 rld
Wide Handbook®on Child and Youth Psychiatry and Allied Disciplines prof.dr.Theo Compernolle MD.,PhD. (Editor) |
| rld
Wide Handbook® on Child and Youth Psychiatry and Allied Disciplines prof.dr.Theo Compernolle MD.,PhD. (Editor) |
A Professional Handbook Covering the Field of Child and Youth Psychiatry and Allied Disciplines: Bipolar Disorder
Bipolar Disorder, Depression, Mania, Attention Deficit Hyperactivity Disorder,Lithium, Child and Youth Psychiatry and Allied Disciplines, Child Psychiatry, Youth Psychiatry,Psychology, Child Psychology, Youth Psychology.
[To the Contents][General Contents ] [Homepage]
Introduction |
Keywords
|
[To the
Contents][General Contents ]
[Homepage]
Introduction
In children,"Mania" has already been described in the 19th Century (For a
review of the literature up to 1952, see Anthony &
Scott,{1960}.
The diagnosis of Manic Depression, Bipolar Depression or BipolarDisorder
(BD), is usually made in young adulthood. Retrospective research in BD adults,
however, shows that they already had symptoms in childhood, but that the
possibility of BD had not been considered.(??? ref)
Even closer to adulthood, in adolescence, the diagnosis is often not made.%^^%{Isaac,1992};%^^%{Strober& Carlson, 1982};%^^%{Gammon et al, 1983}(???Weller et al 1995). Gammon and collaborators%^^%{1983}think the diagnosis of BD is rarely made in childhood and adolescence because physicians do not think about BD, because of its atypical picture in adolescence and the normal emotional instability at that age. Burke%^^%{1990},warns that for most BD they examined, the disorder had already started between the ages of fifteen and nineteen. Akiskal and collaborators%^^%{1985}examined68 children and siblings of patients (aged 6-24 years) with BD who had been referred for various reasons. In many of these children they did not find any typical symptoms of BD before early adolescence. They did, however, find a lot of other symptomatology and 68% of the children observed developed BD in the three following years.
We tried to summarize and synthesize the subject literature in such a way as to it give clinicians and researchers indications when to consider the diagnosis of BD in children. Therefore, we focus on the descriptive phenomenological aspects. We hope to inspire clinicians to consider this diagnosis in children more often and to escape from the limitations of inappropriate adult-oriented descriptions of the syndrome.
We try to describe the symptoms in terms more appropriate for children,in
such a way that BD can be recognised at an earlier age, more appropriate
therapy can be initiated earlier which might improve the prognosis. Earlier
treatment might prevent the development of secondary problems and disorders
in the young adult patient and his family. Earlier detection creates an
opportunity to intervene in potentially destructive family
patterns,which often develop as a result of BD in a family
member%^^%{Beardslee
et al,
1992};%^^%{Preodor&
Wolpert,
1979};%^^%{Gammon
et al,
1983};%^^%{Weinberg
& Emslie,
1991};%^^%{Goodwin&
Jamison, 1990}.
The next step is for researchers to put these descriptive categories to the test. Once clinicians consider BD in children more often, this will stimulate research, especially much needed prospective research. These studies will hopefully also shed more light on whether the childhood disorder is a riskfactor, a subclinical form, a precursor, a miniature form of the adult type or a separate entity.
1.1. Discussion of the DSM criteria
1.2. The earliest symptoms of BD
1.2.1. General features
1.2.2. Periodicity and erratic behaviour
1.2.3. Physical complaints and neuro-vegetative symptoms
1.2.4. Suicide attempts
1.2.5. Intelligence
1.3. Five early clinical pictures of bipolar disorder
1.3.1. The unstable, depressive child
1.3.2. The unstable, tempestuous, aggressive
child
1.3.3. The unstable, irritable, hyperactive
child
1.3.4. The unstable, intelligent, failing child
1.3.5. The psychotic child
[To Contents of Symptoms][To Contents of Chapter][General Contents ] [Homepage]
The DSM (American Psychiatric Association 1994 p.317-363)??? criteria for the diagnosis of a Bipolar Disorder (BD) are:
The description of the disorder in the DSM-IV
( American Psychiatric
Association. 1994) is so adult-oriented, that it hinders the diagnosis
in childhood. The diagnostic criteria suggested by Anthony &Scott%
^^%{1960}too
are mainly based on the clinical picture as it is described in adult psychiatry,
that is, as an "ideal" picture of a periodic, diphasic, endogenous disease.
In adults too, a strict application of these criteria, to make the diagnosis
of BD more precise and valid, is causing an increasing number of cases to
fall outside of the "diagnostic borders." In adults too, such individual
cases, "on the edge of DSM-IV", may be overlooked and undertreated. Fawcett,
J. 1997 ??? Online Coverage from the 150th Annual Meeting of the American
Psychiatric Association May 18 - 21, 1997 © 1997 Medscape, Inc. Fawcett
(1997) ???suggests to minimize missing treatable bipolar disorders, by knowing
when to suspect bipolar "spectrum" illnesses. For example, recurring patterns:
including recurrent affective episodes, recurrent psychoses, recurrent
irritability - or really any recurrent affective patterns, should alert one
to the possibility of a bipolar spectrum illness. Noting sudden changes,
instability, impulsive behavior or binge patterns also herald the possibility
of bipolarity. This is certainly true for children.
In children reliable diagnostic criteria lacking. This creates a vicious
circle: The current diagnostic criteria of BD are not helpful to diagnose
BD in children, as a result the diagnosis of BD is too rarely made in childhood,
as a consequence we lack sufficient data to adapt the diagnostic criteria
for children, which leaves us nothing but the unadjusted adult criteria....
Much more prospective research needs to be done to find out which subtypes from other child psychiatric desorders may be (the precursors of) BD. In this state of affairs we can only present a provisional clinical typology, mainly based on retrospective studies.
Carlson%^^%{Carlson,1984}
writes that at a very early age(1-8 years), the symptoms of a mood disorder
are very non-specific: irritability and emotional lability. Behavioral symptoms
may mask a mood disorder. From twelve adolescents (aged 13-19 years) with
behavioral disorders in the research carried out by
Isaac%^^%{1992},
eight later turned out to have a BD. Akiskal and
collaborators%^^%{Akiskal
et al, 1985}describe 68 young family members of BD patients, who where
referred for many different kinds of bizarre behaviour. Among them: children
isolating themselves socially, children with bizarre verbalizations, aimless
wandering around, and unpredictable behaviour, impulsive children, unusually
fidgety children or moody children. 68% of these children later developed
a BD.
To facilitate the diagnosis of BD, based on the research literature, we describe
five types of symptom clusters where a clinician should consider the possibility
of a BD. First, we describe general features which are quite common to all
types.
Over the years the behaviour of young BD patients gradually becomes more
episodic. Hypomanic behaviour (funny, excited talking with grandiose ideas)
alternates with depression (behavioral inhibition, acting in or acting out)
%^^%{Delong,1990}.
In young children the episodes are not as clear-cut as in adults. A clear
differentiation of episodes of mania and episodes of depression is almost
always
lacking%^^%{Carlson,1984}.
Much more typical are sudden changes in symptomatology.
One should not forget, however, that in adults too there is often no clear
distinction between the episodes. In adults this mixed type, has an earlier
onset, is often more severe and has more neuropsychiatric complications
%^^%{Himmelhoch
& Garfinkel, 1986}.
Although the severity of the mood-swings may be an indication,
Annell%^^%{1969}describes
how in children the changes do not go at once from depression to mania and
vice versa, but often make smaller "jumps"eg. from depression to normality,
to hyperactivity, to mania .
Children with BD often have physical complaints. These, however, are non-specific. Somewhat typical are sleep disturbances such as frequent nightmares causing the child to wake up and eating disorders, such as hyperphagia, hyperdipsia, salt craving, encopresis and especially (sudden) changes in these areas.
Suicide and suicidal thoughts are more frequent%^^%{Hughes et al, 1989};%^^%{Akiskal et al, 1985};%^^%{Barner-Rasmussen et al, 1986};%^^%{Achte,1986}
Although the total IQ of BD children is most often in the normal range%^^%{Akiskal et al, 1985};%^^%{Davis,1979};%^^%{Miklowitz et al, 1988}, in general they tend to have uneven profiles with lower scores on performance IQ and especially on coding and abstracting %^^%{Kestenbaum,1979}.
