Bipolar disorder in children

Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or brain scans to diagnose bipolar disorder.[9] Obtaining information on family history and the use of questionnaires and checklists are helpful in making an accurate diagnosis. Commonly used assessment tools include the K-SADS (Kiddie Schedule for Affective Disorders and Schizophrenia), the Diagnostic Interview Schedule for Children (DISC), and the Child Mania Rating Scale (CMRS).[5]

A combination of medication and psychotherapy is recommended for most pediatric populations with PBD.[14] Mood stabilizers, which help manage manic episodes, and atypical antipsychotics, which help manage both manic and depressive episodes, have been demonstrated to be effective in pediatric populations for the treatment of PBD.[14] Mood stabilizers used for the treatment of PBD include: lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine.[15] Currently, only four types of atypical antipsychotics have been approved for use by the FDA for treatment of PBD: cariprazine, lurasidone, olanzapine-fluoxetine combination, and quetiapine.[15]

Medications for the treatment of PBD can produce significant side effects, so it is recommended that families of patients be informed of the different possible issues that can arise.[12] Although atypical antipsychotics are more effective in treating PBD than mood stabilizers, they can lead to more side effects.[11][16] Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidemia. Extrapyramidal secondary effects may occur with the use of these medications, including tardive dyskinesia, a difficult-to-treat movement disorder.[17] Liver and kidney damage may occur as a result of the use of mood stabilizers.[12] Lithium overdose can also occur in individuals with low sodium levels.[15] Pediatric populations often struggle with medication adherence for PBD, which can be improved with motivational interviewing techniques.[14]

Psychological treatment for PBD can take on several different forms. One form of psychotherapy is psychoeducation, in which children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments.[15] Similarly, family-focused therapy (FFT) is therapy for both individuals with PBD and their caregivers, in which families take part in communication improvement training and problem-solving skills training.[15] Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Another type of therapy used in individuals with PBD is chronotherapy, which helps children and adolescents form a healthy sleep pattern, as sleep is often disrupted by PBD symptoms.[15] Finally, cognitive-behavioral therapy (CBT) aims to make participants have a better understanding and control over their emotions and behaviors.[13]

Alternative treatments are currently being developed for pediatric populations with PBD in which medication and psychotherapy has proven to be ineffective. Currently, interventions involving dialectical behavioral therapy (DBT), as well as dietary supplementation, are being explored.[14]

Without proper treatment, PBD oftentimes has a poor prognosis in children and adolescents.[15] Chronic adherence to medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost 40% in those complying with medication regimens in some studies.[13] Besides noncompliance with medication regimens, another risk factor for a poor outcome of PBD is the existence of comorbid pathologies.[12]

Children with PBD are more likely to commit suicide than other children, as well as misuse alcohol and/or other drugs.[5][15] Children and adolescents with PBD are also at an increased risk for behavior that can result in incarceration.[15]

Hypomanic episodes in adolescents has been shown to not always progress into adult bipolar disorder.[18] However, research surrounding PBD emphasizes the importance of early diagnosis of PBD.[18]

Globally, the prevalence of PBD in children and adolescents under the age of 18 is estimated at about 3.9% as of 2019.[15][18] However, 5 surveys (from Brazil, England, Turkey, and the United States) have reported pre-adolescence rates of PBD as zero or close to zero.[18]

Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger's criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.[19]

In Emil Kraepelin's descriptions of bipolar disorder in the 1920s, which he called "manic depressive insanity", he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.[5]

Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.[12][20]

• International Society for Bipolar Disorders Task Force report on current knowledge in pediatric bipolar disorder and future directions