An independent work group of 25 psychiatrists has issued the first new guidelines for the treatment of children with bipolar disorder in nearly a decade.
The consensus document arose out of a need for updated information first voiced by the Child and Adolescent Bipolar Foundation, a parent advocacy organization, said Robert Kowatch, M.D., professor of psychiatry and pediatrics at Cincinnati Children's Hospital/University of Cincinnati, who organized and chaired the project.
Bipolar management in children has changed considerably since the American Academy of Child and Adolescent Psychiatry published its 1997 Practice Parameters, but the subject remains “infused with considerable controversy, debate, and dyspepsia,” Jon McClellan, M.D., of the University of Washington, Seattle, said in his accompanying commentary (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:236-9).
Although the AACAP practice parameters are under revision, “we wanted something different in approach and a bit more independent,” Dr. Kowatch said. The goal was a “broad-based integration of what we know in the field: educational assessment and family therapy as well as medication.”
The guidelines are intended for “anyone who treats these kids, diagnostically and therapeutically”—psychologists and primary care physicians along with psychiatrists—and reflect the uncertainties surrounding the disorder, he said.
The guidelines lead clinicians through a comprehensive evaluation to differentiate manic symptoms like euphoria, grandiosity, and increase in goal-directed activity from manifestations of other disorders (notably attention-deficit hyperactivity disorder) and from normal behavior (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:213-35).
“There's a lot of controversy in the field about what these kids look like. We wanted to address some of that,” Dr. Kowatch said.
Confronting the difficulty of fitting kids into a diagnostic protocol that was designed for adults, the guidelines attempt “to make DSM-IV criteria developmentally appropriate,” he said.
The sections on treatment include two algorithms—acute manic or mixed episodes with and without psychosis—and shorter discussions of depression, comorbid disorders, and maintenance, using a standard system of evidence levels (randomized controlled trials in children to case reports) to characterize research support.
The biggest problem in “making the guidelines is that we just don't know much about treatment for these kids,” Dr. Kowatch said. “There aren't a lot of controlled data.” Besides lithium, which is approved for patients down to age 12 years, pharmacotherapy is off label, he noted.
Several large clinical trials, currently underway, should sharpen the picture, he suggested.
Robert L. Hendren, D.O., director of child and adolescent psychiatry at the University of California, Davis, said the work group “did a great job in advancing the field by defining what bipolar disorder is in children and adolescents, and what algorithms to consider in treating them,” Dr. Hendren said.
The result unavoidably reflects the limitations of the data. “This group thought carefully about what it is saying, but couldn't recommend whether to start with a mood stabilizer or an atypical antipsychotic; and if a mood stabilizer, they waffled between lithium and divalproex,” he said, “but that's the state of the art.”
He agreed with Dr. McClellan's commentary that the inclusion of brief, intense outbursts of mood and behavior dysregulation under the bipolar rubric implies a fundamental change in the definition of the illness. “There's a real controversy whether this represents bipolar I or II, or a developmental phase for some kids,” he said.