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Sherry Roberts

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Week 8 Main post

Should Bipolar Disorder Be Diagnosed in Children/Adolescents?

According to the Diagnostic and statistical manual of mental disorders (DSM)-5, a diagnosis of mania requires distinct episodes of “abnormally elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy”, on seven consecutive days for mania and 4 days for hypomania, and three (four if the mood is only irritable) so-called B symptoms, such as inflated self-esteem, decreased need for sleep, increased goal-directed or psychomotor activity, pressured speech, flight of ideas and increased distractibility. In addition, high-risk behavior, sexual disinhibition or psychotic symptoms may occur. To enhance the accuracy of diagnosis, an emphasis on the changes in activity and energy as well as mood was included in DSM-5. The diagnosis of bipolarity now requires, as entry criterion A, not only the presence of an elated and irritable mood, but also the association of these symptoms with increased energy/activity (for full criteria see DSM-5 (Grimmer, Hohmann, & Poustka, 2014, p. 111). It would be premature to tag children and adolescents with a bipolar diagnosis. Children with symptoms associated with Bipolar should be diagnosed DMDD. Disruptive mood dysregulation disorder (DMDD) is a condition in which a child is chronically irritable and experiences frequent, severe temper outbursts that seem out of proportion to the situation at hand. Children diagnosed with DMDD struggle to regulate their emotions in an age-appropriate way. In between outbursts they are irritable most of the time (“Child Mind Institute,” 2020). DMDD was introduced as a diagnosis to address what psychiatrists considered to be the overdiagnosis of pediatric bipolar disorder. While the key feature of DMDD is irritability, the hallmark of bipolar disorder is the presence of manic or hypomanic episodes. ADHD can present with mood dysregulation as well. This disorder may be misdiagnosed as bipolar disorder, especially in adolescents and children. Many symptoms overlap with the symptoms of mania, such as rapid speech, racing thoughts, distractibility, and less need for sleep. The “double counting” of symptoms toward both ADHD and bipolar disorder can be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode (Psychiatry online, 2020).

The bottom line is that Bipolar can be diagnosed in children but it has been overly diagnosed and misdiagnosed often when it is simply ADHD, DMDD and ODD. The factor that sets them apart would be mania. Evidently, there is a considerable symptomatic overlap of bipolar symptoms, such as distractibility, excessive talking and reduced social inhibition with other disorders, in particular ADHD.

 

References

Disruptive Mood Dysregulation Disorder Basics. (2020). Retrieved from https://childmind.org/guide/guide-to-disruptive-mood-dysregulation-disorder/

Grimmer, Y., Hohmann, S., & Poustka, L. (2014, December 1, 2014). Is bipolar always bipolar? Understanding the controversy on bipolar disorder in children. US National Library of Medicine, 6, 111. https://doi.org/ doi: 10.12703/P6-111

Psychiatry online. (2020). Bipolar. Retrieved from https://dsm-psychiatryonlineorg.ezp.waldenulibrary.org/doi/full/10.1176/appi.books.9780890425596.dsm16

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Support your position with evidence and examples for diagnosing pediatric bipolar disorder

 

Yes, Bipolar disorder in children is possible and should be diagnosed, and age should not play a role.

Bipolar disorder was not recognized in the pediatric population, but literature reviews on diagnosing children have been established in the past ten years (Hamrin, 2007). Identifying children with bipolar is challenging because of how the symptoms are expressed and their developmental differences compared to adults, comorbid disorders, and developing diagnostic criteria (Hamrin, 2007). Still, the diagnosis of Bipolar disorder in children under 18 years old in the US has increased by 4000% (Chang, 2009).

