Vol 11, N°1 Child and Adolescent Psychiatry
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here has been great public and academic inter- est in the diagnosis and treatment of bipolar disorders (BD) in children and adolescents over the past decade, originally in the US but now extending internationally. Thus, in the US in the past decade, diagnoses of BD in children under 18 years old have risen 4000% in the com- munity.1 Whether this increase is due to increased recog- nition, increased incidence, or overdiagnosis is not clear. However, it is becoming clear that BD begins in child- hood 50% to 66% of the time.2,3 Therefore, if the inci- dence of BD (I or II) in adults is 4%,4 then there are at least 1 to 2 million children in the US alone with BD or the beginning manifestations of the disorder. A recent study comparing age at onset of BD in a US population found that 30% of adults with BD in the Netherlands and Germany had childhood/adolescent onset.5 Thus, while possibly fewer than in the US, there are also likely great numbers of youth in Europe with BD. Much of the interest in pediatric BD has focused on the unique manifestation of mania in younger populations. Academic controversy has centered around the role of extreme irritability in pediatric mania: whether it can be a proxy for euphoria6; whether Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria can be used in children under 12; and whether children with BD eventually become adults with DSM-IV-defined BD.7 Depression is often overlooked, both as a topic and as a clinical reality, in these children. If BD is indeed so preva- lent  in  children  in  the  US  and  internationally,  then C l i n i c a l  r e s e a r c h T Copyright © 2009 LLS SAS.  All rights reserved www.dialogues-cns.org Challenges in the diagnosis and treatment of pediatric bipolar depression Kiki Chang, MD    Keywords:  bipolar  disorder;  depression;  child;  adolescent;  treatment; diagnosis; high risk Author  affiliations:   Associate  Professor,  Pediatric  Bipolar  Disorders  Program, Stanford University School of Medicine, Stanford, California, USA Address for correspondence:  Kiki D. Chang, MD, Stanford University School of Medicine,   Division   of   Child   and   Adolescent   Psychiatry,   401   Quarry   Road, Stanford, CA 94305-5540, USA (e-mail: kchang88@stanford.edu) There has been great public and academic interest in the diagnosis and treatment of bipolar disorders (BD) in chil- dren and adolescents over the past decade, originally in the US, but now extending internationally. Much of the interest in pediatric BD has focused on the unique mani- festation of mania in younger populations. Depression is often overlooked, both as a topic, and as a clinical reality, in these children. While it is becoming clear that adults with BD spend the majority of their symptomatic time in depressive  rather  than  manic  episodes,  less  is  known about the pediatric experience of bipolar depression. However, children and adolescents with BD clearly do experience significant depressive symptoms as well as depressive episodes, and therefore early recognition and treatment  is  necessary.  This  review  addresses  what  is known about the prevalence, presentation, and treatment of depressive symptoms and episodes in youth with BD, and includes a discussion about the recognition and treat- ment of bipolar depressive episodes that occur before the first manic episode. © 2009, LLS SAS Dialogues Clin Neurosci.  2009;11:73-80.