Whereas experts once believed that stimulants would “tip” most children with undiagnosed bipolar disorder into manic episodes, the consensus now is that this is a rare occurrence and fairly easily managed, he said. “Just stop the stimulants.”
An alternative therapy for ADHD symptoms might be atomoxetine (Strattera), a hydrochloride salt, which Dr. Chang considers if stimulants aggravate hyperactive behavior.
If a traditional therapy for ADHD reduces symptoms, both specialists said they feel comfortable in closely monitoring a child through adolescence, when more typical symptoms of bipolar disorder may emerge.
In looking at studies of patients under the age of 10, Dr. Carlson today sees few data to support the use of “powerful, fat-making antipsychotics” for the rest of the child's life (assuming the child proves to have bipolar disorder). She believes there is support in the literature for the short-term use of atypical antipsychotics for management of aggression associated with many diagnoses, however.
Of note, an international review of five longitudinal studies of the children of parents with bipolar disorder found little evidence of classically defined mania in prepubertal children (J. Can. Acad. Child Adoles. Psychiatry 2009;18:200–5).
In the study by Dr. Anne Duffy of Dalhousie University in Halifax, Nova Scotia, children who went on to develop mood disorders seemed to follow a fairly predictable course leading to a first activated episode in adolescence or early adulthood–nonspecific anxiety and sleep problems in childhood, then mood swings in adolescence, with depressive episodes predating mania by several years.
Dr. Chang said while prepubertal mania has been described, it is likely less common than postpubertal mania, “and harder to diagnose given the natural neurodevelopmental propensity of young children to rapidly cycle with their moods.”
Many experts have called for an evaluation of what symptoms constitute a diagnosis of bipolar disorder in children, rather than trying to shade adult-oriented symptoms to fit children. A precise definition would tailor subjects enrolled in clinical trials so that findings would be meaningful and applicable to the children seen in clinical practice, hopefully pointing the way to an evidence-based approach to pharmacotherapy.
In the meantime, treatment guidelines developed by an expert consensus panel that included Dr. Carlson and Dr. Chang offer diagnostic support and provide algorithms for treatment of bipolar I disorder with or without psychosis in children and adolescents (J. Amer. Acad. Child Adolesc. Psychiatry 2005;44:213–35).
A practice parameter with 11 specific recommendations also offers comprehensive guidance to clinicians (J. Am. Acad. Child Adolesc. Psychiatry 2007; 46:107–25).
Dr. Carlson and Dr. Chang describe personal prescribing patterns that conform to these guidelines, most often selecting lithium or another mood stabilizer or an atypical antipsychotic as first line monotherapy, but sometimes recommending combination therapy.
Lithium, valproate, aripiprazole, and quetiapine all figure prominently in his initial treatment strategies, with quetiapine edging out the others if sleep regulation is a particular problem.
A child presenting with rather classic euphoric mania might make Dr. Chang prescribe lithium first, whereas a more chronic picture of predominantly irritable mania or a mixed state would make him lean toward an atypical antipsychotic.
Depression remains a challenge in youthful populations as well as in adults, and Dr. Chang is generally reluctant to prescribe selective serotonin reuptake inhibitors if there is a reasonable suspicion that the child has bipolar disorder.
“We stay away from them if at all possible,” concerned that they may precipitate a manic episode.
He might consider lamotrigine for a child who is already overweight, dosing it very cautiously at first, especially in smaller children, and being cognizant of the risk of a severe rash. He also now considers adding metformin to the regimen of any child or adolescent who gains considerable weight on the atypicals.
Dr. Carlson cited the same sorts of considerations. Atypical antipsychotics, for example, might be her treatment of choice for a child whose most concerning symptoms are aggression and emotional lability, because these drugs tend to ameliorate these symptoms regardless of whether the ultimate diagnosis is bipolar disorder.
Most children with bipolar disorder end up requiring combination therapy for their symptoms, plus occasional agents to manage side effects.
As the regimens grow more complex, the already limited evidence base shrinks to nearly nil, Dr. Chang said. Side effect patterns in children are also poorly understood. “Cognitive side effects have not really been studied at all. We don't have much evidence to guide us, and compared with adults, the cognitive piece is really important,” he said.
When the adult literature suggests a problematic cognitive picture, as in the case of topiramate, Dr. Chang tends to avoid prescribing that drug.