Bipolar disorder type I (BP-I) is considered by the DSM-V to be a cross between a psychotic disorder because of the tendency towards obsessive fixations and a mood disorder due to the wild and often sudden presentations of emotional affect (American Psychiatric Association, 2013). BP-I includes periods of mania marked by increased creativity, hyperactivity, distractability, and risk-taking; and alternately by major depressive episodes that include depressed mood, anhedonia, sleep dysfunction, fatigue, and rumination of feelings of worthlessness and guilt. The diagnosis relies on both the individual states and the swing between the two states to cause significant disruption in most or all aspects of social life (work, school, relationships, etc.). Bipolar disorder type II (BP-II) is considered a less pronounced manifestation of BP-I, though the oscillation between the two extremes of mood are still debilitating and have a major negative impact on all aspects of one’s life.
From their presentation, BP-I is closer to schizophrenia on the spectrum of psychotic disorders than BP-II, and BP-II more closely resembles major depressive disorder than BP-I. Both types of bipolar disorder reduce lifespans by 10 to 20 years through an increased risk of cardiovascular diseases and mental health crises including suicide (McIntyre et al., 2020). BPs are widely considered to be highly heritable, though this is most likely an epigenetic phenomenon created by a combination of currently unknown genetic predisposition and environmental factors such as childhood abuse, trauma, and extreme family instability (Vieta et al., 2018).
The differentiation between adults and children is not specified in the DSM-V even though it is used as the primary reference for determining diagnosis. There are a few references in the text to how BP might manifest in minors, such as, “… however when such beliefs [in high accomplishment] are present despite clear evidence to the contrary or the child attempts feats that are clearly dangerous and, most important, represent a change from the child’s normal behavior, the grandiosity criterion should be considered satisfied” (American Psychiatric Association, 2013a, p. 128). Similarly vague reference to manifestation in children continues throughout the text which leads to a preponderance of misdiagnosis, and one might even suggest that any diagnosis of bipolar disorder in a child could be inappropriate (Connors, 2023): a longitudinal study found that 2.5% of children were diagnosed with bipolar disorder, yet none of them exhibited those symptoms by the end of the study, regardless of whether they were medicated or untreated (Pandeti & Boyes, 2021).
Treatment and Medication
BP during childhood is often approached with a medication-first protocol because the elements of therapy that are normally applied may be emotionally, mentally, or intellectually inaccessible to children, though a simplified version of cognitive behavior therapy may be included in programs were development-appropriate (NYU Langone Health, n.d.).
BP’s first line of medication is usually lithium to stabilize mood both by curtailing mania and relieving depression. Its actions are still not well understood, though it has demonstrated neurogenic, cytoprotective, antioxidant, anti-inflammatory, and synaptic maintaining properties across multiple studies (Kerr et al., 2018). However, it has a distinct neuroendocrine impact that directly affects the reproductive system (Filippa & Mohamed, 2019), a serious consideration when applying this remedy to children. The neurogenic aspect is equally concerning as administering lithium to a brain that is already in a rapidly developing condition can introduce any number of unforeseen negative outcomes. This is beyond the common side effects of drowsiness/somnolence, unwanted weight gain, cognitive impairment, fatigue, nausea, and/or kidney dysfunction (excessive thirst and urination).
Anticonvulsants such as topiramate (Topamax), valproic acid (divalproex, or Depakote), or lamotrigine (Lamictal) may also be considered as they do seem to affect the moods of people with epilepsy through either increasing GABA availability or antagonizing glutamate. These medications can invoke side effects that include a blunted emotional affect, dizziness, drowsiness, gastrointestinal issues, weight gain, and tremors. Despite their popularity for prescription especially for children who exhibit aggression, self-injury, or otherwise destructive behavior, studies have found that this class of drugs has no significant affect on bipolar symptoms in children (Davico et al., 2018).
The third class of medications used to treat childhood bipolar disorder is antipsychotics, mostly second- and third-generation, such as aripiprazole (Abilify), risperidone (Risperidol), and lurasidone (Latuda). Long-term effects have not been established, but there is serious concern about the extrapyramidal side effects and the risks of cerebral atrophy from using intense neuroleptics in actively developing brains (Parry et al., 2019).
Discussion about Risks, Benefits, and Ethics
The first dimension that should be considered when addressing any condition, especially psychiatric, is what the patient’s quality of life (QOL) is. When addressing children with behavioral and psychological disorders as a special population, clinicians should be particularly careful about how the QOL of the child is impacted versus the QOL of the family. Moreover, especially with bipolar disorder, the clinician should be very leery of a medication-first approach as bipolar disorder is quite frequently a childhood trauma response (Aas et al., 2016; Cascino et al., 2021; Citak & Erten, 2021; Farias et al., 2019; Quidé et al., 2020).
This aspect cannot be overstated, that environment is the foremost contributor to a mental health crisis, regardless of age, and while, yes, neurology is directly affected and may need to be addressed, approaching any case medication-first, especially in children, is short-sighted and potentially dangerous . Short-term medication for the sake of overcoming immediate crisis events may be necessary, but the main focus of treatment should always be discovering the source of trauma, relieving that source of trauma, and then mental and emotional support to recover from the trauma.
And, children are vulnerable to trauma from many different dimensions in their lives, from many, many sources. It may be considered that most parents are not the source, but the fear of implication (fear of blame) keeps them from rationally considering who might be victimizing their children. This resistance has likely fueled the over-diagnosis of childhood mental health disorders (Glassgow et al., 2020; Merten et al., 2017), while the application of adult-form BP and other conditions leads to a preponderance of false-positive diagnoses (Pandeti & Boyes, 2021).
In short, because the etiology of bipolar disorder is not well-understood, and more so for children, treating children who exhibit bipolar symptoms from a medication-first protocol with intentions of long-term usage is irresponsible and dangerous, potentially negatively impacting every aspect of neurological development. Short-term pharmaceutical intervention may be necessary for circumstances that include violence, suicidality, and self-injurious behaviors, but investigation should be immediately launched to determine the source of mental and emotional trauma alongside specifically trauma-informed therapies.
References
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Filippa, V. P., & Mohamed, F. H. (2019). Lithium therapy effects on the reproductive system. In P. Á. Gargiulo & H. L. Mesones Arroyo (Eds.), Psychiatry and Neuroscience Update: From Translational Research to a Humanistic Approach—Volume III (pp. 187–200). Springer International Publishing. https://doi.org/10.1007/978-3-319-95360-1_16
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Thanks to Gerd Altmann from Pixabay for the header image!