Magazine article Clinical Psychiatry News

Combo Therapy Is the Rule in Pediatric Bipolar

Magazine article Clinical Psychiatry News

Combo Therapy Is the Rule in Pediatric Bipolar

Article excerpt

Even the experts say it's a tough call to diagnose a child--particularly a young child--with bipolar disorder, making for enigmatic medication decisions in the pediatric population.

"It's always difficult, and the diagnosis is the most important thing before beginning treatment," said Dr. Kiki Chang, founder and director of the Pediatric Bipolar Disorders Program at Stanford (Calif) University.

"It's a diagnosis I've been looking at for the better part of 35 years, and I still find it very hard," agreed Dr. Gabrielle Carlson, professor of psychiatry and behavioral science at the State University of New York at Stony Brook. When it comes to very young children--under the age of 10--"you get into really dicey territory."

The problem is that diagnostic criteria for bipolar I, bipolar II, and bipolar disorder not otherwise specified in the DSM-IV were developed based on research in adults and may be exceedingly difficult to apply to children.

It's been said that all normal 4-year-olds look a bit bipolar, with wild mood swings, euphoria, racing thoughts, grandiosity, periods of extreme creative and physical energy, reports of monsters under their beds, and a seemingly reduced need for sleep (by parental report).

Clinical experience and many longitudinal studies do point to profoundly troubled behavior in some children that does have a flavor of bipolar disorder, and many of these children do go on to have unequivocal bipolar disorder in adulthood.

In the most recently published report from Dr. Barbara Geller's group at Washington University, St. Louis, 44% of young adults identified in childhood with bipolar I disorder symptoms had a manic episode after the age of 18, a rate 13-44 times higher than in the general population (Arch. Gen. Psychiatry 2008;65:1125-33).

However, community diagnoses are notoriously fallible, illustrated by the fact that half of the children referred to the Pediatric Bipolar Disorders Program at Stanford do not have the disease. Often, they prove to have unipolar depression marked by irritability Or pervasive developmental disorder. Or autism, Dr. Chang said.

Significant language impairment and developmental delays complicated the diagnosis of one of Dr. Carlson's patients who, at age 5, nearly got killed running alongside cars because he thought he could run faster than anyone else. He jumped out of a tree, and displayed other examples of "clearly grandiose" behavior. When he was 7, she asked him about chasing traffic and he said, "I was little at the time." The tree? "I never did that again," he said. Later, he boasted he could swim across Long Island Sound--a claim he later traced to his grandfather's musing that he could "swim like a fish."

By age 10, it was clear that child's diagnosis was autism. "He always had interesting ways of putting the world together. But he wasn't delusional when pressed," said Dr. Carlson.

Being precise about a diagnosis in children with unusual, shocking, and/or harmful behaviors would make little difference if medication management was the same whether a child has bipolar disorder or one of the many differential diagnoses masquerading as bipolar disorder, such as depression, attention-deficit/hyperactivity disorder (ADHD), pervasive developmental disorder, anxiety disorders, Tourette syndrome, or the autism spectrum disorders. But it's not.

"The question of diagnosis makes a big difference," Dr. Carlson said. In the case of "diagnostic ambiguity" between severe ADHD and bipolar disorder, she chooses to treat the ADHD first, unless there are clear signs of mania.

One advantage of treating ADHD with stimulants is their quick action, sometimes providing rapid evidence of improvement. Plus, their use over many years in multiple clinical trials in children provides reassurance of their safety and guidance about dosing.

It can be difficult to start on a conservative course of action in the face of extreme behavior and symptoms, but Dr. …

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