BiPolar Dx
DIAGNOSIS OF BIPOLAR
DISORDER IN CHILDREN & ADOLESCENTS
Very important Dx
issues to keep in mind about BPD Dx in children & adolescents:
- “Mania” is very uncommon under age 15.
- “Extreme irritability” is the
typical feature of BPD in children; this is the child equivalent of mania.
- Very rapid & dramatic changes in
mood are characteristic of BPD children.
Very giddy and “whoop tee do!” moods followed by profound sorrow 7
(often) suicidal thoughts and threats over trivial frustrations are common
in BPD children.
- Decreased need for sleep, especially extreme
difficulty getting to bed, characterize many BPD children.
- Precocious sexual activity is often
found in BPD children. When a child
is especially aggressive perpetrating these behaviors, a Dx of BPD should
always be strongly suspected.
- Family history in BPD children usually
is positive for at least one primary relative having a major
depressive disorder, most commonly BPD.
I am far more confident in a Dx of BPD in a child when this
condition has affected a parent, and yet more confident when more than one
relative has BPD. Faroane,
Wozniak, and Biederman, in a large survey, found no primary BPD relatives
in children with ADHD only, but found 80% of children Dx with BPD and ADHD
had a relative with BPD.
- Most studies have shown about 10-15% of
ADHD children also have BPD, while 95% of BPD children (and adolescents)
have co morbid ADHD. Therefore, in most cases, the diagnostic question and
primary clinical concern is which condition is most impairing now.
- I disagree with Dr. Wagners’ comment on
page 2 of the handout (area bracketed) in the sense most children and
adolescents with combined ADHD/BPD, in my experience, do not present with
psychosis nor require psychiatric hospitalization.
I
agree:
A.
These children
and adolescents are much more difficult to parent and cause intense friction
between parents (often leading to divorce);
B.
Their clinical
course is far more problematic and requires careful, expert psychological and
psychiatric Rx;
C.
Management of
medications effective in treating ADHD/BPD children is usually
difficult, at best, since adolescents are historically non-compliant with meds and
side effects of effective BPD Rx medications can be severe.
- Bear in mind Geller, Wozniak, and
others have all described cases of severe BPD in children as young as two. We have made this Dx in several 3 year
olds and many 4 year olds. Early
Dx and Rx can be life-saving for these children, who are very often nearly
impossible to effectively manage while in emotional “melt down”
mode, thus invite abuse (by caretakers as well as parents!).
- The standard wisdom that Rx with TCA’s
and SSRI’s “precipitates” latent manic episodes has not been borne out
when re-examined in recent, large long-term studies.
- It is important to note BPD II is very
different, presenting as commonly in girls as boys, and usually with
repeated episodes of deep depression.
Important: The reason
SSRI’s often seemingly fail to effectively treat depressed teenaged girls is
because the girl has BPD-II. In these
cases, combined Rx with a mood stabilizer and an anti-D medication is
necessary, undoubtedly-in-part accounting for why additions of Lithium to
augment anti-D Rx has been so often so effective in so-called
“treatment-resistant depressions.”
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