The Ongoing Child Bipolar Diagnosis Controversy

As we and others reported last month, a very early diagnosis of bipolar disorder was one of the probable factors that led to a young child’s death. I’m sorry, but unless it’s an extreme exception, adult diagnoses such as bipolar disorder are not recognized in children at 2 or even 3 years old. Children at such young ages are under active, constantly-changing development. There are no widely-accepted, legitimate diagnostic criteria for children generally under 12 for bipolar disorder.

So we were happy to see Furious Seasons write up John McManamy’s take on this issue today.

But one of the challenges of bloggers and folks trying to make heads or tails of this issue is not spending the time (or perhaps have the access to the resources) to critically look at the research. A full-scale literature review takes a lot of effort, even for a trained professional. So I’ll take an outsider’s crack at this topic in more detail here, because I do have access to the resources and some key journal articles that shed light on bipolar disorder in children.

I look for two things in the literature when I want to get up to speed on an area of interest to me. I look for literature reviews and meta-analyses. These overview articles, when appearing in a peer-reviewed journal, offer non-expects like myself a critical 10,000 foot view of the sub-field.

The first such lit review I found was Geller and Luby (1997). Their reference list alone included more than 8 dozen citations to studies mentioned in their article. This article clearly shows empirical support for a syndrome similar to adult bipolar disorder in children, but in 1997, there was still not agreed-upon diagnostic criteria for this phemenon. So while many researchers were writing about children who showed symptoms similar to that of adult bipolar disorder, nobody had done any of the foundational work to say, “This is indeed childhood bipolar disorder and these are its symptoms.” The authors also noted that, as of 1997, there was only one completed, double-blind, placebo-controlled study of any medication for child or adolescent mania. That’s just 10 years ago.

Jumping ahead eight years later, though, for the most recent meta-analysis on this topic, and we still see no clear, agreed-upon diagnostic criteria in Kowatch et al.’s 2005 study. While the study suggested a set of criteria based upon its data analysis, these criteria (like most research) are likely not widely known or disseminated amongst clinicians.

I think the most telling result of the past decade’s worth of further research into this issue comes from Pavuluri et al’s 2005 conclusions:

Considerable advances have been made in our knowledge of pediatric bipolar disorder (BD); however, differing viewpoints on the clinical presentation of BD in children are the rule [emphasis added]. Phenomenological and longitudinal studies and biological validation using genetic, neurochemical, neurophysiological, and neuroimaging methods may strengthen our understanding of the phenocopy. Randomized, controlled treatment studies for the acute and maintenance treatment of BD disorder are warranted.

They also noted,

Combination pharmacotherapies appear promising, and the field awaits further short- and long-term randomized, placebo-controlled trials.

Not exactly a ringing endorsement for the use of any pharmcological treatment for the treatment of bipolar disorder in children, now is it?

More recent studies, such as Singh et al.’s 2006 literature review, also illustrate the complex interaction between ADHD and bipolar diagnoses — that making a bipolar disorder diagnosis without taking into account ADHD as a differential can lead to misdiagnosis.

The key here is that while clinicians and researchers agree that some form of bipolar disorder seems to exist within children and adolescents, virtually nothing is agreed upon when it comes to the form, nature and treatment of that disorder. Clinicians are out there doing what they normally do — doing the best they can with the presenting problems of clients (or their parents), while researchers are coming at the issue from a dozen different angles.

Seeing it from this light, we can understand the confusion and lack of practice guidelines in this area. But as a clinician, when confronted with such a challenging area as this, I would think most would err on the side of being fairly conservative in their treatment. Especially of a child. And especially of a very, very young child with powerful psychopharmacological treatments that have only small amounts of empirical support at present (with absolutely no long-term, logitudinal studies done on children to ensure these medications don’t have serious, long-term detrimental developmental side effects).

Cheng-Shannon et al. (2004) said it best when it comes to prescribing powerful antipsychotic medications in children and adolescents —

Although these medications appear to be well tolerated in short-term studies, long-term follow-up investigations and ongoing clinical monitoring are necessary to confirm their safety in this age group.

References

Cheng-Shannon, J. et al. Second-Generation Antipsychotic Medications in Children and Adolescents. Journal of Child and Adolescent Psychopharmacology, Vol 14(3), Fal 2004. pp. 372-394.

Geller, B. and Luby, J. “Child and adolescent bipolar disorder: a review of the past 10 years.” Journal of the American Academy of Child and Adolescent Psychiatry 36.n9 (Sept 1997): 1168(9).

Kowatch, R.A. et al. Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disorders, Vol 7(6), Dec 2005. pp. 483-496.

Pavuluri, M.N. et al. Pediatric Bipolar Disorder: A Review of the Past 10 Years. Journal of the American Academy of Child & Adolescent Psychiatry, Vol 44(9), Sep 2005. pp. 846-871.

Singh, M. et al. Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children. Bipolar Disorders, Vol 8(6), Dec 2006. pp. 710-720.