Bipolar disorder in children is an uncommon condition that becomes more frequent in teens, approaching the rate seen in adults.
The adult criteria describe a disorder of fluctuating mood cycles, consisting of episodes of elevated mood and persistently increased activity or energy (mania) lasting at least 1 week, and episodes of lowered mood and activity (depression); an episode of mania is necessary for a diagnosis to be made.
A serious illness with recurrent episodes, leading to considerable impairment and an increased risk of suicide.
Diagnosis can be controversial, as criteria overlap with other childhood conditions such as ADHD and comorbid oppositional defiant disorder.
First-line treatment for manic episodes is antipsychotic therapy or mood stabilizers; the evidence base in children and adolescents is small, and comes mostly from industry-supported trials.
Medications have potentially serious adverse effects, so the risks and possible benefits need to be carefully assessed.
Bipolar disorder in children encompasses bipolar I disorder (manic episodes with or without depressive episodes) and bipolar II disorder (depressive episodes with periods of milder, briefer, and less impairing mania, called hypomania).
Bipolar I disorder, which has been most specifically studied in youth, is a chronic disorder of fluctuating mood, consisting of episodes of elevated mood and persistently increased activity or energy (mania) lasting at least 1 week, and episodes of lowered mood and activity (depression). Other symptoms of mania include distractibility, grandiosity, disinhibition, flight of ideas, hyperactivity, reduced sleep, and talkativeness. Varying diagnostic approaches have been proposed in children, but the implications of these approaches for treatment and prognosis remain unclear. Many children exhibiting chronic nonepisodic irritability and severe temper outbursts have been diagnosed with bipolar disorder in the US, despite the lack of distinct mood episodes.
The diagnosis of disruptive mood dysregulation disorder was included in the Diagnostic and Statistical Manual of Mental Disorders to address this over-diagnosis and treatment of bipolar disorder in children; however, the inclusion of this new diagnostic entity has also raised concerns regarding inappropriate diagnosis and over-treatment of irritability with a category that remains poorly validated. Despite concerns regarding over-diagnosis, there is also evidence that diagnoses of bipolar disorder can be significantly delayed and under-treated.
Bipolar I disorder is discussed here.
History and exam
Key diagnostic factors
- history of major depressive episode(s)
- ≥7 days of elated, expansive, or irritable mood and persistently increased activity/energy different from patient's usual self (mania)
- inflated self-esteem or grandiosity
- decreased need for sleep
- pressure of speech
- subjective experience that thoughts are racing
- excessive involvement in pleasurable activities that have a high potential for painful consequences
- impairment in functioning
Other diagnostic factors
- adolescence and young adulthood
- flight of ideas
- family history of bipolar disorder
- history of depression
- physical and/or sexual abuse
- poor sleep
- neurodevelopmental abnormalities
- lack of maternal warmth/expressed emotion (duration)
- life events
- increased sociability and verbal functioning
- persistent affective symptoms (transition to bipolar disorder)
- male sex (when ADHD is comorbid)
- high intellectual performance
- family conflict
- symptoms of inattention
1st investigations to order
- clinical assessment
acute mania/mixed mania
acute depressive episode
mania or depression: not responsive to all previous treatment
- Schizoaffective disorder
- Medication adverse effects
- Bipolar disorder: assessment and management
- Clinical practice guidelines for mood disorders
Bipolar disorder: what is it?More Patient leaflets
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