scores on all Clinical Global Impressions-Bipolar scales and significantly higher Clinical Global Assessment Scale scores when compared with the pre-treatment results of 34 bipolar children (mean age was 11.33).18
The short-term goals for medication management of pediatric bipolar disorder include reducing the manic or depressive symptoms; controlling tantrums, aggressiveness and rage; improving the child's overall functioning; and lessening the rapidity of mood cycling. Long-term goals include sustaining symptom remission, reducing the risk of suicidal ideation or attempts, improving the child's overall moods and functioning (including academic and social functioning), and continuing education about the disorder and its treatment to assist with treatment compliance.
References available at www.advanceweb.com/OT or upon request.
Nancy Ferguson-Noyes, NP, is a pediatric psychiatric-mental health nurse practitioner who practices at Children's Hospital in Boston and at the University Health Care for Kids at the University of New England in Portland, Maine.