BP & Children- REALLY long
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| Tue, 03-15-2005 - 11:47am |
In February, a special workgroup of leading experts and the Child and Adolescent Bipolar Foundation published its ground-breaking Treatment Guidelines for Children and Adolescents with Bipolar Disorder. The panel was lead by Robert Kowatch MD of the University of Cincinnati, Mary Fristad PhD of Ohio State University, Boris Birmaher MD of the University of Pittsburgh, Karen Dineen Wagner MD of the University of Texas at Galveston, Robert Findling MD of Case Western Reserve University, and Martha Hellander JD, research policy director of the CABF. They were supported by an all-star cast that included Joe Biederman MD and Janet Wozniak MD of Harvard, Demitri Papolos MD of Albert Einstein University and co-author of The Bipolar Child, and Elizabeth Weller MD of the University of Pennsylvania, among many others.
The good news is that the panel was able to reach consensus on a woefully misunderstood and notoriously difficult to treat illness in this population. The bad news is there was precious little data to work with. But four-alarm fires can’t wait. We have water. We have buckets.
Early Onset Profile
The panel was on strongest ground in painting a clinical picture of early onset bipolar disorder, one that can differ dramatically in many respects from the adult version, principally in the very frequent and often daily cycling that these kids experience. Manias tend to take the form of mixed episodes, characterized by short periods of euphoria and long periods of irritability. Co-occurring illnesses such as ADHD, conduct disorder, and anxiety are par for the course and complicate the diagnosis.
Telltale signs of mania include: Euphoria (behavior needs to be distinguished from normal elation and placed in context); Irritability (as opposed to kids who are oppositionally defiant, bipolar kids can have meltdowns lasting for hours); Grandiosity (there is a difference between playing teacher and telling the principal how to run the school); Decreased need for sleep (manic children are full of energy); Pressured speech (needs to be distinguished from transitory excitement); Racing thoughts (“there is an Energizer Bunny up there”); Distractibility (needs to be carefully distinguished from ADHD); Increased goal-directed activity (a kid may decide to write a novel, but may become disorganized and nonproductive as mania progresses); Excessive pleasure-seeking and taking risks (including hypersexuality); Psychosis; Suicidality (especially during a mixed or psychotic episode).
The panel noted that kids are more likely to report euphoric symptoms of which their parents may not be aware while the parents tend to focus on irritability as this most affects family functioning. In making a clinical assessment, the panel urged input from the school and others who have worked with the kid such as a coach or physician. Several hours is required for an interview, often in sequential sessions involving a multi-disciplinary team. At least two weeks prior to the first visit, parents should keep daily logs that track their child’s mood, energy, sleep, and unusual behavior.
Although it is very clear that we are learning more about this illness in kids, the scope of our ignorance is nevertheless revealed in the panel’s admission that “no one can say for sure what these children will look like when they grow up.”
Living With Your Bipolar Child
The panel placed important emphasis on the need for parents to mourn the loss of their idealized child, especially if the illness has devastated the lives of other family members, such as a grandfather who completed suicide or an aunt who spent her life in a facility. The panel also stressed the need for family education.
Since bipolar kids are at increased risk of learning disabilities, the panel also urged psychoeducational testing once the child’s mood is stable.
Meds Treatment
Owing to the dearth of quality clinical trials testing meds treatment in kids, the panel had precious little to go on other than their own clinical experience, various small studies, and extrapolating results from adult trials. The only randomized clinical trials in kids involved lithium, which were not exactly large and perfect, either. None of this, however, deterred the panel from giving it their best shot, namely:
Acute (Initial Phase) Mania (Including Mixed) without Psychosis
The panel’s recommendations followed the form of an algorithm (ie, if Treatment A doesn’t work, try Treatment B and on to C). Treatment A involved starting off on monotherapy with either a mood stabilizer or an atypical antipsychotic. The panel did not favor one class of drug over the other. The mood stabilizers lithium, Depakote, and Tegretol, and the atypicals Zyprexa, Seroquel, and Risperdal were the drugs of choice. Geodon, Abilify, and Trileptal were only listed way down in the algorithm owing to total lack of data.
If no response is achieved or the med is not tolerated, the panel recommended trying a different drug.
For a partial response, the panel recommended adding another drug from the same list of drugs. If the combination fails to result in any improvement, the panel advised going right back to square one – just one drug but a different one.
From square one again, it is another circuit around the first leg of the algorithm, three times in all if success proves elusive. Some panel members suggested that a third treatment failure justified yet another trip around the block, but the majority said that on the fourth attempt it is wise to start with two meds.
A single failure on two meds (either no response or partial response) justified the addition of a third (two mood stabilizers – with lithium as one of the mood stabilizers - and an antipsychotic). No extra laps around this segment of the algorithm circuit this time, either on two or three meds. Whether this meant the panel was against random reshuffles of the deck or was simply running out of patience was not made clear. At any rate, the final stages of the algorithm represented grasping at straws, with untested meds (Trileptal, Geodon, Abilify) and last ditch treatments (ECT for adolescents and Clozaril).
Acute Mania (Including Mixed) with Psychosis
Again, the panel spelled out its recommendations in the form of an algorithm, this time starting off with a mood stabilizer plus an atypical. For no response or a trouble tolerating, the panel recommended a different mood stabilizer-atypical combination. For a partial response, the panel advised adding a second mood stabilizer – with lithium as one of the mood stabilizers - to form a three-med cocktail.
Here the algorithm comes to a fork in the road. Nonresponders again try a mood stabilizer and atypical, and two meds once again following another failure (this time staying on the same mood stabilizer but switching the atypical). If they partially respond, they join the initial group of partial responders. Partial responders get two shots at a three-med cocktail (two mood stabilizers – with lithium as one of the mood stabilizers - and an antipsychotic), switching to a different atypical on the second attempt. Nonresponders only have one shot at getting the cocktail right. With failure on three meds, the panel is once again grasping at straws.
Acute Depression
With absolutely no prospective studies involving depressed bipolar kids, the panel did not offer a treatment algorithm. The experts touched lightly on antidepressants, Lamictal, cognitive-behavioral therapy, interpersonal therapy, family-focused therapy, and ECT, but avoided a full discussion of the safety issues involving treating kids with antidepressants (other than a brief reference). Maybe next time.
Long Term Treatment
The panel was flying totally in the dark, with “no clear answers regarding how long treatment should be continued,” though it did note that emotional and environmental factors including sleep deprivation, stress, and negative thinking can trigger relapses or recurrences.
In a different section, the panel recommended psychoeducation for parents and children and skills building for kids (in regard to communication, problem-solving, emotion regulation, and impulse control). The panel emphasized that the child must feel comfortable in talking with his or her therapist, and that being forced to see one can do more harm than good. Therapists can also teach parents essential skills in surviving life with a bipolar child.
Co-occurring Disorders
The panel advised first stabilizing the kid’s bipolar symptoms before treating co-occurring illnesses.
Adverse Effects
The panel recommended careful monitoring of weight, cognitive effects, polycystic ovary syndrome (for girls on Depakote), and specific side effects associated with specific agents.
Conclusion
The panel noted that its Guidelines should not be regarded as an absolute standard of care, but did express hope that early detection and treatment would result in improved outcomes.

