Bipolar disorder in children

Bipolar disorder in children is an uncommon condition that becomes more frequent in teens, approaching the rate seen in adults.

The adult criteria describe a disorder of fluctuating mood cycles, consisting of episodes of elevated mood and persistently increased activity or energy (mania) lasting at least 1 week, and episodes of lowered mood and activity (depression); an episode of mania is necessary for a diagnosis to be made.

A serious illness with recurrent episodes, leading to considerable impairment and an increased risk of suicide.

Diagnosis can be controversial, as criteria overlap with other childhood conditions such as ADHD and comorbid oppositional defiant disorder.

First-line treatment for manic episodes is antipsychotic therapy or mood stabilizers; the evidence base in children and adolescents is small, and comes mostly from industry-supported trials.

Medications have potentially serious adverse effects, so the risks and possible benefits need to be carefully assessed.

Bipolar disorder in children encompasses bipolar I disorder (manic episodes with or without depressive episodes) and bipolar II disorder (depressive episodes with periods of milder, briefer, and less impairing mania, called hypomania).

Bipolar I disorder, which has been most specifically studied in youth, is a chronic disorder of fluctuating mood, consisting of episodes of elevated mood and persistently increased activity or energy (mania) lasting at least 1 week, and episodes of lowered mood and activity (depression). Other symptoms of mania include distractibility, grandiosity, disinhibition, flight of ideas, hyperactivity, reduced sleep, and talkativeness. Varying diagnostic approaches have been proposed in children, but the implications of these approaches for treatment and prognosis remain unclear.[1]Carlson GA, Weller EB. Phenomenology and treatment of bipolar I disorder in children: a critical review. In: Yatham LN, Maj M, eds. Bipolar disorder: clinical and neurobiological foundations. Chichester, UK: Wiley-Blackwell; 2010. Many children exhibiting chronic nonepisodic irritability and severe temper outbursts have been diagnosed with bipolar disorder in the US, despite the lack of distinct mood episodes.

The diagnosis of disruptive mood dysregulation disorder was included in the Diagnostic and Statistical Manual of Mental Disorders to address this over-diagnosis and treatment of bipolar disorder in children; however, the inclusion of this new diagnostic entity has also raised concerns regarding inappropriate diagnosis and over-treatment of irritability with a category that remains poorly validated.[2]Roy AK, Lopes V, Klein RG. Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth. Am J Psychiatry. 2014 Sep;171(9):918-24. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.13101301 http://www.ncbi.nlm.nih.gov/pubmed/25178749?tool=bestpractice.com [3]Axelson DA, Birmaher B, Findling RL, et al. Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. J Clin Psychiatry. 2011 Sep;72(9):1257-62. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3581329 http://www.ncbi.nlm.nih.gov/pubmed/21672494?tool=bestpractice.com [4]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022. Despite concerns regarding over-diagnosis, there is also evidence that diagnoses of bipolar disorder can be significantly delayed and under-treated.[5]Kessing LV, Vradi E, McIntyre RS, et al. Causes of decreased life expectancy over the life span in bipolar disorder. J Affect Disord. 2015 Jul 15;180:142-7. http://www.ncbi.nlm.nih.gov/pubmed/25909752?tool=bestpractice.com [6]Khazanov GK, Cui L, Merikangas KR, et al. Treatment patterns of youth with bipolar disorder: results from the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Abnorm Child Psychol. 2015 Feb;43(2):391-400. http://www.ncbi.nlm.nih.gov/pubmed/24958307?tool=bestpractice.com

Bipolar I disorder is discussed here.