Bipolar and Related Disorders

Spotlight on Pediatric Bipolar Disorder

Avatar photoTori Rodriguez, MA, LPC, AHC
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Child-Bipolar-Disorder
The main focus of the debate surrounding pediatric bipolar disorder pertains to the concept of a prepubertal subtype of the disorder.

While reported rates of bipolar disorder in youth vary across the limited available studies on the topic, a 2019 meta-analysis1 of 19 epidemiological studies (N=56,103) found that the weighted average prevalence of bipolar spectrum disorders among pediatric populations was 3.9% (95% CI, 2.6%-5.8%). However, some experts dispute the validity of the concept of pediatric bipolar disorder.2

In a paper published in the International Journal of Bipolar Disorders in 2021, Parry et al analyzed the studies included in the 2019 meta-analysis and concluded that the disorder is very rare among children.3 They stated that pediatric bipolar disorder “as a diagnostic construct fails to correlate with adult bipolar disorder and the term should be abandoned,” warning of adverse iatrogenic consequences that may result from overdiagnosis of the disorder in youth.

The main focus of the debate surrounding pediatric bipolar disorder pertains to the concept of a prepubertal subtype of the disorder. In a 2020 paper, Duffy et al4 explored potential reasons for the divergent views on the topic, including overlap between mania and symptoms of attention-deficit/hyperactivity disorder; poorly defined symptoms and episodes of mania in prepubertal children; and an “over-reliance on symptoms and structured interviews rather than on a clinical assessment incorporating developmental history, social context, and clinical course.”

In a commentary published in December 2021 in Bipolar Disorders, Manpreet K. Singh, MD, MS, associate professor of psychiatry and behavioral sciences at Stanford University School of Medicine in California, and colleagues discussed some of the points of disagreement regarding the validity of the diagnosis of pediatric bipolar disorder.5 They note that similar doubts existed decades ago regarding the existence of pediatric-onset major depressive disorder — doubts that are “virtually nonexistent today.”

Among the research they cited in support of pediatric bipolar disorder, a study of 3,658 adults with bipolar disorder showed onset of symptoms before age 18 in 70% of participants, with 30% of these individuals reporting onset before age 12. Dr Singh and colleagues also noted the significant diagnostic delays (8-10 years on average) affecting individuals with bipolar disorder and reported that one-third of youths diagnosed with unipolar depression are ultimately diagnosed with bipolar disorder.

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“We should iteratively ask ourselves whether the odds of missing a diagnosis of BD outweigh the odds of overcalling it,” they wrote.5

We interviewed Dr Singh to glean further insights into this ongoing debate.

Manpreet K. Singh, MD

What does the available evidence suggest about the prevalence of bipolar disorder in children? 

Dr Singh: The lifetime prevalence of bipolar disorder is roughly 1%, with a range between 0.5%-2%, which is now considered a conservative estimate based on existing epidemiological data.6 Studies that included more adolescents had significantly higher prevalence estimates. Differences in the definition of bipolar disorder help explain the largest portion of variance between studies. Not surprisingly, broader definitions including bipolar disorder not-otherwise-specified or cyclothymic disorder had the highest rates, while narrow definitions such as bipolar I disorder and bipolar II disorder only had lower rates.

What are your thoughts about the debate regarding the legitimacy of the concept and term “pediatric bipolar disorder?”

Dr Singh: Challenges with the use of the term “pediatric” in pediatric bipolar disorder are curious. If you look at the medical specialty of pediatrics, it clinically evaluates and treats youth as young as the newborn period but also well into the 20s, especially if the youth developed a condition that started in childhood or adolescence and continued on into young adulthood. Research in bipolar disorder has suggested that two-thirds of adults who live with bipolar disorder described the onset of their symptoms in childhood or adolescence.5

We can debate the prevalence of bipolar disorder across development or across borders, but those debates can and should happen without undermining the lived experience of many with this condition. For them, bipolar disorder has been a lifelong challenge that most frequently began in childhood or adolescence.   

What are some key considerations for clinicians regarding the diagnosis of bipolar disorder in children — including how to differentiate from other disorders with overlapping symptoms?

Dr Singh: A careful and systematic evaluation of mania and depressive symptoms would benefit all youth presenting with mood problems. Many clinicians now understand that though some cardinal symptoms might make bipolar disorder more likely, a repeated evaluation accompanied by mood symptom tracking over time can be very informative, especially when the diagnosis is unclear.  

There are several distinguishing characteristics in addition to mood states, such as duration of mood, response to therapy, family history, and whether antidepressants are helpful, that can provide useful clues about differentiating bipolar disorder from other conditions with overlapping symptoms.7 However, a sure way to miss bipolar disorder is to miss asking about mania symptoms. 

What are some of the main ongoing needs in this area? 

Dr Singh: Analyses over the past few years of available citations suggest that research on youth-onset bipolar disorder is declining. Given the significant lifelong burden of early-onset bipolar disorder and the challenges associated with its timely diagnosis and treatment, it is critical to continue to make progress in education and research. Our patients are counting on us to develop ways to diagnose this condition as close to its onset as possible because early detection and treatment are likely to improve prognosis, and at the very least, prevent exposure to undesirable treatments that can potentially worsen the outcome.

The field needs biomarkers for early detection; more evidence-based preemptive interventions, like family-focused therapy, for example, for those found to be at high risk for or in early presyndromal stages of illness; and better treatments for those living with bipolar disorder that track with outcomes.6

References

  1. Van Meter A, Moreira ALR, Youngstrom E. Updated meta-analysis of epidemiologic studies of pediatric bipolar disorder. J Clin Psychiatry. 2019;80(3):18r12180. doi:10.4088/JCP.18r12180
  2. Goldstein BI, Post RM, Birmaher B. Debate: Fomenting controversy regarding pediatric bipolar disorder. Child Adolesc Ment Health. 2019;24(1):95-96. doi:10.1111/camh.12318
  3. Parry P, Allison S, Bastiampillai T. ‘Pediatric Bipolar Disorder’ rates are still lower than claimed: A re-examination of eight epidemiological surveys used by an updated meta-analysis. Int J Bipolar Disord. 2021;9(1):21. doi:10.1186/s40345-021-00225-5
  4. Duffy A, Carlson G, Dubicka B, Hillegers MHJ. Pre-pubertal bipolar disorder: Origins and current status of the controversy. Int J Bipolar Disord. 2020;8(1):18. doi:10.1186/s40345-020-00185-2
  5. Singh MK, Post RM, Miklowitz DJ, et al. A commentary on youth onset bipolar disorder. Bipolar Disord. 2021;23(8):834-837. doi:10.1111/bdi.13148
  6. Goldstein BI, Birmaher B, Carlson GA, et al. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord. 2017;19(7):524-543. doi:10.1111/bdi.12556
  7. Singh MK, Chang KD, Goldstein BI, et al. Isn’t the evidence base for pediatric bipolar disorder already sufficient to inform clinical practice? Bipolar Disord. 2020;22(7):664-665. doi:10.1111/bdi.12987