Bipolar disorder in children
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Bipolar disorder (BD) in children, or pediatric bipolar disorder (PBD), formerly known as "manic depression", is characterized by extreme changes in mood that range from depressive "lows" to manic "highs" (typified by feelings of excessive happiness or rage). It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities - for instance, in getting along with family, friends and teachers, or in completing schoolwork.
Depressive symptoms of BD often include sadness, irritability, an inability to enjoy one's usual activities, changes in appetite or weight, and/or sleeping more than normal or having difficulty falling/staying asleep even when tired. Manic symptoms of BD may include: inflated or unrealistic self-esteem; less need for sleep; talking more/faster than normal; changing the topic of conversation so quickly/often that it interferes with communication; experiencing "racing" thoughts; increased distractibility; difficulty sitting still; an unusual drive to engage in activities or pursue goals; and engaging in risky or dangerous behaviors.
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. 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) critical.
The diagnosis of bipolar disorder in children is a controversial topic. While some believe the DSM-IV-TR criteria should be followed others have proposed other behavioral markers specific for children BD. The DSM-5 may include a new type of mood and conduct disorder, Disruptive Mood Dysregulation Disorder, as a replacement for most pediatric bipolar diagnoses. Some prominent psychiatrists, such as Dr. Stuart Kaplan  and Dr. Allen Frances, advocate applying less severe and better-researched diagnoses such as ADHD and Oppositional Defiant Disorder instead of pediatric bipolar disorder. Another origin for controversy is the rise in the number of diagnoses in the last years, almost exclusively in the USA, with several possible causes for this increase. It has been argued that several factors including biomedical reductionism, neglect of trauma and attachment factors, the symptom checklist but decontextualised model of psychiatric nosology embodied in DSM, influence of the pharmaceutical industry and "diagnostic upcoding" particularly in the US health system have contributed to the epidemic of pediatric BD.
Prevalence of children who meet DSM criteria for BD is around 2%, but it can be argued that DSM criteria are interpreted differently by different researchers. For example ultradian cycling of mood is highly controversial as having validity for episodes of mania or hypomania as a more traditional interpretation requires sustained manic/hypomanic mood states over several days to weeks or months.
Management usually consists of pharmacological and psychological therapy. The drugs most commonly used are mood stabilizers and atypical antipsychotics. Psychological treatment usually combines education on the disease, group therapy and cognitive behavioral therapy. Cases of BD in children have been known for a long time, although they were thought to be rare. This view has changed since the mid 1990s, and future research directions include improving treatments, diagnostic criteria, and the knowledge of BD in children.
Signs and symptoms
Pediatric bipolar disorder causes a significant impairment in the ability of children to function normally, especially in academics and psychosocial areas, and it is a chronic disorder that persists throughout the lifetime. Children with PBD experience chronic periods of mania, characterized by elevated and irritable moods, or depression. The DSM-IV-TR states that the requirements for mania include inflated self-esteem, decreased need for sleep, and being more talkative than usual. It is important to be able to tell the difference between a decreased need for sleep and insomnia which is the difficulty of falling or staying asleep. The American Academy of Childhood and Adolescent Psychology (AACAP) states that the same, unalthered DSM-IV-TR criteria should be used with children, adolescents, and adults. PBD patients are ten times more likely to commit suicide than healthy children. Severe manic and depressive symptoms are associated with early age of diagnosis, meaning children often display more acute symptoms than adults. In children, mania often presents with psychotic symptoms and mixed manic depressive episodes. Such a presentation of mania 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. Children with PBD display anger, dysphoria, irritability, belligerence, and mixed-manic depressive symptoms more commonly and for more erratic time periods than adults. Bipolar disorder is episodic, which means the symptoms do not always appear and may come and go at random times. The need for both elation and grandiosity is recommended and supported by many studies. "Findings from the Course and Outcome of Bipolar Illness among Youth (COBY) study, for example, suggest that, in about 80% of the cases, both elation and irritability are present during the most severe symptomatic episodes among youth with BD..." This requirement is not in the current issue of the DSM, but may be in the future.
