Bipolar Disorders in Children and Adolescents

Naomi A. Schapiro, RN, MS, CPNP

Disclosures

J Pediatr Health Care. 2005;19(3):131-141. 

In This Article

Definition and Diagnostic Criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000), BPDs are characterized by severe fluctuations in mood, namely episodes of mania or hypomania alternating with periods of depression (see Box 1 and Box 2 for criteria for mania and for depression, respectively). In a manic episode, the mood disturbance is severe enough to cause significant impairment in daily activities and interpersonal relationships or to necessitate hospitalization to prevent harm to self or others; there may be psychotic features to the symptoms. Whereas persons experiencing manic episodes typically exhibit euphoria and grandiosity (Weckerly, 2002), they also may present as irritable. In hypomanic states, the same behavioral criteria are used, but the impairment is not severe enough to necessitate hospitalization, and the individual may be able to continue academic or occupational activities. In mixed episodes, the individual exhibits symptoms of both mania and depression almost every day (American Psychiatric Association).

Children can be diagnosed with bipolar I disorder if the constellation of symptoms includes manic or mixed episodes; the child may or may not have had a major depressive episode. Bipolar II disorder consists of episodes of major depression and at least one hypomanic episode. In cyclothymic disorder, individuals fluctuate rapidly between hypomanic and depressive symptoms but do not meet criteria for either full mania or major depression (American Psychiatric Association, 2000). Bipolar disorder not otherwise specified (BPD-NOS) can be used for disorders with bipolar features that do not meet criteria for the other aforementioned diagnoses.

These criteria were developed primarily for adults and, according to the DSM-IV-TR (American Psychiatric Association, 2000), the average age of onset of the BPDs is late adolescence to young adulthood. Currently, recommendations of a National Institute of Mental Health (NIMH) expert consensus panel are to use the adult criteria to diagnose pediatric bipolar disorder as well (NIMH, 2001). However, the typical adult presentation of bipolar I disorder, consisting of discrete periods of both mania and depression interspersed with normal functioning, is not seen as frequently in pediatrics. Instead, symptoms in children seem to be characterized by a long-duration episode of rapid cycling and mixed mania (NIMH), with fluctuations in mood occurring daily or more than once a day (Weckerly, 2002), and the NIMH roundtable encourages clinicians to use the BPD-NOS category as a "working diagnosis" for children with this presentation (NIMH, p. 871).

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