Bipolar Disorders in Children and Adolescents

Naomi A. Schapiro, RN, MS, CPNP

Disclosures

J Pediatr Health Care. 2005;19(3):131-141. 

In This Article

Abstract and Introduction

Abstract

In the past decade, 7 million children in the United States had a mental health problem, with higher rates of medication use, primary care visits, and specialty care visits than children without such problems. Children with bipolar disorders can present diagnostic and referral dilemmas for the primary care pediatric nurse practitioner, and frequently these children take multiple medications that interact with commonly used antibiotics, over-the-counter medications, and contraceptives. Diagnostic criteria for mania are controversial and coexisting attention deficit/hyperactivity disorder, conduct disorder, and anxiety disorders can complicate the diagnosis and treatment. The primary care pediatric nurse practitioner role includes referral, co-management, and advocacy for this vulnerable population.

Introduction

Fifteen-year-old Sean was diagnosed with attention deficit/hyperactivity disorder (ADHD) at age 8 years and has always had behavioral issues. He has taken mixed amphetamine salts (Adderall) since he was age 10, with documented effectiveness in improving his attention and reducing his impulsive behavior. This year his grades have plummeted. Sean has become increasingly irritable and has been out of the house twice overnight with no explanation. Sean's parents are concerned about substance abuse and are not sure if they should seek psychiatric care or drug counseling for him. There is a family history of "mood swings."

Marina is a 16-year-old girl you are seeing for an urgent appointment, whose history and physical examination are consistent with a sinus infection. Marina lets you know that she was hospitalized last month after "losing it and throwing stuff at my mom" and that she has been discharged with instructions to take three psychiatric medications. "I'm feeling better now so I don't want to take so many drugs," she says. Marina was prescribed low-dose oral contraceptives at her school-based health center and wants to know if you can refill her prescription. She is allergic to amoxicillin, having reacted with urticaria at age 8 years. Her current medications are: topiramate, 25 mg at bedtime; quetiapine, 25 mg at bedtime; sertraline, 100 mg daily in the morning; and 0.1 mg levonorgestrel/20 μg ethinyl estradiol (Alesse) daily.

The "new morbidities" of pediatrics, including ADHD, behavioral disorders, depression, and adolescent risk behaviors, are becoming an increasingly important part of primary care (Melnyk, Brown, Jones, Kreipe, & Novak, 2003; Schor, 2004). According to Mental Health, United States, 2002 , 7 million children ages 5 to 17 years had a mental health problem (Simpson, Scott, & Henderson, 2002). Almost 27% of children with mental health problems took some type of medication for more than 3 months, three times the rate of children without mental health problems, and they also used primary care and specialty medical services at higher rates (Simpson et al.). Forty-four percent of youth admitted to inpatient mental health services in 1997 had mood disorders (Pottick, Warner, Isaacs, Henderson, Milazzo-Sayre, et al., 2002). This article will look at the spectrum of mood disorders generally called bipolar disorder (BPD), giving an overview of definitions, etiology, overlapping conditions, current controversies, and treatment. Particular attention will be paid to presentation and co-management issues for the primary care pediatric nurse practitioner (PNP).

Children with bipolar disorder can affect a primary care pediatric practice in several ways: Like Sean, children with ADHD often have coexisting conditions that surface later, such as conduct disorders, substance abuse, and mood disorders. Parents and adolescents may consult the NP in primary care, requesting referrals to specialists. At other times, patients like Marina who present for routine or acute care are taking multiple medications for psychiatric conditions that may have adverse interactions with commonly used antibiotics, over-the-counter medications, and hormonal contraceptives.

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