The diagnosis of childhood BD is controversial, although it is not under discussion that BD typical symptoms are dysfunctional and have negative consequences for minors suffering them. Main discussion is centered on whether what is called BD in children refers to the same disorder than when diagnosing adults, and the related question on whether adults' criteria for diagnosis are useful and accurate when applied to children. More specifically main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults. For the diagnosis of mania the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV-TR) requires a "distinct period of abnormally and persistently elevated, expansive or irritable mood" during at least four days, and a number of extra behavioral and cognitive symptoms such as grandiosity, reduced sleep need and risk seeking behaviors. Regarding diagnosis of children some experts recommend to follow the same DSM criteria than for adults, although taking into account the age of the individual and the normal behavior of those of his age. Others believe that these criteria do not separate correctly children with BD from other problems such as ADHD, and emphasize fast mood cycles. Still others argue that what accurately differentiates children with BD is the distinct irritability with which it courses. The practice parameters of the American Academy of Child and Adolescent Psychiatry encourage the first strategy. A way to determine the differences between PBD and other childhood mood disorders such as ADHD and conduct disorder, is the prevalence of irritability in addition to extreme elation, other manic symptoms, and if it is episodic.
Family history, and the use of questionnaires, checklists, and diagnostic interviews have been helpful in diagnosing children with bipolar disorder. Differences in diagnostic practices [use of "OR" (considering either child or parent response to questions) or "AND" (combining parent and child's responses) criteria] influences diagnosis of PBD and ADHD. It is notable that some studies consider parents' answers alone; some mix children and parent responses. Study setting, diagnostic sample, and conceptualization differences (episodic vs non-episodic; irritability as diagnostic criterion; modified diagnostic criteria) also influence diagnosis. The DSM-V has introduced a new type of mood disorder called Disruptive Mood Dysregulation Disorder (DMDD) that could impact children who have either already been diagnosed with or are in the process of being diagnosed with childhood bipolar disorder. DMDD was originally called Temper (or Tantrum) Dysregulation Disorder with Dysphoria (TDD), but the name was changed as it was felt that it might carry too much negativity in relation to "typical" temper tantrums. The DSM-5’s new diagnosis of DMDD was created to address the "over-diagnosis" of bipolar disorder in children who experience explosive rages.
Number of American children and adolescents diagnosed of BD in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the current century, while in outpatient clinics it doubled reaching the 6%. 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. The data suggest that doctors had been more aggressively applying the diagnosis to children, rather than that the incidence of the disorder has increased.
The reasons for this increase in diagnosis are unclear. On the one hand, the recent consensus from the scientific community (see above) will have educated clinicians about the nature of the disorder and the methods for diagnosis and treatment in children. That, in turn, should increase the rate of diagnosis. On the other hand, assumptions regarding behavior, particularly in regard to the differential diagnosis of bipolar disorder, ADHD, and conduct disorder in children and adolescents, may also play a role. In addition, some argue that the rise in diagnosis of pediatric bipolar disorder is the result of the influence of the pharmaceutical industry on psychiatry, especially with regard to big pharma's recent push to expand the market of atypical antipsychotics to children and the elderly. Another possible reason for the recent increase in diagnoses is a shift in the diagnostic pendulum. In previous years, there has been an issue with bipolar disorder being under-diagnosed, but now, as more information get published and more people are gaining a better understanding of what it means to have bipolar disorder, more people are being given this diagnosis.
Another issue is that the consensus regarding the diagnosis in the pediatric age group may only apply to the USA. The British National Institute on Health and Clinical Excellence (NICE) guidelines on bipolar disorder in 2006  specifically described the broadened criteria used in the USA to diagnose bipolar disorder in children as suitable "only for research" and "were not convinced that evidence currently exists to support the everyday clinical use of (pediatric bipolar phenotype) diagnoses" which increase the "risk that medicines may be used to inappropriately treat a bipolar diathesis that does not exist."(p526). A 2002 German survey  of 251 child and adolescent psychiatrists (average 15 years clinical experience) found only 8% had ever diagnosed a pre-pubertal case of bipolar disorder in their careers. A similar survey of 199 child & adolescent psychiatrists (av 15 years clinical experience) in Australia and New Zealand  also found much lower rates of diagnosis than in the USA and a consensus that bipolar disorder was overdiagnosed in children and youth in the USA. Concerns about overdiagnosis in the USA have also been expressed by American child & adolescent psychiatrists  and a series of essays in the book "Bipolar children: Cutting-edge controversy, insights and research"  highlight several controversies and suggest the science still lacks consensus with regard to bipolar disorder diagnosis in the pediatric age group.
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. Atypical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidemia. 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. Liver and kidney damage are a possibility with mood stabilizers.
Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioral therapy. 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. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Finally cognitive-behavioral training is directed towards the participants having a better understanding and control over their emotions and behaviors.
Family therapy has strong support for treatment of pediatric bipolar disorder. Family Therapy is a branch of psychotherapy that works with families. It tends to view change in terms of the systems of interactions between family members. Families are seen as an interconnected force where the actions of the family members affect the health or dysfunction of each individual and the family as a whole. Family therapists focus on relationship patterns and are generally more interested in what goes on between family members rather than within one or more individuals. One family member may have a problem and the family relationships may be contributing to or maintaining that problem. For example, when a child has a behavior problem, family therapists may see the child as a 'scapegoat' and view the problem as actually residing within the family system. Family therapists avoid blaming any family member for the problem, and instead help the family interact in different ways that may solve the problem. There are both general, historical models of Family therapy (i.e., Structural, Strategic, Bowenian) and more specific, evidence-based approaches that are based on the earlier models. Strong research evidence suggests that both general and specific family therapy approaches are effective with a wide variety of clinical problems, including the treatment of bipolar spectrum disorders.
Cognitive behavioral therapy (CBT) is also effective in treating bipolar disorder in young people. CBT is the term used for a group of psychological treatments that are based on scientific evidence. These treatments have been proven to be effective in treating many psychological disorders among children and adolescents, as well as adults.
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. 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. Some children, such as Rebecca Riley have died as a direct result of psychiatric labels and drugging to control their behavior but the practice continues.
Emil Kraepelin in the 1920s noted that mania episodes were rare before puberty. 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. True recognition came twenty years after, with epidemiological studies showing that in approximately 20% of adults with BD already had symptoms in childhood or adolescence. Nevertheless onset before age 10 was thought to be rare, below 0.5% of the cases. 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.
Current research directions for BD in children include optimizing treatments for this population through well designed clinical trials, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder, finding out why so many pediatric cases are among boys whereas many adult cases are in women, and improving diagnostic criteria. Regarding the latter the mental health professionals charged with forming the new Diagnostic and Statistical Manual for Mental Disorders (the DSM-V) have proposed a new diagnosis, Disruptive Mood Dysregulation Disorder, which (though it is still thought to be some kind of biologically based mental illness requiring drug and psychotherapeutic treatment) is considered to cover some presentations involving behavioral outbursts in different settings and locations that is as of now currently thought of as simple childhood-onset bipolar disorder occurring before puberty. To be ethical, researchers must obtain the full and informed consent of participating human subjects including the children when experimenting on them with psychotropic (mind altering) drugs.
A recent study conducted by the examined neural mechanisms involved in how children with bipolar disorder process faces of other individuals (average age 14.21+/- 3.11 years old) in order to study amygdala dysfunction. The use of looked at neural activation in relation to emotional aspects of faces (i.e. hostility, fear) vs. nonemotional aspects (nose width). Compared with controls, patients showed greater hostility when viewing neutral faces and reported more fear when viewing them. Also, compared with controls, patients had greater activation in the left amygdala, accumbens, putamen, and ventral prefrontal cortex when saying how hostile they viewed faces, and higher levels of activation in the left amygdala and bilateral accumbens when they rated the fearfulness of faces. This study emphasized the differences in abnormal emotion-attention in children with that may interpret s of those around them.
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Handbooks for researchers and clinicians
Resources for parents
- "Information about Bipolar Disorder – Resources For Parents and Teachers, Provides information about IEPs and school issues, as well as sample letters."
- "Message Boards (Forums) For Parents of Children with Bipolar Disorder"
- "Informed consent for child drugging and Human rights"
- The Ups and Downs of Raising a Bipolar Child: A Survival Guide for Parents by Judith Lederman, Candida Fink – 2003 – 320 pages
- The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder. by Demitri Papolos, Janice Papolos – 2007 – 474 pages
- Bipolar Disorder and The "Quest For The Test"
- Understanding the Mind of Your Bipolar Child: The Complete Guide to the Development Treatment and Parenting of Children with Bipolar Disorder. by Gregory Thomas Lombardo – 2006 – 364 pages
- Straight Talk about Your Child's Mental Health: What to Do When Something Seems Wrong by Stephen V. Faraone – 2003 – 390 pages
- Parenting a bipolar child: what to do & why by Gianni Faedda, Nancy B. Austin – 2006 – 278 pages