Controversy Surrounding Bipolar Disorder in Children and Adolescents

Question:

"Is bipolar disorder a ‘real’ condition in children and adolescents? I hear so much controversy surrounding this issue in the press and would appreciate your clarification."

Rakesh Jain, MD, MPH:

I received A LOT of questions on this topic at the 2009 Treating the Whole Patient program presented at the U.S. Psychiatric and Mental Health Congress . If there is one controversial issue in the world of mental health, this is it! The single most controversial issue in psychiatry is articulated in your question, and it deserves close examination from us clinicians.

First of all, it’s important to remember that DSM-IV does not tell us that there is any age limit to making a diagnosis of bipolar disorder. From the point of view of what our major diagnostic text tells us, there is no prohibition from making the diagnosis in any age group as long as the criteria are met.

Why then this controversy? None of us question if major depression or panic disorder belongs exclusively in the domain of adulthood, then why is there such concern about BD?

This may be for multiple reasons. ^1,2 Bipolar disorder has only in the last two decades or so been fully appreciated as a common psychiatric condition in both psychiatrists’ and primary care physicians’ offices; some years behind major depression achieved such recognition. Could this then be the reason why we are slower to come to the appreciation of BD’s existence in individuals under 18 years of age?

I think this may play a role, but my feeling is that a far more common reason for such skepticism regarding pediatric BD is because of different clinical presentations in pediatric and adult patients. This issue is key.

What are some of the differences in pediatric and adult BD presentation in our practices? First, pediatric BD often does not have a cyclical presentation of deregulated mood symptoms, and irritability is commonly the most prominent symptom. ³ While adults too can present with ultradian rapid cycling and mixed episode presentations, it appears to be more common in youngsters. To complicate matters, attention-deficit/hyperactivity disorder is unusually common in pediatric BD. ⁴ These two factors, in my opinion, are the most common reasons for diagnostic confusion regarding pediatric BD.

Now, to address the question whether there is even such a thing as pediatric BD. The answer appears to be yes, and this is based on very careful work conduced at the Washington University School of Medicine. ³ Their work does support the notion that pediatric BD is a “real” condition. The thing to remember, though, is that this group used a relatively narrow criterion, and many “real life” patients we see in our practices have a much broader range of symptoms.

Perhaps another major reason for our confusion regarding pediatric BD comes from its amazingly frequent overlap with ADHD, yet differences have been documented. ^5,6 Again, the Washington University group has examined this and found that while the overlap is common, there are patients who clearly have BD and not just a “worse” or more severe form of ADHD. ³

A danger worth pointing out is that BD is both over- and underdiagnosed in clinical practices. In other words, vigilance is called for, and our task is to do our best to make the diagnosis of BD in pediatric patients after careful examination of the current presentation, longitudinal course, as well as family history. A recent article on this topic from Leibenluft is very instructive reading. ⁷ I would also like to recommend another article that focuses on this issue in the primary care office by Cummings and Fristad. ⁸ Both articles are available for free download at www.ncbi.nlm.nih.gov/pubmed .

Happy reading!

There is no question that pediatric BD is “real,” but stay tuned as a huge amount of research is coming our way that will shed more light on this issue!

—Rakesh Jain, MD, MPH

References

1. Chang KD . Course and impact of bipolar disorder in young patients. J Clin Psychiatry . 2010;71(2):e05.
2. Findling RL . Diagnosis and treatment of bipolar disorder in young patients. J Clin Psychiatry . 2009;70(12):e45.
3. Craney JL, Geller B . A prepubertal and early adolescent bipolar disorder-I phenotype: review of phenomenology and longitudinal course. Bipolar Disord . 2003;5(4):243-256.
4. Singh T . Pediatric bipolar disorder: diagnostic challenges in identifying symptoms and course of illness. Psychiatry (Edgmont) . 2008;5(6):34-42.
5. Frazier JA, Breeze JL, Makris N, et al . Cortical gray matter differences identified by structural magnetic resonance imaging in pediatric bipolar disorder. Bipolar Disord . 2005;7(6):555-569.
6. Biederman J, Makris N, Valera EM, et al . Towards further understanding of the co-morbidity between attention deficit hyperactivity disorder and bipolar disorder: a MRI study of brain volumes. Psychol Med . 2008;38(7):1045-1056.
7. Leibenluft E . Pediatric bipolar disorder comes of age. Arch Gen Psychiatry . 2008;65(10):1122-1124.
8. Cummings CM, Fristad MA . Pediatric bipolar disorder: recognition in primary care. Curr Opin Pediatr . 2008;20(5):560-565.