Bipolar disorder in children

Bipolar disorder (BD) in children, or pediatric bipolar disorder (PBD), is a condition that affects mood and energy. It is characterized by extreme changes in mood that range from depressive "lows" to manic "highs." It has been a controversial diagnosis, with big differences in how commonly it is diagnosed across clinics and countries.^[1] Until the 1990s, bipolar disorder was thought to be rare in children and adolescents. There has been a rapid increase in research on the topic, but training and clinical practice lag behind.

Identifying BD in youth is challenging because, while adults with BD often have distinct periods of depression and mania that last for weeks, months, or longer, youth diagnosed with BD frequently have depressive and manic symptoms that occur daily, and sometimes simultaneously either as rapid shifts or periods of high energy negative mood.^[2] Comorbid disorders are common, which makes determining what symptoms are signs of BD and which are due to other disorders (e.g., depression, ADHD, disruptive behavior problems) crucial both for accurate diagnosis and effective treatment.

Signs and symptoms

In children with BD, there may be a more rapid change in mood than in adults.^[1] In children, mania may present with psychotic symptoms and mixed manic depressive episodes.^[3] This presentation 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.^[3] Children with PBD experience recurrent periods of mania, characterized by elevated and irritable moods, or depression.^[1]

Diagnosis

The diagnosis of childhood BD is controversial,^[1] although it is recognized that BD typical symptoms are dysfunctional and have negative consequences for minors suffering them.^[4] Main discussion is centered on whether what is called BD in children refers to the same disorder than when diagnosing adults,^[3] and the related question on whether adults' criteria for diagnosis are useful and accurate when applied to children.^[1] More specifically main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.^[5]

Diagnostic criteria may not separate correctly children with BD from other problems such as ADHD, and emphasize fast mood cycles.^[5]

Family history, and the use of questionnaires, checklists, and diagnostic interviews have been helpful in diagnosing children with bipolar disorder.^[1] The Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (K-SADS-PL) is a semi-structured diagnostic interview that assesses Axis I psychopathology in youth based on present and lifetime symptoms.^[1] Other assessment tools include the Diagnostic Interview Schedule for Children (DISC), the Child Mania Rating Scale (CMRS), the Child Behavior Checklist (CBCL), the Parent General Behavior Inventory (P-GBI), the Young Mania Rating Scale (YMRS) and the Child Bipolar Questionnaire (CBQ).^[1]

Treatment

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.^[3] Atypical antipsychotics are more effective than mood stabilizers, but have more side effects.^[4] Atypical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidemia.^[3] 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 anti-psychotics.^[3] Liver and kidney damage are a possibility with mood stabilizers.^[3]

Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioral therapy.^[5] 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.^[5] Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool.^[5] Finally cognitive-behavioral training is directed towards the participants having a better understanding and control over their emotions and behaviors.^[5]

When all treatment options are ineffective clozapine and electroconvulsive therapy have been proposed as last choice possibilities.^[5]

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.^[5] 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. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.^[3]

Children with BD are more likely to commit suicide than other children.^[1]

Epidemiology

Prevalence of children who meet DSM criteria for BD is between 0.1%^[4] and 6%,^[6] with an average rate of 0.5% for bipolar I, and 2% for bipolar spectrum disorders based on a meta-analysis of published studies.^[7] Studies vary in which categories they include (for example, some only focus on bipolar I, and others include cyclothymic disorder and bipolar Not Otherwise Specified, and DSM criteria are interpreted differently by different researchers.^[8]

Increase

The number of American children and adolescents diagnosed with BD in community hospitals increased 40-fold, changing from almost never being diagnosed to reaching rates of up to 40% in some hospital settings in 10 years around the beginning of the current century,^[9][10] while in outpatient clinics it doubled reaching the 6%.^[5] 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.^[11] The data suggest that doctors had been more aggressively applying the diagnosis to children, rather than that the incidence of the disorder has increased.^[12]

An origin for controversy is the rise in the number of diagnoses in the US;^[13] the diagnosis is more likely in the US than in the UK.^[1] The British National Institute on Health and Clinical Excellence (NICE) guidelines on bipolar disorder in 2006 described the broadened criteria used in the US to diagnose bipolar disorder in children as suitable "only for research" with uncertain evidence supporting the diagnosis, leading to inappropriate pharmaceutical treatment.^[14]:526

History

Emil Kraepelin

Emil Kraepelin in the 1920s noted that mania episodes were rare before puberty, although he did mention the possibility that it could occur in children.^[1] In general BD in children was not recognized in the first half of the 20th century with first reviews of cases being published in the 1960s.^[3][15] Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with BD already had symptoms in childhood or adolescence.^[3] Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases.^[3] 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 20th century.^[3]

References