1. dr salman kareem
Junior resident

2.  Controversial topic
 No clear cut definition
 Various different studies

3.  Debate continues about itspresentation,
course and co-morbidity patterns.

4. Signs and symptoms
 The most common presentations among
adolescents and youth with bipolar disorder
in community settings were outbursts of
 mood lability,
 irritability and
 aggression

5.  BD in children and adolescents has many
symptoms which overlap with other disorders
like attention deficit hyperactivity disorder and
disruptive behavior disorder.

6. Recovery and relapse rates
 Recovery in BD is defined as eight
consecutive weeks without meeting any of
the DSM-IV criteria for mania, hypomania,
depression, or mixed affective state.
 With these criteria, studies of childrenand
adolescents with BD have reported that 50-
100% will recover in a period of 1–2 years

7.  longitudinalstudies of a cohort initially
ascertained before puberty have found that
children with BD tend to show lengthy
episodes with frequent mixed states, and
high rates of relapse following remission or
recovery.

8. Issues of mixed episodes and
rapid cycling course

9. DSM V
 A proposed new diagnostic category, temper
dysregulation with dysphoria (TDD), within
the Mood Disorders section of the manual.
The new criteria are based on a decade of
research onsevere mood dysregulation, and
may help clinicians better differentiate
children with these symptoms from those
with bipolar disorder or oppositional defiant
disorder

10. Diagnostic Issues relevent to
children

11. Comorbidity: Disruptive
Disorders
 ADHD
 Bipolar disorder is difficult to distinguish between ADHD
 The three major symptoms that they both share are:
 Impulsiveness
 Distractibility
 Hyperactivity
 Up to 30% of children diagnosed with ADHD are given a diagnosis of bipolar disorder
 Up to 50% of children with bipolar disorder fit the criteria for the diagnosis of ADHD
 Children with a bipolar parent have a higher than average rate of ADHD
 Symptoms of bipolar in children are often mistaken for ADHD and the symptoms of bipolar
are different in adults.
 1/3 of children diagnosed with ADHD actually suffer from normal symptoms of bipolar
disorder
 Oppositional Defiant Disorder
 Conduct Disorders
 Mood Disorders
 Possible symptoms of pediatric bipolar disorder overlap with other mood disorders. Some of
these include: rapid mood changes, inappropriate moods, and bursts of rage

12. Longitudinal Study
 The National Institute of Mental Health funded Course and Outcome of
Bipolar Illness in Youth (COBY) followed 263 children ages 7 to 17 for 2
years. They found that 70% recovered from their first episode of mania
or depression. However, they relapsed an average of three times. These
children only had symptoms 60% of the time but only were diagnosed
with bipolar disorder 20% of the time. Many with no bipolar symptoms
had other problems such as ADHD. Children originally diagnosed with
bipolar disorder eventually developed typical adult bipolar symptoms.
 The COBY study has also shown that children and adolescents with
bipolar disorder (171, mean age of 13.2 years) continue to suffer from the
same disorder 2 years later, with 68% recovering from their initial
episode but 58% experiencing a recurrence. This shows stability of
bipolar disorder through adolescence and, among some, into early
adulthood.
 86 patients with pre pubertal onset bipolar disorder for four years with a
mean age of 10.8 years, 72% of them relapsed.

13. TREATMENT

14. MOOD STABILIZERS
FDA Approval Dose Monitoring
Lithium 12 y/o and older
15-20 mg/kg/day
Divided doses
Increase every 4-5
days
Level 0.6-1.4 MEq/L
√TFTs; Renal function
Q3 months
Depakote Adults
10-15 mg/kg/day
Divided doses
Total dose should not
exceed 60 mg/kgs
Level 15-125 ug/ml
LFTs, CBC w/ diff and
Plts Q6 months
Findling, 2008 & AACAP 2010

15. LITHIUM: ADVERSE EVENTS
Mild to Moderate
Side Effects
Rare Side Effects
Long Term
Concerns
Drug Interactions
Nausea
Diarrhea
Abdominal Distress
Sedation
Increased thirst
Tremors
Weight gain
Increased urination
Acne
Convulsions
Stupor
Seizures
Coma
Hypothyroidism
Polyuria
Polydipsia
Based on renal
clearance
AACAP, 2010
Findling, 2008

