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. …