Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder

PRACTICE PARAMETERS FOR THE ASSESSMENT AND TREATMENT OF CHILDREN AND ADOLESCENTS WITH BIPOLAR DISORDER

Diagnostic assessment.
1. Premorbid history.
  1. Cognitive, motor, sensory, social, or other developmental problems.
  2. Premorbid personality characteristics; i.e., temperament, mood, anxiety, and/or behavioral problems.
2. History of present illness.
  1. Document DSM-IV (APA, 1994b) target symptoms (both manic and depressive symptoms), as well as associated phenomena (e.g., psychotic symptoms, suicidality). The symptoms should represent a significant change from baseline functioning, with associated changes in the child's mental status. Rapidity of onset and any precipitating stressors should be noted.
  2. Examine the longitudinal course of illness. It is often helpful to create a life chart to identify cyclical and/or seasonal patterns.
  3. Assessment for associated or confounding symptoms, especially substance abuse, organic factors, and/or behavioral disorders.
3. Family history.
  1. Obtain a thorough family history of mood, anxiety and psychotic disorders, suicidality, impulse control disorders, neurological and medical conditions, and substance abuse.
  2. Family emotional, communicative, interactional, and coping styles and resources.
4. School information.
  1. Obtain information about school functioning, both premorbid and subsequent to the onset of symptoms, either directly or from written reports from appropriate staff, such as the principal, school psychologist/counselor, teacher, and/or nurse after release of information is granted.
5. Neuropsychological functioning.
  1. Suspected disabilities in either intellectual functioning, communication abilities, and/or motor skills should be evaluated to help with the differential diagnosis and/or to identify comorbid problems. Assessments to consider include psychological testing (IQ, neuropsychological testing, adaptive functioning, and/or academic testing), speech and language assessment, and/ or an occupational/physical therapy evaluation.
6. Consultation and collaboration with other mental health and/or social service providers as necessary.
7. Physical evaluation of the child. A thorough evaluation is needed to rule out organic conditions.
  1. A pediatric examination is needed, including a thorough neurological evaluation, especially in the presence of either psychotic symptoms and/or catatonia, with consideration of neurological consultation, EEG, and computed tomographic and magnetic resonance imaging head scans. This may be done in collaboration with the primary family physician or other health care providers.
  2. Medical conditions that mimic either mania or depression, such as metabolic, endocrine, infectious disorders, or acute intoxication/withdrawal, need to be evaluated as indicated. Routine laboratory tests (i.e., blood counts, renal and liver functions, thyroid functions, toxicology screen, pregnancy test, and urinalysis) are usually indicated, both as part of the organic workup and also as baseline assessments for medication therapy. If the risk factors are present, testing for HIV should be done, with appropriate informed consent.
Diagnostic formulation.
1. A diagnosis of bipolar disorder is made when the required DSM-IV (APA, 1994b) target symptoms for mania/mixed state are present, either currently or by history, and other disorders, such as schizophrenia or organic affective disturbances, have been adequately ruled out. Once the diagnosis has been established, it should be reassessed longitudinally to ensure accuracy.
2. In the assessment of children and adolescents presenting with symptoms suggestive of bipolar disorder, evaluation includes consideration of:
  1. Recent onset of biopsychosocial stresses.
  2. Educational and vocational potential, disabilities, and achievement.
  3. Peer, sibling, family, and sociocultural problems and strengths.
  4. Environmental factors, including disorganized home, presence of child abuse/neglect, and/or mental illness in parents or guardians.
  5. Developmental abnormalities (motor and language delays).
  6. Child/adolescent interpersonal strengths, especially the ability to form adult and peer relationships.
3. Differential diagnosis.
  1. The following conditions may be misdiagnosed as bipolar disorder:
    1. Schizophrenia.
    2. Schizoaffective disorder or other psychotic disorders (delusional disorders, schizophreniform disorder, psychosis not otherwise specified).
    3. Organic affective disorders.
    4. Childhood disruptive behavior disorders.
    5. Borderline personality disorder (or other personality disorders/traits that present with affective instability and erratic behavior).
    6. Posttraumatic stress disorder.
  2. The following conditions often occur comorbidly with bipolar disorder:
    1. Substance abuse disorders.
    2. Childhood disruptive behavioral disorders.
    3. Anxiety disorders.
  3. The following medical conditions may mimic bipolar disorder:
    1. Organic mania:
      1. Organic mania due to substance abuse or withdrawal (amphetamines, cocaine, phencyclidine, inhalants, methylenedioxymethamphetamine).
      2. Organic mania due to prescribed medications, such as antidepressant agents (induced mania), sympathomimetics, bromocriptine, stimulants, and/or corticosteroids.
    2. Neurological disorders (e.g., brain tumors, posttrauma, CNS infections, including HIV, multiple sclerosis, temporal lobe seizures, Kleine-Levin syndrome).
    3. Metabolic conditions (e.g., hyperthyroidism, urermia, Wilson's disease, collagen vascular disorders, delirium).
Treatment.
1. Substantial scientific evidence suggests that the only specific treatment of bipolar disorder is medication therapy using a mood stabilizer. However, medications need to be used in conjunction with a multimodal treatment model that also includes psychoeducational services, individual and family supportive and psychotherapeutic interventions, educational programs, and community support services. Psychotherapeutic interventions must be sensitive to cultural issues.
  Most of the treatment recommendations are based on studies of adults. However, the limited available research on early-onset bipolar disorder, plus clinical consensus within the field, suggests that these findings can be applied to youth as long as pertinent developmental factors are incorporated into the treatment plan.
  
