Paediatrics: Bipolar disorder

Bipolar disorder

The diagnosis of bipolar disorder (BiPD) in children and adolescents remains controversial due to concern about how best to operationalize and apply the diagnostic criteria to children and young people in general and pre-pubertal children in particular.

Prevalence

There have been few epidemiological studies addressing this issue. All epidemiological studies have reported mania as being very rare or non-existent in prepubertal children. A number of epidemiological surveys of 9–18-yr-olds estimated the prevalence of mania to be between 0–0.6%. Large retrospective surveys of adults with bipolar disorder have noted that onset before age 10 occurs in 0.3–0.5% of patients, although many more described mood symptoms (commonly depression) beginning in childhood. Over recent years several groups in the US have proposed that early onset bipolar disorder is much more common than previously reported. A closer inspection of these cases (most of whom have ADHD and/or oppositional defiant disorder) suggests that they do not in fact meet the full diagnostic criteria and that they are probably better charac-terised as having severe mood dysregulation.

Clinical features

Because of the controversy surrounding the recent increases in the diag-nosis of early onset bipolar disorder, and the symptom overlap with other disorders, clinicians are recommended to reserve this diagnosis for those who have clearly met the diagnostic criteria for a manic episode. The symptoms with the best specificity are;

·  elevated mood;

·  grandiosity/inflated self-esteem;

·  pressured speech;

·  racing thoughts;

·  decreased need for sleep;

·  hypersexuality.

Differential diagnosis

Differential diagnoses include, schizophrenia, schizoaffective disorder, ADHD, conduct disorder, substance abuse, autism spectrum disorders, organic causes, e.g. acute confusional states, epilepsy (pre or post ictal confusional states) and medication side effects, e.g. akathisia due to neuro-leptics. Sexual, emotional, and physical abuse may present with hypervigi-lance, disinhibition, and hypersexuality.

Management

The current evidence for both drug and psychological treatments of bipo-lar disorder in children and adolescents is extremely limited and treatment should be carried out by specialist child and adolescent mental health services. The goals of therapy will include reduction in core symptoms, psycho-education, relapse prevention, and facilitating normal growth and development.

Pharmacotherapy

Most of the recommendations for the pharmacotherapy of BiPD in child-ren and adolescents are based on findings in adults. Neither the effective-ness nor the safety of anti-manic (this term is used as there is no agreed definition of mood stabilizer), antipsychotic and anticonvulsant medica-tions in early and adolescent onset bipolar disorder is not yet established. To date only lithium in licensed in the UK for treatment of bipolar disor-der in those 12yrs and older.

Prognosis

Longitudinal studies show:

·Children with ADHD do not have an increased risk of BiPD in later life.

·No studies have demonstrated that pre-pubertal mania progresses to the classic adult disorder.

·Very low rates of conversion of depression to mania among pre-pubertal children.

·Adolescent onset BiPD tends to have a relapsing and remitting course similar to adult presentations.

·Around 20% of adolescents who have an episode of major depression experience a subsequent manic episode by adulthood. This is predicted by:

·  depressive episode of rapid onset with psychomotor retardation and psychotic features;

·  family history of affective disorder especially mania;

·  history of mania or hypomania following antidepressant treatment.

·Adolescents presenting with an initial manic episode show higher relapse rates (approximately 50% during 5yr follow-up).

·The presence of psychosis is associated with chronicity.