Bipolar disorder in children: Assessment and diagnosis

Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has increased over the past years with a 40-fold increase between 1995 and 2003.¹

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Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults.² Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.

importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease.¹

This article describes current and evolving approaches to assessment and diagnosis of bipolar disease in children. Although some children meet the criteria established for adults categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-5),^3,4 many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult. For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis.

The aim of this brief update on assessment and diagnosis approaches is aimed at helping pediatricians and other healthcare providers who care for children navigate the diagnostic challenges of this disease to ultimately improve treatment and management.

Diagnosis based on classical conceptualization

The DSM provides the classical conception of bipolar disease based on episodes of mania, depression, or mixed moods, as well as episodes of hypomania, primarily irritable moods (Table 1⁵).^3,4 Based on these criteria, individuals are diagnosed with bipolar I, bipolar II, cyclothymia, or bipolar disorder not otherwise specified (Table 2⁵).

New to the most recent DSM-5 is an emphasis on changes in activity and energy as well as mood.^4,6 Along with the presence of elated and irritable mood, the diagnosis of bipolar disease also requires an association of these symptoms with increases in activity and energy.

In addition, the DSM-5 includes a new diagnostic category that addresses questions of duration of symptoms and, in particular, an ongoing debate over nonepisodic or persistent irritability.⁶ Part of the debate has centered on how to classify children with chronic or persistent nonepisodic irritability who do not fit into any existing diagnostic categories for bipolar disorder.

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Work by Leibenluft and colleagues suggests the use of bipolar phenotypes, which offer a way to categorize patients by subtypes of disease.^7,8 One of the subtypes, called “broad" phenotype, is associated with a clinical syndrome given the name “severe mood dysregulation (SMD)” and includes 3 core features of which the cardinal feature is chronic, nonepisodic irritability (along with marked hyperarousal and persistent negative mood). Although SMD and childhood bipolar disorder share symptoms, other factors such as family history and lifetime course of the diseases along with differences in the neural mechanisms of the dysfunction seen in each disease indicate that SMD differs substantially from bipolar disease.^6-8

Based on this, the DSM-5 introduced a new diagnostic category called “disruptive mood dysregulation disorder (DMDD)" that characterizes a disorder in which a person has persistent irritable mood for at least 12 months along with severe recurrent temper outbursts at least 3 times a week.⁶

It is thought that inclusion of DMDD as a new disease category may avoid misdiagnosing children with bipolar disorder who don’t have the disorder.⁶ The question remains, however, whether this new category really represents a new disease or not. Initial findings suggest that this new label is given to children who are severely impaired and who have several comorbidities, such as depressive disorder, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD).

The presence of irritability and its heterogeneity in children with possible bipolar disease is a major area of ongoing research to help clinicians make the correct differential diagnosis. Along with ADHD, ODD, and major depression, other conditions with high irritability as a major symptom that clinicians need to weigh in making the differential diagnosis include generalized anxiety disorder and posttraumatic stress disorder.⁶

A valuable diagnostic indicator of bipolar disease is the presence of episodic irritability combined with further manic symptoms. Nonepisodic irritability has a low specificity for bipolar disorder.⁶

NEXT: Diagnosis based on phenotyping

Diagnosis based on phenotyping

For children who do not fall into the classic categories of bipolar disorder, assessment based on phenotyping may provide clarity.⁵ As mentioned earlier, Leibenluft and colleagues described childhood-onset bipolar disease in terms of subtypes (Table 3⁷).^7,8 These subtypes address a number of issues that remain controversial in the assessment and diagnosis of childhood bipolar disease, including issues of symptom duration and frequency of mood states.

Use of phenotyping, or these subtypes, may help clinicians in their assessment of children with symptoms that don’t completely fulfill the DMS criteria for bipolar disorder. Again, clinicians need to recognize that many of these symptoms may overlap with symptoms of other childhood disorders such as anxiety and depressive disorders, ADHD, and ODD.

