The State of the Evidence on Pediatric Bipolar Disorder

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Educational Objectives

After reading this article, you will be familiar with:

• The pathophysiology of pediatric bipolar disorder (PBD)
• Assessment tools and measures
• Treatment options
• Comorbidities

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