|
|
|
|
|
|
 |
|
 |
Childhood-onset Bipolar Disorder: Under-diagnosed, Under-treated and Under Discussion
A host of problems has contributed to this unfortunate state of affairs--not the least of which is the misconception that bipolar disorders in the pediatric age group are rare and unlikely to be seen before puberty. From at least the 1930s onward, standard clinical textbooks have omitted reference to the condition. This prevailing view has persisted to the present day, despite clinical observations of mania and melancholia in the young since ancient times. Compelling reports from general population and family studies show progressively higher rates of early onset mood disorders in successive generations since 1940. The fact that DSM-IV--the diagnostic manual whose criteria are used by mental health practitioners across the country to make psychiatric diagnoses--defines bipolar disorder no differently in children than it does in adults, further compounds this outlook. The last revision of the DSM took place over six years ago, whereas most of what we now know about childhood-onset bipolar disorder (COBPD) did not reach the literature until after the completion of the most recent revision. DIFFERENCES BETWEEN CHILDHOOD AND ADULT-ONSET FORMS OF BIPOLAR DISORDER While adult-onset and juvenile-onset forms of bipolar disorder have certain similar features in common, the stark difference in the frequency and duration of mood/energy cycles, known as ultra-ultra rapid or ultradian cycles, between the adult and childhood-onset forms has had a confounding affect on clinical diagnostic practice. The juvenile form of the disorder is also wrought by prolonged temper tantrums and rages, as well as the frequent overlap of symptoms of other commonly diagnosed childhood disorders. Ultra-ultra Rapid or Ultradian Cycles of Mood and Energy Diagnostic and treatment studies of children with bipolar disorder have all observed the tendency towards ultra-ultra rapid or ultradian cycles--rapid swings of mood and energy multiple times within the day--one of the key hallmarks of COBPD. Over 75% of individuals with COBPD have rapid, continuous, or ultra-ultra rapid (ultradian) cycles of mood. Clinically, this phenomenon can be observed as rapid and dramatic shifts in mood and energy that often cause parents to describe their children as unpredictable, alternating between belligerent, nasty, hostile, and silly, goofy, giddy mood states. This Dr. Jekyll and Mr. Hyde portrait of behavior distinguishes COBPD from other disruptive disorders of childhood with which it is commonly confused. Labile, unstable, and rapidly changeable mood is particularly striking among young patients under 10 years of age. In one of the largest studies of childhood-onset bipolar disorder, the frequent occurrence of ultra-ultra rapid or ultradian cycling in mood and energy was reported by parents as being present as early as age six in a sizable percent of the sample. Although this is a key feature of the condition for a majority, it is not included in the current diagnostic criteria of the DSM-IV, making it likely that not more than one quarter of children with early-onset bipolar disorder will be properly diagnosed. The addition of ultradian or ultra-ultra rapid-cycling to these criteria would certainly serve to improve current diagnostic practices and lead to a greater appreciation of the rate of pediatric bipolar disorder in the general population. A manic episode may be unrecognized if rapid shifts of mood and energy and labile presentation are not viewed as salient characteristics of the disorder. It is therefore clear that there exists an urgent public health need to revise the DSM-IV criteria for COBPD. Temper Tantrums and Rages Severe, prolonged temper tantrums with aggressive, often violent and destructive rages, have diagnostic value, noting that the energy manifested by tantrums of bipolar youths can be extraordinary to witness, hard to believe, and difficult to imitate. Such rages have been found to be one of the prominent clinical features of COBPD in a large sample of juvenile-onset cases. A full 92% of the sample, had recurrent rageful, and often violent tantrums lasting longer than 45 minutes with oppositional/defiant behaviors. Bossy, demanding, intense, explosive, aggressive, and intimidating were some of the most common terms used by parents to describe the behavior and demeanor of their children. In contrast to existing diagnostic criteria of the DSM-IV, that require persistence of symptoms, a more fitting prototype of bipolar disorder in childhood would incorporate its unstable and ultra-ultra rapid-cycling clinical presentation, as well as the tendency towards temper tantrums and prolonged rages. The Comorbidity of COBPD with Attention Deficit Disorder and Oppositional Defiant Disorder In addition to differences in phenomenology, course, and cycling pattern, symptomatic overlap with other conditions, including attention deficit disorder with hyperactivity (ADHD) and oppositional defiant disorder, is apparently a cardinal feature of COBPD. Distinguishing children with