title: Bipolar disorder in children and adolescents: current challenges.
abstract: OBJECTIVE
  To demonstrate the diagnostic and treatment challenges in juvenile-onset bipolar disorder.
  
  
  METHODS
  Three case vignettes are outlined to demonstrate different bipolar presentations in children and adolescents.
  
  
  RESULTS
  These case examples illustrate important issues in the diagnosis and management of juvenile-onset bipolar disorder. These issues include diagnostic confusion with atypical initial presentation and the effect of developmental factors on symptom expression. The relationship among genetic risk, early affective instability, and the stress generated by affectively ill family members is complex and circular. Comorbidity with disruptive behaviour disorders, as well as anxiety disorders, is demonstrated by the cases discussed. Comorbid disorders may affect outcome and require separate treatment intervention. There is evidence for the prophylactic antimanic effect of lithium carbonate in children and adolescents, but its specificity as an antimanic agent is still uncertain. There is less evidence, at present, for effectiveness of other mood stabilizers in this age group, although sodium valproate may prove more effective in mixed mania and rapid cycling, which are so often seen with early-onset bipolar disorder.
  
  
  CONCLUSIONS
  While the existence of juvenile-onset bipolar disorder is no longer in dispute, several outstanding issues related to diagnosis and long-term management remain. Careful prospective research will be necessary to sort out these issues definitively.
authors.affiliation: Division of Child and Adolescent Psychiatry, London Health Sciences Centre, Ontario.
authors.forename: M
authors.initials: M
authors.lastname: Steele
authors.forename: S
authors.initials: S
authors.lastname: Fisman
mesh_terms: D000293:Adolescent; D000374:Aggression / Q000187:drug effects; D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D001714:Bipolar Disorder / Q000175:diagnosis* / Q000188:drug therapy / Q000523:psychology; D002648:Child; D002997:Clomipramine / Q000627:therapeutic use; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D016651:Lithium Carbonate / Q000627:therapeutic use; D008297:Male; D010348:Patient Care Team; D018967:Risperidone / Q000627:therapeutic use; D014635:Valproic Acid / Q000627:therapeutic use
chemical_list: D016651:Lithium Carbonate; D014635:Valproic Acid; D018967:Risperidone; D002997:Clomipramine