Heading Off Early Symptoms of Bipolar Disorder in Children at High Risk
At the American Academy of Child and Adolescent Psychiatry (AACAP) annual meeting in Toronto in October 2011, there was a symposium on risk and resilience factors in the onset of bipolar disorder in children who have a parent with the disorder.
Family Focused Therapy Highly Encouraged
Amy Garrett reported that family focused therapy (FFT) in those at risk for bipolar disorder was effective in ameliorating symptomatology compared to treatment as usual. Family focused therapy, pioneered by Dave Miklowitz, PhD of UCLA involves three components. The first component is education about the illness and methods of self-management. The second is enhancement of communication in the family with practice and rehearsal of new modes of conversation. The third component is assistance with problem solving.
In Garrett’s study, 50 children aged 7 to 17 were randomized to family focused treatment or treatment as usual. These children were not only at high risk for bipolar disorder, they were already prodromal, meaning they were already diagnosable with bipolar not otherwise specified (BP-NOS), cyclothymia, or major depressive disorder, and had also shown concurrent depressive and/or manic symptoms in the two weeks prior to the study. At baseline, compared to controls, these children at high risk for full-blown bipolar disorder by virtue of a parental history of the illness showed increased activation of the amygdala and decreased activation of the prefrontal cortex. Most interestingly, after improvement with the family focused therapy (FFT), amygdala reactivity to emotional faces became less prominent and dorsolateral prefrontal cortical activity increased in proportion to the degree of the patient’s improvement.
The discussant for the symposium was Kiki Chang of Stanford University, who indicated that the results of this study of family focused therapy were already sufficient to convince him that FFT was a useful therapeutic procedure in children at high risk for bipolar disorder by virtue of having a parent with a history of bipolar illness. Chang is now employing the therapy routinely in all of his high-risk patients.
Editors Note: This is an extremely important recommendation as it gives families a specific therapeutic process in which to engage children and others in the family when affective behavior begins to become abnormal, even if it does not meet full criteria for a bipolar I or bipolar II disorder.
FFT also meets all the important criteria needed for putting it into widespread clinical practice. Family focused therapy has repeatedly been shown to be effective in adults and adolescents with bipolar illness and now also in these children who are prodromal. The psychoeducational part of FFT is common sense, and dealing with communication difficulties and assisting with problem solving also have merit in terms of stress reduction. Finally, this treatment intervention appears to be not only safe but also highly effective in a variety of different prodromal presentations of affect disorders even if children do not meet full criteria for bipolar disorder. While the few studies of early intervention with psychopharmacological agents have not yet identified efficacious medications for the prodromes of bipolar disorder and in particular medications with a high degree of safety, such family focused therapy appears to be an ideal early intervention.
I would concur with Dr. Chang’s assessment. Family focused therapy (FFT) should be offered to all children with this high-risk status who have begun to be symptomatic. Early onset of unipolar depressive disorder or of bipolar disorder carries a more adverse prognosis than the adult onset variety and thus should not be ignored. If more serious illness is headed off early, it even raises the possibility that the full-blown illness will not develop at all.
Gray Matter Volume Abnormalities
Tomas Hajek of Dalhousie University in Halifax presented data indicating that in children at high risk for bipolar disorder, gray matter volume in the right inferior frontal gyrus is increased. Read more
Primary Care Doctors Important in Detecting and Managing Childhood Mental Illness
The National Alliance on Mental Illness (NAMI) conducted a survey to determine ways that primary care providers can better communicate with parents about a child’s mental illness. In a news release NAMI executive director Michael Fitzpatrick said, “Most Americans rely on family doctors and pediatricians for early detection of mental illness and in many cases treatment.”
NAMI concluded that primary care providers could play a larger role in detecting mental illness in children. They found that in 63% of families, the first signs of behavioral or emotional problems were evident in children by age 7. More than half of families reported that their primary care physicians were not knowledgeable about mental health treatments. Almost two-thirds of families reported that their primary care providers were not knowledgeable about local resources to support families with mentally ill children.
