Which children are at risk for bipolar disorder?
What Accounts for Increase in Childhood Bipolar Diagnoses?
The Symptoms of Bipolar Disorder in Children
Well, we're still learning quite a bit about what childhood bipolar disorder actually is, but our conceptualization now is that it's not necessarily that much different from adults. The key symptoms or features of it are distinct periods of mania, in which you have high energy, intensely high or irritable moods, rapid speech, less sleep, distractibility, very active, alternating with periods of depression, which – like in adults – can manifest itself as withdrawal, sadness, negativity, hopelessness, suicidal thoughts, changes in sleep pattern, changes in appetite, things like that. It may manifest slightly different or in different patterns, but the basic core concept is fairly similar between kids and adults.
You're going to have some developmental differences because kids can't do some of the same things that adults can do when they're manic so some things are a little bit different. For instance, think about a euphoric mood in a child. All kids get really happy at times. But in a manic child, there's sort of a drivenness to it. It's out of context for the situation, oftentimes uncontrollable giggling and laughing, talking about things that are funny and they don't know why, laughing inappropriately at very upsetting topics, things like that. Kids can certainly show a decreased need for sleep, getting by on much less sleep than other kids their age during the change, mood symptoms, being very active during the middle of the night, doing many things, making concoctions, moving furniture, stuff like that.
One thing that we're also finding is that in adults, bipolar disorder manifests more in terms of the depressive phase than the manic phase. So adults with bipolar disorder spend much more time depressed than they do manic. The reverse appears to be true for younger school-age children. As they get closer and closer to puberty, though, then it becomes more like the adult pattern. So you've got more of the mania in the younger kids, and then, as they get more and more towards puberty you get more of the depression, looking more like the adult pattern.
Diagnosing Bipolar Disorder: How Young Is Too Young?
Certainly, I think that we're getting better and better at identifying distinct periods of mania and depression in younger kids. However, I'd say the illness does tend to be more clearly manifested as children get older. That doesn't mean that they don't have problems, but it's just easier to do the assessment. However, we've seen kids as young as 5 years old come into the clinic with pretty clear histories of manic symptoms that we are fairly confident about diagnosing.
I think probably age 5 is about the earliest that I've felt comfortable, though I've talked to families of kids that were showing these symptoms fairly clearly as young as age 3. However, differentiating that from other child psychiatric problems and difficulties I think is extremely difficult the younger you go.
It might be useful to note that the recent guidelines which were put out by the American Academy of Child and Adolescent Psychiatry suggest caution against making the diagnosis in preschoolers.
Is Bipolar Disorder Still Relatively Rare in Kids?
If we look at the epidemiologic studies – these are studies in the community, going house to house, and that's the best way to look at how common an illness is – we find that true bipolar disorder is relatively rare in children, probably less than 1 percent. Now, what we do know, on the other hand, is that particularly in the last 10 years or so the diagnosis has been assigned much, much more often. But what's not clear is whether that means that there actually is more of the illness around or if the criteria that are being used to label it have been changing. What we do know is if we look in clinics and how often the diagnosis is being given by physicians to children that it's skyrocketed, that there's been a 40-fold increase in that in the last 10 years.
Puzzling Out a Diagnosis: ADHD or Bipolar Disorder?
That's where this issue about episodes comes into it because ADHD doesn't really manifest itself in particular episodes. The child is pretty much always ADHD, pretty much always hyperactive, whereas with mania this should be a distinct change.
This whole controversy has really taught us is that there is a significant group of children who don't fit well into any of the diagnostic categories, and in particular these are children with very, very severe irritability and ADHD-like symptoms. They're not bipolar because they don't have clear episodes, but they're more than just garden variety ADHD because they're much more impaired and they struggle much more with symptoms. There really isn't a great diagnostic home for them in the current system.
Furthermore, these children with very severe irritability and ADHD who don't fit well into a category are probably considerably more common than children with clear bipolar disorder, probably three times as common. So I think that's a lot of what's going on here.
Certainly, bipolar disorder and ADHD are not mutually exclusive, and actually the majority of children with bipolar disorder will have at some point met diagnostic criteria for ADHD. Whether that's exactly the same ADHD – a child for whom ADHD is their only illness may be a little bit different – but ADHD and bipolar disorder certainly can co-exist. But there are kids with ADHD who have severe irritability and mood difficulties who don't have bipolar disorder, and trying to parse that out and put these kids in a diagnostic category where we can identify and treat them appropriately has been a big challenge.
It's really important to remember that these very irritable children with ADHD symptoms around whom there's the controversy are as impaired as the children with true bipolar disorder. So it's not that you have perfectly healthy children being given this diagnosis of bipolar disorder. It's not so much overdiagnosis in that sense. It is more a question of what's the best diagnosis for them.
In terms of numbers of hospitalizations, how impaired they are in school or how suicidal they are, they're every bit as impaired as the bipolar children. Right now, we have made a lot of progress in psychiatric diagnosis. We can be much more reliable, get people to agree on the diagnoses, but it's still an inexact science. Our psychiatric diagnoses don't map neatly onto the brain. That's something we're obviously working towards, but until we get there there are going to be children like these who don't necessarily fit neatly into any one category.
Diagnosis of Childhood Bipolar Disorder Takes Time and Patience
Well, unfortunately, right now in child psychiatry we don't have a specific diagnostic test. We really have to rely on the history we get from the parent or caregiver and interviewing the child, observation in the office, and spending sometimes longitudinal follow-up of the child with their family to look at symptoms and how they change over time. It's not a quick process. It can't be done in 20 minutes, and it oftentimes requires a great deal of effort on the child and the family's part, along with the clinicians.
