Pediatricians may be underrecognizing mania in children who are diagnosed
with attention-deficit/hyperactivity disorder (ADHD) and may be unlikely to
refer to a psychiatrist until the child is depressed or suicidal.
A comparison of children in designated pediatric and psychiatric sites who
exhibited "prepubertal and early adolescent bipolar disorder
phenotype" (PEA-BP) found that those seen in pediatric settings were
more likely to receive stimulants and less likely to receive antimanic
medications than children seen in psychiatric settings. The article appeared
in the August Journal of the American Academy of Child and Adolescent
Pediatricians should be encouraged to refer children who are diagnosed with
ADHD for psychiatric consultation if the children respond poorly to
monotherapy with ADHD medications, have a worsening course, or develop
non-ADHD symptoms, said lead author Barbara Geller, M.D., and colleagues.
"Two take-home messages are that the pediatrician may underrecognize
mania and may be more likely to wait until a child is depressed or suicidal
before referring to a psychiatrist," Geller told Psychiatric
She is a professor of psychiatry at Washington University School of
Medicine in St. Louis.
In the study, children from designated psychiatric and pediatric
facilities, regardless of diagnosis, were given a comprehensive
assessment—including the Washington University in St. Louis Kiddie
Schedule for Affective Disorders and Schizophrenia—by experienced
researchers who were blinded to diagnostic status. The study took place
between 1995 and 1998.
Based on the assessment, they found 93 patients with PEA-BP. Inclusion
criteria for boys and girls, who were aged 7 to 16, included good physical
health and a current DSM-IV diagnosis of BP-I (manic or mixed phase)
for at least two weeks. At least one of the two cardinal symptoms of mania
(elation, grandiosity) was required to avoid diagnosing mania only by symptoms
that overlapped with those of ADHD (hyperactivity, distractibility). Those
with any of several potentially confounding medical and psychiatric conditions
In general, the researchers found that patients at psychiatric sites had
more severe illness and received more complex treatment than those at
pediatric sites. Moreover, patients in psychiatric settings were less likely
to be living in a biologically intact family.
Scores on the Children Global Assessment Scale (CGAS) were significantly
lower in subjects with PEA-BP in psychiatric versus pediatric sites, and rates
of mixed mania (defined as overlapping periods of mania and major depressive
disorder) and suicidality were significantly higher at psychiatric sites.
Significantly more subjects with PEA-BP at psychiatric versus pediatric
sites were taking an antimanic medication (32.8 percent versus 3.4 percent),
while stimulant medication was significantly more common among subjects
treated at pediatric sites (93.1 percent versus 45.3 percent).
"Child psychiatrists undergo two years of specialized training in
addition to training in general psychiatry and are therefore competent in
identifying symptoms of mania and of other psychiatric disorders,"
Geller and colleagues wrote in the report. "It may not be feasible,
however, to expect nonpsychiatrist practitioners to have this same level of
expertise. By contrast, educating nonpsychiatrist practitioners that some
children with ADHD may have more complex disorders could be
An abstract of "Children With a Prepubertal and Early
Adolescent Bipolar Disorder Phenotype From Pediatric Versus Psychiatric
Facilities" is posted at<www.jaacap.com/pt/re/jaacap/abstract.00004583-200508000-00008.htm>.▪