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To date, there is little consensus on using these subtypes or phenotypes to assess bipolar disorder in children. Clinicians need to recognize, however, that assessment and diagnosis of bipolar disease, similar to all psychiatric diseases, may be moving in a new direction away from DSM classifications to a new way of classifying mental illness based on dimensions of observable behavior and neurobiological measures.¹

Paradigm shift: Fear of harm

One new phenotype proposed for bipolar disorder based on dimensions of behavior supported by specific physiological features is “fear of harm (FOH).” Children with this dimension exhibit fear and aggressive obsessions associated with severe injury to self and others.¹ An analysis done to determine the heritability of bipolar disease based on a number of dimensions of behavior found that FOH was considerably more significant than all other dimensions, including mania and depression, in the heritability of bipolar disease.

Analysis also shows that one-third of children at risk for or diagnosed with bipolar disorder will have no FOH, one-third will have low FOH, and one-third will have high FOH. Children with high FOH have significantly higher severe mania and depression.¹

Table 4 highlights common symptoms of FOH that taken together create a single syndrome.¹ Most of these symptoms are readily identifiable and, when paired with a family history of mental illness (particularly mood disorders and alcoholism) can help clinicians make the differential diagnosis of this new phenotype of bipolar disorder.

Identification of this new phenotype of bipolar disease represents another evolution in the approach to assessment and diagnosis of the disorder in children.

Next: Recommendations for diagnosis

Recommendations for diagnosis

Given the ongoing and evolving nature of assessment and diagnosis of bipolar disorder in children, pediatricians and other healthcare providers who care for children will need to stay abreast of new developments as they emerge. Until then, some clarity to help assess and diagnose this disease comes from recommendations in recently published American Academy of Child and Adolescent Psychiatry guidelines (Table 5).^5,9

Table 6^5,10 also lists a number of suggested tests and approaches for evaluating children who present with symptoms of potential bipolar disorder.

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Summary

Despite a rapid increase in the diagnosis of bipolar disease in children over the past years, diagnosis remains challenging and controversial. This is, in part, because clinical presentation may differ from adult onset disease and doesn’t allow for easy diagnostic classification based on DSM categories. More recent data suggesting the use of bipolar phenotypes, or specific single-syndrome phenotypes such as FOH, may help facilitate diagnosis. Recommendations by current guidelines also may help clinicians navigate this challenging clinical situation.

REFERENCES

1. Papolos DF, Bronsteen A. Bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr. 2013;25(3):419-426.

2. American Academy of Child and Adolescent Psychiatry (AACAP). Bipolar Disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents. Available at: www.ParentsMedGuide.org. Published June 2009. Accessed April 17, 2015.

3. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DMS-IV-TR). Washington, DC: American Psychiatric Association; 2000.

4. American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013.

5. Renk K, White R, Lauer BA, McSwiggan M, Puff J, Lowell A. Bipolar disorder in children. Psychiatry J. 2014;2014:928685.

6. Grimmer Y, Hohmann S, Poustka L. Is bipolar always bipolar? Understanding the controversy on bipolar disorder in children. F1000Prime Rep. 2014;6:111.

7. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS. Defining clinical phenotypes of juvenile mania. Am J Psychiatry. 2003;160(3):430-437.

8. Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry. 2011;168(2):129-142.

9. McClellan J, Kowatch R, Findling RL; Work Group on Quality Issues, Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(1):107-125. Erratum in: J Am Acad Child Adolesc Psychiatry. 2007;46(6):786.

10. Baroni A, Lunsford JR, Luckenbaugh DA, Towbin KE, Leibenluft E. Practitioner review: the assessment of bipolar disorder in children and adolescents. J Child Psychol Psychiatry. 2009;50(3):203-215.

Ms Nierengarten, a medical writer in St Paul, Minnesota, has over 25 years of medical writing experience, coauthoring articles for Lancet Oncology, Lancet Neurology, Lancet Infectious Diseases, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.