Diagnosing Bipolar Disorder in Children and Adolescents
Kiki D. Chang, MD
Department of Psychiatry and Behavioral Sciences and the Bipolar Disorders Program, Stanford University School of Medicine, Stanford, California
Pediatric Bipolar Disorder Prevalence
Bipolar disorder is common worldwide and often develops in people at young ages. When 480 adults with bipolar disorder were asked when they had their first full mood episode, approximately half reported that their first depressive or manic episode happened during childhood or adolescence (AV 1).1 While this study has some limitations, such as the subject’s bias and memory, similar research has found that, in about half to two-thirds of adults with bipolar disorder, the illness began in childhood.2
In the United States, as many as 2 million children could be suffering from bipolar disorder (I, II, or NOS).3 A review4 of community-based diagnoses of bipolar disorders in children found that these diagnoses increased 40-fold between 1994 and 2003, which may be due to increased recognition, overdiagnosis in some areas, and more accurate diagnosis in other areas. This increase may also be attributed to the prevalence of the disorder in successive generations of families; the more genetic coding for the disorder a person has, the earlier the onset.
Importance of Correct and Early Diagnosis
Studies1,3 of adults with bipolar disorder who were children at illness onset have reported that an average of about 16 years passed before these patients received a correct diagnosis and first treatment. Some children may be misdiagnosed with depression or ADHD. However, treatment for bipolar disorder is different than that for depression or ADHD, so recognizing this disorder early can prevent exposing a child to unnecessary stimulant or antidepressant treatment. Stimulants and antidepressants may induce kindling or even advance the progression of the bipolar disorder to a worse state. Not treating bipolar episodes may lead to treatment-resistance once patients are accurately diagnosed. Further, childhood bipolar disorder derails social and academic/cognitive development. Appropriately diagnosing patients as early as possible re-establishes normal psychosocial and academic development.
Differential Diagnoses of Pediatric Bipolar Disorder
Adolescents with bipolar disorder are difficult to diagnose, but younger patients are even more difficult to diagnose. ADHD is a primary differential diagnosis, especially in children younger than age 12 years, because manic symptoms such as hyperactivity and distractibility overlap with the criteria for ADHD. A child who is experiencing a manic episode may exhibit traits of ADHD and sometimes will get misdiagnosed as having ADHD. Conversely, some children with severe ADHD may be misdiagnosed as having bipolar disorder.
Unipolar depression is another primary differential diagnosis. Irritability is more commonly a sign of depression than mania in children, although it can also be part of a manic episode. The DSM-IV criteria for MDD in children allow for either depressed mood or irritable mood during an episode.5
Another cluster of common differential diagnoses is anxiety disorders. Anxiety disorders, such as GAD, OCD, or PTSD, can lead to a heightened sensitivity to stressors. For example, a child may react to a perceived threat with a “fight or flight” response, leading to affective outbursts such as lashing out at a teacher or trying to run off the school grounds when feeling too much pressure at school. These outbursts may be wrongly attributed to an irritable manic episode instead of anxiety.
Angry outbursts may also be a sign of intermittent explosive disorder. If no other manic symptoms are present during this time, the accurate diagnosis may be intermittent explosive disorder rather than bipolar disorder. And finally, the presence of psychosis could mean that the child has an early psychotic disorder, including schizophrenia or schizoaffective disorder, and bipolar disorder should be ruled out. Watch this patient video to view an example of diagnosing young patients with bipolar disorder (AV 2).
Use of Adult Bipolar Disorder Criteria for Young Patients
While the DSM-IV diagnostic criteria for bipolar disorder have not yet been adapted for children, the consensus among researchers and clinicians is to use these criteria to make the diagnosis. A young patient must meet the full criteria for a manic episode for a bipolar I diagnosis, although depression is not required (AV 3).5
Although the diagnostic criteria for adults are used for children, being aware of developmental concerns and what is normal in children can help to make an accurate diagnosis. Cardinal symptoms of mania aid in differential diagnosis. For example, grandiosity, a cardinal symptom of mania, is not part of the diagnostic criteria for ADHD, depression, or schizophrenia, so it is useful in making the diagnosis of bipolar disorder. However, in order to identify grandiosity in a child, knowing what a normal experience is for that patient is critical in the diagnostic process.
Another cardinal symptom is the decreased need for sleep. Children, especially those with ADHD, often have trouble falling asleep, but the criteria for a manic episode require an actual decreased need for sleep, meaning no naps or “sleeping in” the next day are necessary. This lack of sleep does not affect their normal energy levels. Racing thoughts and increased goal-directed activity are also unique to mania, but the latter can also be confused with symptoms of OCD.
Behaviors that meet criteria for a manic episode differ by age. In adolescents, exhibitions of excessive involvement in pleasurable activities, such as excessive spending, sexual indiscretions, substance abuse, or impulsive activities, may be similar to those of adults. Younger children, however, may have hypersexual behavior, become excessively involved in projects, stay up late, or write, draw, or scribble excessively on their walls or their books.
Pediatric Bipolar Disorder Spectrum
Bipolar diagnoses include bipolar I disorder, bipolar II disorder, and bipolar disorder NOS. Bipolar disorder NOS has been increasingly diagnosed in children. These children have enough symptoms to meet mania criteria but do not meet the duration requirement6; in other words, patients do not have hypomania for 4 full days or mania for 7 days (AV 4). Younger children tend to have short bursts of manic periods.
Other disorders in children appear to occur on a spectrum with the bipolar disorders (AV 5). Children with severe mood dysregulation do not have true manic episodes or symptoms, but they tend to be very temperamental and have outbursts. Children with severe mood dysregulation often develop depression rather than bipolar disorder in adulthood. At the other end of the spectrum are bipolar I and bipolar II disorders. In midspectrum are possible prodromal states, including bipolar disorder NOS, full depression with a family history of bipolar disorder, or ADHD and a family history of bipolar disorder. Children who have family histories of bipolar disorder are highly susceptible to developing bipolar disorder.7 Subsyndromal states of bipolar disorder may indicate a progressing bipolar disorder.
For Clinical Use
Pediatric-onset bipolar disorder is common. Bipolar disorder NOS and other bipolar spectrum disorders are common in children and adolescents and are often difficult to diagnose in younger patients. For optimal patient care, clinicians should:
- Establish the presence of a full manic episode to make the diagnosis of bipolar I disorder
- Be aware of developmental concerns in children that can help to make an accurate diagnosis
- Understand the range of diagnoses associated with the bipolar spectrum
ADHD = attention-deficit/hyperactivity disorder, DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, GAD = generalized anxiety disorder, MDD = major depressive disorder, NOS = not otherwise specified, OCD = obsessive-compulsive disorder, PTSD = posttraumatic stress disorder
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- Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolar disorder. J Pediatr. 2007;150(5):485–490.
- Perlis RH, Miyahara S, Marangell LB, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Biol Psychiatry. 2004;55:875–881.
- Post RM, Kowatch RA. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry. 2006;67(1):115–125.
- Moreno C, Laje G, Blanco C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64(9):1032–1039.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
- Birmaher B, Axelson D, Strober M, et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(2):175–183.
- Chang KD, Steiner H, Dienes K, et al. Bipolar offspring: a window into bipolar disorder evolution. Biol Psychiatry. 2003;53(11):945–951.