1.2.2.1. The unstable, depressive child
1.2.2.2. The unstable, tempestuous, aggressive
child
1.2.2.3. The unstable, irritable, hyperactive
child
1.2.2.4. The unstable, intelligent, failing child
1.2.2.5. The psychotic child
Reviewing the research literature into the earliest symptoms of BD, five clinical pictures emerge that might help to diagnose BD in childhood.
Retrospectively, a group of BD patients turns out to have been emotionally
unstable from early
childhood%^^%{Carlson,1984};%^^%{Dyson&
Barcai, 1970}, with a low level of emotional response, if not depression
as the most important
feature%^^%{Akiskal
et al, 1985}. Depression in children and adolescents sometimes is a precursor
of BD (Akiskal 1995).???
It is more difficult, however, to diagnose depression in a child than it
is in an adult. Rating scales, such as the Child DepressionRating
Scale-R%^^%{Poznanski
et al, 1985}, and the Weinberg Screening Affective
Scales%^^%{Weinberg&
Emslie, 1988}, can be
helpful%^^%{Hughes
et al, 1989}. These rating scales try to sort the depression out of a
combination of unspecific symptoms, because the child him/herself is most
often unable to clearly formulate depression or feelingsof depression.
The severity of depression can also be estimated based on a the level of
hopelessness of the child.
Kashani%^^%{Kashani,1989}investigated
hopelessness at 3 age levels (8, 12, 17 years in 210 school children) and
discovered that the degree of hopelessness of a child in relation to himself
and the future correlated very much with the prognosis: The less hope, the
more severe depression later.
Before the onset of a clearcut BD, in childhood these patients sometimes
suffered from affective
storms%^^%{Dyson&
Barcai, 1970}. The child loses control over its emotions and relatively
unimportant matters lead to unreasonable, extreme, destructive behaviour.These
storms are transient and irregular, they may last minutes or hours, never
weeks or months. They may have some psychotic qualities, but there is no
cognitive
disintegration%^^%{Davis,1979}.
Dyson and
Barcai%^^%{1970},
describe as concurrent features of these storms: lack of concentration, low
frustration tolerance and explosive anger. After such a phase the child often
becomes depressed feeling guilty and sorry.
Due to these emotional storms the child lacks appreciation and reinforcement
of the people around him/her.That in its turn can lead to irritability, and
further to a wide variety of behavioral disorder symptoms, even delinquent
behaviour.
Delong and
Nieman%^^%{1983},
treated sixteen behaviorally disordered children(aged 6.3 - 13.5 years) at
risk of BD with Lithium and found that this had a positive impact on the
following behaviour: restlessness, hyperactivity,lack of attention, lack
of concentration, explosive outbursts, excited talking,aggression, quarrelling,
disobedience, withdrawal and depression.
Carlson,%^^%{1984},
studied the data he could find about the childhood (1,5 to 8 years) of his
patients and found that irritability and emotional instability were the most
important features. The irritability remains when the child grows older and
is probably a symptom which may help to differentiate BD from
ADHD%^^%{Fristad
et al, 1992}. Children with BD are much more irritable, probably because
of their greater inadequacy, which again and again causes them problems and
troubles.
Another cause of the irritability may be the lack of understanding of the
parents for the fundamental problem of the child. Parents seem to be bad
observers and are overfocussed on the behavioral problems of their
child%^^%{Kashani
et al, 1984}. In families with a BD child, there is not much room for
the expression of emotions, which might also provoke irritation in the child.This
irritability together with emotional instability may also play a role, not
only in the genesis of symptoms such as: aggressive, impulsive and unpredictable
behaviour; explosive outbursts, quarrellings and disobedience, but also in
the opposite kind of symptoms, such as withdrawal and
depression%^^%{Akiskal
et al,
1985};%^^%{Kestenbaum,1979};%^^%{Delong&
Nieman, 1983}.
When neither a child's mood nor his/her behaviour gives any clue, one may
sometimes discover a BD when a child is failing at school, notwithstanding
a good intelligence and the absence of learning disabilities.
Isaac%^^%{Isaac,1991}
examined 5 children, ages 9-11, who were referred to a school for special
education because of their emotional problems. He concluded that all five
met the criteria of BD. In a group of 68 family members of a BD patient,
six children were referred to Akiskal because of they were failing at school.
Four of them later developed
BD%^^%{Akiskal
et al, 1985}. Müller
%^^%{Müller
et al, 1984}, examined 80 family members of BD patients and found that
they more often failed a grade (9 compared to 1 in the control group), obtained
lower grades (38 compared to 23) and less often succeeded in their final
examinations (15 compared to 38). Among the BD patients themselves 30% did
not finish school. Hence, failure at school can be a symptom of a latent
or early BD. The reasons why BD children fail at school are: their lack of
attention and concentration, their impulsiveness, their temper
tantrums%^^%{Kestenbaum,1979},
and because of their feelings of guilt, sorrow and depression due to this
failure (Davis, 1979).
%^^%{Glassner&
Haldipur, 1985}, described the future BD-child as one who is initially
special in his family and who performs well at school. Because of the high
expectations of the parents, however, these children experience so much stress
that they tend to fail later. This might also be the reason why these children
later enter lower professions than one would expect based on their intelligence.
Children and adolescents with BD, often have psychotic features%^^%{Strober & Carlson, 1982}. These symptoms can be so dominant that the BD is mistaken for schizophrenia. Ballenger and collaborators %^^%{1982}, describe this phenomenon in adolescents. Campbell and collaborators%^^%{1972} also found that some children aged 6-12 who were diagnosed as suffering from schizophrenia, improved on Lithium. In retrospect the schizophrenic behaviour (explosivity, aggression, hyperactivity and apsychotic-like logorrhea) looks very much like an early BD. Varanka %^^%{1988}found that the psychotic symptoms in 10 BD children (aged 6-12) improved on Lithium. The most evident improvement was related to the psychosis as much as to the speech, movement, concentration and thinking disorders.
[To Contents of Symptoms][To Contents of Chapter][General Contents ] [Homepage]
2. Assessment
2.1. Direct Examination
Their are quite a few hindrances to the diagnosis of BD in children and
adolescents. It is difficult to get a feeling of the clinical picture (Bowring
and Kovacs 1992)(Cogen 1996)
- when there are no generaly accepted diagnostic criteria
- when the base rate of the disorder is low
- when the clinical picture varies so much within and across episodes, and
its expression is influenced by developmental factors
- when there is so much overlap with other disorders,
and the tools to differentiate are still being developed.
It will always be difficult to diagnose BD in children based on the criterium
of mood-disorder, because children have greater difficulties to express verbally
their mood in general and depression specifically. Therefore self-rating
scales, which are a valuable screening instrument in adults, are much less
useful with
children%^^%{Carlson,1984}.
Hence, the observation of behavioral symptoms in those children and the
description of these symptoms by parents and teachers, are the most important
instrument of
diagnosis%^^%{Akiskal
et al, 1985};
%^^%{Isaac,1992};
%^^%{Hughes
et al, 1989}. Results obtained with behavior rating scales like the CBCL
(???) in differentiating ADHD and BD (???) look promising.
2.2. History Taking
Not withstanding the disagreement about the exact hereditary pattern of BD,
given the obvious role of genetic factors, a thorough
family history is be very important for the (differential) diagnosis of BD
in
children%^^%{Akiskal
et al, 1985}. Many children who develop BD, have family members diagnosed
as BD, other Affective Disorders and ADHD (see
etiolgy below).
Moreover, this Family History has implications for treatment. Depressive
children with family members who have a bipolar disorder, when treated with
tricyclic anti-depressive medication, have a greater chance of developing
mania. This observation seems to have predictive value towards the future
development of a bipolar rapid cycling disorder in
adulthood{Strober & Carlson,
1982 };
{Geller, 1993 }.
Anyway, the conclusion is that one should think about the possibility of an incipient BD when treating children with a family history of BD or related disorders.
2.3. Special Assessment
Since there are no pathognomic signs for neither BD nor ADHD in childhood, a final differential diagnosis will often be impossible, and thus a "mis-diagnosis" often unavoidable. Only time will tell.
There is enough evidence to warrant a test-therapy with mood stabilizers
with children belonging to the five categories described
above, especially when their symproms are therapy resistant.Many authors,
often implicitly, even seem to consider a succesful
treatment with Lithium as an indication if not a
proof for the diagnosis of BD. Vice versa, the succesful treatment with stimulant
medication of Lithium-resistent BD-like symptoms is used as support
for the diagnosis of ADHD. There is not enough evidence, however, to conclude
that Lithium and Stimulant Medication are (biological) markers
for respectively BD and ADHD.
