Psychiatric Times
May 2005
Vol. XXII
Issue 6
Given the hectic pace of clinical practice, it is difficult to keep up with the research on pediatric bipolar disorder (PBD). This is particularly true in the area of pharmacological management. An effective, evidence-based algorithm for the pharmacological treatment of PBD will offer support for clinical decision making. For example, a single mood stabilizer has been shown to be ineffective in more than 50% of cases (DelBello et al., 2002; Kafantaris et al., 2001a, 2001b). Furthermore, a systematic approach to medication management will prove useful in updating a patient's treatment when faced with the development of medication tolerance. Finally, this framework will provide doctors with powerful means of collaborating with families. Our preliminary studies have also demonstrated effectiveness of integrating psychotherapy that is based on validating parents and children, while effectively solving problems related to affect dysregulation (Pavuluri et al., 2004a).
Defining the Targets of Treatment
Pediatric bipolar disorder manifests differently from adult BD. It can be quite difficult to differentiate between actual grandiosity and the fatuous self-aggrandizement that can arise out of insecurity. It is critical to ask specifically about symptoms of psychosis and hypersexuality. Parents and children rarely report these symptoms spontaneously. However, if several of these symptoms appear together, causing dysfunction with substantial mood dysregulation, PBD must be considered.
Bipolar II disorder (BD-II) tends to present with major depressive episodes alternating with hypomanic episodes. Parents often described mood dysregulation as rapid mood swings (Geller et al., 1995). Given the consistency of these reports, the researchers attempted to integrate this description into the phenomenology of PBD. However, PBD can often be non-episodic and chronic (Geller et al., 2004), especially if left untreated. Mixed episodes and comorbid attention-deficit/hyperactivity disorder and anxiety are very common in PBD. Oppositional defiant disorder is reported to be present in many youth with PBD, but cannot be diagnosed according to strict criteria in the face of PBD. Such symptoms may represent a reactive phenomena originating from PBD.
Symptoms, pattern of onset and offset, and timeline will help the clinician establish the diagnosis. Comorbid ADHD is diagnosed if it precedes the onset of PBD symptoms or if the child has very early onset PBD with unresolved ADHD after successful PBD treatment. However, it is possible that these symptoms represent residual intrinsic over-activity and inattention observed in PBD. Family history of BD adds value in considering the diagnosis (Faraone et al., 2003). However, family history should not be considered a diagnostic feature. Conversely, the absence of a family history does not rule out the diagnosis of PBD.
