We are closely monitoring this phenomenon. Consequently, we chose guanfacine (Tenex) (given the longer half-life compared to clonidine) or propranolol as an alternative for extreme hyperarousal that does not respond to mood stabilization. Given the recent review presenting equivocal evidence of trazodone's efficacy as a sleep medication (James and Mendelson, 2004), it was placed lower than melatonin, which had better data to support safety and efficacy in idiopathic insomnia (Smits et al., 2003), though it was not tested for sleep problems directly in PBD.

RAINBOW Therapy Intervention

RAINBOW therapy (Figure) integrates interpersonal psychotherapy principles with CBT for the child, parents and siblings (Pavuluri et al., 2004a). This intervention can also be exported to the child's school, if the family opts. It integrates the theoretical underpinnings of the phenomenology of PBD; the biological process of affect dysregulation; and the psychosocial burden placed on families. It also complements the medication management of the child.

Connecting and Enriching Community Resources

Given the multiple demands on the clinician's practice and restricted availability to take multiple supportive phone calls, it is necessary to arrange alternative and additional sources of support for the families of affected children. This is particularly effective if the support comes from families with similarly affected children. Families are taught how to advocate for their child. Reading materials are also made readily available. Many Web sites maintain a list of physicians that treat PBD and often provide feedback on a doctor's effectiveness; <www.bpkids.com> is particularly valuable resource for patients and their families.

Conclusion

Pediatric bipolar disorder affects the cognitive, behavioral and affective domains of a child's being. Affect dysregulation is the central feature. It is not clear that the juvenile-onset version of PBD is contiguous with adult BD. The primary goal of pharmacotherapy is mood stabilization, dealing with complex comorbid, residual, breakthrough and/or associated symptoms. It is imperative that any medication management be coupled with a meaningful holistic therapeutic approach that is practical and tailored to PBD.

Dr. Pavuluri is director of the Pediatric Mood Disorders Clinic and the Bipolar Research Program for Juvenile Research at the University of Illinois, Chicago (UIC).
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