NAMI’s suggestions for primary care providers included educating themselves about early-onset mental illness and local resources for families, providing screening tools for parents and youth in order to encourage discussion of mental health, emphasizing that mental health is as important as physical health to a child’s wellbeing, asking questions about mental health as a routine part of office visits, and listening to families’ concerns without judgment.
Primary care providers are also encouraged to let families know that there is hope and that they are not alone in facing this difficulty, that mental illness in a child is not the parents’ fault, and that their children have many strengths.
Primary care doctors should also be prepared to: refer a mentally ill child to psychiatrists, psychologists, and other specialists if needed; follow up, including collaborating with other healthcare providers to develop and implement a treatment plan; and encourage patients and their families.
Puberty Occurs at Younger Ages
Experts disagree about the data that show an earlier onset of depression and bipolar disorder in every successive generation since the first World War (this change is called the cohort effect). Nonetheless, it is interesting that so many other medical conditions are increasingly seen in young children. These include asthma, arthritis, obesity, allergy, diabetes, and a host of other conditions. WebMD reported that menarche and the onset of puberty are also occurring at younger ages. Puberty used to be a largely teenage occurrence, and now it occurs in many children as early as age 7.
Mothers’ SSRI Use May Lead to Increased Risk of Pulmonary Hypertension in Infants
The New York Times summarized findings about the effect of mothers’ antidepressant use on enfants from an article published by Kieler et al. in the British Medical Journal this year.
Researchers have long suspected a link between the use of selective serotonin reuptake inhibitors, or S.S.R.I.’s, and [pulmonary hypertension in babies], but previous studies have been small and inconclusive (with results ranging from there being no link to a six times greater risk).
This research, based on 1.6 million births in Denmark, Finland, Iceland, Norway or Sweden from 1996 to 2007, showed that among women using S.S.R.I.’s, the risk of persistent pulmonary hypertension for infants more than doubled (particularly for use late in pregnancy). It’s still a small risk: 3 in 1000 births, as opposed to 1.2 per 1000 births overall. But it’s a small risk of a serious problem.
Pulmonary hypertension, Dr. Juliette Madan, a pediatrician at the Dartmouth Hitchcock Medical Center explained, is diagnosed when an infant struggles to get enough oxygen into her lungs, and therefore into her bloodstream. The condition can be deadly, although Dr. Madan said that it’s usually treatable — with possible lifelong consequences.
But other research suggests that untreated depression during pregnancy has its own risks, including pre-term birth and low birth weight. Given that, how should a pregnant woman and her doctor weigh the competing risks?
See the New York Times for a discussion on how to balance mother’s health with babies’ health.
Prenatal BPA Exposure Might Lead to More Hyperactivity, Depression, and Anxiety in Young Children
BPA can be found in the lining of cans.
An article published by Braun et al. in Pediatrics last year suggests that children who were exposed to higher levels of BPA while in the womb exhibited more anxious and depressed behaviors and poorer emotional control and inhibition at age 3. Braun described the implications of this finding to Medscape Medical News:
“At this point, we don’t know what these findings mean in terms of clinical disorders of behavior,” Joe M. Braun, MSPH, PhD, from the Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, told Medscape Medical News. “Future studies will need to determine if BPA exposures are associated with clinical behavior disorders,” he said.
BPA is used in a variety of consumer products, including dental sealants, food/beverage containers and linings, medical equipment, and thermal receipts, such as those from ATM machines. Virtually all people in industrialized nations are exposed to the plasticizer.
“People who are concerned about BPA exposure could decrease or eliminate their consumption of canned or packaged foods; they could also avoid contact with thermal receipts,” Dr. Braun said.
Omega-3 Fatty Acids Could Help Treat ADHD in Children
An article by Bloch & Qawasmi published in the Journal of the American Academy of Child and Adolescent Psychiatry last year suggested that omega-3 fatty acids could improve ADHD in children. The effects were milder than the standard pharmacological treatments for ADHD, but given that omega-3s have few side effects, there would be little risk to using them to supplement traditional treatments or in cases where traditional treatments cannot be used.
Editors note: It would also be worth seeing if omega-3s helped mood symptoms too. A meta-analysis we wrote about here suggests that the omega-3 fatty acid EPA or the combination of EPA plus DHA has positive effects on depression in adults.
