Concerns About Diagnosing Pediatric Bipolar Disorder

Diagnosing bipolar disorder in pediatric patients can be problematic for a host of reasons, including a lack of objective tests, high rates of comorbidity, a fluctuating course of illness, confusion about presenting symptoms, and concerns about overdiagnosis. In addition, social stigma and the potential side effects of psychotropics make overdiagnosing bipolar disorder in children a high-stakes proposition. However, missing a bipolar diagnosis prevents the patient from receiving the care they need. Fortunately, there’s consensus on several key issues of phenomenology, such as symptoms and psychiatric comorbidity, which can be used by clinicians in assessing pediatric patients for whom bipolar diagnoses might be appropriate.

Pediatric patients with bipolar disorder have the same symptoms that characterize this illness in adult populations,¹ and, while it might not always appear so in youths, the disorder is cyclic in the young as well.² The distinguishing early symptoms and features of pediatric bipolar disorder are increased energy, distractibility, pressured speech, elevated mood, and rapid mood fluctuations with spontaneous interepisode recovery being uncommon. Although irritability and aggression are frequent chief concerns and observable difficulties, these issues are not specific to bipolarity and may not always be useful when trying to ascribe an accurate diagnosis. A family history of mood disorders is also common among patients with pediatric bipolar disorder. If there’s a concern that a youth may suffer from bipolarity, you should identify distinct, spontaneously occurring mood states and characterize them appropriately as manic, mixed, hypomanic, euthymic, dysthymic, or depressive. Mood states will change as pediatric bipolar patients grow older; depression and mixed states will increase and pure manic/hypomanic states will decrease.

Despite differing research methodologies, there’s a clear consensus among researchers that psychiatric comorbidity, such as ADHD, disruptive behavior disorders, and anxiety disorders, is common in this population.¹ In fact, you should probably assume the presence of another condition until completing the necessary evaluations. To detect comorbidities, it’s helpful to (1) identify periods of euthymia, even if brief, and then (2) identify whatever psychiatric symptoms/syndromes are still present. Comorbidity matters because identifying and understanding the relationship between bipolar disorder and co-occurring conditions can help clarify the clinical perspective for patients and their families. Not ascribing all of a patient’s difficulties to bipolar disorder will help to educate patients and families about the treatment process, as well as clarify which symptoms may remain after the bipolar disorder itself is effectively treated.

Financial Disclosure:Dr Findling, in the past 12 months, has received research support from AstraZeneca, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson & Johnson, Eli Lilly, Merck, Otsuka, Pfizer, Rhodes, Shire, Supernus, and Wyeth; has served as a consultant to Alexza, Bristol-Myers Squibb, Forest, GlaxoSmithKline, KemPharm, Eli Lilly, Lundbeck, Merck, Novartis, Noven, Otsuka, Pfizer, Schering-Plough, Seaside Therapeutics, Sepracor, Shire, Sunovion, Supernus, and Transcept; and has served as a speaker for Shire.

Abbreviations: ADHD = attention-deficit/hyperactivity disorder

REFERENCES

1. Kowatch RA, Youngstrom EA, Danielyan A, et al. Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disord. 2005;7(6):483–496.

2. Findling RL, Gracious BL, McNamara NK, et al. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder. Bipolar Disord. 2001;3(4):202–210.​