Partial (minimal to moderate) improvement with monotherapy, augment with another of the first-line recommendations. Stage 2: Monotherapy with an alternative drug, then augmentation. Stage 3: Possible medication combinations—lithium plus Divalproex, lithium plus atypical, or Divalproex plus atypical. Stage 4: Combination of 2-3 mood stabilizers
Stage 5: Alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (all Level D). Stage 6: For nonresponse or intolerable side effects—clozapine for children or adolescents, or electroconvulsive therapy (ECT) for adolescents only. BPD II, manic or mixed, with psychosis
Stage 1: Same as BPD I without psychosis except for first-line treatment warrants a combination of mood stabilizer and an atypical antipsychotic. Stages 2–4: Varying combinations and augmentations. Stage 5: Alternate monotherapy (oxcarbazepine) plus an atypical antipsychotic. (Bipolar Disorder in Children and Adolescents, 2005). Prognosis
Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies. Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.Children with bipolar disorder are more likely to commit suicide than other children. Epidemiology
The prevalence of bipolar in youth is estimated at 2%. History
Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century.
In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillargers criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.In Emil Kraepelins descriptions of bipolar disorder in the 1920s, which he called "manic depressive insanity", he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century. References
Bipolar disorder in children and adolescents: treatment and diagnosis: new treatment guidelines available. (2005). The Brown University Psychopharmacology Update, 16(4), 1+. https://link.gale.com/apps/doc/A130389603/AONE?u=mcc_main&sid=AONE&xid=5c0b7c9e
Mahoney, D. (2004). More studies on bipolar disorder sorely needed.