Bipolar Disorders

Abstract

Pediatric bipolar disorder (PBD) is a recurring complex psychopathological mood disorder causing significant impairment in children. PBD spectrum includes bipolar I (full manic episode), bipolar II (depression with hypomania) and bipolar not otherwise specified (NOS) (“others” in mid-spectrum who may be exhibiting prodromal PBD states but do not fit criteria clearly).The clinical presentation of PBD often does not meet the Diagnostic and Statistical Manual of Mental Disorders criteria for bipolar disorder (BD), which was developed in adults and not adapted for children. The diagnosis becomes difficult because symptom presentation is variable and largely dependent on developmental age. Although discrete episodes of mania and depression that define BD in adults may match the presentation of some patients who have BD in adolescence, patients who have BD of childhood and prepubertal onset may or may not manifest these clear-cut episodes. The duration of episodes in children may be as short as 1 to 2 days. Mood symptoms can be chronic, can present as predominantly mixed episodes, or can continuously cycle rapidly, with severe irritability or aggression as the usual presenting symptoms. Disruptive behavior, hyperarousal, racing thoughts, elation, and grandiosity also may characterize the moods. A major depressive presentation is associated with a significant risk for developing subsequent BD. Poor psychosocial skills as well as cognitive and attention deficits may manifest along with mood and behavior changes. The chronic relapsing mode of PBD may extend into early adulthood. Longitudinal studies abound on PBD; yet, there is no firm agreement on exactly what constitutes the diagnosis of PBD.Complicating the diagnosis of PBD is the high rate of comorbidity with attention deficit hyperactivity disorder (ADHD) and psychiatric disorders such as anxiety, conduct, substance abuse, and oppositional defiant disorders. Children who have both PBD and ADHD tend to manifest a more severe course of illness, presenting with psychosis and comorbid depression often requiring hospitalization. Although both PBD and ADHD include symptoms of distractibility and hyperactivity, the distinguishing symptoms of mania, flight of ideas, decreased need for sleep, and exhibition of sexual tendencies are present in PBD but usually not in ADHD.PBD is thought to result from an interaction among genetic and environmental risk factors in which family environment is important. The genetic endowment of parents might contribute to the family dysfunction, predisposing already genetically affected offspring to evolution of the disorder. PBD is a highly heritable disorder having a documented genetic determinant, although its basis is not yet fully elucidated. Family history is the most significant risk factor for developing the illness. Studies show an increased risk of psychopathology in the offspring of parents who have BD. Early depression, anxieties, and dysregulated behavior may be useful markers for later development of BD in high-risk children. Those symptoms may be episodic. Some researchers suggest that PBD markers may be detectable almost a decade before the onset of the clinical disorder.Ongoing research is searching to identify PBD prodromes and early risk markers for the later developments of PBD. Clinical staging is proposed in identifying the PBD evolution among at-risk children. Early symptoms in the evolution include abnormalities in temperament, anxiety, sleep disruption, minor mood disturbance, difficulties with emotion regulation, and adjustment problems, progressing into mixed mood episodes, followed by frank bipolarity later in adolescence and adulthood. Heritable biomarkers in the areas of attention, executive function, and affect processing are subjects of ongoing research. There may be structural, functional, and biochemical alterations in the brain predisposing the child to mood instability.Research has suggested that physical, sexual, and emotional childhood traumas that occur at a time of sensitivity of the maturing central nervous system may predispose to and modulate the clinical expression and course of the PBD. Traumas cause organic changes in the brain that lead to mood dysregulation. These changes may result in a rapid cycling course, psychotic features, suicidal behavior, and an earlier age of onset, all of which induce a more severe clinical PBD profile. Traumas can result from any stressful event. Examples include behavioral, educational, family related, or substance abuse induced episodes; negative life events, such as low socioeconomic status, ongoing family conflicts, or low quality of life; or any disappointing life events such as school failure or termination of relationships.As many as two thirds of adults given a diagnosis of BP had symptoms beginning in childhood. This finding underscores the importance of risk and prodrome recognition, along with early and accurate diagnosis that allows intervention before full development of the highly impairing disorder. Expert agreements on what constitute key features and valid biomarkers for PBD diagnosis are needed.Comments: When reviewing community-based studies, the diagnosis of PBD has increased dramatically over the past decade. In retrospective studies in adults, 10% to 20% revealed the onset of symptoms when they were younger than 10 years of age, and 60% when younger than 20 years, with most self-reporting a delay of 10 years in making the diagnosis. Although unfortunate, this finding may not be surprising, because there are less clear diagnostic criteria for children and because pediatricians have not been trained to consider this diagnosis. Early diagnosis is important in order to initiate appropriate treatment and minimize morbidity and mortality, such as through suicide. As pediatricians, we need to consider the diagnosis in children who exhibit irritability and aggression, and a family history of bipolar disease is important to determine. Future research is needed to better examine treatment options in children and whether earlier treatment will result in better outcomes. The challenge of managing PBD is yet another example of the importance of mental health training for pediatricians and for collaboration with mental health providers to provide the best possible care to our patients.Janet Serwint, MDConsulting Editor, In Brief