16. DEPAKOTE: ADVERSE EVENTS
Mild to Moderate Side
Effects
Rare Side Effects Drug Interactions
Nausea
Sedation
Weight gain
Headache
Tremor
Hepatic failure
Pancreatitis
Leukopenia
Thrombocytopenia
Polycystic ovarian syndrome
Increased valproate including
erythromycin, fluoxetine,
aspirin, ibuprofen
AACAP, 2010
Findling, 2008

17. ATYPICAL ANTIPSYCHOTICS
Drug FDA Approval Dose (mg/d)
Risperdone 10-17 0.5-2.5
Ariprazole 10-17 15-30
Olanzapine 13-17 2.5-20
Quetiapine 10-17 400-600
Ziprasidone 17 and older 120-160
AACAP, 2010 & Findling et al., 2008 & Kowatch et al., 2005

18. ATYPICAL ANTIPSYCHOTICS:
ADVERSE EVENTS
Mild to Moderate
Side Effects
Rare but Serious
Side Effects
Long-term
Concerns
Metabolic
Syndrome
Akathisia
Dizziness or fainting
due to orthostasis
Increased appetite
Weight gain
Tiredness
Nausea
Night tremors
Decreased sexual
interest
Heartburn
Tremor and muscle
stiffness
Prolongation of the
QTc interval
Increased risk for
seizures
Neuroleptic malignant
syndrome (NMS)
Tardive dyskinesia
(TD)
Weight gain
Changes in blood fats
and blood sugar
Increase in prolactin
Risk factors that
increase the likelihood
of a person
developing
cardiovascular disease
and/or diabetes,
including:
Weight gain
High blood sugar
High blood fat
AACAP, 2010

19. Treatment for Bipolar
Depression
 Psychotherapy (First line)
 Cognitive Behavioral Therapy (CBT)
 Interpersonal Psychotherapy (IPT)
 Family Focused Therapy
 Lithium
 SSRIs (as adjunctive treatment to mood stabalizer)
 Bupropion (as adjunctive treatment to mood
stabilizer)
 Lamotrigine
 Divalproex
 ECT
Kowatch et al., 2005

20. ANTIDEPRESSANT INDUCED MANIA
Antidepressants may induce mania in children with a
bipolar diathesis
In a survey of child and adolescent psychiatrists: 10/228 (4.4%) of
children under 13 y.o. treated by psychiatrists switched to BD
(Reichart & Nolen, 2004)
Treatment for Adolescent Depression Study (TADS), of 439 12-17
year olds: 0 switches to BD after 12-week follow-up (2004)
large private insurance database, 5.4% switch rates, increased
risk for youth on antidepressants and risk greatest for age group
of 10-14 y.o. (San Martin et al., 2004)

21. Frequency of Child Bipolar Disorder
 Prevalence is largely unknown as there are no well
accepted criteria for the diagnosis of Child Bipolar
disorder.
 This is because DSM IV criteria are generally viewed as
inadequate for use with younger children.
 The best guess is that the disorder occurs at least as
often as adult bipolar disorder (e.g., about 1%)
 However, many believe that this disorder is
significantly under diagnosed in children.

22. Frequency of Child Bipolar Disorder
 It is suspected that a significant number of children
diagnosed with ADHD at an early age actually have
early-onset bipolar disorder instead of (or along with)
ADHD.
 According to the American Academy of Child and
Adolescent Psychiatry, up to one-third of children
and adolescents with depressive disorders may
actually have early onset of bipolar disorder.
 20 to 40 % of adults with Bipolar Disorder report a
childhood onset of symptoms.

23. Child/Adolescent Bipolar Disorder:
Clinical Presentation
 As with adults, Bipolar disorder in children is
viewed a serious mental disorder
 Characterized by recurrent episodes of depression,
mania, and/or mixed symptom states.
 Some evidence suggests that child bipolar disorder
may be a different and possibly more severe form of
the illness than older adolescent and adult-onset
bipolar disorder.

24. Child/Adolescent Bipolar
Disorder:
Clinical Presentation
 While older adolescents often have a clinical
presentation that is somewhat similar to that seen
with adults.
 The clinical presentation of early-onset bipolar
disorder in children can look quite different than
that seen in older individuals.
 Clinicians may fail to diagnose this disorder when
using DSM IV criteria for the diagnosis of this
condition.

