It is clear from the work of several groups that some children and adolescents meet the full DSM-IV criteria for BP (Tables 5.4.2.1 and 5.4.2.2), despite the fact that the criteria were not specifically adapted for use in the pediatric population (3,4,5). When examining the DSM-IV criteria for a manic or hypomanic episode, it is obvious that normal children can exhibit many of these features to some degree, especially in certain situations or environments. It is of utmost importance to evaluate whether the mood and symptoms are abnormal or clearly different from the child’s usual mood and behavior given the context and developmental level. For instance, elevated mood, high activity level and rapid speech would not be considered evidence of mania in a 7-year-old at a birthday party, an amusement park or on Christmas morning.

Consideration of how manic symptoms may manifest differently across development can facilitate accurate diagnosis. For instance, in contrast with an adult who is in a manic episode, a school-age child is not likely to exhibit behaviors such as engaging in risky business ventures, driving recklessly, going on spending sprees, or having sexual relations with multiple partners. However, they can exhibit inappropriate sexual behavior (touching others inappropriately, frequent public masturbation or drawing sexually provocative pictures) or engage in uncharacteristically dangerous, risk-taking play such as jumping from high places or performing frequent and exaggerated daredevil stunts on a bicycle (6).

The distinction between a manic and hypomanic episode can be difficult, but also must be taken in a developmental context. Beyond the differences in minimum duration, manic episodes require marked impairment, which should be measured against what would be the expected level of functioning for a child given his/her chronological age and intellectual capabilities, in the psychosocial domains that are relevant to youth (school, family, peers). A hypomanic episode does not require impairment, although there must be an unequivocal positive or negative change from usual functioning and the mood and functional changes must be observable by others. Given that lack of insight can be associated with mania or hypomania, it is imperative to obtain information from caregivers or other significant adults in the child’s or adolescent’s life in order to accurately assess symptoms and potential change in functioning.

A recent metaanalysis of seven published phenomenology studies of pediatric mania determined weighted rates and confidence intervals for 11 symptoms of mania that were measured across most of the studies (Table 5.4.2.3) (4). Increased energy and distractibility were the most common symptoms, while hypersexuality was the least frequent. Elated/euphoric mood and irritability were the two symptoms with the most variability in rates across studies, though there was also significant heterogeneity in the rates of decreased need for sleep, racing thoughts, poor judgment, pressured speech, and distractibility. Sampling issues and methodological differences among the studies, such as the average subject age, or the use of the child in addition to the parent as informants, may have accounted for much of the variability in symptom rates (4). However, differences in how groups conceptualized symptoms may also have contributed to the variability. Though it is not a symptom of mania per se, psychosis frequently occurs in BP youth. The weighted rate of psychosis was 42% (95% CI 24-62%) in the metaanalysis, but again there was significant heterogeneity among the studies.
The rate of psychosis was 35% in a report of a large BP-I sample published subsequently (3).

One factor that may contribute to the difficultly of diagnosing BP in youth is that the most common symptoms of pediatric mania from the metaanalysis also happen to be frequently present in other pediatric psychiatric disorders. A recent study comparing the phenomenology of bipolar disorder and ADHD found that there were no significant differences between the BP vs. the ADHD subjects in rates of irritability (98% BP vs. 72% ADHD), accelerated speech (97% vs. 82%), distractibility (94% vs. 96%) or unusual energy (100% vs. 95%) (7). Thus, the lack of specificity makes it problematic to diagnose mania by simply counting the presence or absence of symptoms.

The overlap of manic symptoms with features of other psychiatric illnesses emphasizes the diagnostic importance of symptoms that tend to be more specific to mania. Some authors have advocated that two of these mania-specific symptoms, elated/elevated mood and grandiosity, are core features of the manic syndrome so that they should be considered cardinal or hallmark symptoms (6,7,8). As shown in the metaanalysis above, these two symptoms are present in most manic youth, though there was considerable heterogeneity among studies in the rates of euphoria/elation, and one of the largest studies in the analysis required the presence of either elevated mood or grandiosity as an inclusion criterion for the BP subjects. However, a subsequently published large study of BP-I youth that did not require either of these symptoms also had high rates of elated/elevated mood (86%) and grandiosity (57%) (3). Long-term longitudinal studies of youth meeting the DSM-IV criteria for mania with or without cardinal symptoms have not been completed. Although the cardinal symptom approach has the potential to improve diagnostic accuracy, additional research such as the Longitudinal Assessment of Manic Symptoms (LAMS) and the Course and Outcome of Bipolar Youth (COBY) studies are necessary before elated/elevated mood or grandiosity can be required for a diagnosis of mania.

Irritability has been defined as “… an emotional state characterized by having a low threshold for experiencing anger in response to negative emotional events” (9). Irritability can encompass multiple temporal features of abnormal emotional reactivity, including a lower threshold to anger, a faster increase in anger, a higher “peak” level of anger, and a longer duration of anger.

