Bipolar Disorder in Children Continues into Adulthood, Early Intervention Important
At a symposium on new research on juvenile bipolar disorder at the meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) in 2010, researchers shared new findings about juvenile bipolar disorder. One was Kathleen Merikangas’ finding published in AACAP’s journal in 2010 that the incidence of Bipolar I and II disorders is substantial in the child population (2.6%), and most children with the illness are severely impaired. This estimate of the incidence of bipolar disorder in children approaches the 3.0% incidence of the disorder in adults.
Another finding came from Janet Wozniak of Massachusetts General Hospital. Wozniak followed children with a bipolar diagnosis longitudinally and found substantial evidence of impairment and continuity of the diagnosis over 2-3 years. She found that 73.1% of the original 78 children (aged 10.5 years at first evaluation) were still fully symptomatic with a BP-I diagnosis after 3.6 years of follow up. Only five children of the 78 achieved a euthymic status without treatment. Nine children became euthymic while on treatment, while 5 experienced subthreshold major depressive disorder and another six had subthreshold manic symptomatology.
Dr. Wozniak indicated that these data were similar to Barbara Geller’s eight-year followup study, in which patients remained symptomatic for two-thirds of the weeks of followup and 44.4% continued to show full-blown manic episodes. Researchers Barbara Geller, David Axelson, and Joe Biedermann all have found that while there is a high incidence of initial improvement or transient remission in childhood bipolar disorder, there is an equally substantial relapse rate, indicating that the considerable morbidity of childhood-onset bipolar illness continues into adolescence and young adulthood.
All of these prospective studies converge with the retrospective studies in adults published in 2004 and 2009 by Perlis et al. in the STEP-BD research program and those by this researcher published in 2010 (Post et al.) in the Bipolar Collaborative Network (BCN), wherein onset of illness prior to age 13 was associated with a more severe course of illness and more adverse outcome than illness that began in adulthood. Wozniak’s prospective data, together with these retrospective data indicating the difficult course of illness with childhood onset, has led her to recommend to families that they “brace themselves for a long hard haul.”
At the symposium Wozniak emphasized the importance of early intervention, because children with more chronic persistent illness had greater functional incapacity (as seen in lower global assessments of function (GAF) scores), less cognitive flexibility (as measured by the set shifting portion of the Wisconsin Card Sort Test), increased family conflict, and more other Axis I comorbidities. They appeared to lose academic, social, and cognitive capabilities over time. Thus it is important to intervene psychotherapeutically and psychopharmacologically in order to prevent this downhill adverse course.
Emerging consensus
The data from many research groups now clearly indicate a substantial continuity of bipolar-I disorder in children as they are followed prospectively over three to five years and into adolescence. This is reflected in the COBY data of Axelson and his colleague Birmaher, in the Geller 8-year followup data, in the Wozniak prospective data, in prospective data from Melissa DelBello at the University of Cincinatti, as well as in the retrospective data from the adults in the BCN and STEP-BD networks.
These convergent findings, along with the new epidemiological data published by Merikangas et al., indicate that childhood-onset bipolar illness is in fact common and associated with substantial impairment and continuity into adult illness. Therefore, treatment initiatives should focus on the importance of early intervention in order to reduce symptoms and dysfunction and hopefully yield more benign illness outcomes.
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