Dr. Carbray is Clinical Associate Professor and Administrative Director, Pediatric Mood Disorder Clinic, Institute for Juvenile Research, University of Illinois at Chicago, Chicago, Illinois, and Dr. McGuinness is Professor, University of Alabama at Birmingham, School of Nursing, Birmingham, Alabama.
Dr. Carbray is a member of AstraZeneca’s speakers’ bureau. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Julie A. Carbray, PhD, APN, BC, Clinical Associate Professor and Administrative Director, Pediatric Mood Disorder Clinic, Institute for Juvenile Research, University of Illinois at Chicago, 1747 Roosevelt Road, Chicago, IL 60608; e-mail: email@example.com.
The diagnosis of pediatric bipolar disorder (PBD) has increased ten-fold over the past decade (National Institute of Mental Health, 2006). There was a time when this diagnosis was believed to be rare; however, PBD has received increasing attention in both the scientific community and the general public (Lofthouse & Fristad, 2004). Not surprisingly, the increasing frequency of the diagnosis has led to assertions that it is overused. Currently, the diagnosis of PBD is well recognized by the scientific community, and lifetime prevalence estimates range from 1% to 1.6% of the general population (McClellan, Kowatch, & Findling, 2007). Nevertheless, considerable controversy surrounds the delineation of its core symptoms and prevalence (Pavuluri, Birmaher, & Naylor, 2005); actual rates of PBD are estimated to be greater due to the high level of misdiagnosis and comorbidity with other psychiatric illnesses. Children affected by the disorder are typically at higher risk for engaging in dangerous behaviors such as unprotected sex, substance abuse, accidents, and even suicide. While the scientific community studies the illness, both children and their families face the consequences of this devastating problem.
The age-specific symptom profile of PBD continues to evolve even as clinicians struggle to help these youth. For now, consensus exists that the core symptoms are elation and grandiosity; irritability may also accompany these symptoms (Pavuluri et al., 2005). These elements of PBD vary across a spectrum and may also include episodes that are mixed with depression and mania and/or rapid cycling. Irritability and a high rate of both attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders have been the most predominant comorbid features of the PBD spectrum (Birmaher et al., 2002, 2006; Pavuluri et al., 2007). Psychosis and suicide attempts and completion have also been reported (Birmaher et al., 2006).
Unlike adults, whose bipolar symptoms are often obvious displays of grandiosity, overconfidence, and aggressiveness, PBD symptoms may be more subtle. Although typical features of the illness are those seen in adulthood, the literature contains reports of different symptoms, which has resulted in greater clarification of subtypes. PBD has been described as having narrow or broad phenotypes (i.e., an outward manifestation of one’s genetic makeup) (Pavuluri et al., 2005). The narrow phenotype includes recurrent episodes of major depression and mania or hypomania, which may fit the classic Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, definition of bipolar disorder, types I or II (American Psychiatric Association, 2000). Conversely, the broad phenotype differs by way of a high intensity of irritability, mood instability, temper outbursts, and symptoms of depression and impulsivity and lacks distinctive episodes of recovery and relapse (Pavuluri et al., 2005).
The diagnosis of PBD is further complicated by the frequent comorbidity with ADHD and other disruptive disorders. Some estimates hold that up to 90% of children affected by PBD have coexisting diagnoses; these youth are often initially diagnosed with ADHD alone (Joshi & Wilens, 2009). Geller, Warner, Williams, and Zimerman (1998) and Geller et al. (2000) offered the important observation that children with PBD experience grandiosity, elated mood, hypersexuality, flight of ideas, and decreased need for sleep, unlike healthy children or those with isolated ADHD. Thus, the mood dysregulation symptoms of mania or depression, along with cycling, will differentiate children with PBD from those with ADHD alone. However, further work must be done to describe the similarities and differences of these two disease entities. The continuity of the symptoms and presentation of the illness over the life span have not been established and need further research (Joshi & Wilens, 2009).
The neurobiological basis of the illness is now becoming clearer. A developing brain model from neuroimaging studies suggests a fronto-limbic circuitry dysfunction that exaggerates emotional stimuli and then cuts off problem-solving skills in affected children (Pavuluri & Bogarapu, 2008). The implication for families is that their child or adolescent has great difficulty regulating mood when he or she experiences extremes in emotion. Often, parents who have had great success in parenting their other children suddenly feel as though they cannot do anything right when they intervene with their child who has PBD. Because of this amplification of emotional stimuli and difficulties with problem solving, families of children with PBD must combine both medication and psychotherapy to best help their child achieve better control over mood dysregulation and its adverse effect on relationships, sense of self-esteem, and routine functions.