2. Differential
Diagnosis
From the description of the five types of childhood BD, it is clear that
the mean disorders to be considered in a differential diagnosis are: Conduct
Disorder (D.6.1.), Adjustment
Disorder(D.18.), Substance
Abuse(D.25), other Mood
Disorders(D.19) and Psychotic
Disorders(D.22). Especially
the differentiation with ADHD
(D.6.1.) is very relevant. Other
differential diagnoses are: thyroid disorders, neurologic disorders and rare
genetic disorders like the Velo-cardio-facial Syndrome (Papolos DF et al,
1996).
Many criteria, important for the differential diagnosis were mentioned above
in the description of the five clinical BD-types.
ADHD is characterized by a lack of concentration and attention, impulsiveness
and hyperactivity which begins at a very young age, most often before
age6%^^%{Bowring&
Kovacs, 1992}. 50% to 80% of these children still have problems in the
areas of attention, concentration and behaviour in adolescence and adult
life%^^%{Compernolle
& Postmes, 1995}.
Mania is basically a mood disorder with abnormal emotional and mental
excitement,sometimes with ADHD like symptoms such as irritable hyperactivity
and attention and concentration problems. This typical picture however is
seldom seen beforeage 12. BD children show interest in new stimuli, more
than one usually sees in ADHD
children%^^%{Delong&
Aldershof, 1987}. If they are creatively gifted, BD children are often
able to stay involved in fantasy or construction play without outside stimulus.
ADHD children too can stay focused, or even over-focused, but they are then
typically distracted by an outside attraction like a TV or video-game.
Diagnostic problems may arise when mania starts with a history of an ADHD-like
picture. A sudden worsening of symptoms such as agitation and hyper-activity
together with new symptoms of mania, may be the basis for a differential
diagnosis.
For example: a young patient with a history of ADHD may show some improvemen
tin early adolescence, and then suddenly show irritability and unstable moods
with rapid talking, hyper- activity, impulsiveness, and inhibited social
behaviour etc. Such a picture is more likely to be a first manic phase rather
than a new ADHD episode.
One difficulty is that in the early stages of BD, the hyperactivity and attention
problems can be much more evident than the mood disorder.
In ADHD high expectations together with the anxiety of the parents, may easily
give the child the feeling of never being able to live up to their expectations
and this may result in depression. In ADHD however the depression after such
an emotional storm never reaches the depth of depression seen in children
who later develop BD. Moreover, in ADHD, one does not find the same family
history of affective
disorders%^^%{Kestenbaum,1979}.
The conclusion from the literature reviewed is that whenever the course ofan
ADHD is atypical, one should also think about the possibility of an emergent
BD.
66% of 59 BD children (aged 3.1-20) improve on Lithium, compared to 0% of
19 ADHD children (aged
5.3-15.3)%^^%{Delong
& Aldershof, 1987}. The opposite istrue too. BD children do not improve
on standard ADHD therapy with stimulant medication.
When a hyperactive child does not improve with the standard ADHD medication,
one should think about the possibility of a
BD%^^%{Isaac,1991}.
The chances that a supposedly ADHD child is in fact a BD patient, are high when the hyper-activity occurs episodically, in contrast to the usual continuous hyper-activity of the typical ADHD child%^^%{Coll& Bland, 1979};%^^%{Delong& Nieman, 1983}.
Since ADHD, as well as BD often runs in the family, it is important to take down a very detailed family history. A complicating factor, however, is that ADHD and BD are also found in the same family pedegree (Wozniak et al 1995)???, which seems an argument to consider the possibility of comorbidity of ADHD and BD, unless we are dealing with a Pseudo-comorbidity due to the fact that BD in childhood may have been mistaken for ADHD.
In both groups children are emotionally inadequate and their scores on hyperactivity scales are roughly similar. However, in the case of mania, there is more depression, more psychosis, less social competence and more extreme emotional instability. They are aggressive more often and the course of the disease is rather episodic. Some authors suggest that aggression and anti-social behaviour are indications of the possibility of a BD, especially when this behaviour cannot be explained by the influence of a delinquent peer group%^^%{Sheard,1971}; %^^%{Yesevage,1983}; %^^%{Schmidt& Freidson, 1990}. Given the high frequency of aggression and delinquency in follow up studies on ADHD children%^^%{Compernolle & Postmes, 1995}, this issue needs certainly more research.
From the research mentioned above and in the paragraph
on the Etiology of BD, it is evident that given the
clinical picture in childhood it is difficult to predict what the case will
look like in adulthood. Retrospectively, looking back from adulthood to
childhood, different processes may be hypothesised (See
Figure 1).
From adolescence on the clinical picture can be very similar to adult-BD
(6), making the differential diagnosis similar in scope and in difficulty
as in adult psychiatry.
As we have seen, in younger children, the symptoms are very different from
the adult criteria of BD.
A child with the clinical features of an ADHD, for example, can turn out
to have an ADHD (1 in Figure 1), a Pseudo-BD (2), a BD (3) or a combination
of ADHD and BD (5) in adulthood. A mixed case with features of BD and ADHD
in childhood (4) can turn out to be an ADHD or a BD in adulthood.
If many cases of Childhood ADHD are in fact precursors of BD or non-diagnosed BD, then it is possible that the finding of ADHD and MD in the same family pedigrees , and the hypothesis of a biological link between the two (Wozniak et al 1995)??? %^^%{Biederman et al, 1991}is an artefact of this "mis-diagnosis". Since there no pathognomic signs for neither BD nor ADHD in childhood, a final differential diagnosis will often be impossible, and this kind of "mis-diagnosis" often unavoidable.
Some features of depression make it more likely for the depression to become bipolar: the rapid onset of symptoms, severe psychomotor retardation andpsychotic symptoms such as exaggerated self-blame and hypochondria%^^%{Strober & Carlson, 1982};%^^%{Strober et al, 1993};%^^%{Isaac,1992}.
Since emotional tantrums also happen in children with attention deficit
hyperactivity disorder (ADHD), schizophrenia and borderline personality
disorders, this may cause difficulties for the differential diagnosis, especially
when in one of these conditions the tantrums are followed by a depressive
reaction.
Mania may cause high risk behavior, hurting others, like that in conduct
disorder, which also often starts in (early) adolescence. But, the behavioral
style, the motives of a child with conduct disorder are more callous, more
a- or antisocial. (Bowring and Kovacs; Weller and colleagues???). Moreover,
psychotic like symptoms and thoughts disorders are not present in conduct
disorders, while they sometimes are in BD.
Delong%^^%{Delong,1978}
emphasises the importance of cyclical changes. He discovered that nine in
twelve children (4-14 years) with chronic behavioral disorders who reacted
favourably to Lithium therapy were characterized by cyclical changing moods,
periodic manic excitation and periods of social withdrawal.
For the differential diagnosis with emotional storms in schizophrenic
patients,it is important that in BD the cognitive functioning remains
normal%^^%{Campbell
et al, 1972}.
The differentiation between borderline personality disorder and BD,
especially Mixed Episodes can be difficult (Fawcett J 1997). Borderline
personality disorder patients in general are much more inactive then BD
patients%^^%{Davis,1979}.
Below we describe how in a family with an adult BD, a child may develop a pseudo-BD, which further complicates the differential diagnosis.
[To the
Contents][General Contents ]
[Homepage]
3.Epidemiology
In adults, the prevalence of Bipolar Disorder is 0,4 to
1,2%(eg.Regier,
1988}(Robins et al)???. It is as prevalent in men as in women.
Looking at the statistics one is tempted to conclude that BD does not occur
under the age of
fifteen%^^%{Sibisi,1990}.
From retrospective studies , however, we learn that in over half of the cases
the first symptoms appear in childhood, often between age eight and fifteen,
sometimes as early as
six.%^^%{Isaac,1992};%^^%{Strober&
Carlson,
1982};%^^%{Gammon
et al,
1983};%^^%{Burke,1990;%^Ac^%{Akiskal
et al, 1985}(Lish and coworkers).
[To the Contents][General Contents ] [Homepage]
Notwithstanding the disagreement about the exact hereditary pattern of BD,
given the obvious role of genetic factors, a thorough family history can
be very important for the (differential) diagnosis of BD in
children%^^%{Akiskal
et al, 1985}.
Mendlewicz and
Rainer%^^%{1974},
found that a parent with BD has a 25 % chance of having a child with BD and
41% chance of having a child with unipolar depression. In their review of
the literature, however, other authors find a range from 6% to 35% genetic
transmission%^^%{VanGent & Nabarro,
1984};%^^%{Rosenthal,1970}.
