Note: This article was originally presented as an independent educational activity under the direction of CME LLC. The ability to receive CME credits has expired. The article is now presented here for your reference.
After reading this article, you will be familiar with:
• The pathophysiology of pediatric bipolar disorder (PBD)
• Assessment tools and measures
• Treatment options
Who will benefit from reading this article?
Psychiatrists, child and adolescent psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.
Pediatric bipolar disorder (PBD) is a serious psychiatric illness that impairs children’s emotional, cognitive, and social development. PBD causes severe mood instability that manifests in chronic irritability, episodes of rage, tearfulness, distractibility, grandiosity or inflated self-esteem, hypersexual behavior, a decreased need for sleep, and behavioral activation coupled with poor judgment. While research in this area has accelerated during the past 15 years, there are still significant gaps in knowledge concerning the prevalence, etiology, phenomenology, assessment, and treatment for PBD.
This article briefly summarizes the scientific evidence that has contributed to our understanding of this disorder. The research literature in the areas of prevalence, etiology, pathophysiology, assessment, diagnosis, and treatment is reviewed.
Prevalence of PBD
Unfortunately, there are still no authoritative data on the prevalence of PBD: estimates depend on whether the disorder is defined as a narrow or broad phenotype.1 Children with the narrow phenotype fit symptom criteria for a bipolar disorder diagnosis as defined by DSM-IV-TR, whereas children with the broad phenotype experience serious mood dysregulation and associated symptoms but may not meet symptom number or duration criteria defined by the narrow phenotype.
One community study showed a lifetime prevalence of bipolar disorder of 1% in youths aged 14 to 18 years, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).2,3 However, Brotman and colleagues4 found the lifetime prevalence of severe mood dysregulation to be 3.3% in children aged 9 to 19 years from an epidemiological study sample. These findings indicate that a high percentage of the population may experience symptoms consistent with the broad phenotype of PBD.
Retrospective studies of adults with bipolar disorder have reported that as many as 60% experienced symptoms before age 20 years and 10% to 20% reported symptoms before age 10 years.5-7 It remains unclear, however, how subthreshold symptoms in childhood relate to adult-onset bipolar disorder, as well as whether there is continuity between the childhood-onset presentation and the more classic presentation of adult bipolar disorder.
Geller and colleagues8 showed continuity in both disorder presence and nature of symptoms in children with bipolar I disorder who were observed for 8 years into adulthood. The findings from their study indicate that the unique symptom presentation of early-onset bipolar disorder continues into adulthood for these children.
Despite a lack of knowledge on exact prevalence and the continuity or overlap between childhood-onset and adult-onset presentations, the psychosocial and interpersonal effects of PBD (whether broad or narrow phenotype) on patients and their families is devastating. A community study showed that PBD is associated with substantial impairment in social (66%), family (56%), and school (83%) functioning.2 PBD has been associated with behavioral problems in school, low grades, having few or no friends, frequent teasing, poor social skills, poor sibling relationships, and parent-child relationships characterized by frequent hostility and conflict.9,10
1. Pavuluri MN, Birmaher B, Naylor MW. Pediatric bipolar disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2005;44:846-871.
2. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry. 1995;34:454-463.
3. Orvaschel H, Puig-Antich J. Schedule for Affective Disorders and Schizophrenia for School-age Children—Epidemiologic Version 4. Fort Lauderdale, FL: Nova University;1987.
4. Brotman MA, Schmajuk M, Rich BA, et al. Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry. 2006;60:991-997.
5. Egeland JA, Hostetter AM, Pauls DL, Sussex JN. Prodromal symptoms before onset in manic-depressive disorder suggested by first hospital admission histories. J Am Acad Child Adolesc Psychiatry. 2000;39:1245-1252.
6. Lish JD, Dime-Meenan S, Whybrow PC, et al. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281-294.
7. Loranger AW, Levine PM. Age at onset of bipolar affective illness. Arch Gen Psychiatry. 1978;35:1345-1348.
8. Geller B, Tillman R, Bolhofner K, Zimerman B. Child bipolar I disorder: prospective continuity with adult bipolar I disorder; characteristics of second and third episodes; predictors of 8-year outcome. Arch Gen Psychiatry. 2008;65:1125-1133.
