Treatment sequences for the multisymptomatic child with bipolar disorder are not adequately described or based on a systematic clinical trial database, and systems for longitudinal tracking of symptoms are rarely utilized. We present a patient whose symptoms of depression, anxiety, attention-deficit/hyperactivity disorder, oppositional behavior, and mania are rated by a parent and plotted on a weekly basis in the Child Network under a Johns Hopkins Institutional Review Board-approved protocol. This 9-year-old girl remained inadequately responsive to lithium or risperidone. We describe a range of other treatment options and a possible sequence for their introduction. We encourage the use of systematic longitudinal ratings to help better visualize course of symptom fluctuations and response of the child to treatment. Given the highly fluctuating course of many symptoms in very young children as illustrated here, prospective monitoring appears essential. The current case also highlights the great unmet need for comparative effectiveness data in children less than 10 years of age to better guide clinical therapeutics.
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