25. Child/Adolescent Bipolar
Disorder:
Clinical Presentation
 Most cases of child bipolar disorder do not
present with the sudden or acute onset often
found with adults.
 Most do not show the improvement between
episodes, often found with adult bipolar
disorder.
 With children the symptom onset may be more
insidious.

26. Child/Adolescent Bipolar
Disorder:
Clinical  With children, Presentation
 initial symptoms of the disorder can be depressive in
nature
 With these being confused with and treated as MDD.
 In other cases, ADHD like symptoms appear first
 with these symptoms being followed later by a full manic episode.
 Unlike adults - children in a manic state are more
likely to be irritable and prone to destructive
outbursts than to be elated or euphoric.

27. Child/Adolescent Bipolar
Disorder:
Clinical Presentation
 Children, more often show
 rapid cycling and mixed states rather than clear manic or
clear depressive episodes, and
 an “ongoing and continuous mood disturbance that is a
mix of mania (or hypomania) and depression”.
 The rapid and severe cycling between moods
produces chronic irritability and few clear periods
of wellness between episodes.

28. Child/Adolescent Bipolar Disorder:
Clinical Presentation
 Depression and dysphoria are an almost constant part of
pediatric bipolar disorder.
 As noted earlier, hyperactivity is often the first
manifestation of early-onset bipolar disorder.
 When children are initially seen because of bipolar
symptoms,
 approximately 90% of early-onset, and
 30 % of adolescents with bipolar disorder meet criteria for a
diagnosis of ADHD.
 Comorbid conduct disorder is also quite common.

29. Bipolar Disorder vs. ADHD
Bipolar Disorder (Mania)
1. More talkative than usual,
or pressure to keep
talking
2. Distractibility
3. Increase in goal directed
activity or psychomotor
agitation
ADHD
1. Often talks excessively
2. Is often easily distracted
by extraneous stimuli
3. Is often “on the go” or
often acts as if “driven by
a motor”
Differentiation: Elated mood, Grandiosity, Decreased
need for sleep, Hypersexuality, and Irritable mood.
Hart (2005)

30. Child Bipolar Disorder:
Comorbidity
 Attention Deficit Hyperactivity Disorder (ADHD)
 Between 60 - 80% display symptoms
 Oppositional Defiant Disorder (ODD) & Conduct
Disorder (CD)
 70 - 75%
 Substance Abuse (adolescents)
 40 - 50%
 Anxiety Disorders
 35- 40%

31. Child Bipolar Disorder: Genetics
 Bipolar Disorder has a heavy genetic loading
 In the general population, a conservative
estimate of an individual's risk of bipolar
disorder is about 1.2 %.
 More than two-thirds of those with bipolar
disorder have at least one close relative with the
disorder or with unipolar major depression

32. Child Bipolar Disorder: Genetics
 When one parent has bipolar disorder, the risk to
each child is about 15 – 30 %
 When both parents have bipolar disorder, the risk
increases to 50 – 75 %
 The risk to siblings and fraternal twins is 15 – 27 %
 The risk in identical twins is approximately 70 %
 Note. Despite these figures only about 5% of
children with a parent with Bipolar disorder would
be expected to develop the disorder in childhood.

33. Etiology :What is Inherited?
 A significant question is What is Inherited??
 The answer is not entirely clear, but …
 It's believed this condition is caused by an imbalance in
neurotransmitters.
 a low or high level of a specific neurotransmitter such as
serotonin, norepinephrine or dopamine is the likely
cause.
 Others have suggested that it is an imbalance of these
substances that may be the problem
 Here, a specific level of a neurotransmitter may not as
important as its amount in relation to the other
neurotransmitters.
 Still other studies have found evidence that a change in
the sensitivity of the receptors may be the issue.
 It seems likely that the neurotransmitter system is at
least part of the cause of bipolar disorder, but further
research is still needed to define its exact role.

34. Etiology of Bipolar Disorder
Environmental Factors
 That more than hereditary is involved in Bipolar
Disorder is indicated by the fact that in studies
involving identical twins, raised in the same home,
one twin sometimes develops bipolar disorder while
one does not .
 Here it is suggested that environmental factors may
play a role in bipolar disorder.
 For some, stresses such as a death in the family,
divorce, or other traumatic events seem to trigger a
first episode of mania or depression.