When you're concerned about mental health issues, talking to the general practitioner as a first step is reasonable. However, making a diagnosis of bipolar disorder is probably best done by a child psychiatrist or a mental health professional working with a team of child psychiatric professionals. It's something that requires a decent amount of experience and also time, which generally pediatricians and general practitioners just don't have.
Well, I think that in some ways there have been some positive aspects to this because we definitely know that there are some kids out there that have bipolar disorder. Adults with bipolar disorder date the onset of their illness, at least one-quarter of them, to prior to age 12. So adults with bipolar disorder remember having a lot of these symptoms when they were younger, and I think that with some of the seminal research coming out it stirred up some controversy and interest in the topic and got people looking at some of these very difficult, moody kids in a different way and helped move them along to asking some questions to help with the diagnosis of bipolar disorder. That being said, I think that, as Dr. Leibenluft points out, we have a lot of very sick children that we have to try to assess and treat, and just because they're irritable, moody, aggressive and energetic does not mean that they have bipolar disorder. And so there's the concern that since it's been difficult to diagnose and identify that perhaps there also may be an element of overdiagnosis.
The Pros and Cons of Medication for Bipolar Disorder
When it's active, bipolar disorder really affects social, family, educational functioning, functioning with peers. These kids lose significant chunks of their lives or appropriate developmental steps in their lives when they have these severe mood episodes. So I think that it's an illness that we can't not treat. I think it has a significant impact in the short term. And given that these are such key developmental periods for kids, that's going to have a long-term effect on their overall success.
Since we don't have tons of research in medication treatment specifically for childhood bipolar disorder, we do use what's been proven to be effective in adults. With adjusting doses and with careful monitoring, we use those same medications in kids. Some exciting new results are coming out with at least the second generation anti-psychotic medications. Several studies show that they are effective for manic symptoms in kids, and so that as a class seems to be emerging as a medication that's both efficacious in adults and kids with bipolar disorder.
Side effects can be very troublesome, and that's why it's so important to do a diagnostic assessment and assessment of the impairment of the illness because it's really a risk-benefit analysis. Although there hasn't been direct measurement of whether kids are more sensitive to side effects with these medications, certainly clinically with the second generation anti-psychotics, for instance, weight gain and metabolic changes seem to be quite common and at least as difficult as it is in adults if not more so.
Kids can certainly develop [side effects of anti-psychotics that manifest as] extrapyramidal symptoms, which are movement problems or stiffness or restlessness or things like that, at rates at least comparable to adults. These are serious medications, and you need careful follow-up and monitoring to prescribe them safely.
In addition to the weight gain, which might be particularly problematic in youth, many of these medications also impact on our ability to think clearly, to do complex kinds of problem solving, and so it's really important to assess how the medication might impact on the child's ability to do their schoolwork.
Finding a Medication That Works in Kids
Right now, we haven't identified specific diagnostic markers or tests that would sort of guide us to say this particular child is going to be more likely to respond to this particular medication. So we do have to use an element of what we call empirical treatment, or try something and do a careful assessment of whether the medication is being helpful. If it's helpful, great, if not, then move onto to a different medicine or different combination.
Sometimes we're very lucky, and the first medication we try works well with not too many problematic side effects, and things go well for an extended period. Other times, it really is multiple trials of different medicines and having to work on combinations of medicines. It can be very frustrating for the kids, the parents and, frankly, for the treating physician as well.
A child's brain is undergoing tremendous change over time, through puberty and even into young adulthood. How that affects how they respond to the medication is something that we don't entirely understand. Unfortunately, there are many cases of kids who've responded well to a medication for three months, six months, a year but then seem to break through, or it doesn't seem to have the same kind of efficacy that it used to. Even with dose increases and things like that, we're not able to salvage the medicine and have to move toward a different combination.
Targeting Symptoms and Tracking Treatment for Bipolar Disorder
When the physician is giving treatment, it's important to have agreement between the physician and the family about what the target symptoms are. What are the most important symptoms that are being treated? Then when there's agreement on those target symptoms, it can be extremely helpful for the parents and, where appropriate, the child to track those symptoms on a day-to-day basis. It can be on a calendar. On a scale of one to five, just write a number down, and you can do it for one symptom or three symptoms or whatever, and then bring that calendar with you when you go to see the doctor. That way, people can be very, very systematic about exactly which medicines are helping, which aren't, when things have been added or taken away.
There are psychotherapeutic interventions that can be used for bipolar disorder, and a number of them have been shown to be effective, but they have all been used in combination with medication. If someone is in the midst of a true manic episode or a depressive episode, they typically are so impaired that it's virtually impossible to really participate in psychotherapy. So if you really do have true bipolar disorder and you're in the midst of an episode, it's typically a question of psychotherapy in combination with medication.
Parents don't want to put their children on medications they don't need. When parents bring the child in and the question of medications is on the table, usually the decision is ultimately driven by how severe the symptoms are.
The first thing is you have to get the most severe symptoms that are affecting safety and functioning under control. So the things that you're concerned about are aggression, dangerous, reckless behavior, suicidal thoughts. Many of these kids unfortunately suffer from psychotic symptoms, hallucinations that can really cause a great deal of suffering and impairment. So I'm treating those acute symptoms as well as the agitation, restlessness, or if they're depressed, I'm treating the lack of motivation, not getting out, not going to school, things like that.
Right now, I think we have to use a bit more of a chronic illness management model with this because the medications we have are helpful but they're not absolute cures. If we look for everything to get better all at once, this oftentimes is why medication gets switched around quite a bit or medications get added when perhaps if we're a little more patient, we might be able to get a better result waiting and making fewer changes or more cautious changes.
Video: Improving Care for Children and Teens with Bipolar Disorder
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