As noted above, irritability is present in nearly all manic children and adolescents, so it is a sensitive marker for pediatric BP. However it is also part of the DSM-IV diagnostic criteria for disorders such as disruptive, major depressive, generalized anxiety, and posttraumatic stress disorders. In addition, it is frequently present in youth with other psychiatric diagnoses (e.g. ADHD; pervasive developmental disorders). Therefore irritability has low specificity for BP. The DSM-IV criteria for a manic episode explicitly allows for the presence of irritable mood alone to satisfy the “A” criterion, though it qualifies this by requiring an additional symptom criterion. Some reports have prompted substantial controversy by stating that chronic presentations of irritability alone, particularly when the irritability is severe and accompanied by aggression and volatility, is the primary mood disturbance in bipolar youth and that elevated or expansive mood is uncommon (10,11,12). However, the high prevalence of elated/expansive mood in most cross-sectional pediatric BP samples stands in contrast to these reports. Prospective evaluations of the phenomenology of new manic episodes in youth have not been published, so it is difficult to assess how frequently pediatric mania presents with only irritable mood.

Some groups have emphasized that BP youth present with chronic manic symptoms and have reported mean durations of 3–4 years for manic or mixed episodes (13,14). Others have noted that although BP youth may have chronic symptomatology and prolonged symptom-free periods are uncommon, it is an episodic illness and the duration of full threshold manic and mixed episodes are considerably shorter than 3–4 years in most cases (15,16). The DSM-IV criteria for manic, mixed or hypomania episode require a distinct period of abnormal mood and accompanying symptoms and some authors have advocated that an episodic course is a key feature that should be present for a definitive diagnosis of BP (8). As noted below, BP youth have high rates of comorbid ADHD, rapid mood fluctuations, and complex admixtures of manic and depressive symptoms. These features can make it difficult to identify distinct episodes that are embedded in this “mixed” presentation. However, a strict application of the “distinct period” of abnormal mood and symptoms criterion has certain advantages. The adult bipolar phenotype has an episodic component. In addition, nonspecific symptoms of mania (irritability, rapid speech, psychomotor agitation, distractibility) usually do not present with distinct episodes in other pediatric psychiatric disorders. Though there is no definitive evidence that mania in youth must have an episodic presentation, the presence of distinct periods of manic symptoms in a child or adolescent likely increases the probability of bipolarity and is a reasonable requirement for a conservative approach to the BP diagnosis in youth.

Depressive symptoms are noted to be prominent features in most phenomenological studies of pediatric BP, and BP adults frequently recall having significant depressive symptoms in childhood or adolescence (2,17,18). BP youth can have clear periods of depression that meet the full criteria for a major depressive episode (MDE) (see Chapter 5.4.1 for the DSM
criteria for MDE). Over 50% of BP youth had a prior history of a MDE in a recent report (3). As described in the differential diagnosis section following, major depression may precede the onset of mania, so that some children and adolescents who appear to have unipolar depression may actually have BP with depression as their initial presentation. Mild or transient manic symptomatology that does not meet the diagnostic threshold for mania or hypomania may also precede an MDE, although the presentation of full DSM-IV criteria BP-II (MDE plus at least one hypomanic episode) does not appear to be common in youth with bipolar spectrum illness (3). All of these factors highlight the need to carefully probe for a history of manic symptoms in youth presenting with depression.

Many researchers have reported that BP youth present with mixed states and complex cycling patterns between depression and mania. Some groups have reported chronic mixed states lasting years in duration and rapid cycling between mania and depression as frequently as several times per day (10,19). The issue is complicated by the fact that there are no clear boundaries that delineate a mixed state from an actual switch in episode polarity, or from mood lability and/or transient dysphoria occurring in the midst of mania. The DSM-IV criteria for a mixed episode require that the criteria for both a manic episode and a major depressive episode be met nearly every day during at least a 1-week period. This could be satisfied by an episode consisting of: 1) an amalgamation of manic and depressive symptoms that present concurrently (expansive, irritable, and depressed mood, high energy, racing thoughts, rapid speech, hopelessness, guilt and suicidality); 2) cycling between distinct short periods of predominantly manic symptoms and predominantly depressive symptoms; or 3) or some combination of both types of presentations. Overlapping criteria and features plus the symptoms of other comorbid psychiatric disorders can make it difficult to determine whether symptoms should be attributed to depression or mania. For example, irritability, racing thoughts, and psychomotor agitation can occur in both mood states and it sometimes can be challenging to differentiate decreased need for sleep from insomnia occurring in an agitated depression. Published studies have used the recall of interviewees from over a long time interval, which limits reliable evaluation of symptom patterns. It is not clear whether the reports of multiple mood cycles in a day represent periods where the child switches from meeting the full criteria of the manic syndrome to a period where they are completely depressed or whether they are manifestations of mood lability within the manic state. However, the evidence does indicate that the majority of BP youth have symptoms of depression interspersed in some manner with manic symptoms.

