Bipolar disorder in children

Bipolar disorder (BD), previously called manic-depressive disorder, is a type of mood disorder characterized by periods of extremely elevated or irritable mood, which can sometimes alternate with episodes of depression. Bipolar disorder can be diagnosed in children as young as preschool. The lifetime prevalence of BD is between 0.5 to 1.6%, and the prevalence may be as high as 1% in youths alone. When diagnosed in children, BD is most commonly characterized by increased energy, distractibility, pressured speech, irritable mood, grandiosity, and elevated mood.ref name=Carr> Carr A. 2009. Bipolar disorder in young people: Description, assessment and evidence-based treatment. Devel. Neurorehabilitation. 12: 427-441</ref> BD is an increasingly common diagnosis in children, due to several factors including an expansion of diagnosis criteria from classic manic depressive symptoms to more general manic symptoms, availability of knowledge about BD in children, and desire for insurance reimbursement for treating symptomatic behaviors of bipolar disorder. [1, 2, 3] More than 60% of adults with BD report having their first mood episode before the age of 19, as the typical age of onset is during adolescence. [4] The diagnosis of bipolar disorder in children is a highly controversial issue, as the disease was previously thought to rarely occur in youths. [2,3] When the DSM-IV was published in 1994, pediatric bipolar disorder was not included as a diagnosis. However, the American Psychological Association is currently working on criteria and classification for a new subset of BD, Pediatric Bipolar Disorder (PBD), to be included in the 2013 publication of DSM-V.[5] One of the main challenges in categorizing PBD as a separate diagnosis in DSM-V is understanding the symptomology of BD in children, which has been poorly studied in the past but is now beginning to be more thoroughly understood. [5]

Characteristics

Signs and Symptoms

Pediatric Bipolar Disorder (PBD) causes a significant impairment in the ability of children to function normally, especially in academics and psychosocial areas, and it is a chronic disorder that persists throughout the lifetime.[6.7] Children with PBD experience chronic periods of mania, characterized by elevated and irritable moods, or depression. PBD patients are ten times more likely to commit suicide than healthy children.[4, 8] Severe manic and depressive symptoms are associated with early age of diagnosis, meaning children often display more acute symptoms than adults.[8] In children, mania often presents with psychotic symptoms and mixed manic depressive episodes.[2] Such a presentation of mania often differs from classic descriptions of mania in adults, yet children who are diagnosed with bipolar disorder show the same brain abnormalities as adults, further complicating diagnosis. [2, 7] Children with PBD display anger, dysphoria, irritability, belligerence, and mixed-manic depressive symptoms more commonly and for more erratic time periods than adults. [2]

Brain Structure

Functional magnetic resonance imaging (fMRI) is a non-invasive tool used to show concrete links between brain functioning and psychiatric disorders. Changes in blood flow in the brain, which are indicators of neural activity, can be viewed using fMRI technology. Using fMRI images, altered mechanisms of brain functioning have been seen in PBD patients in brain areas such as the ventral prefrontal cortex, cingulated cortex, amygdalae, and hippocampus.[7] In fMRI comparisons of healthy children with previously unmediated PBD patients, treatment of the PBD patients with a second generation antipsychotic then an anticonvulsant resulted in increased activity in affective brain regions while cognitive regions showed decreased brain activity.[9] Prescription of antipsychotics may permanently alter the brain development in children, as shown by fMRI studies, and is a reason why treatment plans should be carefully monitored.

Treatment

Pscychopharmacology

Prompt treatment of PBD is important because it minimizes developmental delays and dysfunctions; however, current treatment recommendations are based off of adult treatment models.[6, 7] Increasingly, psychopharmacology is being looked to for treatment of PBD, but studies showing the safety and efficacy of psychopharmacology in treating PBD are rare. From 1993 to 2003, 90.6% of pediatric bipolar patients who visited an outpatient physician practice were prescribed a psychotropic medication.[10] Although doctors are prescribing medication to treat PBD, there is no standard treatment for it because the current research available has found high rates of adverse events in many pharmacological treatment options and that children are at greater risk for adverse events when taking such medications. Current treatment options for bipolar disorder in children include antipsychotics, atypical antipsychotics, second generation antipsychotics, mood stabilizers, or anticonvulsants. The only FDA medications approved to treat bipolar disorder in children are: lithium, risperidone, aripiprazole, olanzinpine, and aripriprazole; however, even these drugs have negative side effects such as sedation, somnolence, and weight gain.[4,8]

Alternative Treatments

Alternative treatments have been shown to reduce bipolar symptoms while causing few side effects. One current theory is omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help to manage bipolar disorder in children.[11] Both EPA, which can be metabolized into DHA, and DHA are components of cell membranes, and abnormalities of these phospholipids in cell membranes have been found in bipolar disorder.[11] PBD patients who supplemented their diet with omega-3 fatty acids saw a reduction of mania symptoms.[8] Other alternative treatments, such as a micronutrient diet, have found similar results. In one study of using micronutrients to treat PBD, parents purchased a 36-ingredient micronutrient product and monitored their child’s progress over six months.[12] Symptoms were reduced by 50% in almost half of the subjects, with few side effects. [12]

Pscyhotherapy

Psychotherapy has also been shown to be helpful in treatment of BD. [3] In individual psychotherapy, children are closely monitored for symptoms and progress while gaining life skills.[2] Because PBD impacts children’s academic, social, and family life, psychotherapy is also used to help mange functional and developmental impairments.[2] Through educating and informing parents and family members, children with PBD are able to maintain treatment gains.[3] By educating family members, medication adherence and communication within the family is improved, leading to greater treatment gains.[2]