New Treatment Guidelines for Bipolar Children

New guidelines have been issued for treating bipolar disorders (search) in children.

“Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines,” write the guidelines’ authors, who included Robert Kowatch, MD, of the psychiatry department at Cincinnati Children’s Hospital.

Kowatch and colleagues don’t claim to have all the answers. Their report says the guidelines aren’t intended as an “absolute standard,” and they call for more studies on bipolar disorders — and their treatments — in children.

The guidelines appear in the March edition of the Journal of the American Academy of Child & Adolescent Psychiatry. The guidelines were drafted by a team of doctors, clinicians, and members of the Child and Adolescent Bipolar Foundation (CABF).

The CABF is a national nonprofit advocacy group for families raising children diagnosed with or at risk for bipolar disorder.

The guidelines focus on diagnosis, therapy, and the use of mood-stabilizing drugs. The authors also say they don’t know how bipolar children will fare as adults. “No one can say for sure what these children will look like when they grow up,” they write.

“However, it is clear that they manifest a serious disorder and that early diagnosis and aggressive treatment are necessary for these patients to function successfully within their families, peer groups, and schools. There is also the hope that early recognition and treatment of pediatric bipolar disorders will reduce or eliminate the many negative outcomes associated with these disorders.”

More Pediatric Bipolar Diagnoses

“Once considered rare in children, pediatric bipolar disorder is now widely diagnosed in the United States,” says Jon McClellan, MD, in a journal editorial.

Bipolar disorder is more likely to affect children of parents who have the condition, according to the National Institute of Mental Health. Adults with the disorder have clearly defined periods of mania and depression yet children and teens have very fast episodes of mood swings. They can suffer episodes of depression and mania many times a day. They tend to be more irritable and destructive rather than overly happy. It can also be difficult to tell the difference between normal behavior and other problems seen during this age period.

McClellan, a member of the psychiatry department at Seattle’s University of Washington, did not work on the guidelines. In his editorial, he calls the project “laudable” given the “considerable controversy” about pediatric bipolar disorder.

The guidelines only apply to children aged 6 and older. That’s commendable, says McClellan’s editorial. “There is no valid justification for diagnosing bipolar disorder in preschoolers,” he writes. “Labelling severe tantrums in toddlers as major mental illness lacks face validity and undermines credibility in our profession.”

How to Distinguish Misbehavior From Mental Illness

The guidelines call for careful diagnosis to separate normal childhood antics and misbehavior from true bipolar disorder, in which patients experience bouts of mania and depression. The child and at least one parent are needed to assess the child’s mental health.

Frequency, intensity, number, and duration of symptoms — “FIND,” for short — are important.

They say that for example, a child who becomes silly and giggly to a noticeable or bothersome degree for 30 minutes twice per week has some unusual behavior, but the frequency, intensity, number of episodes, and duration may not qualify for a bipolar disorder diagnosis.

It’s also important to note the context of the behavior. “Hot, hungry, stressed, and/or tired children without psychopathology may become irritable,” write the authors.

Likewise, grandiose statements (such as “I am Superman”) might not signal mental illness, depending on the child’s age, say the authors in the journal.

When children are diagnosed with bipolar disorder, it’s vital that they get proper care. Medications known as mood-stabilizing drugs, such as lithium (search), can help control bipolar disorder. In addition therapy can help, and family involvement is important, write the authors.

“It is often necessary to use several medications in combination because these kids are very ill, often suicidal, or too manic and depressed to attend school,” says Kowatch, in a news release. “Stabilizing their moods and allowing them to return to school as soon as possible is critical if they are to lead normal lives.”

By Miranda Hitti, reviewed by Brunilda Nazario, MD

SOURCES: Kowatch, R. Journal of the American Academy of Child & Adolescent Psychiatry, March 2005; vol 44: pp 213-235. McClellan, J., Journal of the American Academy of Child & Adolescent Psychiatry, March 2005; vol 44: pp 236-239. News release, Child & Adolescent Bipolar Foundation.