Bipolar
Bipolar
Bipolar
ABSTRACT
This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar
disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles.
The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the
classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a
diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often
associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is
not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness.
The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials
are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment.
Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral
and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the
impact of the illness on family and community functioning. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(1):107Y125.
Key Words: bipolar disorder, mood stabilizers, practice parameter, practice guideline.
Ulrich Schoettle, M.D., members of the Work Group on Quality Issues; Marilyn
Benoit, M.D., Eugene Beresin, M.D., and Ellen Sholevar, M.D., Council
Representatives; Guy Palmes, M.D., Sherry Barron-Seabrook, M.D., and Syed
Naqvi, M.D., Assembly of Regional Organizations Representatives; David
Axelson, M.D., and Gabrielle Carlson, M.D., independent expert reviewers, and
Kristin Kroeger Ptakowski, Director of Government Affairs and Clinical Practice.
Members of the consensus group were asked to identify any conflicts of interest they
may have with respect to their role in reviewing and finalizing the content of this
practice parameter.
This practice parameter was approved by AACAP Council on June 17, 2006.
This practice parameter is available on the Internet (www.aacap.org).
Reprint requests to the AACAP Communications Department, 3615
Wisconsin Avenue, NW, Washington, DC 20016.
0890-8567/07/4601-01072006 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/01.chi.0000242240.69678.c4
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The following definitions are derived from DSM-IVTR unless otherwise specified:
Bipolar I disorder: Bipolar I disorder requires the
occurrence of a manic (or mixed) episode with duration
of at least 7 days, unless hospitalization is required.
Episodes of depression are not required, but most
patients experience major or minor episodes of
depression during their life span. In comparison, the
ICD-10 (World Health Organization, 1992), the
diagnostic system used by much of the world, describes
bipolar I disorder as an episodic illness with bouts of
mania and depression and requires that manic episodes
last 1 week or more. Both DSM-IV-TR and ICD-10
stipulate that the episodes represent a significant
departure from the individual`s baseline function and
note that the typical age at onset is young adulthood.
Thus, these definitions are consistent with the classic
conceptualization of the disorder. The definition of
mania is a critical issue in the pediatric literature. Many
of the published studies used DSM-III-R criteria, which
did not specify duration criteria for mania. Therefore,
brief outbursts of manic-like symptoms could be
classified as mania.
Mixed episode: A period lasting 7 days or more in
which symptoms for both a manic and depressive
episode are met.
Bipolar II disorder: This illness requires periods of
major depression and hypomania (episodes lasting at
least 4 days) but no full manic or mixed manic episodes.
Rapid cycling: The occurrence of at least four mood
episodes in 1 year. Per DSM-IV-TR, rapid cycling
episodes still must meet the prerequisite duration
criteria (e.g., 7 days for a manic episode). Note that
this definition is different from that used in some
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ASSESSMENT
Recommendation 2. The DSM-IV-TR Criteria, Including the
Duration Criteria, Should Be Followed When Making a
Diagnosis of Mania or Hypomania in Children and
Adolescents [MS].
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TREATMENT
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SOMATIC TREATMENTS
Recommendation 6. For Mania in Well-Defined DSM-IV-TR
Bipolar I Disorder, Pharmacotherapy Is the Primary
Treatment [MS].
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The development of bipolar disorder during childhood or adolescence disrupts ongoing developmental
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be adequately addressed to help promote longterm academic growth, especially given the high
rates of comorbid disruptive behavior disorders.
School consultation and an individual educational
plan are often necessary to help develop an
appropriate educational environment. Some youths
will need specialized educational programs, including day treatment or partial hospitalization programs. For older teenagers, vocational training and
occupational support may also be important needs
to address.
6. Community consultation. Consultation may be
needed with other involved community, juvenile
justice, and/or social welfare programs. Some
youths, because of either the severity of their
symptoms or confounding environmental stressors, will need referral for intensive communitybased services to maintain them at home. Alternatively, some patients may need foster care or
residential services. Finally, patients and families
often receive benefit by participating in community support and advocacy programs.
Recommendation 11. The Treatment of Bipolar Disorder
NOS Generally Involves the Combination of
Psychopharmacology With Behavioral/Psychosocial
Interventions [CG].
Other medications, including stimulants and antidepressants, may be used to treat comorbid ADHD or
associated depression. Perhaps the most common
dilemma is whether and when to use stimulants in
children when there is a question of whether one is
dealing with mania/hypomania or ADHD with mood
lability and low frustration tolerance. Two studies
(Carlson and Kelly, 2003; Carlson et al., 2000;
Galanter et al., 2003) found that boys with ADHD
plus manic-like symptoms responded as well as those
without manic symptoms to methylphenidate and that
stimulant treatment did not precipitate progression to
bipolar disorder. These data challenge existing beliefs
that the failure to respond to stimulants is diagnostic of
mania or that stimulant treatment may predispose
children to the development of bipolar disorder. Of
course, these data also raise the question of whether
manic symptoms equate to true mania. Because
stimulants and SSRIs can cause irritability and
disinhibition, distinguishing medication side effects
from an emerging manic episode is a potential
challenge. One retrospective review found that 58%
of youths with juvenile bipolar disorder (n = 82) had
experienced an emergence of manic symptoms after
exposure to a mood-elevating agent, most often
antidepressants (Faedda et al., 2004). The development
of activation secondary to mood-elevating agents does
not equate to a diagnosis of bipolar disorder (Carlson
et al., 2000). If this were the case, then high rates of
bipolar disorder would be evident in the follow-up
studies of children with ADHD in those subjects who
did not respond well to stimulants.
SCIENTIFIC DATA AND CLINICAL CONSENSUS
Practice parameters are strategies for patient management, developed to assist clinicians in psychiatric
decision making. American Academy of Child and
Adolescent Psychiatry practice parameters, based on
evaluation of the scientific literature and relevant clinical
consensus, describe generally accepted approaches to
assess and treat specific disorders or to perform specific
medical procedures. These parameters are not intended
to define the standard of care, nor should they be
deemed inclusive of all proper methods of care or
exclusive of other methods of care directed at obtaining
the desired results. The ultimate judgment regarding the
care of a particular patient must be made by the clinician
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