  The following elements are necessary to develop a multimodal treatment formulation:
  1. Thorough diagnostic assessment. Acute mania or severe depression (especially psychotic depression) may require hospitalization, depending on the severity and potential danger of the symptomatology, as well as the social supports of the family. Hospitalization may be necessary because of the extensive array of psychiatric and neurological evaluation resources required to complete the initial assessment, and the need for a more structured, safe environment in which to evaluate the patient.
  2. Assessment for suicide potential, since this population is at significant risk for attempting/completing suicide.
  3. Identification of other pertinent issues, i.e., family dysfunction, school difficulties, and premorbid and/or comorbid disorders, requiring ongoing treatment.
  4. Evaluation and initiation of medication therapy.
  5. Education of the patient and family as to the nature of the illness, potential prognostic issues, and treatment needs.
  6. Development of a long-term treatment plan, including medication management, appropriate psychotherapy and psychoeducational services for the patient, supportive services for the family (advocacy groups, support groups), appropriate educational and vocational services, and residential services when indicated.
  7. Designation of a case manager for chronically disabled individuals because of the wide range of services needed.
  8. Provisions for long-term periodic diagnostic reassessments to ensure accuracy of diagnosis.
2. Psychopharmacology. The phase of the illness needs to be considered when making decisions on medication therapy.
  1. Acute mania/mixed mania.
    1. Prior to initiating medications, a thorough psychiatric evaluation is needed, including documentation of the symptoms targeted for therapy. Informed consent is needed from the parents and adolescent patients, and assent, when possible, should be obtained from preadolescents.
    2. In adults, lithium has been the most extensively researched antimanic agent, and its efficacy has been documented. The anticonvulsants valproate and carbamazepine are also used, with greater evidence supporting the efficacy of valproate. During the acute phase, it may be necessary to augment the antimanic agent with either an antipsychotic agent or a benzodiazepine to address the associated psychomotor agitation and/or psychotic symptoms.
    3. To determine whether or not an antimanic medication is effective, it must be used for at least 4 to 6 weeks at adequate dosages and blood levels. If no effects are seen at that point, consideration should be given to either adding or changing to a different antimanic medication.
    4. As the acute manic symptoms stabilize, the patient may cycle through a period of confusion and disorganization. These symptoms may also progress into a depressive episode. It is important to recognize these as phases of the disorder; otherwise, the tendency may be to make significant changes in the medication regimen that may, in fact, only prolong recovery. The antimanic agent should be maintained through this phase, with modifications in dosage or augmenting agents to further ameliorate the presenting symptomatology.
  2. Depressed phase.
    1. Care must be taken in using antidepressant agents because they may induce a manic episode. Patients with established bipolar disorder should be maintained on an antimanic agent prior to initiating antidepressant therapy.
    2. As patients recover from mania, it is common for them to cycle through a depressive phase. This phase often resolves with continued antimanic treatment; therefore, the addition of an antidepressant may not be necessary unless the depressed phase persists or becomes severe.
  3. Remission.
    1. Long-term maintenance therapy with an antimanic agent is indicated to prevent relapse. Data are inadequate to specify how long prophylactic treatment should be maintained. However, one study of youth suggests at least 18 months of therapy is necessary, and, undoubtedly, some patients will need lifelong treatment.
    2. If multiple psychotropic agents were needed to treat the patient's acute symptoms, attempts to taper adjunctive agents (e.g., antipsychotic agents, benzodiazepines) should be made once remission has been achieved and the patient is clinically stable. Patients with bipolar disorder may be at increased risk for tardive dyskinesia with long-term neuroleptic use. Similarly, if more than one antimanic agent has been used to control manic symptoms, an assessment is needed to determine if remission can be maintained with a single agent. Close monitoring for relapse is necessary during these changes.
