A 5-year-old boy with recurrent mania successfully treated with carbamazepine

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.

Psychopharmacology and preschoolers: a critical review of current conditions

Rates of prescriptions for very young children have increased notably in the last 20 years. These changes have occurred in the context of increasing attention to early childhood mental health, availability of medications perceived to be safer than older medications, application of the medical model to the mental health care of young children, as well as other cultural shifts. Psychopharmacological treatment for any patient, but especially very young children, requires consideration of central nervous system (CNS) and metabolic development and issues of diagnostic validity and should be guided by an empirical literature. In young children, this literature is quite limited. In this article, the authors review developmental issues involved in psychopharmacological treatment and present existing literature and practical guidelines for common preschool diagnoses, recognizing that for some disorders, the extant literature does not support even consideration of medications.

Preschool Bipolar Disorder

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Psychopharmacological treatment for very young children: contexts and guidelines

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Defining and validating bipolar disorder in the preschool period

The clinical characteristics and adaptive functioning of preschoolers who met DSM-IV criteria for bipolar disorder versus psychiatric and healthy comparison groups were investigated. A community-based sample of 303 preschoolers (3-6 years of age) and their caregivers was ascertained. Diagnostic classification based on parent report of mania symptoms was made using an age-appropriate psychiatric interview. Results indicated that 26 preschoolers met DSM-IV criteria for bipolar disorder who could be identified based the presence of 13 core age-adjusted mania items. These children could be clearly differentiated from children in two psychiatric groups (DSM-IV disruptive disorders, and major depressive disorder) and a "healthy" comparison group based on a specific symptom constellation. Findings indicated that preschoolers in the bipolar group were significantly more (p < .05) impaired than the two psychiatric and healthy groups based on independent measures. Further, even after controlling for comorbid attention-deficit/hyperactivity disorder (81% comorbidity rate), the bipolar group remained significantly (p < .05) more impaired in multiple domains compared to preschoolers with DSM-IV disruptive disorders and healthy controls. Findings suggested that children as young as 3 years can manifest DSM-IV bipolar disorder when age adjusted symptom descriptions are employed, and that these children can be distinguished from healthy and disruptive disordered preschoolers. Recommendations for future research in this area that integrates developmental and mental health models are made.

A one-year open-label trial of risperidone augmentation in lithium nonresponder youth with preschool-onset bipolar disorder

OBJECTIVE

The aim of this study was to assess the safety and efficacy of risperidone augmentation of lithium in preschool-onset bipolar disorder (BD) among youth who insufficiently respond to lithium monotherapy.

METHOD

Thirty-eight subjects between the ages of 4 and 17 years (mean age = 11.37 +/- 3.8 years) with onset of BD in preschool years (manic or mixed episode) entered this 12-month trial. All subjects received lithium monotherapy. Patients who failed to adequately respond to lithium monotherapy after 8 weeks and those who relapsed after an initial response were given risperidone augmentation for up to 11 months. The Young Mania Rating Scale (YMRS) was the primary outcome measure. Response was defined as a > or =50% decrease from baseline. Additional data were collected on diagnostic comorbidity, family history, number of hospitalizations, perinatal risk factors, history of physical or sexual abuse, Child Depression Rating Scale-Revised (CDRS-R), Clinical Global Impression (CGI) scale for BD (CGI-BP), Children's Global Assessment Scale (C-GAS), and adverse medication effects.

RESULTS

Of the 38 subjects treated with lithium monotherapy, 17 responded, whereas 21 required augmentation with risperidone. Response rate in the youths treated with lithium + risperidone was 85.7% (n = 18/21). Significant predictors of inadequate response to lithium monotherapy requiring augmentation were: (1) attention-deficit/hyperactivity disorder (ADHD), (2) severity at baseline, (3) history of sexual or physical abuse, and (4) preschool age. Combination treatment of lithium and risperidone was found to be safe and well tolerated.

CONCLUSIONS

A substantial proportion of youth with a history of preschool-onset BD treated with lithium were either nonresponders or partial responders. Subsequent augmentation of lithium with risperidone in these cases was well tolerated and efficacious. Potential predictors of lithium nonresponse identified in this study may guide the choice of medications earlier in the treatment process.

Treatment of mania in children and adolescents

Bipolar disorder (BPD) is a severe and complex illness that seriously disrupts the lives of those afflicted. Increased rates of suicide attempts and completions, poorer academic performances, disturbed interpersonal relationships, increased rates of substance abuse, legal difficulties, and multiple hospitalizations all have been associated with BPD. At least 1% of children and adolescents have this disorder. This commentary is designed to review and summarize the recent literature on the treatment of manic and/or hypomanic phases of BPD in children and adolescents.