Bipolar Disorder in Children- Efficient and careful diagnostic tools needed.

Bipolar disorder is generally defined as recurrent periods of mania and depression (Bipolar I) or hypomania and depression (Bipolar II). According to the website of National Institute of Mental Health (NIH), the lifetime prevalence of bipolar spectrum disorders is 0 to 3 % among adolescents, depending on assessment measured and the range of the spectrum considered. The prevalence of child onset bipolar is not well-established because there is no clear boundary of diagnosis and most of the symptoms overlap with other disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Schizophrenic disorders.
According to the article we read for class, ‘Bipolar disorder and mechanisms of action and mood stabilizers’ by Rapopart.et.al, 2009,  the mechanisms of bipolar disorder are believed to be due to imbalance neurotransmission, disease progression with worsening, cognitive decline, and progressive brain atrophy which can result in impairment of executive functioning, episodic memory, and sustained concentration. In neuroanatomical aspects, there is also thinning of the cortical mantle, widening of cortical sulci, and dilation of the lateral ventricles in bipolar patients. Neuroinflammation and excitotoxicity(incidence of  neural cell death due to over activation) are found to be underlying causes in Bipolar disorder. Neuroinflammation is due to increase Arachidonic Acid, a polyunsaturated omega-6 fatty acid derived from diet,  and excitotoxicity is  due to elevated brain glutamate/glutamine(excitatory neurotransmitter) ratio, and increase dopamine ,a  neurotransmitter that is usually found to be increased psychotic symptoms, levels.
In this blog, early onset bipolar symptoms and diagnosis in children will be discussed. Some general notable facts about bipolar disorder from the article, ‘The effect of the first manic episode in affective disorder: a case register study of hospitalized episodes’, by Kessing, Lars.1998. include –
–           “ Younger age at onset was associated with increased risk of developing a manic/circular episode for patients who presented with a depressive first episode “(Kessing, 1998)
–          “Courses of episodes were the same for patients for whom the first manic episode occurred later during the illness. Duration of intervals between episodes declined steadily with the number of episodes. “(Kessing, 1998)
–          The study found out that bipolar patients had the same rate of recurrence throughout the illness irrespective of at which episode or at what time their first manic episode occurred.
–          Patients who presented with depression but later developed mania were younger at onset than patients who remained unipolar. (Kessing, 1998)

According to the article, ‘A Summary of Clinical issues and Treatment Options’, by Canadian Network for Mood and Anxiety Treatments (CANMAT), ‘early onset is often defined as occurring before the age of 25. The younger the age of onset of bipolar disorder, the more likely it is to find a significant family history of the condition. Early onset bipolar disorder most commonly begins with depression.’ (CANMAT, 1997) ‘Depression with psychotic features may be a predictor of future full-blown bipolar disorder in the early onset group. Rapid cycling, mixed states, and psychotic features are more common in early onset conditions.’ (CANMAT, 1997) Hallucinations and delusions are also common precursor symptoms associated with bipolar disorder.
Principal components analysis of early intervention symptoms in children with and without bipolar diagnosis in Children, according to Fergusa.et.al, 2003, include-

1. Depression, II. Irritability/Dyscontrol, III. Mania, and IV, Psychosis/Suicidality.

Around age 7 and 8 –  “ The depression component (I) explained 14.2% of the variance and included nine symptoms (severe fatigue, periods of sadness, increased sleep, low self-esteem, more withdrawn, suicidal thinking, change in appetite, cries easily, and excessive guilt).
From age – 1 onward and greater incidence seen by age 3 – The irritability/dyscontrol component (II) explained 14.1% of the variance and included seven symptoms (temper tantrums, poor frustration tolerance, impulsivity, increased aggression, decreased attention span, hyperactivity, and irritability).
Around age 7 and 8 – Mania component (III) explained 11% of the variance and included six symptoms of mania (racing thoughts, extended mood elevation, pressured speech, grandiosity or delusions, bizarre behavior, and brief mood elevations).
Around age-9 onward – Psychosis/Suicidality component (IV) explained 10.2% of the variance and included five symptoms (hearing voices, paranoid thoughts, suicidal gestures, suicidal attempts, and obsessive thoughts).
According to the article, component II, ‘Irritability or dyscontrol‘ is the earliest symptom to discriminate the bipolar children from the other groups. This factor, according to the article, includes ‘temper tantrums, poor frustration tolerance, impulsivity, increased aggression, decreased attention span, hyperactivity, and irritability’. This factor is also supposed to be associated with later clusters of more classic manic and depressive symptoms that can lead to a diagnosis of bipolar illness. The symptoms in this category also overlaps with those of ADHD and they are believed to be the earliest precursors to classic bipolar see in adults and some adolescents, according to Fergus.et.al, 2003.
Diagnosing bipolar disorder, especially in children, is not a clear cut process and should not rely only on the established guidelines of symptoms. The diagnosis should take into consideration both the unique bipolar symptoms that are apparent in adolescents and adults and if necessary, also compare the symptoms with anatomical brain abnormalities from imaging brain scans.