Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents, and is controversial, mainly because adult bipolar medication can cause serious harm in childhood, so misdiagnosis is problematic. PBD is hypothesized to be like bipolar disorder (BD) in adults, thus is proposed as an explanation for periods of extreme shifts in mood called mood episodes.[1] [2] These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes.[1] Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously.[2] Mood episodes of children and adolescents with PBD deviate from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time (i.e. days, weeks, or years) and cause severe disruptions to an individual's life.[2] There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS).[2] Just as in adults, bipolar I is also the most severe form of PBD in children and adolescents, and can impair sleep, general function, and lead to hospitalization.[2] Bipolar NOS is the mildest form of PBD in children and adolescents.[2] The average age of onset of PBD remains unclear, but reported ages of onset range from 5 years of age to 19 years of age.[3] PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.[4]
Since 1980, the DSM has specified that the criteria for bipolar disorder in adults can also be applied to children.[5] However, the exact criteria for diagnosing pediatric bipolar disorder, especially bipolar NOS, remains controversial and heavily debated.[4] As a result, there are big differences in how commonly PBD is diagnosed across clinics and in different countries; in the United States, PBD is often misdiagnosed.[5][6] Identifying bipolar disorder in youth is challenging. In particular, PBD and ADHD have many overlapping symptoms at the surface, such as the hyperactivity characteristic of the manic episodes that occur in PBD.[7] As a result, many children and adolescents with PBD are instead diagnosed with ADHD.[7] Misdiagnosis of PBD can lead to complications in youth and adolescents as different disorders require different types of medications that may make symptoms of PBD more severe.[8]
Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or imaging to diagnose bipolar disorder.[9] 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] It is important to assess the child's baseline mood and behavior and determine if the symptoms present episodically. Family history is also important to obtain as bipolar disorder is heritable. Additionally, it is helpful to get information from different sources such as family members and school.[10] Medication, substance use, or other medical problems should be ruled out to appropriately diagnose bipolar disorder. [10]
Early diagnosis is important for children to start treatment soon and leads to better outcomes. Often, anxiety disorders and sleep disturbances precede the mood symptoms of PBD.[10][11] If a child presents with symptoms of anxiety and changes in sleep pattern with major changes in energy and deterioration of function, especially in school, this may warrant evaluation for PBD. [12]
The American Psychiatric Association's DSM-5 and the World Health Organization's ICD-10, use the same criteria to diagnose bipolar disorder in adults and children with some adjustments to account for differences in age and developmental stage, particularly with depressive episodes.[5][13] For example, the DSM-5 specifies that children may exhibit persistently irritable moods instead of a depressed mood.[1] Additionally, children will more than likely fail to meet their expected body weight instead of presenting with weight loss.[12]
In diagnosing manic episodes, it is important to compare the changes in mood and behavior to the child's normal mood and behaviors at baseline instead of to other children or adults.[10] For example, grandiosity (i.e., unrealistic overestimation of one's intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child's normal self-view in between episodes.[1]
The diagnosis of childhood bipolar disorder is controversial.[5] It is recognized that bipolar disorder typical symptoms are dysfunctional and have negative consequences for minors with the condition.[14] The main discussion is centered on whether what is called bipolar disorder in children refers to the same disorder in adults,[15] and the related question on whether the criteria for adult diagnosis is useful and accurate when applied to children.[5] More specifically, regarding the symptomatology of mania and its differences between children and adults.[16]
Diagnostic criteria may not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles.[16] For example, irritability, distractibility, and poor judgment are symptoms commonly seen in pediatric bipolar disorder and ADHD. Elated mood and decreased need for sleep can be specifically diagnostic of PBD.[10]
Family history is a strong predictor of childhood development of bipolar disorder.[10][11] Children of parents with bipolar disorder should be monitored for possible development of bipolar disorder especially if they exhibit sleep disturbances and symptoms of anxiety disorders early on.[10]
Other factors that can contribute to pediatric bipolar disorder include substance use disorder and childhood adversity such as abuse or school trauma.[12][17]
A combination of medication and psychosocial intervention is recommended for most pediatric populations with PBD and has been proven to lead to improved prognosis.[18][11][17] In order to choose the best medication and therapy, it is important to consider the child's age, their psychosocial environment, presentation and severity of symptoms, and their family history.[11]
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.[18] Mood stabilizers used for the treatment of PBD include: lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine.[19] Lithium appears to be particularly effective in children with a family history of mood disorders especially if the family members have been successfully treated with lithium.[17] 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.[19]
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.[15] Although atypical antipsychotics are more effective in treating PBD than mood stabilizers, they can lead to more side effects.[14][20] 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.[21] Liver and kidney damage may occur as a result of the use of mood stabilizers.[15] Lithium overdose can also occur in individuals with low sodium levels.[19] Pediatric populations often struggle with medication adherence for PBD, which can be improved with motivational interviewing techniques.[18]
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.[19] 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.[19] 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.[19] Finally, cognitive-behavioral therapy (CBT) aims to make participants have a better understanding and control over their emotions and behaviors.[16]
Psychotherapy can be tailored to each individual and address needs that medication alone cannot to help improve lifestyle and functionality. Additionally, psychotherapy improves medication adherence.[11]
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.[18]
Without proper treatment, PBD oftentimes has a poor prognosis in children and adolescents.[19] 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.[16] Other risk factors for poor outcomes of PBD and increased severity of symptoms are comorbid pathologies and early onset of disease.[10][12][15][17]
Children with PBD, especially early onset, are more likely to commit suicide than other children, as well as misuse alcohol and/or other drugs.[5][10][12][19] Children and adolescents with PBD are also at an increased risk for behavior that can result in incarceration.[19]
Hypomanic episodes in adolescents have been shown to not always progress into adult bipolar disorder.[22] However, research surrounding PBD emphasizes the importance of early diagnosis of PBD for improved prognosis.[22]
Globally, the prevalence of PBD in children and adolescents under the age of 18 is estimated at about 3.9% as of 2019.[19][22] However, 5 surveys (from Brazil, England, Turkey, and the United States) have reported pre-adolescence rates of PBD as zero or close to zero.[22]
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.[23]
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.[citation needed] 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.[15][24]