David Earl Johnson, LICSW

4 minute read

A major researcher from NIMH, Ellen Leibenluft, MD, Chief, Unit on Affective Disorders, Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, has made an unequivocal statement about bipolar disorder in children. Not surprisingly, she asserts bipolar disorder is “rare” in children. This article is a follow up to this one. Psychiatry Weekly

““Clearly,” Dr. Leibenluft says, “some children do meet the DSM-IV criteria for bipolar disorder. However, these children are relatively rare. Far more common, perhaps as many as 3% of children in the community, are those who are extremely irritable and have ADHD-like symptoms, but don’t meet the DSM-IV criteria for bipolar disorder. A diagnosis of bipolar disorder requires distinct manic episodes, during which time one’s mood is altered, sleep and activity patterns change, and there are differences in reward-seeking behavior. More commonly, children present instead with chronic and nearly constant irritability.” Sometimes, clinicians may diagnose these irritable children with bipolar disorder based on outbursts that occur during extreme frustration, but, Dr. Leibenluft points out, these outbursts are far too short in duration to meet the necessary criteria for a manic episode. “One of our first steps in studying this population of chronically irritable children was to define criteria so that we could reliably identify a reasonably homogeneous clinical group. We defined criteria to capture children who don’t have clear manic episodes but have very severely impairing and chronic irritability, as well as ADHD-like symptoms. We refer to them as severely mood dysregulated (SMD). Then we recruit controls and children who clearly meet the DSM-IV criteria for bipolar disorder and compare the three groups.” Dr. Leibenluft’s group’s research is still too new to have followed the SMD group into adulthood, but they have analyzed large, epidemiologic community-based data sets with a particular eye for individuals who, as children, were chronically irritable. “What we’ve found,” Dr. Leibenluft says, “is that these children are not, in general, at high risk for bipolar disorder as adults. Rather, they’re at significantly increased risk for depressions.” Leibenluft and colleagues have also taken extensive family histories for the patients they see in their clinic. “I have to presage this by pointing out that what we’re doing is most decidedly pilot work,” she cautions. “We’ve actively recruited these children, so they are probably not representative of the population as a whole, and the sample is still relatively small. That said, while studies indicate that children with bipolar disorder are a great deal more likely than controls to have parents with bipolar disorder, we’ve found that SMD children have familial rates of bipolar disorder similar to what one finds in the general population. This suggests that SMD and bipolar disorder may not be genetically equivalent.” [..]“Of course, this conclusion has treatment implications.” Dr. Leibenluft emphasizes that, prior to treatment, one must do a thorough evaluation of these patients, assessing symptoms and possible environmental stressors. It’s not uncommon for SMD children to have language or learning problems, social cognitive difficulties, and/or anxiety symptoms, all which can contribute to irritability, and some of which can be addressed through non-pharmacologic interventions. When commencing with pharmacologic treatment, one must move forward systematically and carefully. “Since SMD is not a DSM-IV diagnosis, there aren’t controlled treatment trials in these youth, though our lab is currently investigating the efficacy of lithium. We suggest a systematic, evidence-based approach: If they have ADHD, treat that. If they have anxiety disorders, treat that, possibly with an SRI or cognitive-behavioral treatment. One needs to be very mindful that these children may become agitated on a stimulant or SRI, and so they should be treated cautiously and monitored closely. But we do not say, out of hand, that, like bipolar children, youth with SMD should not be treated with stimulants or SRI’s without first receiving antipsychotic or mood stabilizing treatment. If an SMD patient does not respond to frontline treatment, then we may switch to, or add, an antipsychotic or mood stabilizer. We also suggest that families track their child’s symptoms daily so that it’s clear whether the target symptoms are responding, and if so to which medication. These children and their condition are complicated, and clinicians should adopt a careful, systematic approach to treatment.””

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