The siblings of a BD patient have a 21% chance of developing a bipolar anda 19 % chance of developing a unipolar disorder%^^%{Mendlewicz & Rainer,1974}. The mother of a depressive child is in 40% of the cases and the father in 10% of the cases depressive at the moment the diagnosis is made in their child. They have unipolar more often than bipolar depression.The lifetime prevalence for a psychiatric disorder is 73% for the mother and 55% for the father of BD children%^^%{Hughes et al, 1989};%^%{Müller et al, 1984}. When the mother has bipolar depression, the chances of genetic transmission to the children is at its highest%^^%{Angst,1972};%^^%{Zerbin-Rüdin,1979}.
The family history seems to have an influence on the onset of the earliest symptoms. The more family members have a depressive disorder, the more often this is a bipolar disorder, the greater the chances that a child will BD and the earlier one will see BD symptoms%^^%{Smeraldi et al, 1982};%^^%{Strober & Carlson,1982}.
Interestingly enough, when one finds ADHD in the family history, the riskof
having BD is
higher%^^%{Biederman
et al, 1991}. One may wonder howeverif in these cases the ADHD diagnosis
was correct to begin with.
Depressive children with family members who have a bipolar disorder, when
treated with tricyclic anti-depressive medication, have a greater chanceof
developing a mania. This observation seems to have predictive value towardsthe
future development of a bipolar rapid cycling disorder in
adulthood{^%{Geller, 1993">Strober
& Carlson, 1982; {Geller,1993}(???).There seems to be no link between
BD and
schizophrenia%^^%{Strober
et al, 1988}, but there is arelationship with schizoaffective
disorders%^^%{Winokur
et al,
1969};%^^%{Mendlewicz&
Rainer, 1974}.
Anyway, our conclusion must be that child and youth psychiatrists and psychologists should always think about the possibility of an incipient BD when treating children with a family history of BD.
In families with a BD child, there is a higher incidence of individuals withan affective disorder. This affective disorder can cause dysfunctional family patterns which are then transmitted from generationto generation {Davenport et al,1979}. A family member with a BD can have an influence on the onset of BD, the discovery of BD, the courseof BD and the occurrence of a "pseudo BD" in children.
Moreover, BD families often belong to lower socio- economic classes, the parents are less educated (67% compared to 47% in the control group) and the mothers more often have unskilled jobs (50% compared to 21%)%^^%{Müller et al, 1984}.
Parents who suffer from BD themselves often have high expectations
of their children. Because they have not succeeded themselves, they expect
their children to do so. 73% of children who later turned out to have BD
were treated in the family as very special, if not gifted
children%^^%{Cohen
et al,
1954};%^^%{Gibson
et al,
1959};%^^%{Glassner&
Haldipur, 1985}.
Because in families with a BD parent, parents are aware of the genetic aspects
of BD, they often fear that their own child might develop BD
too%^^%{Davenport
et al,
1979};%^^%{Mayo
et al, 1979}. Hence, together with the high expectations, a child mightbe
the focus of a lot of unexpressed anxiety.
The concealing of BD
Many authors describe how BD often remains undiagnosed.
Waters%^^%{1980},
discovered that many BD patients deny the problems whiletheir spouses are
very aware of them. The reason may be that BD patientsfear the confrontation
with reality and their own emotions.Glassner and
Haldipur%^^%{1985},
describe how BD children hide their lack of confidencefrom their
peers.Davenport%^^%{1979},
and
Mayo%^^%{1979},
describe how fearful families with a BD parent are aboutthe expression of
emotions, because every expression of an emotion may bethe signal or the
"cause" of the next manic episode. Family-members tend to suppress emotions
and, if emotions are felt, they are often denied.This way a child will not
learn to cope with these emotions and as a resultmay express them with an
inappropriate emotional outburst or with hyperactivebehaviour. This is a
way in which a "pseudo BD" may develop.
The course of BD
Although adoption studies demonstrate that BD will occur independently of
family circumstances, even when family circumstances are
optimal%^^%{Mendlewicz
& Rainer, 1974}, the family can have a negative influence on the
course of the BD symptomatology of a child.
The BD of a child can become worse because the child in such a family does
not learn to express his/her emotions adequately and as a result will exhibit
emotional outbursts more often. Because of the high expectations, the child
may feel gradually more inferior, which may make the prognosis more negative.
In the family however, this failing child is still praised, which makes the
child more and more dependent on the unrealistic norms and appreciation of
hisfamily%^^%{Glassner&
Haldipur,
1985};%^^%{Davenport,1979}.
Especially those children who are unable to free themselves from this emotional
entanglement, will show symptoms like hyperactivity, hostility, uncooperative
behaviour, sleeping problems, depression and
isolation%^^%{Mayo
et al, 1979}. Children who are able and who are allowed to have friendships
outside the family, and who are thereforel ess dependent on their family
members, will have fewer or less severe symptoms.In general they are better
able to express their fears and hopes for change.
A manic episode of an adult BD family member is often a very destructive
incident for the family. Open conflict between the parents, which often occursin
a manic episode of a parent, most often elicits anxiety or behavioral problems
in the
children%^^%{Jenkins&
Smith,
1991};%^^%{Romans
& McPherson,1992}.
There are also family patterns that are protective and stabilizing. In families with a BD patient, the children of parents living together, have much fewer and less severe symptoms (31%) than the children of divorced parents (71%).The children themselves prefer a somewhat rigid but quiet family life style%^^%{Davenport et al, 1979}.
The genesis of a "pseudo-BD"
In general from this research, one gets the impression that independent ofgenetic
influences, the patterns of interaction in a BD family risk havinga negative
influence on the development of a child. Almost all children ina family with
a BD parent have psychiatric or psychological
problems%^^%{Gaensbauer
et al,
1984};%^^%{Davenport
et al,
1984};%^^%{Zahn-Waxler
et al, 1984}. When a child is unable to defend himself againstthis family
process and is unable to connect with friends outside the family,this behaviour
may be indicative of early
BD%^^%{Mayo
et al, 1979}.
But from the first year of life, children of BD parents are more evasive,more
anxious and less interested then children of parents without
BD%^^%{Gaensbauer
et al,
1984};%^^%{Zahn-Waxler
et al, 1984}. When they are two years old these same children have more
temper tantrums, and are more often impulsive and hyperactive, intense and
excited but at the same time often shy and dependent. They very often havesleep
and eating problems.
We suggest the possibility that this, together with the tendency to conceal
problems and with the anxiety- provoking symptoms in a parent, may cause
a "pseudo-BD" picture. A syndrome which has some features in common with
BD, but where the symptoms are caused by such family influences and modelling
by a BD parent or family member. This may makes the differential diagnosis
even more difficult.
[To the Contents][General Contents ] [Homepage]
[To the Contents][General Contents ] [Homepage]
4. The Early Treatment of BD
4.1. - Child oriented interventions
6.1. Lithiumtherapy
6.2. The unstable depressive child
6.3. The unstable tempestuous aggressive child
6.4. The insecure, irritable, hyperactive child
6.5. The psychotic child
4.2. - Parent oriented interventions
4.3. - Family oriented interventions
4.4. - School oriented interventions
4.5. - Inpatient oriented interventions
4.6. - Psychopharmacological interventions
4.7. - Other Interventions
[To the
Contents][General Contents ]
[Homepage]
The treatment of BD is bio-psycho-social, multifactorial and multidisciplinary. Psycho-education of the family and the patient, family therapy, individual therapy, school interventions and pharmacotherapy seem to be the most important ingredients.
Psychotherapy has also been conceptualized as a prophylactic intervention
with strategies seeking to improve interpersonal relationships and stress
management. Stressful life events are viewed as potential precipitants for
recurrent episodes. Therefore, the attempt of therapy is to reduce the number
and severity of events. Attention is also given to routines, activities or
substances that may disrupt one's normal schedule in attempts to enhance
circadian integrity. These are important interventions, because it has been
found that sleep deprivation (which can be self-induced in adolescents) may
trigger a manic episode.
Collaboration with educators is invaluable, as teachers are able to provide
objective observations comparing the child to their age peers. Working with
educators can help promote strategies for intervening with depressed or manic
children, and thereby help facilitate an environment that enhances learning.
Leren observeren
Psychoeductatie
Psychoeducation should incorporate child, adolescent and parent. They should be informed of symptoms of manic and depressive episodes and supported in the exploration and identification of symptoms of the index episode and of future symptoms indicative of a recurrence. The physician should discuss treatment options that include medication and psychotherapy.