COBPD from those with ADHD by clinical assessment alone is difficult since three of the seven criteria for COBPD are shared with ADHD. These criteria are: distractibility, physical agitation and talkativeness. In a 1995 study of 43 manic children, aged 12 or younger, who were referred to an outpatient psychopharmacology clinic, 94% of the sample also met full DSM-III-R criteria for ADHD. In a study of parent reports, which retrospectively examined the evolution of symptomatology in a group of 120 children and adolescents (ages 3-18) diagnosed with bipolar disorder, 93% were reported to have DSM-IV ADHD, and over 90% met full criteria for oppositional defiant disorder. Family-genetic studies are uniquely suited for the evaluation of such complicated diagnostic pictures. A separate study found that both disorders were elevated in relatives of pro-bands diagnosed with ADHD and BPD and, a significant percentage of the relatives had both conditions. A phenomenon, known as "co-segregation," whereby the conditions segregate together in families, suggests that COBPD and ADHD may be transmitted together, not independently, at least in a subgroup of families. What is beginning to emerge is a view that this same phenomenon can be observed between COBPD and a number of childhood psychiatric disorders including conduct disorders, Tourettes syndrome, OCD, and other anxiety disorders. EPIDEMIOLOGICAL AND NATURALISTIC FOLLOW-UP STUDIES Historical biases stifled any attempt to quantify COBPD rates in juvenile epidemiological samples, and until recently, almost all available data on bipolar disorder in childhood and adolescence had been derived from small samples of patients and anecdotal reports. The first large-scale review of the world literature that took issue with prevailing diagnostic practices was a meta-analysis of 2,168 cases in 1994. It concluded that while clinical features of pediatric and adult bipolar disorder have similarities, pediatric cases cannot be defined solely by features characteristic of the adult disorder. This review and subsequent diagnostic studies have paved the way for a re-evaluation of the long-standing myths that have largely obscured our understanding of the condition and its rate in the general population. The first report in the literature, on a community sample of adolescents, was published in 1988. These youth had rates of hypomania as high as 13%, endorsed four or more manic symptoms of at least 2 days duration and, compared to the rest of the sample, had significantly higher rates of attention deficit, conduct, and anxiety disorders, as well as psychotic symptoms. In 1995, the first major epidemiological study of bipolar disorder was conducted in a sample of over 1700 Oregon high school students. Researchers found a lifetime prevalence of bipolar disorders of 0.90-1.41%--a rate equivalent to that seen in the adult population. When less stringent episode duration criteria were applied to this group, the rates rose to 9.0%, comparable to earlier reports, and to recent findings in a study of an adult population with hypomania. More than half of the bipolar subjects in the Oregon study had received some form of mental health treatment, yet only one subject had been treated with lithium, suggesting that many of these students were not recognized as having bipolar disorder by mental health professionals with whom they came into contact. Conclusion Within the complete and incorrect criteria being used to diagnose bipolar disorder in youth by the majority of mental health practitioners around the country, coupled with the burgeoning administration of stimulants and antidepressants to the general pediatric population and their potential for serious adverse effects, a public health nightmare is brewing. When we take the high frequency of overlapping symptoms of two commonly accepted and diagnosed conditions in child psychiatry, together with the one week duration requirement of mood episodes used to make the diagnosis by DSM-IV criteria, combined with the historical bias against diagnosing BPD before puberty, we need not search further for reasons as to why this condition is so poorly recognized and so often misdiagnosed in childhood. Since revisions of DSM-IV are not planned until after the year 2005, it behooves pediatricians, pediatric neurologists and child psychiatrists alike to become more aware of this area of diagnostic confusion and controversy. The stakes are clearly quite high. NOTE: Due to space limitations, this article has been edited. For a copy of Dr. Papolos' article in full with a list of references on the studies mentioned in this article, please contact NARSAD at (516) 829-0091.
Current DSM-IV Criteria for COBPD
|
|
| ||||||||||||||||
Over the last decade, mood disorders in children and adolescents have received increased recognition. However, in contrast to the growing body of literature on non-bipolar depression, bipolar disorder (manic-depression) has been relatively neglected, and its diagnosis in childhood remains the subject of great controversy in the fields of clinical child psychiatry and psychology.
