Research report
Clinical characteristics of bipolar disorder in very young children

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Abstract

Background

Clinical information about bipolar disorder (BPD) in preschool-age (3–7 years old) children is extremely limited. This study examined clinical presentations, applicability of the DSM-IV diagnostic criteria, comorbidity, recovery and relapse rates, as well as some treatment strategies used in the management of BPD in preschoolers.

Methods

The charts of 26 outpatient children, ages 3–7, refereed to a child psychiatry outpatient clinic with mood and behavioral symptoms, were retrospectively reviewed.

Results

The majority of the patients were referred with the tentative diagnosis of ADHD but the most common diagnoses made by child and adolescent psychiatrists at the time of initial evaluation were BPD NOS (61.5%), followed by BPD I (26.9%), and mood disorder NOS (23.1%). Thirty-eight percent of the patients had one or more comorbid diagnoses. The most common presenting symptoms were irritability (84.6%) and aggression (88.5%). The most widely prescribed class of medications after diagnosis in the clinic was atypical antipsychotics and mood stabilizers. Twenty-six percent of the patients were treated with a combination of atypical antipsychotics and mood stabilizers.

Limitations

Retrospective design; small sample size; lack of a comparison group.

Conclusions

The course of BPD with onset in preschool years is complicated with high recovery and relapse rates. The questions of development of age-appropriate diagnostic criteria, long-term prognosis and treatment strategies used in this population require further intensive investigation.

Introduction

A growing number of publications during recent years have challenged the assertion that bipolar disorder (BPD) in young children is an extremely rare or a nonexistent condition (Akiskal et al., 1985, Biederman, 1998, Carlson, 1995, Craney and Geller, 2003, Dilsaver and Akiskal, 2004, Geller et al., 2000a, Geller et al., 2004, Geller et al., 2000b, Kowatch, 1998, Luby et al., 2002, Weller et al., 2003a, Weller et al., 1986). Wozniak et al. (1995) reported that 16% of children clinically referred for psychiatric evaluation had a bipolar disorder. Of those, 70% have the onset of manic symptoms at age 5 or younger. In 23% of these children, symptoms of mania were reported as being “always present” (Wozniak and Biederman, 1997). However, despite an increased attention during the recent years to the phenomenon of the early onset bipolar disorder (EOBPD), there is a paucity of data regarding the phenomenology, diagnostic criteria, naturalistic course, comorbidity, and the treatment of BPD in children with an onset of this illness before age 7 years. As a result, EOBPD is probably under- and misdiagnosed due to the lack of age-appropriate diagnostic criteria for BPD in young children. Despite some improvements in diagnostic criteria for mania in DSM-IV compared to previous versions of DSM, which applied “adult” criteria to diagnose mania in children, mania in childhood is still frequently underdiagnosed or misdiagnosed (Weller et al., 2003a). Current DSM-IVTR criteria require a distinct period of abnormally and persistently elevated, expansive, or irritable mood, with a duration of 4 days for a hypomanic episode, or 7 days for a manic episode. The application of episode-duration criteria developed for adult BPD, with mania presenting as discrete episodes, limits the chance of diagnosing BPD in very young children (Faedda et al., 2004). Recent studies demonstrate that in contrast to adult BPD, EOBPD most commonly presents with frequent daily mood swings, characterized by frequent short episodes of intense mood liability, hostile aggressive behavior, and chronic irritability rather than classic euphoric mania (Biederman et al., 1998a, Geller et al., 1998, Kowatch et al., 2005, Weller et al., 2003a, Weller et al., 2003b). Several recent research studies have demonstrated that discrete episodes of mania in young children are often not present and the cycling pattern of these patients may best be described as ultrarapid or ultradian cycling (Geller et al., 2000b). EOBPD is sometimes misdiagnosed as attention-deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), anxiety, oppositional-defiant disorder (ODD) and conduct disorders (CD). There is a lack of definite diagnostic criteria to diagnose and treat this population of very young children, who often have more severe and developmentally complicated subtype of BPD, characterized by complex episodes, poorer course, and fewer remissions (Carlson et al., 2000).

Although several recent studies described the clinical characteristics and phenomenology of pediatric bipolar disorder (Biederman et al., 2004, Dilsaver and Akiskal, 2004, Findling et al., 2001, Geller et al., 2004, Kowatch et al., 2005, Scheffer and Niskala Apps, 2004), the majority of these studies have focused on the 7 to 17 year age group. The effect of pharmacotherapy on the course and outcome of the EOBPD is even less well described with no controlled studies of any medications in children ages 3–7 years with BPD. The questions of the clinical presentation, diagnostic criteria, treatment, recovery, and relapse rates in very young (3–7 years old) children remain controversial and largely understudied. The objective of this retrospective chart review was to examine the referral pattern and clinical characteristics of bipolar disorder in children between the ages of 3 and 7 years.

Section snippets

Methods

This study was approved by the local Institutional Review Board and adhered to the privacy requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The medical charts of 26 children, who were referred for behavior problems, treated as outpatients at the Cincinnati Children's Hospital Medical Center (CCHMC), Division of Psychiatry during the calendar years from 2000 to 2004, were ≤ 7 years old at initial evaluation and diagnosed with a Bipolar Disorder, including

Results

A total of 26 charts were reviewed. The male to female ratio was 3:1 (73.1% versus 26.9% respectively). Twenty-four out of twenty-six patients were Caucasian (92.3%), one African-American and one biracial (3.8% each). The mean age of the subjects at the time of initial study evaluation by a child and adolescent psychiatrist was 5.3 ± 1.3 years.

Discussion

Despite controversies surrounding the question of validity of the diagnosis of BPD in very young children, growing clinical and scientific evidence suggests that children in the age group 3 to 7 years are being referred for psychiatric evaluations and are diagnosed with BPD (Luby and Mrakotsky, 2003, Scheffer and Niskala Apps, 2004). The diagnostic process, however, is then complicated due to a paucity of data on the age-specific diagnostic criteria, clinical presentation and the course of BPD

Limitations

Generalization of the present results may be limited by the following: (a) use of retrospective design; (b) relatively small sample size; (c) lack of a comparison group. The diagnoses listed could be different if structured and semi-structured (e.g., WASH-U-KSADS) instruments were applied. CGI and CGAS ratings were also applied retrospectively, which limits its reliability. The majority of the patients in our study were from outpatient clinics and results may be different if compared to the

Acknowledgments

The authors acknowledge Drs. Michael Sorter and Pamela Campbell for their contribution.

Disclosure: Dr. Kowatch has financial affiliations with Bristol-Myers Squibb, Glaxo-Smith Kline, Janssen, Astra-Zeneca, Cephalon Inc., Abbott and Pfizer. Dr. Pathak has research funding from Forest Laboratories Inc. and Cephalon Inc. The other authors have no financial relationships to disclose.

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