Recognizing the need to better treat children and adolescents with bipolar disorder, the Child and Adolescent Bipolar Foundation recently released new treatment guidelines that focus on diagnosis, acute treatment, comorbidity, and maintenance treatment. Robert A. Kowatch, MD, and colleagues hope the new guidelines will help settle some of the debate regarding the diagnosis and longitudinal course of bipolar disease in children and that early recognition and aggressive treatment will reduce or eliminate the negative outcomes associated with the disorder.

“These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder,” the researchers reported. “These guidelines are subject to change as our evidence base increases and practice patterns evolve.” Dr. Kowatch is Director of the Pediatric Mood Disorders Center at Cincinnati Children’s Hospital Medical Center. The guidelines were published in the March Journal of the American Academy of Child and Adolescent Psychiatry.

The new guidelines were formulated by a group of leading researchers in child psychiatry and are the “most up-to-date and comprehensive set of guidelines for the treatment of children and adolescents with bipolar disorder,” said Dr. Kowatch. “They represent a major step toward practicing evidence-based medicine in this difficult-to-treat group of patients. Many of these patients require several types of medications to stabilize their moods, and these guidelines offer several treatment options that are useful for clinicians and families.... Doctors are getting somewhat better at recognizing bipolar disorder in children, but there wasn’t much to guide them in terms of treatment.”

The guidelines were designed to help clinicians identify the classic form of the illness (bipolar I) in children ages 6 to 17 and to offer strategies for treating mania and depression, with or without psychosis, in young patients. The recommendations are based on evidence from research studies conducted in children and adults, case reports published in medical journals, and consensus by a group of leading researchers as to current clinical practices.

ASSESSMENT OF ACUTE MEDICATION

Dr. Kowatch and colleagues acknowledged limitations of DSM-IV criteria for classifying bipolar disorder in children and young adolescents, particularly regarding mania. They proposed that for ascertaining the presence or absence of manic symptoms, clinicians should use the FIND strategy. FIND guidelines for diagnosing bipolar disorder include: Frequency (symptoms occur most days in a week); Intensity (symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains); Number (symptoms occur three or four times a day); and Duration (symptoms occur four or more hours a day, total, not necessarily contiguous).

The panel of researchers developed two treatment-specific algorithms for acute phase treatment of bipolar I disorder, manic or mixed, depending on whether the child presented with or without features of psychosis. Both treatment algorithms consist of six potential stages of treatment. When a child does not respond to treatment, “it is important to consider factors frequently associated with nonresponse such as misdiagnoses, poor adherence to treatment, presence of comorbid disorders (eg, ADHD, substance abuse, anxiety disorders), and exposure to environmental and biological stressors,” the researchers wrote.

COMORBIDITY AND MAINTENANCE TREATMENT

When treating comorbid disorders, the authors recommended that the treatment plan be modified to include treatment of each disorder, because comorbid conditions worsen the prognosis of bipolar disorder. “This is a complex process that may require one or more periods of trial and error to achieve the correct combination of medications and psychotherapy,” they stated. All coexisting disorders, they recommended, should be carefully monitored at baseline and afterward, and the benefits and side effects of each treatment must be continuously assessed.

“The sections on the treatment of comorbid psychiatric disorders are very helpful because having two or more disorders at the same time is common among children and adolescents with bipolar disorder,” commented Daniel Nelson, MD, Medical Director of the Child Psychiatric Unit at Cincinnati Children’s Hospital Medical Center. “By far, a majority of the children we care for with bipolar disorder have high comorbidities.”

The researchers believe that the basic goals of maintenance treatment include prevention of relapse and recurrence; reduction of subthreshold symptoms, suicide risks, affective cycling, and mood instability; reduction of vocational and social morbidity; and promotion of wellness. They recommended that medication tapering or discontinuation be considered if the patient has achieved remission for a minimum of 12 to 24 consecutive months. “For less severely ill patients or in patients for whom a diagnosis is less clear, a briefer treatment period may be indicated.” The researchers wrote, “The risk associated with a potential relapse should be compared with the risk associated with continued pharmacotherapy. Patients for whom greatest caution should be taken are those with a history of suicidal behavior, severe aggression, and/or psychosis. It was acknowledged that for many patients, long-term or even lifelong pharmacotherapy might be indicated.”

The complete guidelines can be found on the Journal of the American Academy of Child and Adolescent Psychiatry’s Web site: www.jaacap.com.

—Colby Stong

Kowatch RA, Fristad M, Birmaher B, et al. Treatment guidelines for children and adolescents with bipolar disorder: child psychiatric workgroup on bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2005;44:213-235.

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