Severe irritability: Bipolar disorder or something else?

Much has changed in research about children with irritability in recent years, notes Ellen Leibenluft, MD, chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health.

In the mid-1990s, the idea gained currency that children with bipolar disorder do not always have manic episodes and that children with extreme irritability and attention-deficit/hyperactivity disorder (ADHD) might have bipolar disorder. Over about 8 years, the percentage of mental health visits with children given the bipolar disorder diagnosis increased from almost none to about 0.4%.

However, to study the issue, researchers defined a category of children with “severe mood dysregulation (SMD),” with criteria that included having very severe temper outbursts and increased reactivity to negative emotional stimuli.

Data gathered in more recent years show irritable children with ADHD almost never grow up to have real manic episodes, Leibenluft says. “Therefore it doesn’t make sense to assign them the diagnosis of bipolar disorder.”

That matters a lot, she indicated in a recent talk at the National Institutes of Health (NIH), because if SMD were a form of bipolar disorder it should be treated with antipsychotic medication and lithium, the first-line treatment for pediatric bipolar disorder. “Stimulants and serotonergic reuptake inhibitors (SRIs) . . . would be relatively contraindicated because you’d be concerned about flipping a child into mania,” she says.

However, she adds, “if SMD is ADHD and anxiety or depression, then you would exactly treat with stimulants for the ADHD and SRIs for the anxiety or depression.”

There is a risk these children may have unipolar depression, Leibenluft says, but if they do it’s more likely that there has been a change in the last few months such as the child lacking interest in usual activities, being sad a lot, displaying changes in appetite, or being even less able to concentrate or sleep well.

In contrast, with children with just irritable ADHD presentation, she says, “It’s more likely it’s what the kid has always been like.”

Leibenluft says that in extreme situations, the pediatrician may want to consult with a psychiatrist.

One important outcome of the recent studies is the indication that irritability is “a common yet relatively understudied clinical presentation in children.” There’s a need, she says, to know much more about its treatment, measurement, neural circuitry, and genetic influences. She points out, “Even when you control for psychiatric illness, irritability in adolescence is associated with decreased education and income in adulthood. So it’s important.”

Leibenluft adds, “An important thing to remember is that attentional control is important not just for doing the task, but for controlling your emotions. One of the main ways that we manage to control our emotions adaptively is through directing our attention toward or away from frustrating things.”

View Leibenluft’s presentation at http://videocast.nih.gov, under Past Events for May 21, 2014.

The NIH Clinical Center is doing studies of both bipolar and severely irritable children and may be able to do an assessment by phone, or possibly in person, with expenses paid. Contact the center via e-mail to irritablekids@mail.nih.gov or call 301.496.8381.

Ms Foxhall is a freelance writer in the Washington, DC, area. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that might have an interest in any part of this article.