What questions should be asked to parents when screening their children and adolescents for bipolar disorder?

Screening Questions for Parents About Pediatric Bipolar Disorder

When screening children and adolescents for bipolar disorder, ask parents specifically about distinct, spontaneous periods of mood elevation with decreased need for sleep and psychomotor activation—these hallmark features differentiate bipolar disorder from other childhood psychiatric conditions. 1

Critical Screening Questions to Ask Parents

Core Mood Episode Questions

• Ask about distinct periods of abnormally elevated, expansive, or euphoric mood that are clearly different from the child's baseline functioning and represent a marked departure from their usual behavior 1

• Inquire about decreased need for sleep where the child feels rested despite sleeping only 2-4 hours—this is the single most important differentiating feature from other psychiatric disorders 1

• Document whether mood changes are episodic or chronic: Bipolar disorder manifests as distinct episodes with clear periods of elevation alternating with baseline or depressed mood, not chronic persistent irritability 1

• Ask about the duration of mood episodes: Symptoms must last at least 4 consecutive days for hypomania or 7 days for mania to meet DSM criteria 1

Associated Manic Symptoms

• Screen for psychomotor activation and increased goal-directed activity that occurs spontaneously during mood episodes, not in response to environmental triggers 1

• Ask about grandiosity that represents a marked change in the child's mental state, not just normal childhood boasting or temperamental traits 1

• Inquire about racing thoughts, pressured speech, or flight of ideas during distinct time periods 1

• Document reckless or impulsive behavior that is uncharacteristic and occurs during mood episodes 1

Temporal Pattern and Course

• Use a life chart approach: Ask parents to map when specific symptom clusters began, their duration, and any periods of remission to characterize the longitudinal course 1

• Document whether symptoms fluctuate in a cyclical pattern with clear periods of elevation, baseline functioning, and possibly depression 2

• Ask about symptom consistency across settings: While bipolar symptoms should be evident in different realms of the child's life, recognize that parent reports are more useful than teacher reports for discriminating cases 2

Family and Treatment History

Genetic Risk Factors

• Obtain detailed family psychiatric history, particularly of bipolar disorder and mood disorders in first-degree relatives, as they have a four- to sixfold increased risk 1, 3

• Ask about mood lability, anxiety, attention difficulties, hyperarousal, and depression in the child, as offspring of parents with bipolar disorder display these early warning symptoms 3

Treatment Response History

• Document any antidepressant-induced mood elevation or agitation, as manic episodes precipitated by antidepressants strongly suggest underlying bipolar disorder, with approximately 20% of youths with major depression eventually developing manic episodes 1, 3

• Inquire about response to past psychiatric treatments and any prior psychiatric hospitalizations or emergency department visits for mood-related issues 1

Critical Differential Diagnosis Questions

Distinguishing from Other Disorders

• Differentiate from ADHD and disruptive behavior disorders: Ask whether symptoms occur in distinct episodes versus being chronic and persistent, as high rates of comorbid ADHD complicate diagnosis 1

• Rule out trauma-related symptoms: PTSD-related irritability is typically reactive to trauma reminders or environmental triggers, whereas manic irritability occurs spontaneously as part of a mood episode 1

• Assess for environmental triggers and patterns: Ask about events that reinforce outbursts, psychosocial stressors, and whether symptoms are reactions to situations versus spontaneous mood changes 1

Substance Use and Medical Causes

• Obtain detailed substance use history including tobacco, alcohol, marijuana, and misuse of prescribed or over-the-counter medications, as substance-induced mood disorder must be ruled out 1, 4

• Screen for medical conditions: Ask about thyroid problems, recent illnesses, or other medical issues that could cause mood symptoms 1

Comorbidity and Safety Assessment

Associated Problems

• Assess suicidality thoroughly: Ask about prior suicidal ideas, plans, attempts, and current impulsivity, as bipolar disorder has high rates of suicide attempts 5, 1

• Screen for substance abuse, as rates are particularly high in adolescents with bipolar disorder 1

• Evaluate for anxiety disorders, developmental disorders, and cognitive/language impairments, which commonly co-occur 1

Functional Impairment

• Document impairment across different realms: Ask about changes in school performance, peer relationships, family functioning, and daily activities during mood episodes 1

• Inquire about aggressive behaviors or homicidal ideation during mood episodes 1

Age-Specific Considerations

Young Children (Under Age 6)

• Exercise extreme caution in children under age 6, as the diagnostic validity of bipolar disorder in preschoolers has not been established 1

• Consider alternative explanations first: developmental disorders, psychosocial stressors, parent-child relationship conflicts, and temperamental difficulties before considering bipolar disorder 1

Adolescents

• Recognize that adolescent mania is frequently associated with psychotic symptoms, markedly labile moods, and mixed manic-depressive features 1

• Ask about irritability, belligerence, and mixed features, which are more common than euphoria in adolescent presentations 1

Common Pitfalls to Avoid

• Do not rely on irritability alone, as it is non-specific and occurs across multiple diagnoses—focus on the hallmark features of decreased need for sleep, distinct mood episodes, and psychomotor activation 1

• Obtain collateral information from multiple sources whenever possible, as patients often lack insight during manic episodes and family members can describe behavioral changes more objectively 1

• Schedule follow-up visits to observe symptom evolution over time and reassess diagnosis periodically, as the clinical picture may evolve 1

• Do not overlook the possibility of multiple diagnoses being present, as symptom overlap can lead to missing one condition when focusing on another 1