9. Geller B, Craney JL, Bolhofner K, et al. Two-year prospective follow-up of children with a prepubertal and early-adolescent bipolar disorder phenotype. Am J Psychiatry. 2002;159:927-933.
10. Schenkel LS, West AE, Harral EM, et al. Parent-child interactions in pediatric bipolar disorder. J Clin Psychol. 2008;64:422-437.
11. Mick E, Faraone SV. Family and genetic association studies of bipolar disorder in children. Child Adolesc Psychiatr Clin N Am. 2009;18:441-453.
12. Pandey GN, Rizavi HS, Dwivedi Y, Pavuluri MN. Brain-derived neurotrophic factor gene expression in pediatric bipolar disorder: effects of treatment and clinical response. J Am Acad Child Adolesc Psychiatry. 2008;47:1077-1085.
13. Pavuluri MN, Passarotti A. Neural bases of emotional processing in pediatric bipolar disorder. Expert Rev Neurother. 2008;8:1381-1387.
14. Pavuluri MN, West A, Hill SK, et al. Neurocognitive function in pediatric bipolar disorder: 3-year follow-up shows cognitive development lagging behind healthy youths. J Am Acad Child Adolesc Psychiatry. 2009;48:299-307.
15. DelBello MP, Versavel M, Ice K, et al. Tolerability of oral ziprasidone in children and adolescents with bipolar mania, schizophrenia, or schizoaffective disorder. J Child Adolesc Psychopharmacol. 2008;18: 491-499.
16. Pavuluri MN, Yang S, Kamineni K, et al. Diffusion tensor imaging study of white matter fiber tracts in pediatric bipolar disorder and attention-deficit/hyperactivity disorder. Biol Psychiatry. 2009;65:586-593.
17. National Institute of Mental Health. Research Roundtable on Prepubertal Bipolar Disorder. http://www.bpkids.org/site/DocServer/artroundtable.pdf?docID=121. Accessed November 6, 2009.
18. Pavuluri MN, Henry DB, Devineni B, et al. Child mania rating scale: development, reliability and validity. J Am Acad Child Adolesc Psychiatry. 2006;45:550-560.
19. Birmaher B, Axelson D. Course and outcome of bipolar spectrum disorder in children and adolescents: a review of the existing literature. Dev Psychopathol. 2006;18:1023-1035.
20. Birmaher B, Axelson D, Goldstein B, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. Am J Psychiatry. 2009;166:795-804.
21. Geller B, Williams M, Zimerman B, et al. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord. 1998;51:81-91.
22. Geller B, Sun K, Zimerman B, et al. Complex and rapid-cycling in bipolar children and adolescents: a preliminary study. J Affect Disord. 1995;34:259-268.
23. West AE, Schenkel LS, Pavuluri MM. Early childhood temperament in pediatric bipolar disorder and attention deficit hyperactivity disorder. J Clin Psychol. 2008;64:402-421.
24. Faraone SV, Glatt SJ, Tsuang MT. The genetics of pediatric-onset bipolar disorder. Biol Psychiatry. 2003;53:970-977.
25. Chang KD. The use of atypical antipsychotics in pediatric bipolar disorder. J Clin Psychiatry. 2008;69(suppl 4):4-8.
26. Pavuluri MN, Henry DB, Devineni B, et al. A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2004;43:859-867.
27. Kafantaris V, Coletti DJ, Dicker R, et al. Adjunctive antipsychotic treatment of adolescents with bipolar psychosis. J Am Acad Child Adolesc Psychiatry. 2001;40:1448-1456.
28. Kafantaris V, Dicker R, Coletti DJ, Kane JM. Adjunctive antipsychotic treatment is necessary for adolescents with psychotic mania. J Child Adolesc Psychopharmacol. 2001;11:409-413.