Some children and adolescents present in clinical and research settings with what appears to be significant manic symptomatology, but do not meet full DSM-IV criteria for BP-I or BP-II disorders. Reasons for this include: 1) The manic symptoms are not present for sufficient time to meet the DSM-IV duration criteria for a manic, hypomanic or mixed episode; 2) the mood disturbances and symptoms do not occur in distinct episodes; 3) the potential manic symptoms are not clearly temporally associated or do not intensify with the abnormal mood; or 4) it cannot be reliably determined whether the abnormal mood and symptoms are attributable to BP or better accounted for by another psychiatric diagnosis. The diagnosis and management of these children and adolescents is controversial, though many present for mental health treatment with significant impairment and are frequently assigned a diagnosis of bipolar disorder not otherwise specified (BP-NOS) (3,5). Empirical research in subthreshold presentations of bipolarity in youth is in its early stages. One large study comparing the presentation of youth with an operationalized diagnosis of BP-NOS with those who met full criteria for BP-I found that BP-NOS subjects differed from those with BP-I primarily on duration and severity of manic symptomatology, but not on the fundamental phenomenology of manic symptoms, comorbid disorders, or family psychiatric history (3). The majority of BP-NOS youth fulfilled the mood and symptom criteria for mania and/or hypomania, but did not meet the 4-day duration criteria for a hypomanic episode or the 7-day duration criteria for a manic/mixed episode. Nevertheless, these cases of BP-NOS uniformly presented with histories of significant impairment and nearly all had some form of psychiatric treatment prior to assessment. Preliminary results indicate that some of these BP-NOS cases progress to meet the DSM-IV criteria for BP-I or BP-II disorders within 2 years of followup (15). However it is currently unknown how many will eventually become bipolar adults or which subthreshold presentations predict development of BP-I or BP-II disorder versus those that are not truly bipolar.

As described later in more detail under Differential Diagnosis, clinicians must be cautious about attributing symptoms to mania or hypomania unless they show a clear temporal association with the abnormally elevated, expansive, and/or irritable mood. The manic syndrome exists as a collection of concurrent symptoms and mood abnormalities, not a list of symptoms that occur in temporal isolation. Chronic symptoms such as hyperactivity or distractibility generally should not be considered evidence of mania unless they clearly intensify with the onset of abnormal mood. Prolonged presentations of nonspecific manic-like symptoms that do not change in overall intensity should raise the possibility of an alternative psychiatric diagnosis.

There are several structured and semistructured interviews that can be used for the diagnosis of BP. The most widely used interviews in BP studies are two similar instruments: the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children— Present and Lifetime version (K-SADS-PL)(41) and the Washington University KSADS (WASH-U-KSADS) (42). However, these interviews are lengthy and time-consuming and are mainly used for research purposes. Thus, symptom checklists based on the DSM criteria for BP as well as depressive disorders are also useful.

For any of the interview methods noted above, when assessing mood episodes it is important to evaluate their frequency, intensity, number, and duration (FIND) (30).

Two clinician-based rating scales are currently used for the assessment of manic symptoms and their severity in youth, the Young Mania Rating Scale (YMRS)(43,44) and the KSADS
Mania Rating Scale that was derived from the KSADS-P mania module (KSADS-MRS) (45). However, further studies to evaluate the validity of these rating scales are necessary.

It appears that parental reports are more effective in identifying mania than youth or teacher reports (46). The General Behavior Inventory (GBI) (47,48), the parent version of the YMRS (P-YMRS) (49), and more recently the Child Mania Rating Scale for Parents about their children (CMRS-P)(50) have been shown to have appropriate psychometric properties and be useful for the screening of BP symptoms in youth, but further studies to evaluate the specificity of these instruments for BP are warranted.

Other parent-report instruments have been used to screen for BP in youths, but these instruments were not designed specifically for mania. For example, the CBCL has been used to identify a pattern of psychopathology associated with mania (42,51,52,53,54). A consistent pattern of elevated scores was noted on Aggressive Behavior, Attention Problems, Delinquent Behavior, and Anxious/Depressed profile (55,56,57). However, the sensitivity of the CBCL for identifying mania was substantially lower than that of the mania-specific instruments cited above (57,58). Low scores are helpful in “ruling out” mania (or any psychopathology) while high scores are not useful for “ruling in” mania (57,58). For this reason, mania-specific scales are preferable in screening, over a more general scale such as the CBCL.

Mood timelines or diaries using school years, birthdays, and holidays as anchors are very helpful in the assessment of the onset and course of mood disorders. These instruments use colors or ratings from 0 to 10 to chart daily changes in mood along with any corresponding significant stressors, illnesses, and treatments. These instruments can help children, parents, and clinicians to visualize the course of their mood, and identify events that may have triggered the depression, hypomania/mania, or irritability and examine the relationship between treatment and response.

Clinicians should always evaluate for psychosocial functioning, family psychopathology, ongoing negative life events (family conflicts, abuse), child’s functioning in several areas (peer relationships, school functioning), and for the presence of psychiatric and medical conditions and suicidal and homicidal ideation (for instruments to evaluate these domains, see the respective chapters). If necessary, once the child’s mood is stable, psychoeducational testing is warranted (Chapter 4.2.4).

Also, the clinician together with the child and parents should evaluate the appropriate intensity and restrictiveness of care (hospitalization). The decision for the level of care will depend on factors such as the severity of mood symptoms, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, child’s and parents’ adherence to treatment, parental psychopathology, and family environment.

At the present time, no biological or imaging tests are clinically available for the diagnosis of BP.