Making the difficult diagnosis of bipolar disorder in the school-age child

The diagnosis of bipolar disorder in children can be elusive and is often masked by rapid-cycling mood states or a comorbid disruptive behavior disorder. Bipolar disorder also manifests itself differently in children than it does in adults.

When evaluating a young patient for suspected pediatric bipolar disorder, a careful assessment that satisfies the following four criteria can help lead to an accurate diagnosis:

1. Uncovering mood disorders in at least one parent or family member. Because high rates of mood disorders have been reported among family members of youths with bipolar disorders, a meticulous family history—in which the lifetime diagnoses of both biological parents is secured—becomes crucial.
2. Finding consistent episodes of elevated mood alternating with episodes of depression or euthymia, with rapid cycling between one mood and the other. While bipolar disorder in adults is generally characterized by long, distinct mood states and periods of recovery between episodes, this condition in children appears with briefer mood states and low rates of recovery between episodes.
3. Identifying greater degrees of mood swings that are distinct from episodes of disruptive behavior. Ask about the child's mood states, not necessarily his or her behavior, and scrutinize spontaneous mood swings carefully. During periods of mania and other mood states, children with bipolar disorder may exhibit both irritable and elevated moods, which may mimic symptoms of a behavioral disorder. It is helpful to find out how often these irritable or elevated moods were present during episodes of mania and other mood states.
4. Considering a diagnosis of bipolar disorder only after ruling out other diagnoses, including that of an anxiety or disruptive behavior disorder. Affective disorders such as ADHD and OpDD are not by themselves characterized by discrete moods and cycling between mood episodes, but their symptoms may appear in children with bipolar disorder, so it is important to first rule out such conditions, as well as general medical considerations.