# 11 - Clinical guidance

# Clinical guidance

Prescribing in children and adolescents
CHAPTER 5
Bipolar disorder in children and adolescents
Clinical guidance
Before prescribing
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■Establish clinical diagnosis informed by structured instrument assessment if possible. 
Symptom checklists should be avoided, especially in primary care. Try to monitor 
symptom patterns prospectively with mood or sleep diaries. If in doubt, seek specialist advice early on.
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■Explain the diagnosis to the patient and family and invest time and effort in psycho­
education. This is likely to improve adherence and help children and adolescents 
and their families appreciate early warning signs of a relapse. Furthermore, there is 
evidence that such approaches reduce relapse rates, at least in adults.1
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■Measure baseline symptoms of mania (e.g. Young Mania Rating Scale2 [YMRS] and 
the parent YMRS3), depression (e.g. Children’s Depression Rating Scale4 [CDRS]) 
and impairment (e.g. Clinical Global ­Impression –­ BD version5). Use these to set clear 
and realistic treatment goals.
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■Measure baseline height, weight, waist and hip circumference, pulse, blood pressure 
and electrocardiogram (ECG) and obtain baseline bloods as appropriate (fasting blood 
glucose, HbA1c, fasting lipid profile, full blood count [FBC], urea and electrolytes 
[U&E], creatine kinase, LFTs, prolactin and thyroid function).
What to prescribe
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■Tables 5.3, 5.4, 5.5 and 5.6 summarise medication use in bipolar mania and depression and acute mania.
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■For the treatment of mania and hypomania in children and adolescents, UK NICE 
guidelines suggest following the same recommendations as for ­adults  –­ second-­
generation antipsychotics (SGAs) may be used as first-­line treatment, and mood stabilisers (MS) can be added after a failure of two trials of SGAs.6 The difference in 
comparison with adult guidelines is that NICE recommends that SGAs should not be 
routinely offered for more than 12 weeks. This information should be shared with the 
child or adolescent and their family.
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■SGAs seem to show greater short-­term efficacy (effect size [ES] = 0.65 compared with 
placebo) than MS (ES = 0.20 compared with placebo) in youth, according to a 
2010 meta-­analysis.7
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■SGAs produce significantly greater weight gain (particularly olanzapine) and 
­somnolence in children and adolescents compared with adults,7 although weight gain 
assessment is made complicated by normal growth at this time of life.
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■Valproate should be completely avoided in all adolescents.
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■Adherence to lithium cannot be assumed and blood level testing may be difficult in 
adolescents.
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■Overall, we recommend the use of SGAs as first line for the acute treatment of mania 
in children and adolescents (Tables 5.3 and 5.5).
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■It is helpful to document family history of response and non-­response to pharmacological treatment as there is evidence to suggest that pharmacological response, at 
least for lithium, runs in families.8