Pediatric bipolar disorder (PBD) is a chronic and disabling illness leading to serious disruption in the lives of children and adolescents with this condition. Children and adolescents diagnosed with the condition experience significantly higher rates of morbidity and mortality compared with otherwise healthy children, including reduction in quality of life ; impairment in social, familial, and academic functioning ; and alarmingly high rates of suicidal ideation and behavior. Recent years have shown a dramatic increase in the frequency of diagnosis of PBD, with a 40-fold increase in the number of the youth diagnosed with the disorder between 1994 and 2003, demonstrated in a national survey of office-based physicians. Once considered an adult-onset illness, retrospective data indicate that most adults with bipolar disorder (BD) first showed symptoms during childhood or adolescence. Pediatricians, who are likely to face the task of initial recognition and management of the youth with BD, play a crucial role in ensuring a successful outcome for youngsters with this condition.

The first step in treating children and adolescents with BD is making an accurate diagnosis. Even for the experienced child and adolescent psychiatrist, this step is often a complex clinical task for several reasons. Even as the diagnostic validity, phenomenology, and course of PBD remain active research endeavors, developmental differences in the presentation between the youth and adults have been established. Although adults exhibit distinct episodes of depression and mania, the pattern of illness observed in young people is often characterized by mixed or dysphoric mood states accompanied by irritability. Furthermore, compared with adults, children and adolescents exhibit fewer distinct episodes, higher rates of mood switching, and fewer symptom-free intervals. Adding to the challenge of diagnosis is the presence of additional psychiatric disorders in most patients with PBD, which is most frequently attention-deficit/hyperactivity disorder (ADHD). Several symptoms of BD overlap with those of other psychiatric disorders, ADHD in particular, making it oftentimes difficult to distinguish among them. Research clarifying the expression of BD in children and adolescents is needed to facilitate early and accurate diagnosis of the condition by clinicians.

Pharmacotherapy is regarded as an essential component of treatment in PBD. Historically, treatment strategies have been extrapolated from the adult literature. However, research in the treatment of psychiatric disorders has repeatedly shown that one cannot assume medications effective in treating adults are similarly effective in treating children and adolescents. Although far less is known about evidence-based treatments for pediatric versus adult BD, data to support interventions are rapidly emerging. Although PBD is considered to represent a spectrum of illness, encompassing bipolar I, bipolar II, cyclothymia, and BD not otherwise specified (NOS), the literature has largely focused on the management of acute manic and mixed states occurring in narrowly defined bipolar I. Less attention has been devoted to maintenance strategies to prevent symptom recurrence as well as to the treatment of less-classic illness phenotypes (such as BD II and BD NOS) and the depressive phase of illness. Furthermore, there is a paucity of data to guide interventions in psychiatric comorbidities of PBD and the management of the youth who are depressed and are genetically at risk for BD. The long-term safety and efficacy for agents used to treat juvenile BD is yet to be established.

Amid the challenge of recognizing and managing BD in children and adolescents, it is evident that the youth require prompt treatment to ameliorate symptoms and to prevent or reduce the psychosocial morbidity that accompanies the illness. Moreover, the probability of recovery lessens with earlier onset and longer duration of illness, further emphasizing the importance of early detection and treatment. Although optimal treatment uses a comprehensive approach consisting of pharmacotherapy, psychotherapy, and psychosocial interventions, this article is limited to a review of available data regarding the pharmacologic management of PBD. This article summarizes the extant literature of published studies for the treatment of manic, mixed, and depressive illness phases occurring in children and adolescents with BD as well as what is known about maintenance treatment in this population. In addition, this article reviews safety and monitoring concerns for each medication and offers practical suggestions for pediatricians initiating pharmacotherapy.