29. Bowden CL. Lamotrigine in the treatment of bipolar disorder. Expert Opin Pharmacother. 2002;3:1513-1519.
30. Calabrese JR, Suppes T, Bowden CL, et al. A double-blind, placebo-controlled, prophylaxis study of lamotrigine in rapid-cycling bipolar disorder. Lamictal 614 Study Group. J Clin Psychiatry. 2000;61:841-850.
31. Pavuluri MN, Henry DB, Moss M, et al. Effectiveness of lamotrigine in maintaining symptom control in pediatric bipolar disorder. J Child Adolesc Psychopharmacol. 2009;19:75-82.
32. Wilens TE, Biederman J, Forkner P, et al. Patterns of comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder. J Child Adolesc Psychopharmacol. 2003;13:495-505.
33. Pavuluri MN, Herbener ES, Sweeney JA. Psychotic symptoms in pediatric bipolar disorder. J Affect Disord. 2004;80:19-28.
34. Prince JB, Wilens TE, Biederman J, et al. Clonidine for sleep disturbances associated with attention-deficit hyperactivity disorder: a systematic chart review of 62 cases. J Am Acad Child Adolesc Psychiatry. 1996;35:599-605.
35. Pliszka SR, Greenhill LL, Crismon ML, et al. The Texas Children’s Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2000;39:908-919.
36. Smits MG, van Stel HF, van der Heijden K, et al. Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: a randomized placebo-controlled trial. J Am Acad Child Adolesc Psychiatry. 2003;42:1286-1293.
37. Saletu-Zyhlarz GM, Anderer P, Arnold O, Saletu B. Confirmation of the neurophysiologically predicted therapeutic effects of trazodone on its target symptoms depression, anxiety and insomnia by postmarketing clinical studies with a controlled-release formulation in depressed outpatients. Neuropsychobiology. 2003;48:194-208.
38. Balon R. Sleep terror disorder and insomnia treated with trazodone: a case report. Ann Clin Psychiatry. 1994;6:161-163.
39. Rush CR, Baker RW, Wright K. Acute behavioral effects and abuse potential of trazodone, zolpidem and triazolam in humans. Psychopharmacology (Berl). 1999;144:220-233.
40. James SP, Mendelson WB. The use of trazodone as a hypnotic: a critical review. J Clin Psychiatry. 2004;65:752-755.
41. Brown RT, Amler RW, Freeman WS, et al; American Academy of Pediatrics Committee on Quality Improvement: American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder. Treatment of attention-deficit/hyperactivity disorder: overview of the evidence. Pediatrics. 2005;115:e749-e757.
42. Birmaher B, Axelson DA, Monk K, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:415-423.
43. Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994;33:1000-1006.
44. Newcorn JH, Schulz K, Harrison M, et al. Alpha 2 adrenergic agonists: neurochemistry, efficacy, and clinical guidelines for use in children. Pediatr Clin North Am. 1998;45:1099-1122.
45. Fristad MA, Goldberg-Arnold JS, Gavazzi SM. Multifamily psycho-education groups (MFPG) for families of children with bipolar disorder. Bipolar Disord. 2002;4:254-262.
46. Miklowitz DJ, Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. New York: Guilford Press; 1997.
47. Miklowitz DJ, George EL, Axelson DA, et al. Family-focused treatment for adolescents with bipolar disorder. J Affect Disord. 2004;82(suppl 1):113-128.
48. Miklowitz DJ, Axelson DA, Birmaher B, et al. Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry. 2008;65:1053-1061.
49. Hlastala SA, Frank E. Adapting interpersonal and social rhythm therapy to the developmental needs of adolescents with bipolar disorder. Dev Psychopathol. 2006;18:1267-1288.
50. Goldstein TR, Axelson DA, Birmaher B, Brent DA. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry. 2007;46:820-830.
51. West AE, Pavuluri MN. Psychosocial treatments for childhood and adolescent bipolar disorder. Child Adolesc Psychiatr Clin N Am. 2009;18:471-482.