Diagnosis of Bipolar in Childhood

British Dispute that Childhood Mania is Bipolar Mania: It used to be that pre-teen appearance of mania was considered quite rare.  Now, it is being diagnosed quite frequently.  Some British psychiatrists say that the symptoms being called mania are not as clear cut as adult mania and may not be the same disorder. Is preadolescent mania the same condition as adult mania? A British perspective. Harrington R, Myatt T. Biol Psychiatry. 2003 Jun 1;53(11):961-9. (Ed: In the mid-1970s, child psychiatric units were very rare in the U.S. outside of a few major cities.  In small town America, very few children under age 15 ever needed psychiatric hospitalization and when the need arose, it rarely lasted more than a few days. Few children were diagnosed with psychiatric illnesses or given medication. Undoubtedly, people weren't paying much attention to the emotional hardships of many children then.  However, there is the danger of over-medicalization. One wonders if more children suffer severe psychiatric illness in the modern world. The same trends are present in other countries, even third world countries.  Of course, we also know that obesity and childhood obesity is increasing worldwide, including in poor third world countries.  Therefore, it is at least theoretically possible the same could be happening psychiatrically.  There are researchers who claim that rates of adult depression have skyrocketed in modern times, but others dispute that conclusion.)

Harvard Says Bipolar Disorder in Children is Separate from Conduct Disorder: They looked at clinical features, patterns of psychiatric comorbidity, functioning in multiple domains, and familiality and concluded that children with CD and BPD had similar features of each disorder irrespective of the comorbidity with the other disorder. Can a subtype of conduct disorder linked to bipolar disorder be identified? Integration of findings from the Massachusetts General Hospital Pediatric Psychopharmacology Research Program. Biederman J, Mick E, Wozniak J, Monuteaux MC, Galdo M, Faraone SV. Biol Psychiatry. 2003 Jun 1;53(11):952-60; A study of 67 youth with blind interviewers found 97% agreement on the diagnosis of mania between the interviewer and the clinical diagnosis of the treating psychiatrist. Convergence between structured diagnostic interviews and clinical assessment on the diagnosis of pediatric-onset mania. Wozniak J, Monuteaux M, et al. Biol Psychiatry. 2003 Jun 1;53(11):938-44. (Ed: The diagnosis has high inter-rater reliability, but is it really Bipolar Disorder?)

Euphoria Not a Sign of Mania in Children: In a study, 86 children satisfying DSM-IV criteria for bipolar disorder with and without the proposed cardinal symptom of euphoria were compared in their bipolar symptom pattern, functioning and patterns of comorbidity. Severe irritability was the predominant abnormal mood rather than euphoria (94% vs. 51%). Grandiosity was not uniquely overrepresented in youth with mania, nor did the rate of grandiosity differ whether irritability or irritability and euphoria were the Criterion A mood symptom. Neither symptom profile, patterns of comorbidity nor measures of functioning differed related to the presence or absence of euphoria. These findings challenge the notion that euphoria represents a cardinal symptom of mania in children. Instead they support the clinical relevance of severe irritability as the most common presentation of mania in the young. How Cardinal are Cardinal Symptoms in Pediatric Bipolar Disorder? An Examination of Clinical Correlates. Wozniak J, et al. MGH-Harvard. Biol Psychiatry. 2005 Sep 27. Ed: Severe irritability also needs to be differentiated from learned anti-social behavior. The irritability should be both severe and something and comes and goes as the condition cycles and not in response to simple frustrations from the environment.

Mania Uncommon in Research Sample of Children and Teens: Children ages 7-18 with a history of manic symptoms from a population-based twin sample obtained from state birth records (n = 1610) enriched for ADHD with a random control sample (n = 466), which allowed a look at the population prevalence of the disorder found 9 juveniles with DSM-IV manic (n = 1), hypomanic (n = 2) or below threshold episodes (n = 6). The population prevalence of broadly defined mania in the random sample was only 0.2%. The possible manic episodes showed significant comorbidity with population-defined severe combined and talkative ADHD subtypes. Children and adolescents with ADHD appear to be only modestly at increased risk for bipolar disorders. Comorbidity between ADHD and symptoms of bipolar disorder in a community sample of children and adolescents. Reich W, et al. Washington University, St. Louis, . Twin Res Hum Genet. 2005 Oct;8(5):459-66. Ed: Calling a child bipolar may aid insurance reimbursement and also justify the use of anti-psychotics and other mood stabilizers. In community psychiatric units, my hunch is that the bipolar diagnosis is frequently used combined with an ADHD diagnosis and anti-psychotics are used very freely. Children and teens with anger problems are often called bipolar in my experience. Also, I see many children and teens who appear agitated from their stimulant medication and seem to calm down when it is discontinued. However, this is not a scientific observation and so may not be an accurate observation.

British Follow-up Data Disputes Child Mania-Adult Mania Linkage: A six year follow-up study of males ages 9-13 studied ones diagnosed mania+ADHD (n = 15), or ADHD without mania (n = 65), who were compared to males with no psychiatric diagnosis (n = 17). They were reevaluated after 6 years using computer-assisted structured interviews for Axis I and Axis II disorders, questionnaires about functioning and service utilization, and a clinician-rated assessment of global functioning. There were no group differences in the prevalence of Axis I or Axis II disorders, with the exception of alcohol abuse, which was higher in controls. Manic symptoms persisted in only one mania+ADHD subject, while three (5%) of the ADHD subjects had new-onset manic symptoms. There were no clear cases of bipolar disorder. The groups were not distinguished on levels of service utilization or criminal behavior, but global functioning was significantly lower at follow-up in the mania+ADHD group compared with controls. U Newcastle. Manic symptoms in young males with ADHD predict functioning but not diagnosis after 6 years. Hazell PL, Carr V, Lewin TJ, Sly K. J Am Acad Child Adolesc Psychiatry. 2003 May;42(5):552-60

Heavy Use of Stimulants and Anti-Depressants in U.S. Children Might Be Triggering Mania: Bipolar Disorder (BD) is at the same frequency in adolescents in the Netherlands as the U.S. However, among pre-pubertal children, BD is frequently diagnosed in the US and seldomly in the Netherlands.  It is hypothesized that this may be related to the greater use of antidepressants and stimulants for depression or attention deficit disorder with hyperactivity by US children. In those children who are genetically at risk to develop BD, these drugs may lead to a switch into mania. Erasmus Univ. Earlier onset of bipolar disorder in children by antidepressants or stimulants? An hypothesis. Reichart CG, Nolen WA. J Affect Disord. 2004 Jan;78(1):81-4

Stimulants May Cause Mania in Many ADHD Children: The onset of mania was linked temporally in 21% of 82 juveniles to the starting stimulant medication. Faedda GL, Glovinski IP, Austin NB et al. Treatment emergent mania in pediatric manic depressive illness: role of antidepressants and stimulants. Presented at the 1^st annual Pediatric Bipolar Disorder Conference; March 21-22, 2003; Washington, DC.