50% to 66% of this disorder starts in childhood, and at the moment, there are at least 1 to 2 million children in the US with bipolar or the beginning manifestations (Chang, 2009). According to Mohr (2001), 20% of adults with bipolar disorder reported symptoms before 19 years of age. Kogan (2004) also supports early onset when he reported on the first consecutive 1,000 adult bipolar disorder patients enrolled in the National Institute of Mental Health Systemic Treatment Enhancement Program for Bipolar Disorder Study and found that 27.7% of the adults in the study experienced prepubertal onset under age 13 years, and 37.6% had adolescent-onset between ages 13 and 18 years. Geller (2001) followed 72 children from prepubertal age to adulthood, and 48% of them developed bipolar disorder by the mean age of 20.7 years.

Pediatric bipolar is a complex mood disorder with different features occurring in about 17 to 30% of their population (Youngstrom, 2005). While adults have excessive spending, inflated self-esteem, and inappropriate attire, children usually present with behaviors like being argumentative, bossy, excessive giddiness, and attitudes of superiority like being smarter and stronger than others (Youngstrom, 2005). Children also have irritability, rage, and affective storms with prominent aggression, which is reactive and impulsive (Biederman, 1996). Youth with this disorder are out of control and destructive and demonstrates severe impairment in social and academic functioning (Geller,1998).

Due to its complexity, to diagnose, a clinical phenotype of juvenile mania to help clarify the diagnostic criteria was suggested by Leibenluft et al., (2003)  to include patients who meet the full DSM-5 symptoms and duration criteria for hypomania or mania plus symptoms of elevated mood or grandiosity. These symptoms must be present between 1 to 3 days. Irritable hypomania or mania without elevated mood, with patients who exhibit chronic, non-episodic illness with severe irritability and hyperarousal but without symptoms of mania(Leibenluft, Charney,  2003). Geller and colleagues have provided empirical data suggesting that all DSM-5 symptoms, but not standard episodes, criteria must be met to diagnose childhood bipolar(Luby, 2009). Other signs to look out for include increase talking, decreased sleep, overreacting emotionally, racing thoughts, being distracted, flights of ideas, pressured speech, poor judgment, unusual energy, increased goal-directed activity, and getting involved in more risky or pleasurable activity with painful consequence (American Psychiatric Association, 2000).

60%-90% of children with bipolar have ADHD. Three common overlapping symptoms in both diagnoses are excessive talking, increased activity, and being distracted, but bipolar symptoms are not present every day like ADHD (Biederman, 2004). Children with bipolar have more persistent mood instability with explosive outbursts and have elevated mood, grandiosity, and flight of ideas not seen in ADHD (Geller, 2002).  While depression is common in adults, it is overlooked in the pediatric population though it is expected (Chang, 2009). In a phenomenological study of 438 children with a bipolar spectrum disorder, 53% had a history of major depressive disorder, with 76% with past suicidal ideation and 31% making a prior suicide attempt (Chang, 2009). Studies show that ADHD heralds bipolar symptoms, so children with ADHD should be screened for symptoms of pediatric bipolar (Tilman, 2003). Most of the youth in bipolar studies have a history of trauma, so it will be beneficial to evaluate for comorbid PTSD as well (Tilman, 2003).

Reliable scales for diagnosing the pediatric population include The Young Mania Rating Scale, which though is designed for adults, showed validity in a study involving 612 children and adolescents with bipolar (Youngstrom, 2002). The Washington University Kiddie Schedule for Affective Disorders and Schizophrenia was used for 93 youths with bipolar and showed good validity and showed that children with mania in bipolar 1 are different from adults with longer episodes, mixed in nature more chronic (Hamrin, 2007). A sample of 642 youths ages 5- 17 years, showed that the Parent-Young Mania Rating Scale, the Parent General Behavior Inventory, and the Parent Version of Child Behavior Checklist is best for making a pediatric bipolar diagnosis (Hamrin, 2007).

