Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

245 Bipolar disorder in children and adolescentstimes more likely to develop BP disorder. However, offspring of BP parents arealso at risk of developing depression, anxiety, and disruptive disorders. The resultsof these studies (Table 10.3) should be carefully examined because of the difficultiesin diagnosing children with BP disorder and due to the following methodologicalproblems:(1) small sample sizes with few young children(2) lack of longitudinal follow-up(3) inclusion of a heterogeneous group of parents (BP and unipolar)(4) lack of controls(5) retrospective assessments(6) offspring assessments not conducted blind to parental diagnosis(7) no direct assessment of offspring(8) lack of analysis of developmental influences on psychopathology(9) use of unspecified diagnostic criteria(10) lack of standardized assessments of psychopathology and family history(11) no assessments of parental comorbid psychiatric disorders(12) no psychiatric assessment of the proband’s spouse(13) no measurement of the effects of environmental stresses(14) no evaluation of the presence of subsyndromal symptoms and whethersevere disruptive disorder symptoms are part of the clinical picture of BPdisorder during childhood(15) lack of control for intrafamilial correlationsAn ongoing study at the University of Pittsburgh Medical Center, USA, in a largesample of children of BP and non-bipolar parents, taking into account the abovelimitations, will help to clarify the initial symptoms of BP disorder in children. Forexample, answers are being sought for questions such as: is the psychiatric symptomatologyin the offspring of BP parents the way that BP non-mood disordermanifests in young children, prodromal symptoms of BP disorder, or the manifestationsof other non-mood psychiatric disorders?TreatmentThere are no randomized controlled trials (RCT) for bipolar disorder in childrenand adolescents. Open studies in samples of children and adolescents with moretypical DSM or Kraepelinian or DSM-type BP syndromes have suggested thatapproximately 40–80% respond to lithium, valproate, and carbamazepine(e.g., Geller and Luby, 1997; Kowatch et al., 2000) Despite the response and overalltolerance to these medications, most of these patients usually require othermedications to control their mood (e.g., the atypical antipsychotics) or for themanagement of their comorbid disorders (e.g., stimulants for ADHD). Patients