Posted by Phillipa on October 20, 2008, at 13:20:56
So sad really didn't believe kids could be bipolar but article for Nurses on MedScape says otherwise and compairs to adults. Love Phillipa
Bipolar I Disorder Can Begin in Childhood, Extend Into Adulthood CME
News Author: Caroline Cassels
CME Author: Charles Vega, MD
DisclosuresRelease Date: October 17, 2008; Valid for credit through October 17, 2009 Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians
To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.Learning Objectives
Upon completion of this activity, participants will be able to:Identify disease characteristics of bipolar I disorder in children.
Describe the course of bipolar I disorder in children.
Authors and Disclosures
Caroline Cassels
Disclosure: Caroline Cassels has disclosed no relevant financial relationships.Charles Vega, MD
Disclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.October 17, 2008 New research suggests bipolar I disorder is a continuous disease that can begin in childhood.
The pioneering study the first to prospectively demonstrate the disorder can begin in childhood and extend into adulthood shows that up to 44% of children who experience manic episodes as children continue to experience them as young adults.
"This paper supports that mania in children exists because if you follow very young children with the disorder into adulthood, the illness continues," principal investigator Barbara Geller, MD, from Washington University, in St. Louis, Missouri, told Medscape Psychiatry.
The study is published in the October issue of the Archives of General Psychiatry.
Difficult Diagnosis to Swallow
The first National Institute of Mental Healthfunded group to describe child bipolar I disorder, Dr. Geller's research team was also the first to demonstrate the condition has higher familial aggregation than found in similar studies of adult bipolar I disorder.
Nevertheless, she said, the concept of bipolar disorder in childhood is a difficult one for many parents and clinicians to accept. Further, recent data showing enormous increases in chart review diagnoses of pediatric bipolar disorder has fueled further skepticism about its existence.
"The thought that a child can be too happy, too cocky, too exuberant, is anathema to many people. But when we're talking about childhood bipolar I disorder, we are talking about children who are so silly and giddy that families are asked not to bring them to church; who are so cocky, expansive, and grandiose that they go to the principal's office and tell them to fire teachers they don't like; bright kids who fail classes because they are fully convinced they know it all and don't study," she said.
The importance of the current article was to determine whether mania in childhood is different from adult mania or a continuation of the same disorder.
The prospective, longitudinal study included 115 children with an average age of 11 years diagnosed with a first episode of child bipolar disorder during the period from 1995 to 1998 and followed up for 8 years.
During 9 follow-up visits, the children and their parents were interviewed separately about symptoms, diagnoses, daily cycles of mania and depression, and interactions with others.
More Effective Medications Needed
The study had a very high retention rate, with 108 (93.9%) of the 115 children assessed at all 9 follow-up points. Participants' average age at follow-up was 18.1 years. At the end of follow-up, the results of the study revealed that all of the children had a mood disorder over 60.2% of the time and that episodes of mania occurred 39.6% of the time.
The authors report that although 87.8% of subjects recovered from mania, 73.3% relapsed. Low maternal warmth predicted earlier relapse. When investigators examined the characteristics of children's second and third episodes of mania, they found they were similar to the first episode and characterized by psychosis, daily cycling between mania and depression, and a long duration 55.2 weeks for the second episode and 40 weeks for the third.
When investigators separately analyzed data from the 54 participants who had reached the age of 18 years at the end of the follow-up period, they found that 44.4% continued to have manic episodes. In addition, 35.2% had substance use disorders, a rate similar to those diagnosed with bipolar I disorder as adults.
According to Dr. Geller, the 44% frequency rate of manic episodes among those 18 years and older with bipolar disorder is 13 to 44 times higher than the population prevalence. In addition, she pointed out the rate is also much higher than repeat episodes in comparable studies of bipolar I disorder in adult populations.
These findings, said Dr. Geller, strongly support the hypothesis that bipolar disorder in childhood continues into adulthood and "shows the illness is continuous, providing validation, as does our previous family study, that mania actually exists in children and that it is continuous with the adult disorder."
Currently, she added, treating bipolar disorder in both children and adults is challenging.
"Generally, the current medications don't work as well as we would like them to work, so that at this point the approach for any individual patient is based very much on trial and error," she said.
