Thursday, February 12, 2009

Bipolar Disorder in Children and Adolescents

Bipolar disorder is notoriously difficult to diagnose and the diagnosis in youth isn’t any easier. However, there is importance in regarding a BP II or BP NOS diagnosis as preliminary since children falling into these categories are likely to develop BP I.

In comparing childhood and adolescent onset, a recent study showed that early onset BP was associated with more severe symptoms in adolescence. As well, children had a greater length of illness and greater mood lability. Suicidal behaviours including attempts, gestures, and ideations are common among the paediatric BP community.

Symptoms are similar to those in adults, though children tend to show more irritability than euphoria in manic episodes. Consequences of social factors, poor academic performance and leaving home, which do not apply to adults will also have severe impacts on later quality of life.

The two most common misdiagnoses are ADHD and schizophrenia. Particularly, the comorbidity of BP and ADHD increases the difficulty of diagnosis. There are five symptoms not overlapping with ADHD (uncomplicated) which are used to distinguish the two disorders in diagnosis. These five manic symptoms are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the in absence of sexual abuse or overstimulation). Additionally, given the rapid-cycling nature of paediatric BP, the episodic manic states may help in differentiating from ADHD.

The differentiation of schizophrenia from psychotic depressive states is made by noting the affect of speech (which is more emotionally consistent in depression), presence of delusions (less likely in depression), and quality of delusions (mood consistent with depression),

Treatment

Medications used in the treatment of paediatric BP are the same as those used in the treatment of adult BD. However, pharmacotherapy in adolescents is an area that is still grossly under-researched.

As with adults, the use of anti-depressants can induce manic episodes. As well, treatment of misdiagnosed ADHD with stimulants can also worsen manic symptoms.

A recent study showed no difference in cognitive function between medicated and unmedicated manic BP adolescents and another study demonstrated good tolerance and quality of remission with quietipine.

It is important to continue pharmacotherapy even when symptoms improve because of the high rate of recurrence.

For non-pharmacological treatment, I think FFT-A (Family Focused Therapy for Adolescents) is especially important as children are not yet fully independent and the support of family can improve recovery significantly. However, participation of parental figures and other family members may not be possible because of, unfortunate, disinterest in the child’s health. Interpersonal Social Rhythm Therapy encourages the practice of daily routine and stable relationships. Other therapies (art, music, play, animal) can also be used to augment individual and family therapy.

Resources

1 800 SUICIDE

UBC has a site with a comprehensive list of resources available in Vancouver.

A U.S. self-help organization, The Child and Adolescent Bipolar Foundation, has a website for parents.

A non-profit source for bipolar disorder.

MySpace. Also has links to other resources.

References
1, 2, 3, 4, 5, 6, 7, 8

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