Because PBD shares vague borders with ADHD and anxiety disorders—or that it can be misdiagnosed as other mood disorders such as major depression—the initial psychopharmacological interventions for children and adolescents with PBD often include either stimulant or antidepressant medications. Although the well-intended clinician hopes to elevate depressive symptoms or control hyperactivity in a child, those with PBD often have paradoxical responses to these trials, resulting in extreme irritability, mixed states, or even mania (McClellan et al., 2007). Although not diagnostic, failed trials with stimulant and anti-depressant medication and typical psychotherapies—combined with a family history of bipolar illness—should make the clinician suspect that PBD is a possibility. The more prudent approach for psychopharmacological interventions with affected children starts with prescription hygiene (i.e., removal of selected medications to clarify their effect, interactions, and adverse effects) so that adverse effects of medications can be minimized and a stepwise approach to psychopharmacological intervention realized. A conservative approach to medication dosages is particularly important; side effects and adverse effects need to be carefully managed.
An important component of psychopharmacological treatment is family engagement. Family members can carefully record symptoms and track their frequency, intensity, number, and duration to evaluate results. Several rating scales are available to track PBD symptoms from parent or clinician reports, helping to add more input into choosing the right psychopharmacological approach (Henry, Pavuluri, Youngstrom, & Birmaher, 2008; Pavuluri, Henry, Devineni, Carbray, & Birmaher, 2006).
The medication management goals with PBD are straightforward: Initially intervene to stabilize both mood and sleep, and then seek to manage comorbid symptoms such as hyperactivity or anxiety (McClellan et al., 2007; Pavuluri et al., 2004). Currently, only three agents for this indication have been approved by the U.S. Food and Drug Administration (2009): risperidone (Risperdal®) (for ages 10 to 17), lithium (for age 12 and older), and aripiprazole (Abilify®) (for ages 10 to 17). Dosages are weight based: A 10-year-old who weighs 125 pounds will require more medication to achieve therapeutic effects than a 17-year-old who weighs 95 pounds. In actual practice, many agents used for mood stabilization are used off label (McClellan et al., 2007). Firstline medication choices will typically include either an atypical antipsychotic agent or mood-stabilizing drug, depending on which mood symptoms are most disrupting the child’s life. After mood symptoms are well controlled, residual symptoms such as inattention and anxiety, or even depressive symptoms, can be addressed using symptom-specific medications.
In addition to careful medication management, psychosocial interventions are a necessary component of comprehensive treatment for children and adolescents with PBD (McClellan et al., 2007). Family-based interventions for children with PBD have been developed and tested and offer families the following benefits: established routines to counteract cycling effects, management of extremes of mood, and development of coping strategies for management of negative thoughts and impulsivity (Fristad, Goldberg-Arnold, & Gavazzi, 2002; Lofthouse & Fristad, 2004; Miklowitz et al., 2004; Pavuluri et al., 2004; West, Henry, & Pavuluri, 2007).
Family-based psychotherapies are time limited and consist of specific weekly psychoeducation and cognitive-behavioral therapy techniques for parents and children. One program that may be useful is Child-and Family-Focused Cognitive-Behavioral Therapy (Pavuluri, 2008; Pavuluri et al., 2004). This program has been developed and tested with children and adolescents with PBD and uses daily mood charts, parent empowerment tools, and cognitive-behavioral strategies that help families manage the illness and separate the illness from the developing child. These kinds of psychotherapy programs result in much higher family satisfaction and improved treatment outcomes compared with treatment as usual (Fristad et al., 2002; McClellan et al., 2007; West et al., 2007). In addition, this form of therapy gives children and families a framework for building skills that can directly address the distinct qualities of emotional dysregulation, cycling, comorbidity, and disrupted problem solving.
Conclusion and Implications
Typically, the family of the child affected by PBD has sought care from a number of providers but has been battered by the effects of the illness. These families want to partner with providers who can show empathy and manage the unique characteristics of the illness in a family context. Children with PBD are victims of their mood instability, and they struggle to do the right thing despite their reactivity. The medication regimens for the illness are often used off label and are more complicated due to comorbid conditions. These conditions require special patience on behalf of the treatment team and family. A careful approach to symptom control, combined with an engaged family, is important for facilitating recovery. By understanding both the diagnostic signature and the neurobiological basis of the illness, psychiatric nurses can help these children and their families find relief from the illness and improve their lives and well-being.
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