Bipolar disorder in children and adolescents - A guide to diagnosis and treatment

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.