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The diagnosis of bipolar disorder in children has many similarities to Bipolar disorder (BD), a type of mood disorder previously called manic-depressive disorder. All forms of BD are characterized by periods of extremely elevated or irritable mood, which can sometimes alternate with episodes of depression. Bipolar disorder can be diagnosed in children as young as preschool. The lifetime prevalence of BD is between 0.5 to 1.6%, and the prevalence may be as high as 1% in youths alone. When diagnosed in children, BD is most commonly characterized by increased energy, distractibility, pressured speech, irritable mood, grandiosity, and elevated mood. BD is an increasingly common diagnosis in children, due to several factors including an expansion of diagnosis criteria from classic manic depressive symptoms to more general manic symptoms, availability of knowledge about BD in children, and desire for insurance reimbursement for treating symptomatic behaviors of bipolar disorder.

The diagnosis of bipolar disorder in children is a highly controversial issue, as the disease was previously thought to rarely occur in youths. However, more than 60% of adults with BD report having their first mood episode before the age of 19, as the typical age of onset is during adolescence. When the DSM-IV was published in 1994, pediatric bipolar disorder was not included as a diagnosis. Currently, the American Psychological Association is currently working on criteria and classification for a new subset of BD, Pediatric Bipolar Disorder (PBD), to be included in the 2013 publication of DSM-V. One of the main challenges in categorizing PBD as a separate diagnosis in DSM-V is understanding the symptomology of BD in children, for it has been poorly studied in the past but is now beginning to be more thoroughly understood.

Signs and symptoms
Pediatric bipolar disorder (PBD) causes a significant impairment in the ability of children to function normally, especially in academics and psychosocial areas, and it is a chronic disorder that persists throughout the lifetime. Children with PBD experience chronic periods of mania, characterized by elevated and irritable moods, or depression. PBD patients are ten times more likely to commit suicide than healthy children. Severe manic and depressive symptoms are associated with early age of diagnosis, meaning children often display more acute symptoms than adults. Children with PBD display anger, dysphoria, irritability, belligerence, and mixed-manic depressive symptoms more commonly and for more erratic time periods than adults. In children, mania often presents with psychotic symptoms and mixed manic depressive episodes, yet these symptoms differ from classical descriptions of mania in adults. Although the presentation of manic periods in children is unique,children who are diagnosed with bipolar disorder show the same brain abnormalities as adults, further complicating diagnosis.

Brain structure
Functional magnetic resonance imaging (fMRI) is a non-invasive tool used to show concrete links between brain functioning and psychiatric disorders. fMRI technology produces images which show how blood flow in the brain changes. Neural activity can therefore be visualized because it causes changes of blood flow in the brain. Using fMRI images, altered mechanisms of brain functioning have been seen in PBD patients in brain areas such as the ventral prefrontal cortex, cingulated cortex, amygdalae, and hippocampus. In fMRI comparisons of healthy children with previously unmediated PBD patients, treatment of the PBD patients with a second generation antipsychotic and an anticonvulsant resulted in increased activity in affective brain regions and decreased activity in cognitive brain regions. fMRI studies show prescription of antipsychotics may permanently alter the brain development in children, and it is a reason why treatment plans should be carefully monitored.

Treatment
Prompt treatment of PBD is important because it minimizes developmental delays and dysfunctions; however, current treatment recommendations are based off of adult treatment models.

Pscychopharmacology
Increasingly, psychopharmacology is being looked to for treatment of PBD, but studies showing the safety and efficacy of psychopharmacology in treating PBD are rare. From 1993 to 2003, 90.6% of pediatric bipolar patients who visited an outpatient physician practice were prescribed a psychotropic medication. Although doctors are prescribing medication to treat PBD, there is no standard treatment for it because the current research available has found high rates of adverse events in many pharmacological treatment options, and children have been found to be at greater risk for adverse events when taking psychotropic medications. Current treatment options for bipolar disorder in children include antipsychotics, atypical antipsychotics, second generation antipsychotics, mood stabilizers, and anticonvulsants. The only FDA medications approved to treat bipolar disorder in children are: lithium, risperidone, aripiprazole, olanzinpine, and aripriprazole; however, even these FDA approved drugs have negative side effects such as sedation, somnolence, and weight gain.

Alternative treatments
Alternative treatments have been shown to reduce bipolar symptoms while causing few side effects. One current theory is omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help to manage bipolar disorder in children. Both EPA, which can be metabolized into DHA, and DHA are phospholipid components of cell membranes, and abnormalities of these phospholipids in cell membranes have been found in bipolar disorder. PBD patients who supplemented their diet with omega-3 fatty acids saw a reduction of mania symptoms. Other alternative treatments, such as a micronutrient diet, have found similar results. In one study of using micronutrients to treat PBD, parents purchased a 36-ingredient micronutrient product and monitored their child’s progress over six months. Symptoms were reduced by 50% in almost half of the subjects, and there were few side effects.

Psychotherapy
Psychotherapy has also been shown to be helpful in treatment of PBD. In individual psychotherapy, children are closely monitored for symptoms and progress,and they are also taught life skills by a therapist. Because PBD impacts children’s academic, social, and family life, psychotherapy is also used to help manage functional and developmental impairments. One additional aspect of psychotherapy in treating PBD is family therapy. Through educating and informing parents and family members, children with PBD are able to maintain treatment gains. Additionally, by educating family members, medication adherence and communication within the family is improved, leading to greater treatment gains.