Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Why do you need to know about bipolar disorder?
Publish date: April 27, 2018
Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?
Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.
While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.
there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or children but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In help, can Young Mania Rating Scale or the parent version of the Mood Disorders QuestionnaireNow that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.
In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).
You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.
You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at email@example.com.