What is the diagnostic process for bipolar disorder in children?

Diagnosing Bipolar Disorder in Children

The diagnosis of bipolar disorder in children requires careful assessment of distinct, spontaneous periods of mood changes with associated sleep disturbances and psychomotor activation, following DSM-IV-TR criteria including duration requirements. 1

Diagnostic Process

• A comprehensive diagnostic assessment must incorporate both current and past history of symptomatic presentation, treatment response, psychosocial stressors, and family psychiatric history 1
• Organize clinical information using a life chart to characterize the course of illness, patterns of episodes, severity, and treatment response 1
• Look for evidence of marked changes in the child's mental and emotional state, rather than reactions to situations, temperamental traits, or simple anger outbursts 1
• Assess for a marked departure from baseline functioning that is evident and impairing across different settings (not isolated to one environment) 1

Key Diagnostic Features to Assess

• Distinct periods of abnormally elevated, expansive, or irritable mood 1
• Decreased need for sleep (not just insomnia) 1
• Affective lability 1
• Psychomotor activation 1
• Cognitive changes associated with mood episodes 1
• Family history of mood disorders 1

Differential Diagnosis Considerations

• Carefully evaluate for other conditions that may present with similar symptoms:

  • ADHD and disruptive behavior disorders 1
  • Posttraumatic stress disorder 1
  • Anxiety disorders 1
  • Developmental disorders 1
  • Substance abuse 1

• Symptoms of irritability, reckless behaviors, or increased energy occur in multiple conditions and lack specificity 1

Special Considerations by Age Group

Adolescents

• Acute psychosis may be the first presentation of mania in adolescents and requires assessment for associated features like decreased need for sleep, affective lability, lack of negative symptoms, and/or positive family history 1
• Adolescents with bipolar disorder have high rates of suicide attempts and completed suicides 1
• Substance abuse rates are high in adolescents with bipolar disorder 1

Young Children

• The diagnostic validity of bipolar disorder in young children, especially preschoolers, has not been established 1
• Use extreme caution before applying this diagnosis in children younger than 6 years 1
• For preschool children with mood and behavioral concerns, carefully assess for developmental disorders, psychosocial stressors, parent-child relationship conflicts, and temperamental difficulties 1
• Interpreting adult diagnostic criteria in very young children is challenging with no definitive studies outlining developmentally valid methods for assessing manic symptoms in this age group 1

Diagnostic Classifications

• Follow DSM-IV-TR criteria, including duration criteria, when making a diagnosis of mania or hypomania in children and adolescents 1
• Use Bipolar Disorder NOS for youths with manic symptoms lasting hours to less than 4 days or for those with chronic manic-like symptoms representing their baseline functioning 1
• Consider the Leibenluft classification system that subdivides juvenile mania into three phenotypes:
  • Narrow (classically defined DSM-IV-TR mania)
  • Intermediate (well-demarcated periods of mania/hypomania lasting 1-3 days)
  • Broad (chronic difficulties with irritability and hyperarousal) 1

Assessment Tools and Methods

• Parent report appears more useful than teacher or youth report for discriminating cases 1
• When there is good agreement between parents and teachers regarding manic symptoms, children are more likely to have a complicated, refractory course of illness 1
• Assess symptoms in perspective given family, school, peer, and other psychosocial factors, rather than simply using a checklist 1

Common Pitfalls to Avoid

• Mistaking common behaviors in disruptive children (excessive silliness, grandiose statements) as true manic symptoms 1
• Failing to distinguish between chronic irritability and episodic mood changes 1
• Diagnosing very young children (under age 6) with bipolar disorder without sufficient evidence 1
• Overlooking comorbid conditions that require treatment as part of a comprehensive plan 1
• Not considering cross-cultural issues that may influence the expression or interpretation of symptoms 1

By following these evidence-based guidelines for assessment, clinicians can improve diagnostic accuracy for bipolar disorder in children, which is essential for appropriate treatment planning and improving outcomes related to morbidity, mortality, and quality of life.