Expressed emotion (gezinstherapie)
4.6.1. Cautionary note
4.6.2. Consensus on the treatment of BD in adults
4.6.3. Pharmacotherapy of BD in children
4.6.3.1. Lithiumtherapy
1. Cautionary note
We could not find controlled or long-term treatment studies in children.
Our conclusion is the same as in%^^%{Kafantaris' {1995}???, review:
Pharmacological and psychosocial treatments of BD in children are understudied.
In our opinion the reason for this is that BD in children is underdiagnosed
to begin with.
Hence the need to proceed with caution. The safest way is probably to carefully
follow the lead of the research done in adult psychiatry. The AmericanPsychiatric
Association's Practice Guideline for the Treatment of Patients with Bipolar
Disorder (Supplement of the Am.J.Psychiatry December 1994)??? as well as
Expert Consensus Survey (1997)???, conclude that Lithium, Valproate and
Carbamazepine are the most widely used and recommended mood-stabilizing
medication in adults.
Moreover we do not know enough about the efficacy of pharmacotherapy, to
decide how long treatment should be maintained in the children. Some favor
long-term treatment because of the serious consequences of BD. Others
stop medication when the patient is stabilised (Nottelmann and Jensen).(???)
For patients with classic, euphoric mania, the experts of the Consensus Survey
(Kahn et al, 1997), which can easily be accessed via the WWW at : Experts
Consensus Survey???, recommend lithium as the treatment of choice, with valproate
also a first line choice.Valproate is the treatment of choice for mixed episodes,
for mania with dysphoric mood, and for mania in a patient with rapid cycling.
Carbamazepine is a first line alternative for mixed episodes and for rapid
cycling. Lithium is also a first line alternative for mixed episodes.
In bipolar I disorder, long-term or lifetime prophylaxis with a mood stabilizer
is the treatment of choice after two manic episodes and should also be considered
after one manic episode if it is severe or if there is a family history of
bipolar disorder. In bipolar II disorder, prophylaxis may be appropriate
after three hypomanic episodes, if there are antidepressant-induced mood
elevations, frequent depressions, or a family history of bipolar I disorder
In terms of long-term tolerability, defined as the willingness of patients
to stay on medication based on overall side effects, the experts rated valproate
and then lithium as first line choices, while carbamazepine was rated as
second line. Giving the mood stabilizer in a single h.s. dose may improve
compliance. This option is most appropriate with lithium and sometimes with
valproate, while there was no consensus concerning carbamazepine.
Before starting /during treatment with Mood Stabilizers, the following tests
are considered necessary:
Serum levels of lithium, valproate, carbamazepine, selected tricyclics
Thyroid functions
CBC and general chemistry screen
Urinalysis if starting lithium
Complete physical exam (by psychiatrist or another physician)
Pregnancy test if relevant
Second line: Urine toxicology for substance abuse, EKG in patients over 40
Although medications are necessary in the treatment of bipolar disorder, they are usually not sufficient. Psychosocial interventions are necessary for improving medication compliance, together with patient and family education, suicide prevention, psychotherapy for depression (e.g., interpersonal or cognitive/behavioral therapy), and setting limits in mania and hypomania.
Delong
&Aldershof%^^%{1987},advise using Lithium in children
with the following symptoms:
1. Extreme cyclical changes in emotion
2. Hostile rage
3. Manic excitement
4. Family history of an affective disorder and especially of a
bipolardisorder
5. Aggression
6. Evident neuro-vegetative disorders such as hyperphagia,
hyperdipsia,encopresis, and salt craving.
When the depression is unipolar, Lithium only has a positive effect in 14%
of children under age
fourteen%^^%{Geller,1993}.
Depressive children with BD may become manic upon treatment with tricyclical
anti-depressive medication, to become bipolar later. Hence, one might still
consider Lithium therapy in these "not yet bipolar" children especially when
there is a family history of
BD%^^%{Geller,1993}.
When the depression goes together with neuro-vegetative symptoms and other episodic symptoms 82% of the children react favourably on Lithium therapy, even 100% under age fourteen%^^%{Delong& Aldershof, 1987}.
Depressive children with family members who have a bipolar disorder, when treated with tricyclic anti-depressive medication, have a greater chance of developing mania. This observation seems to have predictive value towards the future development of a bipolar rapid cycling disorder in adulthood{Strober & Carlson, 1982 }; {Geller, 1993 }.
Several
authors%^^%{Stewart
et al,
1990};%^^%{Carlson
et al,
1992};%^^%{Delong
& Aldershof,
1987};%^^%{Siassi,1982},
think there is an indication for Lithium when the aggression is explosive
and/or cyclical, unpredictable and/or goes together with emotional symptoms.
Aggression in mentally handicapped children reacts surprisingly frequently
favourably to Lithium
therapy%^^%{Dostal
& Zvolsky,
1970};%^^%{Yudofsky
et al, 1987}.
From 33 children with behaviour disorders in Delong and Aldershof's sample
(aged 5.3-17.4) (1987) only 15% had a positive reaction to Lithium. The more
affective, aggressive, or schizophrenic symptoms there are, the more chance
there is of a favourable reaction towards Lithium.
Hyperactivity in itself does not improve with Lithium (Delong & Aldershof,1987; Shaw et al, 1990; Carlson et al, 1992), but it does react favourably when there are concomitant symptoms of BD or when there is a family history of BD%^^%{Dyson& Barcai, 1970};%^^%{Davis,1979};%^^%{White & O'Shanick, 1977};%^^%{Weinberg& Brumback, 1976}.
Sometimes, in the case of a combination of schizophrenia and depression, the combination of neuroleptics and Lithium will give better results%^^%{Lerner et al, 1988}. Campbell and collaborators%^^%{1972} found that some children aged 6-12, who were diagnosed as suffering from schizophrenia, improved on Lithium. In retrospect theschizophrenic behaviour (explosivity, aggression, hyperactivity and a psychotic-like logorrhea) looks very much like an early BD. Varanka%^^%{1988}, found that the psychotic symptoms in 10 BD children (aged 6-12) improved on Lithium. Most evident improvement was related to the psychosis as much as to the disorders of speech, movement, concentration and thinking.
[To the
Contents][General Contents ]
[Homepage]
Strober and
collaborators%^^%{Strober
et al, 1988} demonstrated that in a group of 50 bipolar probands only
40% of the juvenile onset BD, compared to 80% of the adolescent onset ,reacted
positively to Lithium medication.
One may especially expect a positive reaction to Lithium when there is a
family history of positive response to
Lithium%^^%{Delong&
Aldershof,
1987};%^^%{Fristad
et al, 1992}, or when the BD is not of the mixed
type%^^%{Post
et al, 1989}.
Delong treated 196 psychiatric untreatable children with Lithium, 66% (aged 3.1-20). These who later went on to have a BD reacted positively to Lithium ???(Delong & Aldershof, 1987), which is a higher success rate than the 40% in Strober's group of juvenile onset BD, who also received other medication%^^%{Strober et al, 1988}.
A positive response to Lithium in childhood has been mentioned for several
behavioural and emotional
disorders%^^%{Delong,1978};%^^%{DeLong
&
Nieman,1983};%^^%{Delong & Aldershof,
1987};%^^%{Stewart
et al,
1990};%^^%{Carlson
et al,
1992};%^^%{Siassi,1982};%^^%{Dostal&
Zvolsky,
1970};%^^%{Yudofsky
et al,
1987};%^^%{Dyson& Barcai,
1970};%^^%{Davis,1979};%^^%{White
&
O'Shanick,1977};%^^%{Weinberg & Brumback,
1976};%^^%{Lerner
et al,
1988};%^^%{Campbell
et al,
1972};%^^%{Brady
et al,
1991};%^^%{Estroff
et al,
1985};%^^%{Hesselbrock
et
al,1988};%^^%{Mirin
et al, 1988}.
Viewed in the light of our reveiew we hypothesize that mmore often than thought
these may be the early expressions of an as yet unrecognised BD.
Side effects
Side effects of Lithium seem to be more frequent in children than in adults.A
few authors mentioned the occurrence of only minor side
effects%^^%{McKnew
et al,
1981};%^^%{Weller
et al, 1986}. Caroll and
collaborators%^^%{Caroll
et al, 1987} mention inactivity, sedation, and irritability.
Campbell%^^%{1991}found
more frequent side effects in the 48 children (aged5-13 years) studied, than
one would expect from the research literature.They mention that the occurrence
of side effects depends very much on theage (the younger the more) and the
diagnosis (the cleaner the clinical picturethe fewer the side effects).
