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Bipolar disorder in kids: complicated.

CAMBRIDGE, MASS. -- Bipolar disorder may cause more severe illness in children than in adults, but the pediatric condition is less readily recognizable than its adult-onset counterpart, according to Dr. Barbara Geller of Washington University, St. Louis.

"Most adults with typical bipolar disorder have episodes of mania or depression that last a few months with relatively normal functioning in between. Many children with bipolar disorder will be both manic and depressed at the same time, and will often have a more chronic course of illness without intervening well periods. They will also have multiple daily cycles of highs and lows," Dr. Geller reported at a meeting on bipolar disorder sponsored by Harvard Medical School.

Dr. Geller presented findings from an ongoing, prospective National Institute of Mental Health (NIMH) study of the phenomenology and longitudinal course of prepubertal and early adolescent bipolar disorder.

Pediatric bipolar disorder is difficult to recognize because "children are developmentally incapable of many of the tell-tale manifestations of bipolar symptoms described in adults, such as maxing out credit cards or having four marriages," Dr. Geller said. Also, children are happy and expansive by nature, so it is not intuitive that such behavior may be pathologic, she said.

Further complicating the diagnosis of bipolar disorder in children and adolescents is the high prevalence of comorbid attention-deficit hyperactivity disorder (ADHD) and the significant overlap of symptoms between the two conditions.

"Community physicians recognize ADHD but do not yet recognize symptoms of child mania or do not consider mania in their differential diagnosis of ADHD," Dr. Geller said. Because of this, bipolar disorders in children may be underdiagnosed, she said.

Dr. Geller and her colleagues in the NIMH project comprehensively assessed at 6-month intervals 93 children who met predefined criteria for a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP), and compared them with 81 children with ADHD and with 94 healthy control children. Children and adolescents in the PEA-BP and ADHD groups were outpatients obtained by consecutive new case ascertainment. The community control patients were from a random survey that matched subjects by age, pubertal status, gender, zip code, and parental socioeconomic status. Children in the study ranged in age from 7 to 16 years, with a median age of 10.9, and all of the children with diagnoses received treatment for their conditions from their own community practitioners.

To fit the study phenotype, PEA-BP subjects had to have current DSM-IV mania or hypomania with elation and/or grandiosity as one criterion to ensure that BP was not diagnosed using criteria that overlapped with those for ADHD, such as hyperactivity and distractibility. At baseline, median age of onset of the current episode was 7.6 years, she said.

Diagnoses of mania were determined by using the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS), which was given separately to parents about their children and to children about themselves by experienced research nurses who were blind to group status. WASH-U-KSADS incorporates severity ratings of DSM-IV symptoms of mania, including frequency, duration, context, intensity, functional impairment, occurrence in multiple settings, and notice by peers and adults. The research nurses also assessed all of the children for psychosocial functioning using the Psychosocial Schedule for School Age Children-Revised (PSS-R).

Despite fulfilling the study's diagnostic criteria for mania, fewer than half of the PEA-BP subjects received any antimanic medication during a 2-year longitudinal follow-up, suggesting that "gatekeeper physicians are not considering mania in their differential diagnoses of symptomatic children and that many children may not be getting appropriate treatment," Dr. Geller said.

While the study results showed statistically significant overlap between the PEA-BP and ADHD subjects in certain DSM-IV mania criteria--including hyperactivity, irritability, and distractibility--four distinct, statistically significant, nonoverlapping criteria also emerged and should be used in the differential diagnosis of ADHD to rule out mania, Dr. Geller said. These include elated mood, grandiosity, flight of ideas/racing thoughts, and decreased need for sleep. "The features of mania that don't overlap with ADHD are the most clinically useful determinants of bipolar disorder," Dr. Geller said.

Less differentiation was observed in the comparison of the four items used to rate DSM-IV poor-judgment criterion, including hypersexuality, daredevil acts, silliness, and uninhibited people seeking. The overall prevalence of the poor-judgment criterion was significantly different between the PEA-BP and ADHD patients. Poor judgment occurred in 44.4% of the ADHD group, compared with 90.3% of the PEA-BP group, although hypersexuality (in the absence of abuse) occurred almost solely in the PEA-BP children. Clinician confusion with ADHD may contribute to underdiagnosis of pediatric bipolar disorder, but the complex differential diagnosis of irritability in children may lead to overdiagnosis. "Irritable mood is one of the most frequent reasons children are referred for behavioral assessments, and it is also one of the most common symptoms of mania. But only a small percentage of children with irritability will have mania" Dr. Geller said.

Irritable mood is also common to numerous other child psychiatric disorders, including oppositional defiant disorder, conduct disorder, autism, and Asperger's syndrome. "It is also useful to be mindful that co-occurring irritability and elation is frequent in both child and adult bipolar disorder," she said. "The presence of elation and/or grandiosity among subjects in the PEA-BP phenotype does not preclude irritable mood." In the phenomenology review, coexisting elated mood and irritability occurred in 87% of the PEA-BP patients.

Recovery from bipolar disorder in children appears to be neither frequent nor swift, and relapse after recovery is common, according to the study results. Of the 93 children in the PEA-BP group, 58 recovered after a mean 36 weeks during their first 2 years of follow up, but 32 of those patients relapsed a mean of 28.6 weeks after recovery, Dr. Geller reported. Recovery was defined as at least 8 consecutive weeks without meeting DSM-IV criteria for mania or hypomania. Relapse after recovery was defined as two consecutive weeks of meeting DSM-IV criteria for mania or hypomania with clinically significant impairment.

No significant differences in baseline characteristics were seen between the patients who recovered by the 2-year time point and those who did not. Types of treatment did not predict recovery; however, the data suggest recovery was significantly predicted by living with an intact biologic family. Such children were 2.2 times more likely to recover than those in other living situations. The only significant predictor for relapse after recovery was low maternal warmth. Patients with low ratings on this feature as assessed with the PSS-R were 4.1 times more likely to relapse after recovery.

The course of illness among children with bipolar disorder appears to be more similar to that of adults who have severe, chronic forms of the condition than to "typical" bipolar adults. Most bipolar adults present with mania or major depressive disorder, experience rapid cycling defined by four episodes per year, are ill for a discrete period (2-8 months on average), and respond to treatment. In contrast, the PEA-BP patients often presented with mixed mania (54.8%), usually experienced continuous rapid cycling over long periods, and exhibited treatment resistance. Almost 10% of the PEA-BP group experienced 5-365 cycles per year (ultra rapid cycling) and about 77% experienced more than 365 cycles per year (continuous cycling).

RELATED ARTICLE: Distinguishing Bipolar Disorder From ADHD.

Recognizing DSM-IV mania symptoms that do not overlap with those of attention-deficit hyperactivity disorder can help in the diagnosis.

Nonoverlapping Symptoms

Elated mood Grandiosity Flight of thoughts/racing thoughts Decreased need for sleep

Partially Overlapping Symptoms

Hypersexuality Daredevil acts Silliness/laughing Uninhibited people seeking

Overlapping Symptoms

Irritable mood Accelerated speech Distractibility Increased energy

Source: Dr. Barbara Geller


New England Bureau
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Author:Mahoney, Diana
Publication:Clinical Psychiatry News
Date:Jan 1, 2004
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