The diagnosis of preschool bipolar disorder presenting with mania: open pharmacological treatment

Diagnosis of bipolar disorder (BPD) in preschool children is controversial, although preliminary data suggest that children with BPD may present with classic manic symptoms in a more chronic, rapid cycling presentation. While children with BPD are extremely dysfunctional, presenting symptoms and symptom expression remains to be further defined. Clarification of the presentation of BPD in children could result in better treatment.

Thirty-one patients, ages 2-5 years, were identified by chart review of all children treated at our pediatric bipolar clinic. All available historical, symptom, and treatment information was collected and summarized.

Patients were approximately 2:1 male: female, predominantly Caucasian, with an average age of symptom onset of 3 years. Most frequent presenting symptoms (100%) included irritability, increased energy, and aggression. Prominent symptoms (>80%) included euphoria, grandiosity, decreased need for sleep, pressured speech, and distractibility. Eighty percent of patients had concurrent Attention-Deficit Hyperactivity Disorder (ADHD). Twenty-one of the 31 patients reported prior treatment attempts with either a stimulant or antidepressant without the protective benefit of a mood stabilizer, and of these, 13 (62%) reported a worsening of mood symptoms during that treatment period. Twenty-six of 31 were initially treated in our clinic openly with a mood stabilizer, primarily valproic acid, with a significant decrease in manic symptoms (p=0.03) following initial treatment. Long-term treatment demonstrated continued improvements from baseline (p=0.01).

The retrospective design of this study limits the conclusions that can be drawn. Due to the lack of a formal protocol, treatment was open and based on clinical judgment on an individual case basis.

The symptom expression in these patients allowed for diagnosis according to DSM-IV criteria. Treatment with mood stabilizers was clinically effective, with corresponding significant developmental benefits.