Approach
The diagnosis of bipolar I disorder should be made by a clinician experienced in recognizing manic and depressive episodes.[18][85] Evaluation depends on whether the problem being addressed is an acute episode of mania or hypomania or a lifetime condition (e.g., a patient is presenting with depression or another condition and the clinician wants to know about a possible past manic episode). The evaluation for mania, lifetime or current, should include a thorough history from the patient and caregivers, collateral information from school, and a mental status exam (MSE). Comorbidities will often be present, so a comprehensive assessment of all other disorders is necessary. In adolescents, diagnosis can be complicated by comorbid substance abuse and emerging personality disorder.[14][15] Additionally, psychoeducational and language testing may also be necessary.
History
The history from the parent and patient should be supplemented by collateral histories from teachers and other caregivers to ascertain where and when symptoms are evident. The focus of the history should be establishing the occurrence of manic episodes, because they are central to the diagnosis. In order to establish if the symptoms are different from the child's usual self, it is also necessary to ascertain what the child's usual self is by way of temperament, other psychiatric symptoms, and how they function academically and with peers. A life chart may be helpful in eliciting possible past manic episodes. Stressors and important landmarks or life events (e.g., starting elementary, junior high, or high school; menarche) should be noted.
An important part of the history is the MSE, which for a child has 3 key parts:
To ascertain the presence of manic and depressive symptoms germane to the diagnosis of bipolar disorder, including euphoria, grandiosity, depression, suicidal behavior, psychosis
To directly assess the child's language, presence of thought disorder, psychosis, anxiety, physical or sexual abuse, and illicit substance use, and evidence of racing thoughts and flight of ideas
To reconcile parent and child information.[85]
The core symptoms of mania are irritable, elevated, or expansive mood, and abnormally and persistently increased activity or energy.[4] These symptoms need to be present for a minimum of 7 consecutive days, be present for most of the day, interfere with normal functioning, be noticeable by others, and be different from the child's usual self. Once the presence of the basic symptoms is established, it is necessary to ask about other symptoms of mania, including rapid speech, inflated self-esteem, decreased need for sleep, and pleasure-seeking without regard for consequences. Rating scales can be used to ascertain the severity of a manic episode, but not to make a diagnosis. A mixed episode includes prominent symptoms of depression occurring at the same time as manic symptoms. Therefore, it is necessary to ask about sadness or depressed mood most of the day, every day; diminished interest or pleasure in activities; weight or appetite change; insomnia (to be distinguished from decreased need for sleep) or hypersomnia; fatigue or loss of energy; psychomotor agitation or retardation; poor concentration; and recurrent thoughts of death or suicide.[4]
It is important to establish if there is a family history of bipolar disorder or depression, or of all major psychiatric disorders, including ADHD, anxiety, substance use, learning disabilities, autism, and schizophrenia. If there is a positive family history, descriptions of behavior to ensure accuracy of diagnosis is important, to determine if the relative's condition is lithium-responsive, has been mostly depressed, or is significantly comorbid. One study has shown that lithium-responsive parents have offspring with less-severe bipolar disorder.[86] Adults are sometimes incorrectly given a diagnosis of bipolar disorder in lieu of more pessimistic or stigmatizing diagnoses (e.g., schizophrenia, substance abuse, personality disorder). Information about the patient's developmental history, including details on the mother's pregnancy (maternal smoking, alcohol, and stress), birth history (including birth weight), and developmental milestones, should be ascertained. Psychiatric comorbidity is highly prevalent. Anxiety and ADHD are particularly associated with a deleterious clinical effect on pediatric bipolarity; therefore, comorbidity needs to be carefully assessed and considered in treatment planning. The most common comorbid disorders are anxiety disorders (54%), ADHD (48%), disruptive behavior disorders (31%), and substance use disorders (31%).[87]
It is important to establish whether there are symptoms of inattention, as they may be part of a mixed clinical presentation during the early stages of evolving bipolar disorder in high-risk children (i.e., offspring of parents with bipolar disorder). Neurodevelopmental abnormalities may be antecedents of bipolar disorder in these children.[73]
The child's psychosocial history, including tensions in the home (e.g., between parents or between parent and child), as well as details regarding peer relationships, which are often impaired, should be ascertained.[85] Any areas of tension or conflict will need to be addressed in the management of a child with a diagnosis of bipolar I disorder.
Details about the patient's past medical history, including any previous head injury or central nervous system infections, as well as current medications, should be sought. Possible exposure to lead should be considered.
Screening questionnaires
Screening for past manic episodes using recognized screening tools should occur during the history-taking, as diagnostic information previously acquired from unvalidated checklists is unreliable.[88] Symptoms covered by screening include co-occurring elated or expansive mood, decreased need for sleep, racing thoughts, and persistent increase in activity or energy.
Diagnostic tests
There are no diagnostic tests for bipolar disorder in children.
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