  4. Relapse of symptoms.
    1. When symptoms relapse, it should first be determined whether or not the patient was compliant with prophylactic therapy. If nor, resumption of the antimanic medication should occur. If the patient was compliant and had been previously responding to the agent (without significant side effects), an increase in the medication dose may stabilize the symptoms (keeping in mind the standard dosage ranges and blood levels).
    2. If symptoms relapse and the patient is not adequately responding to the current antimanic agent (at adequate dosages), a trial of a different antimanic, either alone or in addition, should then be undertaken. Adjunctive agents (e.g., antipsychotics, benzodiazepines, antidepressants) may also be indicated, depending on the symptom presentation.
    3. Patients who relapse may require acute hospitalization. This decision should be based on the severity of affective and psychotic symptoms, potential danger to self or others, degree of impairment in the patient's ability to maintain basic self care, and availability of supportive services in the community.
  5. Patients who do not respond to standard therapy.
    1. Before it is decided that the patient is a nonresponder, the patient should receive at least two adequate trials of different antimanic agents, one of which should be lithium. An adequate trial is defined both by duration (4 to 6 weeks) and dosage (using maximal levels if necessary and tolerated).
    2. In adults, other agents with reported antimanic activity include clozapine, benzodiazepines, calcium channel blockers, and thyroid hormones. However, these have not been studied in children and adolescents. If clozapine is to be used, close monitoring for potential seizures, agranulocytosis (with periodic blood cell counts), and weight gain is necessary.
3. ECT.
  1. The efficacy of ECT for bipolar disorder, both mania and depression, is well established for adults. There is also some literature supporting its use in youth with bipolar disorder. It is generally used only for medication-resistant cases. However, it may be considered as an Initial treatment for severe psychotic depression and/or catatonia.
4. Psychosocial therapy.
  1. Psychoeducational therapy for the patient, including ongoing education about the illness, medication effects, social skills training, problem-solving skills strategies, and basic life skills training. Part of the focus should be on relapse prevention, including compliance with medications.
  2. Psychoeducational therapy for the family, focusing on increasing the understanding of the illness, treatment options and prognosis, relapse prevention, and effective coping and parenting intervention strategies.
  3. Specialized education programs and/or vocational training programs.
  4. Individual (usually supportive rather than insight-oriented), group, or family psychotherapy to address associated psychosocial problems that increase morbidity.
5. Treatment of associated disorders or symptoms, such as substance abuse disorders, disruptive behavior disorders, and/or suicidality. .
6. Partial hospitalization or day treatment programs.
  1. Many patients will need the specialized educational and psychiatric services available in either a partial hospitalization or day treatment program to be maintained at home within their community.
7. Residential treatment.
  1. In some cases, the severity of the individual's illness or lack of effective response to treatment (often in conjunction with chaotic social situations) may necessitate long-term hospitalization or residential treatment. This option should only be considered after less restrictive alternatives have been unsuccessful. Once in a long-term residential setting, the patient's status needs to be reassessed at regular intervals, with the goal of returning to a less restrictive setting when possible.
8. Flexible models of care.
  1. Many youth with bipolar disorder will be chronically impaired, with complicated clinical and social needs, and may need an integrated continuum of services, including: case management, intensive community and family support, in-home services, out-of-home care (including respite and specialized foster care), and specialized educational/vocational services.