"Also, because low maternal warmth predicted a worse outcome, treatment plans need to include evaluation of mother-child relationships," Dr. Geller added.
Growing Awareness
Finally, said, Dr. Geller, it is important that clinicians are aware that mania in children does exist and that they know, at least at this time, that outcomes are poor, so that they can appropriately counsel families.
Future research includes observing these study subjects well into adulthood to further examine outcomes. The group also plans to publish neuroimaging and further genetic findings from the same cohort in the near future.
In an accompanying editorial, Ellen Leibenluft, MD, from the National Institute of Mental Health, in Bethesda, Maryland, said the study contributes to a growing awareness that serious mental illnesses do not emerge de novo when individuals reach adulthood but rather reflect early developmental processes.
She points out that this study extends previous seminal work on pediatric bipolar disorder and highlights the need for more research that will eventually foster "work that will allow us to treat youth with bipolar disorder more effectively and eventually give us the knowledge base needed to prevent the onset of bipolar disorder."
The study was supported by the National Institute of Mental Health. The study authors have disclosed no relevant financial relationships.
Dr. Leibenluft has disclosed no relevant financial relationships.
Arch Gen Psychiatry. 2008;65:1122-1124, 1125-1133.
Clinical Context
The diagnosis of bipolar I disorder is controversial, and there has been discussion as to whether the diagnosis even exists. Part of the difficulty of conceptualizing this disorder in children is the difference in disease characteristics between children and adults. Whereas bipolar I disorder in adults is associated with circumscribed episodes with distinct mood types, research in children has indicated that episodes can last an average on nearly 1 year to 4 years. Moreover, children are more likely to have daily cycling, known as ultradian cycling, between mania and depression.There are also limited data regarding the natural history of bipolar I disorder in children. The current study examines a cohort of children older than 8 years to document how bipolar disorder evolves as well as factors that influence outcomes.
Study Highlights
Children eligible for study participation were between the ages of 7 and 16 years. All children were diagnosed with bipolar I disorder, manic or mixed phase, with symptoms for at least 2 weeks and at least 1 cardinal symptom of mania (elation and/or grandiosity). All children had objective evidence of impairment because of the bipolar disorder.
Children with developmental disorders and major medical disorders were excluded from the study protocol.
Treatment was provided by participants' clinicians and was not regulated by the research protocol.
Children were followed up for their symptoms with a tool that was designed to include important elements of bipolar I disorder. Children's interaction with close contacts such as family and teachers was measured as was the degree of impairment related to symptoms.
Children were followed up for these outcomes for 8 years, at which point half of the study cohort was aged 18 years or older. Recovery was defined by a period of 8 weeks without mania.
115 children entered the study, and 93.9% were seen at follow-up visits from baseline through year 8. The mean age at study enrollment was 11.1 years, 87.8% of participants were white, and 67% of children were boys.
All children were in their first bipolar episode during enrollment.
Overall, participants spent 60.2% of all study weeks with any mood episodes and 39.6% of weeks with mania episodes. The mean number of mania or mixed-mania episodes was 2 during the 8-year follow-up.
60.9% of participants experienced psychosis during the initial episode, and 73% had subsequent psychosis during the 8-year follow-up.
87.8% of children experienced recovery from bipolar disorder, but 73.3% of participants had relapses after recovery. The mean time to recovery was 55.6 weeks.
The mean duration of the first mania episode was 142.7 weeks, and subsequent mean durations of episodes were 55.2 and 40.0 weeks.
A low level of maternal warmth predicted relapse to mania and more weeks with manic episodes. A younger baseline age also predicted a higher number of weeks with manic episodes.
At age 18 years, 44.4% of participants had mania, a level which is 13 to 44 times higher vs the prevalence of mania in adults with bipolar I disorder.
35.2% of participants had a substance use disorder by age 18 years.
Pearls for Practice
Compared with bipolar I disorder in adults, bipolar I disorder in children is associated with longer episodes of mood lability and daily cycling between mania and depression.
The current longitudinal study of children with bipolar I disorder found high rates of recovery from mania but also high rates of relapse. Low maternal warmth predicted a higher risk for relapse. The rate of mania remained high in participants aged 18 years.
poster:Phillipa
thread:858440
URL: http://www.dr-bob.org/babble/20081016/msgs/858440.html