The assessment and treatment of juvenile bipolar disorder presents a number
of unique challenges and risks. Despite some advances, there is still much
to learn about this illness and appropriate interventions.
The diagnosis of bipolar disorder in children and adolescents is establishe
d using the same DSM-IV criteria as are used in adults. In children, the di
fferential diagnosis between bipolar disorder and attention deficit hyperac
tivity disorder requires special care.
Somatic treatments have been less well studied in children and adolescents
than in adults, especially for relatively rare conditions such as bipolar d
isorder, which is uncommon before the age of 10 years. This is unfortunate
because it may be inappropriate to translate standard practice for adults t
o use in children.
Medications may have different pharmacokinetics in peripubertal compared wi
th adult patients and may show different interactions according to stages o
f endocrine development. Lithium, for example, has a shorter half-life in c
hildren than in adults, and maintenance treatment with the drug in adolesce
nts appears to be associated with high relapse rates, perhaps because of di
fferences in drug kinetics. Since illnesses with earlier onset tend to be m
ore severe, and more treatment resistant, it is especially important to rig
orously evaluate treatments in juvenile onset conditions. The anticonvulsan
ts that are useful in adults have not been evaluated in controlled trials i
n children. It appears that adolescent patients with bipolar disorder are m
ore likely to require adjunctive antipsychotics than adults. Since typical
antipsychotics are associated with the risk of tardive dyskinesia during lo
ng term use and juvenile patients will be exposed to medication over a long
period, it is important to evaluate atypical antipsychotics in these patie
nts. Juvenile forms of functional psychoses appear to show higher genetic l
oads, and parents and families should be evaluated for their contributions
to the patient's treatment context. Juvenile patients with bipolar disorder
are at significant risk of self-injurious behaviours and require careful s
upervision. Medication regimens must be supervised closely.