Preschool Bipolar Disorder

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Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Section snippets

Review of nosology in older children: implications for study of preschoolers

Amid the ongoing debate on the appropriate criteria for diagnosis in older children, the rate of clinical diagnosis of bipolar disorder in children has increased 40-fold between 1994 and 2003.7 The precise source of this increase in diagnosis remain unclear. However, there is significant concern that the diagnosis may be liberally and nonspecifically applied in many cases. Multiple perspectives exist as to which primary symptoms best characterize the disorder and importantly how to distinguish

Symptom duration and frequency criteria in older children

In addition to questions about the most sensitive and specific symptom criteria for diagnosis, the duration and related temporal features of these symptoms are also an area of debate. The question of whether the same duration criteria for adult bipolar disorder should be applied to children is currently unclear. Leibenluft and colleagues16 have suggested that only those children who meet full symptom criteria and who demonstrate discrete episodes of mania would be designated as “bipolar,” also

Emerging literature in preschoolers

While there is a dearth of studies that have systematically studied mania symptoms in preschoolers as outlined above, the existing literature has begun to shed some light on this area of early psychopathology. Developmental manifestations of mania symptoms among preschool-aged children have been described in case reports of preschoolers with suspected bipolar disorder. For example, common among these case reports are observations of excessive energy, decreased need for sleep, impairing elation,

Evidence for alterations in emotional reactivity

A key issue in investigating the question of whether bipolar disorder can manifest in preschool children is whether those who manifest symptoms of the disorder also demonstrate differences in patterns of emotional reactivity. Since the disorder is characterized by a fundamental impairment in mood and affect regulation, and related to this, by periods of extremely intense emotional responses, investigating the typical emotion reactivity characteristics (in response to incentive events) of this

Family history and bipolar disorder in older children

Elevations in reported rates of bipolar disorder in the older offspring of bipolar parents compared with the offspring of healthy parents vary depending on study design. However, prior studies have suggested that the offspring of bipolar parents are at four to five times greater risk for any affective disorder (including bipolar disorder) compared with the offspring of parents without mental disorders.32, 33 One source of variation might be that some meta-analyses have included both adult and

Implications of bipolar family history in preschool children

The notion that early onset of bipolar symptoms in a parent may increase the risk of heritability of the disorder suggests that such offspring would be an ideal group in which to search for prodromes or early markers of the disorder. Findings to date in preschool populations have suggested that preschoolers with MDD and family history of bipolar disorder have distinctive symptoms of MDD suggestive of mania precursors when compared with those of preschoolers with MDD but no family history of

Differential diagnosis of bipolar disorder in the preschool period

The prevailing controversy about the nosology of bipolar disorder in older children provides an uncertain framework for studies of nosology in preschoolers as outlined above. Amid these diagnostic uncertainties, clinicians are increasingly placed in the position of evaluating preschool children for suspected bipolar disorder. As evidenced by dramatic increases in the rates of clinical diagnosis of bipolar disorder in childhood more generally as mentioned above, clinicians appear to more readily

Treatment considerations

Although the diagnostic characteristics of bipolar disorder in the preschool period remain ambiguous as outlined, and much empirical work is needed, to date there has been relatively more scientific investigation of treatments for presumptive mania in this age group. Most of the available treatment literature has been descriptive and is composed of case reports and retrospective chart reviews. These reports provide some promising findings for the use of atypical antipsychotic agents and mood

Summary

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. Although there is a need for well-controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3

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    Funding for the study of preschool depression and for preparation of this manuscript was provided by NIMH R01 MH64769-01 and 02 grant to Joan Luby, MD.

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