Conflict of Interest

In keeping with the requirement that practice parameters be developed by experienced clinicians and researchers, some of the contributors to these practice parameters are in active clinical practice. Through their practices, it is likely that most of these child and adolescent psychiatrists have received income related to treatments discussed in these parameters. Some contributors are primarily involved in research or other academic endeavors; it is possible that through such activities, many of them have also received income related to treatments discussed in these parameters. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. First, the development process calls for extensive review of the document before it is finalized. All members of the Academy have the opportunity to comment on the parameters before they are approved. Comments have been solicited and received from a broad group of reviewers in child and adolescent psychiatry. Second, the contributors and reviewers have all been asked to base their recommendations on an objective evaluation of the available evidence. Third, we ask that contributors or reviewers who believe that they have conflicts of interest that may bias or appear to bias their work notify the Academy.

Literature Review Process

A National Library of Medicine search was initially done in May 1994, covering the preceding 5-year period. The following topics were reviewed: bipolar disorder and adolescents (39 articles), bipolar disorder and children (105 articles), and bipolar disorder and early onset (21 articles). This search was updated periodically (most recently in December 1995) to identify new articles. Searches were also undertaken to review specific topics (e.g., the use of lithium, valproate, and carbamazepine in children and adolescents). The abstracts generated by these MEDLINE searches were reviewed to identify articles relevant to early-onset bipolar disorder. Pertinent papers published before the 5-year search period were also reviewed, as were review articles and texts addressing the larger adult literature. Finally, the authors also drew from their own research in this area. Articles most often used are marked with an asterisk in the reference section.

This literature review was used to develop the initial draft of the manuscript. After review by the Committee on Quality Issues, this draft was then distributed to a panel of experts for comment. The panel of experts included Hagop S. Akiskal, M.D., William Arroyo, M.D., Joseph Biederman, M.D., Kelly Botteron, M.D., Charles Bowden, M.D., Stacy Bower, R.N., Ian Canino, M.D., Magda Campbell, M.D., Gabrielle Carlson, M.D., Debbie Carter, M.D., Mark DeAntonio, M.D., Mina Dulcan, M.D., Norbert Enzer, M.D., Robert Freeman, R.N., Mary A. Fristad, Ph.D., Barbara Geller, M.D., Peter S. Jensen, M.D., Vivian Kafantaris, M.D., P. Keck, M.D., Wun Jung Kim, M.D., Maria Kovacs, Ph.D., Carlyn Lampert, M.S.W., Benjamin C.P. Lee, M.D., S. McElroy, M.D., Editha D. Nottelmann, Ph.D., Kambiz Pahlavan, M.D., Myrna Pollack, M.S.W., Elva Poznanski, M.D., Andres Pumariega, M.D., David Rue, M.D., Neal Ryan, M.D., Susan Schmidt-Lackner, M.D., Jeanne Spurlock, M.D., Michael Strober, Ph.D., Richard D. Todd, M.D., Ph.D., Michael W. Vannier, M.D., Elizabeth Weller, M.D., Ronald Weller, M.D., and Deborah Zarin, M.D. Their comments were then incorporated into the manuscript, which was then reviewed by the Academy members at large, with a public forum at the Annual Meeting in New Orleans, October 19, 1995. After incorporating the membership's input, a final draft was reviewed and adopted by the Academy's Council June 15, 1996.

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