It is reassuring, however, that only one of the 196 children in the study of Delong and Aldershof (1987) had to stop the medication due to side effects and that only one child developed hypothyroidy. Because of the worsening of the child's behaviour, however, the parents asked for the medication to be continued.
Little is known about the long term side-effects of Lithium in children.Khandelwal and collaborators%^^%{1984} found no side effects3-5 years after they had started the treatment on 4 adolescents (13-15 years).What one might especially fear in children are growth-related side effects.Lithium, however, does not seem to have a negative influence on the growthof the bones%^^%{Birch,1982}, but theoretically one could also expect an indirect influence via an effect on the thyroid.
Since children have a higher clearance rate one may expect them to need higher
dosages. In practice this seems not to be necessary. In general it seems
to be agreed that a blood level of 0.6-1.2 mEq/l is most
effective%^^%{Geller
et al,
1992};%^^%{Shaw
et al,
1990};%^^%{McKnew
et al, 1981}.
Many side effects seem to be independent of dosage and may already occur
with much lower
doses%^^%{Campbell
et al, 1991}. In these cases one cannot prevent side effects from occurring,
because these side effects only disappear at a level where Lithium is no
longer effective.
Tricyclics seem to induce cycling. Therefore, depression as a part of a possible BD is better treated by SSRI's, bupropion, or MAOI's.
If BD could be recognised at an earlier age, more appropriate therapy could be initiated earlier and this might improve the prognosis. Earlier treatment might prevent the development of secondary problems and disorders in the young adult patient and his family. Earlier detection would create an opportunity to intervene in potentially destructive family patterns, which often develop as a result of BD in a family member.
[To the Contents][General Contents ] [Homepage]
BD not only creates a real social handicap and hampers daily functioning, it also has an increased risk of suicide. There is a greater risk for substance abuse, crime, gambling, unstable relationships, aggression towards self and others (Lish et al 1994).
Very important for children is the fact that it interferes with normal development, and the regulation of emotions, acquiring competencies, and social relationships (Nottelmann and Jensen).
The degree to which BD reacts positively to Lithium, depends on the age at
which the disorder begins. BD which begins early, not only often ends up
as a more severe disorder in adulthood, is more often of a mixed type (mixed
states) and has more affective disorders in the family history, but also
seems to be Lithium resistant more
often%^^%{Himmelhoch&
Garfinkel,
1986};%^^%{Strober
et al, 1988}.
There is also a greater risk that Lithium therapy will fail, when the BD
goes together with personality
disorders%^^%{Kutcher
et al, 1990}, is rapid
cycling%^^%{Nolen,1983},
is of a mixed
type%^^%{Post
et al,
1989};%^^%{Swann,1995},
or has concomitant psychiatric
disorders%^^%{Black
et al,
1988};%^^%{Himmelhoch & Garfinkel,
1986}.
As was mentioned above, depressive children with family members who have
a bipolar disorder, when treated with tricyclic anti-depressive medication,
have a greater chance of developing mania. This observation seems to have
predictive value towards the future development of a bipolar
rapid cycling disorder in
adulthood{^%{Geller, 1993">Strober
& Carlson, 1982; {Geller,1993}(???). A Rapid Cycling type BD has a poorer
prognosis.
Properly treated about 70-80% of adults with BD function properly between
the episodes.
[To the Contents][General Contents ] [Homepage]
6. Conclusion
From our review it is evident that childpsychiatrists
and-psychologists should consider the possible diagnosis of BD in the following
types of children:
1. The unstable, depressive child
2. The unstable, tempestuous, aggressive child
3. The unstable, irritable, hyperactive child
4. The unstable, intelligent, failing child
5. The psychotic child
This is especially necessary whenever the symptomatology is episodic, goes
together with vegetative symptoms, suicidal thoughts, and last but most important
when there are BD or BD-like syndromes in the family history.
The differential diagnosis with ADHD is sometimes difficult.
The family has an important influence on the course of the symptoms and therefore
should be included in diagnosis and therapy.
Treatment consist of medication, psychotherapy and psychosocial
interventions.
Although there are no controlled studies in children, the pharmacological
treatment of choice seems to be Lithium. Valproate and Carbamazepine.
The phenomenological typology presented will hopefully not only improve the
early diagnosis of BD in children, but also lead to much needed prospective
studies and controlled research on the early treatment of BD.
[To the Contents][General Contents ] [Homepage]
[To the Contents][General Contents ] [Homepage]
$$%% Achte K (1986). Depression and suicide.Psychopathology, 19(2):210-214. Text#@
$$%% Akiskal HS, Down J, JordanP, Watson S, Daugherty P, Pruit DB. (1985). Affective disorders in referredchildren and younger siblings of manic depressives. Archives General Psychiatry,42:996-1003. Text#@
Akiskal HS. Developmental pathways to bipolarity: Are juvenile-onset depressions pre-bipolar? J Am Acad Child Adolesc Psychiatry. 1995;34(6):754-763.
American Psychiatric Association.(1994). Diagnostic and Statistical Manual of Mental Disorders IV. American Psychiatric Association. Washington DC .Text
$$%% AmericanPsychiatric Association (1994). Practice Guideline for the Treatment of Patientswith Bipolar Disorder. American Journal of Psychiatry, 12:151.Text#@
$$%% Angst J (1972). Genetische Aspecteder Depression. Depressive Zustünde, Kielholz P, (Hrsg).Bern-Stuttgart-Wien: Verlag Hans Huber: 28-35.Text#@
$$%% Annell A (1969). Manic-depressiveillness in children and effect of treatment with Lithium carbonate. ActaPaedopsychiatrica, 292-361. Text#@
$$%% Anthony J & ScottP (1960). Manic- depressive Psychosis in Childhood. Child Psychology andPsychiatry, 1:53-72. Text#@
$$%% Ballenger JC, Reus VI,Post RM. (1982). The atypical clinical picture of adolescent mania. AmericanJournal of Psychiatry, 139(5):602-606.Text#@
$$%% Barner-RasmussenP, Dupont A, Bille H (1986). Suicide in psychiatric patients in Denmark,1971-81 (I.Demographic and diagnostic description). Acta PsychiatricaScandinavica, 73:441-448.Text#@
$$%% Beardslee WR, Hoke L, WheelockJ, Rothberg PC, Veld P vd, Swatling S. (1992). Initial findings on preventiveintervention for families with parental affective disorder. American Journalof Psychiatry, 149:1335-1340. Text#@
$$%% Biederman J, Faraone SV,Keenan K, Tsuang MT (1991). Evidence of familial association between AttentionDeficit Disorder and Major Depressive Disorders. Archives of General Psychiatry,48(7):633-42. Text#@
$$%% Birch NJ (1982). Lithium, bone andbody weight study in long-term lithium-treated patients. Neuropsychobiology,8(2), 86-92. Text#@
$$%% Black W, Winokur G, Bell S,Naarallah A, Hulbert J (1988). Complicated Mania, Comorbidity and ImmediateOutcome in the treatment of Mania. Archives of General Psychiatry, 45:232-236.Text#@
$$%% Bowring MA, KovacsM (1992). Difficulties in Diagnosing Manic Disorders among Children andAdolescents. Journal of American Academy of Child and Adolescence Psychiatry,31(4):611-614. Text#@
$$%% Brady KT, Casto S, Lydiard RB, Malcolm R, Arana GW (1991).Substance abuse in an in-patient psychiatric sample. American Journal ofDrug and Alcohol Abuse, 389-397.Text#@
