References

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Patient FileLightning RoundThe Case: The boy getting kicked out of his classroom

The Question: What is pediatric mania?

The Dilemma: What do you do for a little boy with a family history of mania and who is irritable, inattentive, defiant and aggressive?

Pretest Self Assessment Question(answer at the end of the case) What differentiates pediatric mania from adult onset mania?

A. Elevated, expansive mood is the usual type in pediatric mania

B. Irritable mood is the usual type in pediatric mania

C. Discrete episodes in pediatric mania but last shorter than 4 days

D. Unremitting symptoms lacking discrete episodes is common in pediatric mania

Patient Intake 9-year-old boy

“I am here for new medications to make me behave”

Psychiatric History Impulsivity, inattention and hyperactivity since age 3

By age 5, diagnosed with ADHD and placed on mixed salts of d,l-amphetamine (Adderall) with poor or unclear therapeutic benefits

OROS d,l-methylphenidate (Concerta) also not very effective

Has become progressively more oppositional and disruptive in the classroom in the past year

Teachers and administrators now consider him a threat to other students and maybe to teachers and insist on improved behavior or he will be removed from the mainstream classroom and require special placement

Neuropsychological testing suggests a bright child intellectually who suffers from ADHD and pediatric mania with oppositional defiant disorder but not conduct disorder, and who also has multiple learning disabilities

Pediatrician referred the patient to a child psychiatrist who was unwilling to prescribe an antipsychotic or mood stabilizer until the patient was at least 10 years old

Mother and father are divorced for 3 years

Has an older sister who lives with him, and parents have joint custody of both children, so the patient and his sister live together but with alternate parents, shuttling back and forth about half the time in each household

Medical History None significant

Family History Mother: bipolar

Maternal grandmother: bipolar

Older sister: bipolar

Mother’s side of the family subtly blamed by the father’s side of the family for bipolar disorder and the current problems of the patient (and his sister)

Current medication d,l-amphetamine immediate release 30 mg in the morning and 20 mg at 11 am

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation Seen with his father, his paternal grandmother and a paternal aunt who all sat in on the interview

Patient was fidgety and squirming in his seat, overactive but not overtly irritable

Father says his son is on his best behavior and is usually much more grouchy

The patient actually seemed to feel guilty about his bad behavior and ashamed of not controlling it better

When asked what behaviors he needed to change in order to improve his situation at school, he stated he needed to stop fighting with kids at school and stop hitting classmates

When asked what his medication does for him, he says “zilch”

However, the grandmother, aunt and father all believe that the medication has some effect even though it is inconsistent

The clearest evidence of its effect is that the patient’s concentration and hyperactivity are reportedly better in school but seem to get worse after school is over and he comes home

The patient meets criteria for pediatric mania in that he has a great deal of irritability most days that does not occur in discrete episodes but appears to be chronic

However, he does have “rages” where he hits others and attacks property and yells in furor and anger, that are more discrete and periodic, but these never last for 4 days or more

His tantrums spin out of control for hours at times, and then one of his parents has to come and pick him up from school

Thoughts fly through his head and he jumps from one idea to the next without adequately expressing the first idea, and he feels powerful and invincible

He is defiant and aggressive towards both teachers and classmates

He endorses, and the family agrees, that he meets every one of the diagnostic criteria for ADHD inattentive subtype, almost all of the criteria for hyperactive subtype, and 3 out of 4 for the impulsive subtype

He meets the criteria for oppositional defiant disorder as well but not enough of the criteria to be diagnosed as having conduct disorder

Based on just what you have learned here, do you agree with any of these diagnoses?

Pediatric mania

ADHD

ODD

CD

Developmental reaction to parents’ divorce

Other

How would you treat him?

Increase his stimulant dose

Try another stimulant

Augment with guanfacine XR (Intuniv)

Augment with an atypical antipsychotic

Switch to an atypical antipsychotic

Add or switch to lithium

Add or switch to carbamazepine or valproate

Cognitive behavioral therapy

Family therapy

Other

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued This is obviously a tough situation

Pediatric mania is a controversial concept

Cynics believe it was invented in recent years by psychiatrists and pharmaceutical companies to make money off normative and transient events of development

Few studies in children under 10

Not clear if prepubertal pediatric mania is linked to adult onset bipolar disorder that runs in his family or if it represents a distinct, but genetically-mediated severe subtype of bipolar disorder

Atypical antipsychotics probably best studied for prepubertal mania, but only in children older than 10

Does everybody with pediatric mania also fit the diagnostic criteria for ADHD even though every child with ADHD does not fit the diagnostic criteria for pediatric mania?

Does everybody with pediatric mania also fit the diagnostic criteria for ODD, CD or both even though every child with ODD or CD does not fit the diagnostic criteria for pediatric mania?

Is the fad to over-diagnose ADHD in children now being replaced with a new fad of over-diagnosing mania in children?

Does it matter?

The question really is, with the child threatened to lose placement in a regular classroom, is an atypical antipsychotic or mood stabilizer justified?

Also, can you combine an antipsychotic with a stimulant or is that pharmacologically irrational?

Attending Physician’s Mental Notes, Initial Psychiatric Evaluation, Continued Whatever this is, it seems justified to be more aggressive psychopharmacologically

Options:– increase his stimulant dose– try a different long acting stimulant– augment the stimulant with guanfacine XR for his hyperactive and oppositional symptoms– augment with an anticonvulsant mood stabilizer or even lithium– as time is of the essence here, it may be justified to add an atypical antipsychotic to attempt to salvage the patient’s placement in his current classroom

Aripiprazole (Abilify) was recommended

It may appear to be irrational to give a releaser of dopamine (i.e., a stimulant) with a blocker of dopamine 2 receptors (i.e., an atypical antipsychotic) at the same time

However, this may be useful in some cases since the antipsychotic will block subcortical D2 receptors in limbic regions while the stimulant will increase dopamine release in prefrontal cortex to stimulate D1 receptors (which many antipsychotics do not block)

The net result is blockade of D2 receptors in limbic areas and stimulation of D1 receptors in prefrontal cortex, which may be therapeutic in some patients with combinations of ADHD symptoms with mood/mania symptoms

The case goes on.…

Posttest Self Assessment Question: Answer What differentiates pediatric mania from adult onset mania?

A. Elevated, expansive mood is the usual type in pediatric mania

B. Irritable mood is the usual type in pediatric mania

C. Discrete episodes in pediatric mania but last shorter than 4 days

D. Unremitting symptoms lacking discrete episodes is common in pediatric mania

Answer: B and D

Current experts consider that pediatric mania may be characterized by severe irritability and the absence of discrete episodes of mood disturbance and hyperactivity