Research report
The diagnosis of preschool bipolar disorder presenting with mania: open pharmacological treatment

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Abstract

Background

Diagnosis of bipolar disorder (BPD) in preschool children is controversial, although preliminary data suggest that children with BPD may present with classic manic symptoms in a more chronic, rapid cycling presentation. While children with BPD are extremely dysfunctional, presenting symptoms and symptom expression remains to be further defined. Clarification of the presentation of BPD in children could result in better treatment.

Methods

Thirty-one patients, ages 2–5 years, were identified by chart review of all children treated at our pediatric bipolar clinic. All available historical, symptom, and treatment information was collected and summarized.

Results

Patients were ∼2:1 male: female, predominantly Caucasian, with an average age of symptom onset of 3 years. Most frequent presenting symptoms (100%) included irritability, increased energy, and aggression. Prominent symptoms (>80%) included euphoria, grandiosity, decreased need for sleep, pressured speech, and distractibility. Eighty percent of patients had concurrent Attention-Deficit Hyperactivity Disorder (ADHD). Twenty-one of the 31 patients reported prior treatment attempts with either a stimulant or antidepressant without the protective benefit of a mood stabilizer, and of these, 13 (62%) reported a worsening of mood symptoms during that treatment period. Twenty-six of 31 were initially treated in our clinic openly with a mood stabilizer, primarily valproic acid, with a significant decrease in manic symptoms (p=0.03) following initial treatment. Long-term treatment demonstrated continued improvements from baseline (p=0.01).

Limitations

The retrospective design of this study limits the conclusions that can be drawn. Due to the lack of a formal protocol, treatment was open and based on clinical judgment on an individual case basis.

Conclusions

The symptom expression in these patients allowed for diagnosis according to DSM-IV criteria. Treatment with mood stabilizers was clinically effective, with corresponding significant developmental benefits.

Introduction

Clinical symptoms of bipolar disorder (BPD) have been well described (APA, 1994), but information concerning preschool-aged children with mania is sparse. While early studies suggest that use of DSM-IV criteria for mania is appropriate, the course and presentation of the illness in younger children is poorly documented (Sanchez et al., 1999). One recent study suggests that preschool children with family histories of depression or bipolar disorder, correlate with increased risk in developing manic symptoms, and they recommend long-term follow-up of preschool samples (Luby and Mrakotsky, 2003). Wilens et al. (in press) found that preschool patients with bipolar disorder exhibited similar degrees of impairment and comorbid conditions when compared to 7 to 9 year olds with bipolar disorder.

Studies describing manic symptoms in children report rapid cycling, little to no interepisode recovery, and a high rate of disruptive or aggressive behavior (Findling et al., 2001, Geller and Luby, 1997). A summary of the most recent work in the area of Pediatric Bipolar Disorder admits continued debate over the validity of the diagnosis but a growing consensus of a complex comorbid pattern of presentation with primary symptoms including chronic irritability, mixed mania, and rapid cycling (Biederman, 2003). A nonepisodic, more chronic presentation is also reported in Mota-Castillo et al. (2001) in a case series (N=9) describing mania and its treatment in preschool children. They reported frequent hostile and aggressive behaviors and concurrent ADHD symptoms, as well as more classic symptoms of BPD including inflated self-confidence, excessive energy, pressured speech, and hypersexuality. They also indicated that treatment with divalproex was preliminarily encouraging. These children often presented with a worsening of their symptoms when treated with stimulant medications for ADHD and family histories of BPD. While some studies suggest that both long- and short-term treatments with stimulant medications does not negatively impact manic symptoms (Galanter et al., 2003, Carlson et al., 2000), other studies indicate that early treatment with stimulant medications can result in earlier onset of manic symptoms or a more severe course of the illness (DelBello et al., 2001, Soutullo et al., 2002).

Diagnostic confusion may arise for several reasons including developmental issues and symptom overlap between concurrent BPD and ADHD (Giedd, 2000), conduct disorder (Biederman et al., 1999a, Biederman et al., 1999b, Geller and Luby, 1997), or other psychiatric disorders (Wozniak et al., 1995). The cognitive ability of each patient affects the ability to communicate the more subjective symptoms of the disorder, such as racing thoughts, lack of insight, flight of ideas, and delusional thinking. Developmental abilities can also affect the ability to engage in more demonstrative symptoms including rapid speech, grandiosity, and goal-directed or risky behaviors. Mania can negatively impact the child's normal course of social and emotional development. The appropriate and timely diagnosis is important in selecting effective treatment, which in turn should allow for more normal social and emotional development.

Treatment options for BPD in children are often based on findings in adults. Limited research in children has indicated that various agents may prove effective, including risperidone (Frazier et al., 1999), carbamazepine (Woolston, 1999), lithium (Owen et al., 1997, Geller et al., 1998), valproic acid, etc.(Strakowski et al., 2001). Clinical use of mood stabilizers has recently increased, although controlled research in very young children is extremely limited.

We identify both objective and subjective symptom presentations in 31 preschool-aged children with BPD and our treatment strategies. The bipolar presentation is discussed in terms of symptom frequencies and quantified levels of dysfunction. Treatment approaches are summarized, along with preliminary data on treatment outcome.

Section snippets

Methods

A retrospective chart review was performed of all patients, 5 years or younger, seen at a university clinic specializing in the treatment of bipolar and psychotic disorders. All patients with adequate documentation of manic symptoms warranting a diagnosis of Bipolar I or II Disorder were identified and included in this report. While no structured clinical interviews were available for most of these patients, a thorough clinical interview was conducted for each patient by a research trained

Results

Table 1 summarizes the clinical and demographic information on the 31 patients identified as meeting diagnostic criteria for Bipolar I Disorder. The ratio of boys to girls was ∼2:1. Patients were predominantly Caucasian (87%). Average age of symptom onset for mania was 3 years. All children demonstrated prolonged, chronic manic symptoms. Sixty-eight percent had a first or second-degree relative with BPD according to family report. Seventy percent of these children came from families which

Discussion

Demographic and psychosocial data from these patients were similar to other reports which also found a frequent family history of BPD and greater emotional dysfunction and stress in the families (Mota-Castillo et al., 2001). Approximately one-third of the patients had a relative with BPD, and an additional nine patients reported emotional difficulties within the family not specifically identified as BPD. Twenty-two of the 31 families also reported a history of psychosocial stress.

The most

Conclusions

One question that may require further investigation is what intensity and frequency of symptoms serve to determine whether these signs are pathological. Many signs and symptoms reported as hallmarks for the recognition of BPD might be present at times in other children without BPD. Formalized thresholds for these symptoms would further assist diagnosis. The DSM-IV requires that symptoms must “cause clinically significant distress or impairment” in a variety of areas of functioning in order to

Case histories

Case 1 illustrates classic euphoric mania. A 4-year-old white female presented with a 2-year history of mood problems including rages, euphoria, grandiosity, and irritability. She was described as an extremely engaging child, overly talkative, happy, with excessive distractibility, and hyperactivity. Her mother dressed her in flamboyant hair ribbons and bright dresses at the patient's demand.

The patient was adopted at birth. Her biological mother had a history of impulsivity, depression, and

References (25)

  • Diagnostic and Statistical Manual

    American Psychiatric Association Diagnostic and Statistical Manual IV

    (1994)
  • J. Biederman et al.

    Systematic chart review of the pharmacologic treatment of comorbid attention deficit hyperactivity disorder in youth with bipolar disorder

    J. Child Adolesc. Psychopharmacol.

    (1999)
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