Many people are shocked to hear that anyone as young as Rebecca Riley could be diagnosed as having bipolar disorder and prescribed powerful psychotropic medications. Following are several questions I have been hearing about the case recently that are related to early childhood diagnosis and treatment followed by my answers:

Q: Do you think diagnosing a child as young as Rebecca Riley as having bipolar disorder could be appropriate in certain situations?

A: I find it hard to imagine diagnosing a preschooler with bipolar disorder, because their brains are too immature and incompletely developed to exhibit symptoms well formed enough to meet criteria for bipolar disorder. Typical preschool development includes immature mood regulation and impulse control. Sleep problems are incredibly common in toddlers and preschoolers, as are temper tantrums. How can you define a mood state as a “change from baseline” in a child so young that they haven’t even been around long enough to establish a baseline?

This is not to say that preschoolers cannot exhibit emotional and behavioral patterns that are quite atypical and that need to be evaluated and addressed. But this evaluation must focus on a wide array of specific developmental, medical, neurologic, metabolic, and environmental factors in such a young child before determining that it is primarily a disorder of mood presenting with behavioral symptoms.

Q: How does bipolar present differently in children than adults?

A: This is the million dollar question. Those who support the diagnosis of bipolar in young children have clearly said that bipolar disorder presents very differently in children. Their definition of mania is essentially mood changes that can occur multiple times per day, with bipolar primarily presenting as extreme irritability. This is a change in the use of the term bipolar disorder. The classic diagnosis of bipolar disorder must include well formed mood episodes – specifically a manic episode is necessary that lasts at least a few days, not several hours.

In adult bipolar research, people are exploring the possibility of a spectrum of bipolar disorder that includes a much wider range of mood regulation problems. However this is still early research. Most of the studies about medical treatment of bipolar disorder have been done on people with classic bipolar disorder – distinct episodes of mania and distinct periods of depression.

So the question of a more expansive diagnosis of bipolar disorder is being looked at in adults and children. However, we have few studies of any medication treatments using this spectrum model in adults and even fewer studies in children. Since we are already taking something of a leap of faith in using the medications found helpful in classic bipolar disorder for children, we are even further away from any research base when we expand our diagnostic pool so dramatically.

There is no data so far supporting the idea that these children with very atypical symptoms of “bipolar disorder” grow up to have classic bipolar disorder as adults. So whether these atypical presentations are really precursors to well defined bipolar or signs of some type of bipolar spectrum disorder in adulthood or, in fact, something else entirely remains utterly unclear.

Q: Do you think it is ever okay to prescribe psychotropic medications to children as young as Rebecca Riley was at the time?

A: Psychotropic medication in very young children is something to be extremely cautious about. There may be appropriate times to try medication when there are symptoms that are severe and causing major impairment in life and development. I will only prescribe for very young children after comprehensive evaluation, including multiple evaluators. I consider psychotropic medications for very young children only when other interventions have not worked. If the decision is made to prescribe, I will do so in the context of extremely careful monitoring, active family and environmental support and interventions, and close communication between all of the adults involved in the care and developmental needs of this child.

Q: Do you think that non-medication interventions should always be tried prior to prescribing medications for such young children?

A: As explained above, non medication interventions should be developed and implemented (especially parent and educational interventions) before looking at psychotropic medications in such young children.

Q: If a doctor does prescribe these medications to such young children, what sorts of monitoring should parents expect the doctor to do? How often should the doctor check in with the patient and in what form; for example, is a phone call to the parents standard or should the doctor actually see the child?

A: This varies from doctor to doctor, but regular office visits will be necessary. (“Regular visits” can also vary, but as a very general guideline, which does not always apply, I’d say a couple weeks from the first visit and at least monthly when actively adjusting medications.) Phone calls or emails should be encouraged between visits if family or other caretakers have questions or concerns.

Communication with all members of the team is particularly valuable and can help keep everyone aware of how the child is doing. I think of the team as including, at minimum, the psychiatrist and the family, but I find that it should also include other adults in the system, such as teachers, social workers, other school or medical supports, such as speech and occupational therapists, pediatricians, and other medical personnel.

Conversations with these people or getting reports or emails from them greatly aids my understanding and how I work with all children, but especially very young ones. Gathering collateral information is a central part of my work. Information from family members and my own observations of a small child do not give me a complete picture most of the time.

Please share your insights and opinions.

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    Last reviewed: 22 Jan 2010