We asked Joseph Biederman, MD., Associate Professor of Psychiatry at Harvard Medical School and Chief, Joint Program in Pediatric Psychopharmacology at Massachusetts General Hospital, Boston.
Studies suggest that only one in 200 cases of bipolar (manic-depressive) disorder begins in childhood. If this figure is correct, fewer than one in 20,000 children suffers from the disorder. But that may be an underestimate, since children do not have exactly the same symptoms as adults. Children with mania are seldom elated or euphoric; more often they are irritable and subject to outbursts of destructive rage. Furthermore, childhood bipolar symptoms are often chronic and continuous rather than acute and episodic, as in adults. Bipolar disorder may account for a large proportion of children's psychiatric hospitalizations. Irritability and aggressiveness complicate the diagnosis, since they can also be symptoms of depression or conduct disorder, or even normal responses to stress. But the irritability of bipolar children is especially severe and often leads to violence. Although the aggressiveness may suggest a conduct disorder, it is usually less organized and purposeful than the aggression of predatory juvenile delinquents. The early symptoms of childhood bipolar disorder also include distractibility, impulsiveness, and hyperactivity, the signs of attention deficit hyperactivity disorder (ADHD). Some children with bipolar disorder (or a combination of the two disorders) may be wrongly diagnosed as having only ADHD. Furthermore, the two disorders appear to be genetically linked. Children of bipolar patients have a higher than average rate of ADHD. Relatives of children with ADHD have twice the average rate of bipolar disorder, and when they have a high rate of bipolar disorder (especially the childhood onset type), the child is at high risk for developing bipolar disorder. ADHD is also unusually common in adult patients with bipolar disorder. Both bipolar disorder with ADHD and childhood onset bipolar disorder begin early in life and occur mainly in families with a high genetic propensity for both disorders. Adult bipolar disorder is equally common in both sexes, but most children with bipolar disorder, like most children with ADHD, are boys, and so are most of their bipolar relatives. Adult bipolar patients whose disorder began in childhood often respond poorly to the standard lithium treatment. Like bipolar children, they often have chronic rather than episodic symptoms and become enraged and irritable during their manic episodes. Unstable moods, which are generally the most serious problem, should be treated first. Not much can be done about ADHD while the child is subject to extreme mood swings. Useful mood stabilizers include lithium, valproic acid, and carbamezapine; sometimes several drugs will be needed in combination. After mood stabilizers take effect, the child can be treated for ADHD at the same time with stimulants, clonidine, or antidepressants. The potentially life-threatening depressive states of bipolar children can be managed with antidepressants. The selective serotonin reuptake inhibitor fluoxetine (Prozac) has recently been found effective in a controlled study. Tricyclic antidepressants (TCAs) have not been shown to be effective in double-blind controlled studies, and one TCA, desipramine, has been associated with rare cases of sudden death in young children. Nevertheless, clinical experience suggests that TCAs sometimes save lives. Since these drugs can exacerbate mania, they should always be introduced after mood stabilizers, and an initial low dose should be raised gradually to therapeutic levels. If necessary, high-potency benzodiazepines can be added for anxiety and antipsychotic drugs for psychotic symptoms.
© President and Fellows of Harvard College, 1997. Reprinted with permission.
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