35. Etiology of Bipolar Disorder
Environmental Factors
 Puberty may trigger the disorder in adolescent females.
 Stressful life events can lead to the onset
 Once the disorder is triggered and progresses, it seems to develop
a life of its own.
 Once the cycle begins, a psychological or pathophysiological
process takes over and ensures that the disorder will continue.
 The best explanation for this disorder seems to be
reflected in the "Diathesis-Stress Model."
 Genetics PLUS environmental percipients.

36. Treatment of Child Bipolar
Disorder
 Treatment of children and adults with bipolar
disorder is generally similar to adults with this
disorder.
 Less is known about the effectiveness & safety of the
medications used.
 Lithium appears to frequently have a strong
prophylactic effect against mania, and is sometimes
used with children.
 However, in very early onset bipolar disorder, with a
heavy family loading, children may not respond as well
to lithium as do adults.

37. Treatment of Child Bipolar
Disorder
 As with adults, anti-convulsants are often used to
control rapid cycling and aggressive behavior.
 Depakote – an anti-convulsant – used to control rapid
cycling.
 Tergetol – an anti-convulsant – has anti-manic and anti-aggressive
qualities.
 Other anti-convulsants (Neurontin, Lamictal, Topamax)
Sometimes these are used in combination with
Lithium.

38. Treatment of Child Bipolar
Disorder
 As with adults, certain antipsychotic drugs may also
be used to control symptoms.
Included here are atypical antipsychotic medications
such as Clozaril®, Zyprexa®, Risperdal®, and
Seroquel®.
 Such drugs have been shown to sometimes function
as mood stabilizers in cases were drugs like lithium
and anticonvulsants may not work
 They are used to deal with acute mania, and/or to
treat psychotic depression.

39. Issues in the Pharmacological
Treatment of Child Bipolar
Disorder
 Bipolar youth often require multiple medications for
mood stabilization, treatment of attention problems,
depression, and sometimes psychotic symptoms.
 There can, however, be risks with drug treatments
 Problems can arise in cases of misdiagnosis.
 Sometimes children with undiagnosed bipolar
disorder are mistakenly treated for MDD with
antidepressants.

40. Issues in the Pharmacological
Treatment of Child Bipolar
Disorder
 Treating such children with antidepressants (in the
absence of a mood stabilizer) can actually
precipitate or exacerbate manic symptoms.
 In children with ADHD symptoms, treatment with
stimulant drugs (in the absence of a mood
stabilizer) can result in manic symptoms and/or
worsen symptoms.

41. Issues in Pharmacological
Treatment of Child Bipolar
Disorder
 It is difficult to determine which children will
become manic or experience a worsening of
symptoms
 There is a greater likelihood among children with a
strong family history of bipolar disorder.
 It has been suggested that
 if manic symptoms develop or markedly worsen during
antidepressant or stimulant use, the diagnosis and
treatment for bipolar disorder should be considered.
 Proper diagnosis of Child Bipolar Disorder is
necessary to avoid these problems.

42. Additional Treatment
Approaches
 As with adults, treatments in addition to medication are
often necessary to assist children with bipolar disorder
and their families.
 These interventions may involve
 Educating the family about the nature of childhood
bipolar disorder and involving the family in treatment.
 Insuring that children receive the special educational
services necessary to prevent them from falling behind
academically
 Appropriate classroom accommodations to help them
function effectively in the academic environment.
 Family and individual approaches to therapy should be
provided as necessary.

43. Psychotherapy for BPD
 Psychoeducation-based approaches
 Multi-Family Psychotherapy Group and
Individual Family Therapy (Fristad 2002, 2005)
 Family-Focused Treatment (Miklowitz, 2004)
 Links to fewer relapses, longer delay to relapse
 Child and Family Focused CBT
 Manualized PT, CBT+FFT
 Dialectic Behavior Therapy
 Supportive Therapy
 Interpersonal and social-rhythm therapy (IPSRT)
AACAP, 2010

44. “If uncertainties make you anxious, don’t think about being a child psychiatrist”
Dr. Elizabeth McCullough