The first line of treatment of the pediatric bipolar disorder is pharmacology. For mood stabilizers, divalproex sodium and lithium are useful in treating acute mania (Hamrin, 2007). Lithium is suitable for children with classic euphoric mania without psychosis or comorbid ADHD (Kowatch, 2005). Divalproex can be used as a monotherapy to stabilize children with bipolar for the short term. It is well tolerated with antipsychotics. Carbamazepine is used less due to the side effects of aplastic anemia and Steven-Johnsons’ disease, and it can also not be taken in combination with divalproex sodium because of the CYP450 drug interaction (Kowatch, 2005). Response rates for the use of quetiapine, risperidone, and olanzapine as monotherapy for acute short term management of bipolar in children is between 53% and 82% (Hamrin, 2007). However, studies show that atypical antipsychotics may be a good first-line treatment for children with bipolar disorder, especially youth with psychotic symptoms (Hamrin, 2007). It will be suitable for PMHNP’s to screen youth with mood problems for bipolar disorder as an ongoing everyday diagnostic assessment due to the ‘range of mood symptoms and the cyclical and episodic nature of this disorder’ (Hamrin, 2007).

 

Reference

Biederman, J., Farone, S., Wozniak, J., Mick, E., Kwon, A., & Aleardi, M. (2004). Further evidence of unique developmental phenotypic correlates of pediatric bipolar disorder: Findings from a large sample of clinically referred preadolescent children assessed over the last 7 years. Journal of Affective Disorders, 82, S45-58.

Chang, K. (2009). Challenges in the diagnosis and treatment of pediatric bipolar depression. Dialogues in clinical neuroscience, 11(1), 73–80.

Luby, J. L., Tandon, M., & Belden, A. (2009). Preschool bipolar disorder. Child and adolescent psychiatric clinics of North America, 18(2), 391–ix. https://doi.org/10.1016/j.chc.2008.11.007

…should age play a role in diagnosing pediatric bipolar disorder? (2011). Brown University Child & Adolescent Behavior Letter, 27(7), 2.

Geller, B., Craney, .J., Bolhofner, K., Nickelsburg, M., Williams, M., & Zimerman, B. (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar phenotype. American Journal of Psychiatry, 159, 927-933.

Geller, B., Williams, M., Zimerman, B., Frazier, .J., Beringer, L., & Warner, K. (1998). Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective Disorders, 51, 81-91.

Geller, B., Zimerman, B., William, M., Bolhofner, K., Craney, J., DelBello, M., et al. (2001). Reliablity of the Washington University in St. Louis Kiddie Schedule of Affective Disorders and Schizophrenia (Wash-U-KSADS) Mania and rapid cycling sections. Journal of the American Academy of Child and Adolescent Psychiatry, 40(4), 450-455.

Hamrin, V., & Pachler, M. (2007). Pediatric Bipolar Disorder: Evidence-Based Psychopharmacological Treatments. Journal of Child & Adolescent Psychiatric Nursing, 20(1), 40–58. https://doi-org.ezp.waldenulibrary.org/10.1111/j.1744-6171.2007.00083.x

Kogan, J., Otto, M., Bauer, M., Dennehy, E., Miklowitz, D., Zhang, H., et al. (2004). Demographic and diagnostic characteristics of the first 1000 patients enrolled in the systematic treatment enhancement program for bipolar disorder. (STEP-BD). Bipolar Disorders, 6(6), 460-469.

Kowatch, R., & Debello, M. (2005). Pharmacotherapy of children and adolescents with bipolar disorder. Psychiatric Clinics of North America, 28, 385-397.

Leibenluft, E., Charney, D., Towbin, K., Banqoo, R., & Pine, D. (2003). Defining clinical phenotypes of juvenile mania. American Journal of Psychiatry, 160(3), 430-437.

Mohr, W. (2001). Bipolar disorder in children. Journal of Psychosocial Nursing, 39(3), 12-23.

Youngstrom, E., & Duax, J. (2005). Evidence-based assessment of pédiatrie bipolar disorder, Part I: Base rate and family history. Journal of the American Academy of Child and Adolescent Psychiatry, 44(7), 712-717.

 

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