Risks and Difficulties of Treating Childhood-Onset Bipolar Disorder
Early treatment is needed in childhood onset bipolar disorder
Multiple factors make childhood-onset bipolar disorder a difficult problem for affected children and families. Early onset is common, and treatment is often delayed or inappropriate. It takes an average of nine months to achieve remission, and relapses are common. In studies children have remained symptomatic for an average of two-thirds of the time they receive naturalistic follow up treatment, and the illness impairs social and educational development. Episodes and stressors tend to accumulate, and substance abuse is a frequent complication. Dysfunction and disability occur at a high rate among children with the illness, and suicidal ideation and acts are common.
When we surveyed adults in our treatment network, the Bipolar Collaborative Network (BCN), about the history of their illness, we found that the duration of the time lag between illness onset and first treatment was independently related to a poor outcome in adulthood. A longer delay to first treatment was associated in adulthood with greater depression severity, more days depressed, fewer days euthymic, more episodes, and more ultradian cycling (or cycling within a single day). Because treatment delay is a risk factor that can be avoided or prevented, efforts should be made to initiate treatment early in the course of bipolar illness. Read more
Studies in Adults Shed Light on the Prevalence of Childhood Bipolar Disorder and the Need for Early Treatment
At the 2011 Pediatric Bipolar Disorder Conference in Cambridge, Massachusetts this past March, Dr. Andrew Nierenberg from Massachusetts General Hospital presented a plenary paper, “What can we learn about bipolar youth from bipolar adults in 2011?”
Since it appears that a substantial number of bipolar adults experience illness onset in childhood, Nierenberg said that a useful approach to treating the illness over the lifetime is to begin treatment in childhood. Early intervention may be more effective and easier to accomplish than treatment much later in the course of illness after multiple pathological psychological, biochemical, and physiological occurrences and interactions have occurred.
Nierenberg’s research was gleaned from reviewing several studies that indicated that a substantial subgroup of bipolar adults had an early age of onset. He included data from his own STEP-BD studies published by Perlis et al. in Biological Psychiatry in 2004 and data from our Bipolar Collaborative Network published by Post et al. in the British Journal of Psychiatry in 2008, as well as a study by Hamshere et al. published in the Journal of Affective Disorders in 2008, a study by Goldstein and Levitt published in the American Journal of Psychiatry in 2006, research by Ortiz et al. and by Bauer et al. both published in Psychiatry Research in 2010, and a study by Baldessarini et al. published in the Journal of Affective Disorders in 2010.
These studies indicate that one-fifth to a quarter of adult outpatients with bipolar disorder experienced illness onset prior to age 13, and one-half to two-thirds of patients experienced their onset in childhood or adolescence, i.e., before age 19.
Maternal Smoking and Drinking Linked to ADHD in Kids with Bipolar Illness
At the 57th Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) in New York in October 2010, Tim Wilens of Massachusetts General Hospital (MGH) presented data that maternal smoking and alcohol use during pregnancy both appeared to increase the risk of comorbid attention deficit hyperactivity disorder (ADHD) in children with bipolar disorder.
Genetic Basis for Childhood Onset of Bipolar Illness
Eric Mick of Massachusetts General Hospital reviewed the latest genetics data on bipolar disorder and reported at the 57th Annual Meeting of the American Academy of Child and Adolescent Psychiatry that 20% of people with childhood-onset bipolar illness have a first-degree relative with bipolar disorder, while only 10% of those with adult-onset bipolar disorder have a first-degree relative with bipolar disorder. These data are consistent with others that indicate that there is an increased genetic/familial risk for bipolar disorder in childhood- compared with adult-onset illness.
Mick reviewed a number of findings that suggest that alterations in genes involved in intracellular signaling and in the development and maintenance of long-term memory may also be implicated in bipolar disorder. Classical genome-wide association studies (GWAS), in which a link between any human gene and bipolar disorder is sought, have not found any genes with a large effect or a high predictive value for bipolar illness. In the meantime, other strategies for finding genetic links to bipolar disorder are being pursued, including studying rare gene variants. There is some evidence that these variants occur more frequently in children with early onset bipolar illness.