$$%% Burke KC, Burke JD jr., RegierDA, Rae DS (1990). Age at onset of selected mental disorders in five communitypopulations. Archives of General Psychiatry, 47:511-518.Text#@
$$%% Campbell M, Conzalez NM,Silva RR (1992). The pharmacological treatment of conduct disorders and rageoutbursts. Psychiatric Clinics of North America, 15(1):69-85.Text#@
$$%% Campbell M, Fish B, KoreinJ (1972). Lithium and Chlorpromazine, a controlled cross-over study ofhyperactive, severely disturbed young children. Journal of Autism and ChildhoodSchizofrenia, 2:234-263. Text#@
$$%% Campbell M, Silva R, KafantarisV, Lacascio JJ, Gonzalez N, Lee D, Lynch N (1991). Predictors of side-effectsassociated with Lithium administration in children. Psychopharmacol Bulletin.Text#@
$$%% Carlson GA (1979). Affective psychosein mental retardates. Psychiatr Clin North Am, 2:499-510.Text#@
$$%% Carlson GA (1984). ClassificationIssues of Bipolar Disorders in Childhood. Psychiatric Development, 4:273-285.Text#@
$$%% Carlson GA (1990). Annotation:Child and Adolescent mania. Diagnostic considerations. Journal of ChildPsychiatry, 31(3):331-341. Text#@
$$%% Carlson GA, Rapport MD, PatakiCS, Kelly KI (1992). Lithium in hospitalized children at 4 and 8 weeks: mood,behaviour and cognitive effects. Journal of Child Psychology and Psychiatry,33(2):411-25. Text#@
Caroll JA, Jefferson JW, Greisl JH (1987). Psychiatric use of Lithium for children and adolescents. Hospital Community Psychiatry, 38:927-928.#@
Cogan Mary Beth,1996, Diagnosis and Treatment of Bipolar Disorder in Children and Adolescents. http://www.mhsource.com
$$%% Cohen MD, Baker G, Cohen RA(1954). An intensive study of twelve cases of manic-depressive psychosis.Psychiatry, 17:103-137. Text#@
$$%% Compernolle Th& Postmes G (1995). Aandachtstekortstoornis met hyperactiviteit: een stoornis bij volwassenen die vaak gepaard gaat met een antisocialepersoonlijkheidsstoornis. Tijdschrift voor Psychiatrie, 37(10):769-779.Text#@
$$%% Coll PG, Bland R (1979).Manic-depressive illness in adolescence and childhood. Canadian Journal ofPsychiatry, 24:255-263. Text#@
$$%% Davenport YB, Adland ML, GoldPW, Goodwin FK (1979). Manic depressive illness psychodynamic features ofmultigenerational families. American Journal of Orthopsychiatry, 49(1);24-35.Text#@
$$%% Davenport YB, Zahn-Waxler C,Adland ML, Mayfield A (1984). Early Child-rearing practises in families witha manic depressive parent. American Journal of Psychiatry, 141:230-235.Text#@
$$%% Davis RE (1979). Manic depressivevariant syndrome of childhood, a preliminary report. American Journal ofPsychiatry, 136:702-705. Text#@
$$%% Delong GR (1978). Lithium carbonatetreatment of select behavior disorders in children suggesting manic depressiveillness. Journal of Pediatrics, 93(4):689-694.Text#@
$$%% Delong R (1990). Lithium treatmentand bipolar disorders in childhood. North Carolina Medical Journal,51(4):152-154. Text#@
$$%% Delong GR, AldershofSB (1987). Long-term experience with lithium treatment in childhood: Correlationwith clinical diagnosis. Journal of American Academy of Child and AdolescencePsychiatry, 26(3):389-394. Text#@
$$%% Delong GR, Nieman MA(1983). Lithium induced behavior changes in children with symptoms suggestingmanic-depressive illness. Psychopharmacology Bulletin, 19(2):258-263.Text#@
$$%% Dostal T, ZvolskyP (1970). Anti- aggressive effect of lithium in severe mentally retardedadolescents. Journal of American Academy of Child and Adolescence Psychiatry,29(2):269-277. Text#@
$$%% Dyson WL, Barcai A (1970).Treatment of children of lithium responding parents. Current Therapy Research,12:286-290. Text#@
$$%% Estroff TW, Dackis CA, GoldMS, Pottash ALC. (1985). Drug abuse and bipolar disorders. InternationalJournal of Psychiatry in Medicine, 15:37-40.Text#@
$$%% Fristad MA, Weller EB, WellerRA (1992) The mania rating scale & can it be used in children? A preliminaryreport. Journal of American Academy of Child and Adolescence Psychiatry,31(2):252-257. Text#@
$$%% Gaensbauer TJ, HarmonRJ, Cytryn L, Mathuw DH (1984). Social and affective development in infantswith a manic depressive parent. American Journal of Psychiatry, 141:223-229.Text#@
$$%% Gammon GD, Karen John MS,Rothblum ED, Mullen K, Tischler GL, Weisman MM (1983). Use of a structureddiagnostic interview to identify bipolar disorder in adolescent inpatients:Frequency and manifestations of the disorder. American Journal of Psychiatry,140(5):543-547. Text#@
$$%% Geller B, Cooper TB, Watts HE, CosbyCM, Fox LW (1992). Early findings from a pharmacokinetically designed doubleblind and placebo-controlled study of lithium for adolescents comorbid. withbipolar and substance dependency disorders. Progressive Neurology, 16(3):281-289.Text#@
$$%% Geller B, Fox LW, Fletcher M (1993).Effect of tricyclic antidepressants on switching to mania and on the onsetof bipolarity in depressed 6- to 12-years-olds. Journal of American Academyof Child and Adolescence Psychiatry, 32, 1:43-50.Text#@
$$%% van Gent EM, NabarroG (1984). Lithium en zwangerschap & psychiatriche aspekten. NederlandsTijdschrift voor Geneeskunde, 128(44):2089-2093.Text#@
$$%% Gibson RW, Cohen MB, CohenRA (1959). On the dynamics of the manic depressive personality. AmericanJournal of Psychiatry, 115:1101-1107.Text#@
$$%% Glassner B &Haldipur CV (1985). A psychosocial study of early onset bipolar disorder.Journal of Nervous and Mental Disease, 172(7):387-394.Text#@
$$%% Goodwin FK & Jamison KR (1990). Manic-depressive illness. New York: Oxford UniversityPress. Text#@
$$ Hesselbrock MN, Meyer RE, Keener JJ (1988).Psychopathology in hospitalized alcoholics. Archives of General Psychiatry,42:1050-1055. Text#@
$$%% Himmelhoch JM,Garfinkel ME (1986), Mixed Mania: Diagnosis and Treatment. PsychopharmacologyBulletin, 22(3):613-620. Text#@
$$%% Hughes CW, Preskom SH, WellerE, Weller R, Hassanein R (1989). A descriptive profile of the depressed child.Psychopharmacology Bulletin, 25(2):232-237.Text#@
$$%% Isaac G (1991). Bipolar disorderin prepubertal children in a special educational setting: Is it rare? Journalof Clinical Psychiatry, 52:165-168. Text#@
$$%% Isaac G (1992). Misdiagnosed bipolardisorder in adolescents in a special educational school and treatment program.Journal of Clinical Psychiatry, 53(4):133-6.Text#@
$$%% Jenkins JM & SmithMA (1991). Marital disharmony and children's behavior problems: aspects ofa poor marriage that affect children adversely. Journal of Child Psychologyand Psychiatry, 33(5):793-810.Text#@
$$%% Kafantaris V (1995). Treatmentof Bipolar Disorder in Children and Adolescents. Journal of American Academyof Child and Adolescence Psychiatry, 34(6): 732- 741.Text#@
$$%% Kashani JH (1989). Levels ofhopelessness in children and adolescents: a developmental perspective. Journalof Consulting in Clinical Psychology, 57(4):496-499.Text#@
$$%% Kestenbaum CJ (1979). Childrenat risk for manic depressive illness: possible predictors. American Journalof Psychiatry, 136(9):1206-1208. Text#@
$$%% Khandelwal SK, Varma VK,Srinivasa-Murthy R (1984). Renal function in children receiving long-termlithium prophylaxis American Journal of Psychiatry, 141:278-9.Text#@
$$%% Kutcher SP, Marton P, KorenblumM (1990). Adolescent bipolar illness and personality disorder. Journal ofAmerican Academy of Child and Adolescence Psychiatry, 29(3):355-358.Text#@
$$%% Lerner Y, Mintzer Y, SchestazkyM (1988). Lithium combined with haloperidol in schizophrenic patients. BritishJournal of Psychiatry, 153:359-62.Text#@
Lish JD, Dime-Meenan S, Whybrow PC, et al. The National Depressive and Manic-Depressive Association survey of bipolar members. J Affect Disord. 1994;31(4):281-294.
