Bipolar disorder in children and adolescents: A guide to diagnosis and treatment

The assessment and treatment of juvenile bipolar disorder presents a number of unique challenges and risks. Despite some advances, there is still much to learn about this illness and appropriate interventions. The diagnosis of bipolar disorder in children and adolescents is established using the same DSM-IV criteria as are used in adults. In children, the differential diagnosis between bipolar disorder and attention deficit hyperactivity disorder requires special care. Somatic treatments have been less well studied in children and adolescents than in adults, especially for relatively rare conditions such as bipolar disorder, which is uncommon before the age of 10 years. This is unfortunate because it may be inappropriate to translate standard practice for adults to use in children. Medications may have different pharmacokinetics in peripubertal compared with adult patients and may show different interactions according to stages of endocrine development. Lithium, for example, has a shorter half-life in children than in adults, and maintenance treatment with the drug in adolescents appears to be associated with high relapse rates, perhaps because of differences in drug kinetics. Since illnesses with earlier onset tend to be more severe, and more treatment resistant, it is especially important to rigorously evaluate treatments in juvenile onset conditions. The anticonvulsants that are useful in adults have not been evaluated in controlled trials in children. It appears that adolescent patients with bipolar disorder are more likely to require adjunctive antipsychotics than adults. Since typical antipsychotics are associated with the risk of tardive dyskinesia during long term use and juvenile patients will be exposed to medication over a long period, it is important to evaluate atypical antipsychotics in these patients. Juvenile forms of functional psychoses appear to show higher genetic loads, and parents and families should be evaluated for their contributions to the patient's treatment context. Juvenile patients with bipolar disorder are at significant risk of self-injurious behaviours and require careful supervision. Medication regimens must be supervised closely.