Treatment guidelines for kids with bipolar disorder published

Cincinnati Children’s Kowatch led effort

Early diagnosis and treatment is important for children and adolescents with bipolar disorder, according to new treatment guidelines. The guidelines were sponsored by the Child & Adolescent Bipolar Foundation (CABF), a national parent advocacy group, and were drafted by a scientific consortium led by Robert Kowatch, M.D., director of the Pediatric Mood Disorders Center at Cincinnati Children’s Hospital Medical Center.

“These new guidelines were formulated by a group of leading experts 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 towards 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.”

It is often necessary to use several medications in combination because these kids are very ill, often suicidal or too manic and depressed to attend school. Stabilizing their moods and allowing them to return to school as soon as possible is critical if they are to lead normal lives, said Dr. Kowatch. “Doctors are getting somewhat better at recognizing bipolar disorder in children, but there wasn’t much to guide them in terms of treatment,” added Dr. Kowatch.

The guidelines are designed to help doctors identify the classic form of the illness (called Bipolar-I) in children ages 6 to 17, and suggest strategies for treatment of mania and depression, with or without psychosis, in young patients. The recommendations are based on evidence from research studies done in children and adults, case reports published in medical journals, and consensus by a group of experts as to current clinical practices.

The guidelines will be published in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry but are currently available to the public on their website at www.jaacap.com. “Far too little research has been done on the treatment of bipolar disorder in youth,” said Mina Dulcan, M.D., editor-in-chief of the journal. “The guidelines represent a consensus of existing research results and clinical experience to guide clinicians and families. We hope that the guidelines will not only facilitate clinical care but also inform and enhance new research.”

Bipolar disorder (formerly called manic-depressive illness) is a heritable illness that can be diagnosed in teenagers and even in young children. Symptoms include grandiose delusions, irritable mood often accompanied by aggression and self-injury, decreased need for sleep without daytime fatigue, speech that is difficult to interrupt, racing thoughts, distractibility that varies with mood, increased goal-directed activity, hypersexuality, and in some cases, hearing voices.

“The disorder runs in families, and children with the illness are at extremely high risk of attempting suicide,” said Martha Hellander, research policy director at CABF and co-author of the guidelines. “These kids suffer so badly, and deserve to have evidence-based treatment as early in life as possible. Many respond quickly to mood stabilizing medication, and parents tell us that ’we have our child back.’”

Bipolar disorder is a lifelong condition that can often be managed with medication, psychotherapy and lifestyle changes such as stress reduction, regular sleep, accommodations at school, and avoidance of caffeine, alcohol, and drugs of abuse.

“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,” said Daniel Nelson, M.D., medical director of the Child Psychiatric Unit at Cincinnati Children’s. “By far, a majority of the children we care for with bipolar disorder have high comorbidities.”

Among the other disorders specific to children who have bipolar disorder, children can also suffer from ADHD, oppositional-defiant disorder, conduct disorder, anxiety and tic disorders, and substance abuse. The comorbid disorders and common side effects from treatment medications are also discussed in the guidelines.

In addition to Dr. Kowatch, other authors of the guidelines include Mary Fristad, Ph.D., director of Research & Psychological Services at Ohio State University; Boris Birmaher, M.D., head of the Children’s Mood Disorders Center at Western Psychiatric Institute and Clinic in Pittsburgh; Karen Dineen Wagner, M.D., director of the division of Child and Adolescent Psychiatry at the University of Texas Medical Branch in Galveston; Robert Findling, M.D. professor of psychiatry and pediatrics at University Hospitals of Cleveland; and Martha Hellander. Participants included sixteen other experts on pediatric bipolar disorder and three family representatives from CABF.