Pediatricians Sometimes Miss Mania In Children With ADHD

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 Psychiatry.

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 News.

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 were excluded.

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 possible.”

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>.▪