Like bipolar disorder, conduct disorder frequently emerges during adolescence. These children usually engage in high-risk behaviors with the potential for painful consequences seen in mania. However, unlike the manic child, the conduct disorder child's motives are more hurtful, vindictive, antisocial. (Bowring and Kovacs; Weller and colleagues). Psychotic symptoms are also significant in determining diagnosis. These are not present in disruptive disorders, but may be present during an acute bipolar episode or with thought disorders.
Manic symptoms are recognized as a barometer of psychopathology severity in children and adolescents and have been correlated with greater psychosocial impairment. In addition to the daily interference in functioning and increased risk of suicide, long-term consequences of symptoms include interference with the mastery of developmental tasks such as regulating emotions, acquiring competencies, and establishing and maintaining social relationships (Nottelmann and Jensen). Respondents to the DMDA survey acknowledged the negative impact on their lives, reporting problems with crime, substance abuse, self-injurious behavior or aggression toward others, unstable relationships, gambling and financial difficulties and interruption in their education.
Thorough evaluation and treatment are essential. A biopsychosocial approach to intervention that incorporates psychoeducation and school intervention is warranted. Psychoeducation should incorporate child, adolescent and parent. They should be informed of symptoms of manic and depressive episodes and supported in the exploration and identification of symptoms of the index episode and of future symptoms indicative of a recurrence. The physician should discuss treatment options that include medication and psychotherapy.
While adolescents are treated with the same pharmacologic agents as adults, it appears that adolescents with bipolar disorder tend to have more mixed or rapid cycling presentations; these have been associated with poor response to lithium(Drug information on lithium). Furthermore, questions remain regarding the efficacy of pharmacologic treatment and how long treatment should be maintained in the child and adolescent population. Advocates of long-term treatment acknowledge the serious consequences and course of illness; others favor discontinuing medication after the patient is stable, since the long-term effects of pharmacologic intervention remain unknown and noncompliant adolescents may contribute to their own refractoriness (Nottelmann and Jensen).
Double-blind, placebo-controlled studies are needed with lithium and other mood-stabilizing agents, carbamazepine(Drug information on carbamazepine) (Tegretol) and valproate(Drug information on valproate) in order to assess their role in the treatment of children and adolescents with bipolar disorder. A multisite study funded by the NIMH is underway to investigate the effectiveness of prophylactic medication therapy in adolescents with bipolar disorder.
Psychotherapy has also been conceptualized as a prophylactic intervention with strategies seeking to improve interpersonal relationships and stress management. Stressful life events are viewed as potential precipitants for recurrent episodes. Therefore, the attempt of therapy is to reduce the number and severity of events. Attention is also given to routines, activities or substances that may disrupt one's normal schedule in attempts to enhance circadian integrity. These are important interventions, because it has been found that sleep deprivation (which can be self-induced in adolescents) may trigger a manic episode.
Collaboration with educators is invaluable, as teachers are able to provide objective observations comparing the child to their age peers. Working with educators can help promote strategies for intervening with depressed or manic children, and thereby help facilitate an environment that enhances learning.
The DMDA survey supports the stance that treatment of bipolar disorder can be enhanced by public health efforts that promote early diagnosis and treatment, ensuring adequate medication trials of mood-stabilizing agents for patients with frequent recurrent episodes, improving access to mental health services and expanding research efforts.