Important issues concerning treatment of a bipolar child or adolescent. And prognosis for bipolar children.

Bipolar Treatment Goals:

The goals of treatment, whether inpatient or outpatient, are to control and minimize symptoms of bipolar disorder, lengthen the periods of normal mood states or euthymia, minimize the number of needed hospitalizations, eliminate or minimize medication adverse effects to a tolerable level, and optimize the quality of life for the patient. Quality-of-life issues for a young person include meaningful relationships with family, peers, mentors, coaches, and teachers; optimal academic performance; and optimal occupational performance as it pertains to endeavors such as music, art, dance, athletics, or other personally rewarding areas from which the adolescent derives a sense of competency, mastery, and pleasure.

Although current treatments are empirically derived, most clinicians in outpatient settings provide and recommend both individual and family therapy in addition to medication monitoring and management.

• Cognitive and behavioral methods are used in adolescents, and behavioral methods usually are used in the preadolescent population. This is based on the idea that preteens are not cognitively or verbally mature enough to respond to cognitive restructuring methods.
• Family therapy is encouraged because adjusting to having a child who has bipolar disorder is a family matter that involves parents, the identified child, and siblings.
• The goals of individual therapy and family therapy should be individualized. Nonetheless, global goals of reduction of family stress, improvement of family communications, and addressing unresolved feelings of fear, hurt, or loss as a result of having a mental disorder affect a loved family member are common themes.
• In the family and individual sessions, medication issues and compliance also should be addressed so that optimal care can be attained in the outpatient setting.
• Lastly, the patient and family need psychoeducation about bipolar disorder and its management.

In mental health care centers and in private practices, most patients and their families receive care from many professionals. Psychiatrists, psychologists, behavioral and developmental pediatricians, social workers, and many other therapists are involved in treating the patient, monitoring the response to and tolerance of medications, and providing psychotherapy to the family and the patient. Ideally, these professionals work together in a team approach so optimal care can be attained in the medical, educational, family, and social realms.

Prognosis for Children and Adolescents with Bipolar Disorder:

• In general, the onset of bipolar disorder in childhood and adolescence has revealed a stronger family history for bipolar disorder than later onset; thus, individuals are at increased genetic and familial risk from the beginning of life. An emerging body of evidence indicates that optimal treatment for the genetic or familial form of bipolar disorder may differ from other treatment modalities of other bipolar conditions. Adverse outcomes of early age of onset of bipolar disorder are as follows: (1) the course is generally more severe, and (2) the course of illness is more refractory to treatment than the course of the disorder when the onset starts in adulthood.
• As with so many psychiatric and medical disorders in children and adolescents, early mood disturbances of bipolar disorder may be precipitated or exaggerated by increased stress in home, school, and social settings. As the patient ages, the tendency to have stress as a contributory factor to a mood episode declines and the mood disruptions may occur spontaneously, even in the presence of medication and treatment compliance. This trend seems to be found in the adult population and not in children or adolescents; it is thought to be the result of kindling.
• In the general population, suicide remains one of the top 10 causes of death in adolescents and young adults; it is the fourth most common cause of death in persons aged 10-15 years and the third most common cause of death in persons aged 15-25 years.
  • All persons with bipolar disorder have an increased risk of suicide.
  • The exact increase of the risk in youths is unknown; however, in young adults with bipolar disorder, suicide has a higher incidence in males within the first few years of the diagnosis. Current suicide rates in patients with bipolar disorder range from 10-15%.
  • In adults, treatment with lithium reduces the suicide rate; similar studies in adolescents and children do not exist, but lithium has been demonstrated to reduce substance use in adolescents with bipolar disorder.
• The presence of episodic mood events should be anticipated throughout the life cycle once bipolar disorder has been diagnosed. The frequency and severity of each episode are not readily predictable, but some trends have emerged. In the presence of medication and treatment compliance, relapses may occur during which hospitalization may be required. In the absence of compliance, the course of the illness can be much more severe.
• One potentially reassuring aspect of bipolar disorder is that potential exists for a full and normal life during the periods between mood swings. Thus, many persons with bipolar disorder may continue their college education and careers with much success, and strong relationships may be fostered and nurtured.

Patient Education:

• Psychoeducation of parents and patients is an important aspect of treating an adolescent or child in whom bipolar disorder is diagnosed. The young person must be provided the relevant facts in an age-appropriate and developmentally appropriate manner. The diagnosis, benefits of treatment, and detriment of treatment noncompliance should be made clear and understandable. Inpatient and outpatient psychiatrists, psychologists, social workers, and other therapists involved in the care of the youth and the family should be able to aid the patient and family in the understanding and management of bipolar disorder in a loved one.
• Families and patients can learn about adolescent or childhood bipolar disorders through the American Academy of Child and Adolescent Psychiatry web site in the section titled "Facts for Families" (http://www.aacap.org/cs/root/facts_for_families/facts_for_families). This provides a user-friendly fact and information sheet to families about bipolar disorder and its treatment in the pediatric population.
• Another resource is the Depressive and Bipolar Support Alliance (http://www.ndmda.org), a support group for patients and families of patients who have bipolar disorder. These groups are more for adults, and parents are far more likely to benefit from this group than adolescents or children.
• For excellent patient education resources, visit the HealthyPlace.com Depression Center. Also, see HealthyPlace.com's comprehensive information on Bipolar Disorder.

Sources:

• Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Sep 1997;36(9):1168-76.
• Kowatch RA, Fristad M, Birmaher B, et al. Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. Mar 2005;44(3):213-35.

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