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Section 20
Evaluating Children for Bipolar Disorder

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Perhaps no area in child psychiatry provides as much debate and clinical interest as the accurate diagnosis and treatment of bipolar disorder (BPD) in children and adolescents. Part of the controversy involves the substantial overlap of BPD and attention deficit hyperactivity disorder (ADHD) symptoms, especially in younger children. Several researchers have suggested that 20% of children diagnosed with ADHD should have been more accurately diagnosed with BPD. Other investigators argue that the overlap between ADHD and BPD is actually a complex co-occurrence of both syndromes and not the inaccurate diagnosis of one or the other. Other researchers suggest that since children are developmentally different from adults, we may need to redefine this disorder and perhaps call it something else.

The American Psychiatric Association (APA) reports that the rate of occurrence of BPD among adolescents ages 14 to 18 is 1 %, which is equal to the rate of occurrence among the general population. However, APA also states that an additional 5.7% of children and adolescents have mood symptoms that meet criteria for BPD not otherwise specified, and the relapse rates for BPD among children and adolescents are about 38% after a year and 44% after five years. A study supported by the National Institute of Mental Health (NIMH) indicated that when BPD begins in childhood or early adolescence, it might be a different, possibly more severe, form of the illness than older-adolescent onset and adult-onset BPD. When BPD begins before or soon after puberty, it often is characterized by a continuous, rapid-cycling, irritable and mixed symptom state that may co-occur with disruptive behavior disorders, particularly ADHD or conduct disorder. For a list of childhood BPD manic and depressive symptoms, see the table.

Family genetics and documented family history of BPD often are helpful in assessing the possibility that a child might have BPD. According to the Child & Adolescent Bipolar Foundation (www.bpkids.org),if one parent has BPD, the risk of having BPD to each child is 15 to 30%. If both parents have BPD, the risk increases to a range of 50 to 75%. Even with this information, an accurate diagnosis often is difficult. For example, could some children thought to have BPD instead be severely depressed with ADHD? To further complicate the issue, could some of these children have posttraumatic stress disorder and reactive attachment disorders caused by abuse and neglect? The best response to such questions is that any child or adolescent who appears depressed and exhibits severe ADHD-like symptoms, with excessive temper outbursts and mood changes, should be evaluated by a psychiatrist or psychologist with in-depth experience with BPD, ADHD, depression, and normal childhood development, especially it a family history of the illness exists. This expert evaluation is particularly important since the appropriate diagnosis and treatment management are essential for clinical stability and preventing unnecessary and potentially dangerous medication combinations. In addition to a thorough evaluation by a professional experienced in childhood BPD, it is important for both the child and the family to become educated about the illness. As with any psychiatric issue, psychoeducation should be a strong treatment component for every patient and every patient's family, as it enables them to recognize factors that may exacerbate or complicate a depressive episode or a manic episode. Psychoeducation also enables the family to assist with proper diagnosis and treatment. For example, it is important for family members to understand that adhering to a structured daily routine and sleep schedule may help protect a child with BPD against mood disturbances. Ongoing BPD research supported by the NIMH suggests that sleep deprivation can trigger a manic episode in some people with rapid-cycling BPD, which occurs often among children and adolescents with BPD. For reasons still unknown, people with BPD appear to have delicate "internal clock mechanisms," and losing even a single night's sleep often results in mania.

Family members also should be fully informed as to possible side effects from medications that might be prescribed. Currently three drug types commonly are used to treat bipolar disorder mania: lithium, anticonvulsants, and atypical neuroleptics. While none of these medications have FDA approval for use by children, their use is part of practice parameters as set by the American Academy of Child and Adolescent Psychiatry (AACAP). Experts from both AACAP and NIMH agree that a substantial lack of scientific evidence supports the known off-label prescribing that occurs for children with BPD). Although the same drugs are being used in children and adolescents as in adults, little research shows that the medications are safe and effective in the younger population. Before initiating pharmacotherapy, it is necessary to educate parents about what is known and unknown about these medications, as there are many potentially serious side effects, including weight gain, liver damage, increased anxiety, agitation, kidney problems, thyroid problems, muscle rigidity, tremors, and sedation. The FDA recently issued a black box label warning against the use of all antidepressants for the treatment of depression in children. Prior to the FDA's decision to require the black box warning, AACAP submitted a letter that urged the FDA not to issue the warning. AACAP's position is that the data—based on 4,400 children with BPD, 78 of whom experienced increased suicidal thoughts but no suicides—do not support actions that will remove treatment options for children and adolescents who respond to antidepressant medications. AACAP recommended an enhanced warning section and a written list of symptoms to be reviewed with patients and families. In addition, AACAP recommended continuous close monitoring by the attending physician, with special attention paid to new symptoms or increasing severity of symptoms, such as anxiety, insomnia, hostility, and mania. A complete list of AACAP responses to the black box warning for the FDA, parents, and psychiatrists is available at www.aacap.org/press_releases. While childhood BPD's severe and adverse effects on academic, social, and family function, as well as the disorder's high rates of dangerous behavior, make effective diagnosis and treatment imperative, research of the illness and effective medications are still lacking. In addition, the shortage of child and adolescent psychiatrists impacts treatment availability. Childhood BPD can require careful evaluation and close follow-up. At times, exacerbations may necessitate an inpatient or residential treatment setting. Increased research, careful medication trials, plus evidence-based psychotherapeutic interventions, coupled with intensive education for patients, families, social systems, and schools, will help clarify and treat these difficult diagnostic pictures. A multifaceted approach will help prevent a misuse of medical and social resources and assure that treatment is developed from the perspective of what is known rather than what is postulated or hypothesized. This is ultimately the best care for our child and adolescent patients as they are closely followed by professionals into adulthood.

Symptoms of Childhood Bipolar Disorder
Manic symptoms: • Lack of need for sleep—sleeping an average of four to six hours a night yet not feeling tired the next day • Euphoria—exhibiting a kind of utter exhilaration • Grandiose thinking—believing they are the best at everything (the best student, athlete, musician, artist) and becoming angry with people who dispute this • Hypersexuality —being flirtatious beyond their years; may try to touch adults' private areas, and may use explicit sexual language • Flight of ideas—jumping in rapid succession from topic to topic with unwarranted excitement • Impaired judgment—acting impulsively and indulging in high risk behaviors, such as sexual promiscuity or substance abuse • Depressive symptoms • Persistent irritability • Loss of interest in activities once enjoyed • Rapidly changing moods that last a few hours to a few days • Recurrent talk of death or suicide

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Personal Reflection Exercise #6
The preceding section contained information about evaluating children for bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 20
According to Lake, why is psychoeducation for the family of a bipolar child important? Record the letter of the correct answer the Answer Booklet.