$$%% Mayo JA, O'Connell RA, O'BrienJD (1979). Families of Manic-Depressive Patients: effects of treatment. AmericanJournal of Psychiatry, 136(12):1535-1539.Text#@
$$%% McKnew DH, Cytryn Z, BuchsbaumMS, Hamavit J, Lamour M, Rapaport JL, Gerslon ES (1981). Lithium in childrenof Lithium responsive parents. Psychiatry Research, 4:171-180.Text#@
$$%% Mendlewicz J &Rainer JD (1974). Morbidity risk and genetic transmission in manic depressiveillness. American Journal of Human Genetics, 26:692-701.Text#@
$$%% Miklowitz D, GoldsteinMJ, Nuelerlein H, Schneider KS, Mintz J (1988). Family factors and the courseof Bipolar Affective Disorder. Archives of General Psychiatry, 45:225-231.Text#@
$$%% Mirin SM, Weiss RD, GriffinML, Michael J (1988). Psychopathology in substance-abusers: diagnosis andtreatment. American Journal of Drug and Alcohol Abuse, 14:139-157.Text#@
$$%% Müller E, SchapowahlA, Seelander A (1984). Katamnestische Ergebungen zur somatopsychosozialenEntwickelung in Kindheit und Jugend von Patienten mit monopolar depressivenund bipolar manisch-depressive psychosen, Psychiatrie und Neurologie Medicinein Psychologie, Leipzig, 8(5):486-488.Text#@
$$%% Nolen WA (1983). Carbamazepine, apossible adjunct or alternative to lithium in bipolar disorder. Acta PsychiatricaScandinavica, 67:218-225. Text#@
Nottelmann ED, Jensen PS. Bipolar affective disorder in children and adolescents. J Am Acad Child Adolesc. Psychiatry. 1995;34(6):705-708.
$$%% Post RM, Rubinow DR, Uhde TW,Roy-Byrne PP, Linnoila M, Rossoff A, Cowdry R (1989). Dysforic mania. Archivesof General Psychiatry, 46:353-9. Text#@
$$%% Poznanski EO, Freeman LM,Mokros HB (1985). Child Depression Rating Scale-Revised. PsychopharmacologyBulletin, 21:979-989. Text#@
$$%% Preodor D, WolpertES (1979). Manic-depressive illness in adolescence. Journal of Youth andAdolescence, 8:111-130. Text#@
$$%% Regier D.A., Boyd, J.H., BurkeJ.D. et al (1988), One month prevalence of mental disorders in the US. Archivesof General Psychiatry, 45,977-986Text#@
Robins LN, Helzer JE, Weissman M M, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41:949-958.
$$%% Rosenthal D (1970). Genetic Theoryand Abnormal Behavior. New York: McGraw-Hill.Text#@
$$%% Romans SE, McPhersonHM (1992). The social networks of bipolar affective disorder patients. Journalof Affective Disorders, 25:221-228.Text#@
$$%% Schmidt K, FreidsonS (1990). Atypycal outcome in attention deficit hyperactivity disorder. Journalof American Academy of Child and Adolescence Psychiatry, 29(4):561-570.Text#@
$$%% Shaw J, Bochner F, Moulds RFW,Ravenscroft PJ, Smith AJ (1990). Psychopharmacology of the psychiatric disordersof childhood and adolescence. Medical Journal of Australia, 152(1):32-38.Text#@
$$%% Sheard M (1971). Effect of Lithiumon human aggression. Nature, 230:113-114.Text#@
$$%% Siassi I (1982). Lithium treatmentof impulsive behavior in children Journal of Clinical Psychiatry, 43:482-484.Text#@
$$%% Sibisi CD (1990). Sex differencesin the age of onset of bipolar affective illness. British Journal of Psychiatry,156:842-845. Text#@
$$%% Smeraldi E, GasperiniM, Macciardi F, Bussoleni C, Marabito A (1982/83). Factors affecting thedistribution of age at onset in patients with affective disorders. Journalof Psychiatry Residence, 17(3):309-317.Text#@
$$%% Stewart JT, Myers WC, BurketRL, Lyles W (1990). A review of the Pharmacotherapy of aggression in childrenand adolescents. Journal of American Academy of Child and Adolescent Psychiatry,29(2):269-277. Text#@
$$%% Strober M, & CarlsonG (1982). Bipolar illness in Adolescents with major depression. Archivesof General Psychiatry, 39:549-555.Text#@
$$%% Strober M, Morell W, BurroughsJ, Lampert C, Danforth H, Freeman R (1988). Family study of bipolar I disorderin adolescence. Early onset of symptons linked to increased familial loadingand lithium resistance. Journal of Affective Disorders, 15:255-268.Text#@
$$%% Strober M, Lampert C, SchmidtS, Morrell W (1993). The course of major depressive disorder in adolescents:I. Recovery and risk of manic switching in a follow-up of psychotic andnon-psychotic subtypes. Journal of American Academy of Child and AdolescentPsychiatry, 32:34-42. Text#@
$$%% Swann AC (1995). Mixed or DysphoricManic States Psychopathology and Treatment. Journal of Clinical Psychiatry,56(3): 6-10. Text#@
$$%% Varanka TM, Weller RA, WellerEB, Fristad MA (1988). Lithium treatment of Manic episodes with psychoticfeatures in pre-pubertal children. American Journal of Psychiatry, 145:1557-1559. Text#@
$$%% Waters BGH, Marchenko-BouerI, Offord DR (1980). Interviewing Bipolar patients and their families. AmericanJournal of Psychiatry, 137(5):611-613.Text#@
$$%% Weinberg WA &Brumback RA (1976). Mania in childhood I & case studies and literaturereview. American Journal of Disease in Children, 130:380-2.Text#@
$$%% Weinberg WA & Emslie GJ (1988). Weinberg Screening Affective Scales (WSAS and WSAS-SF).Journal of Child Neurology, 3:294-296.Text#@
$$%% Weinberg WA & Emslie MD (1991). Attention Deficit Hyperactivity Disorder: the DifferentialDiagnosis. Journal of Child Neurology, 6:s23-s36.Text#@
$$%% Weller EB, Weller RA, FristadMA (1986). Lithium dosage guide for pre-pubertal children: a preliminaryreport. Journal of American Academy of Child and Adolescence Psychiatry,25(1): 92-5. Text#@
Weller EB, Weller RA, Fristad MA. Bipolar diagnosis in children: misdiagnosis, underdiagnosis, and future directions. J Am Acad Child Adolesc Psychiatry. 1995;34(6):709-714.???
$$%% White JH & O'ShanickG (1977). Juvenile manic depressive illness. American Journal of Psychiatry,134:1035-6. Text#@
$$%% Winokur G, Clayton PJ, ReichT (1969). Manic-depressive illness in St. Louis. St. Louis: C.V. Mosby.Text#@
$$%% Yesevage JA (1983). Bipolar illness:Correlates of dangerous in-patient behaviour. British Journal of Psychiatry,143:554-557. Text#@
$$%% Yudofsky S, Silver JM, SchneiderSE (1987). Pharmacological treatment of aggression. Psychiatric Annals,17:397-406. Text#@
$$%% Zahn-Waxler C, McKnew DH, CummingME, Davenport YB, Radke-Yarrow M (1984). Problem behavior and peer interactionsof young children with a manic-depressive parent. American Journal of Psychiatry,141:236-240. Text#@
$$%% Zerbin-Rüdin E(1979). Genetic endogener Psychosen. Schweizerisch Archives für Neurologie,Neurochirurgie und Psychiatrie, 125(2):287-299.Text#@
1.
2. Akiskal HS, Walker P, Puzantian VR, et al. Bipolar outcomes in the course
of depressive illness. J Affect Disord. 1983;5:115-128.
3. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Washington: American Psychiatric Association; 1994.
4.
5. Carlson GA. Identifying prepubertal mania. J Am Acad Child Adolesc Psychiatry.
1995;34(6):750-753. 6. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders
in a community sample of older adolescents: Prevalence, phenomenology,
comorbidity, and course. J Am Acad Child Adolesc Psychiatry.
1995;34(4):454-463.
7.
8.
9.
10. Strober M, Carlson GA. Bipolar illness in adolescents with major depression.
Arch Gen Psychiatry. 1982;39:549-555.
11.
[To the Contents][General Contents ] [Homepage]
[To the Contents][General Contents ] [Homepage]
[To the Contents][General Contents ] [Homepage]
Compernolle, Th.: Medical School, Vrije Universiteit, Amsterdam, and
Child and Youth Psychiatric Centre Triversum, The Netherlands
van der Weijden, G. APZ Veldwijk, Dep. Child and Adolescent Psychiatry,
Ermelo, The Netherlands
van den Ham, P.J. PCA Valeriuskliniek, Amsterdam, The Netherlands
Pijpers, G.I.M. Bedrijfsgeneeskundige Dienst Enschede, The
Netherlands
Correspondence:
prof.dr.Theo Compernolle
Academisch Ziekenhuis Vrije Universiteit Amsterdam
Department of Psychiatry
P.O. Box 7057
1007 MB Amsterdam
The Netherlands
tel: +31 20 4440196
fax:+31 20 4440197
e-mail: thc@4u.net
[To the Contents][General Contents ] [Homepage]