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

Diagnosis

Given the clinical difficulties in the diagnosis and treatment of BPD, its evaluation and management are outside the scope of most primary care clinicians (Weckerly, 2002). When parents of a child like Sean consult the primary care PNP, the differential diagnosis is broad and there may be no one "red flag" behavior that would prompt a diagnosis of BPD. However, parental report of severe and prolonged temper tantrums, hyperactivity together with irritable and rapidly alternating moods, reckless and impulsive behavior, and a family history of mood disorders and/or substance abuse should prompt a referral for an evaluation for BPD (Muriel, Bostic, & Dolan, 2002; Weckerly).

While parents can be reliable historians of their child's behavior, the PNP should screen the older child and adolescent directly and separately from the parent for symptoms of depression, either by in-depth questioning or by use of screening tools (Muriel et al., 2002). Muriel and colleagues recommend asking about feelings of guilt, worthlessness, anhedonia, and somatic symptoms, as well as thoughts about dying and more explicitly suicidal ideation or plans. Bright Futures in Practice: Mental Health, Part II- Toolkit (Jellinek, Patel, & Froehle, 2002) offers two screening tools free of charge: the more general Pediatric Symptom Checklist and the Center for Epidemiological Studies Depression Scale for Children (CES-DC). Other depression scales, such as the Children's Depression Inventory (Kovacs, 1985) are available for purchase.

The Achenbach Child Behavior Checklist (CBCL), which has parent, teacher, and youth report forms, can be a cost-effective and time-effective tool in primary care and other clinical settings (Perrin & Stancin, 2002). In a meta-analysis of studies that used both the CBCL and structured diagnostic interviews, Mick, Biederman, Pandina, and Faraone (2003) found statistically significant increases in the Withdrawn, Anxious/Depressed, Thought Problems, Attention Problems, Delinquency, and Aggression clinical scales among children with BPD. However, others suggest that the CBCL has limited ability to distinguish between BPD and other disruptive behavior disorders (Kahana, Youngstrom, Findling, & Calabrese, 2003). Mick and colleagues suggest that the concordance of elevated scales across research studies support the use of the CBCL for screening but not definitive diagnosis.

Currently there is a lack of consistency across research groups about diagnostic criteria and assessment methods in pediatric BPD, which can inhibit efforts at developing scientific and therapeutic advancements (Mick et al., 2003). Researchers and clinicians in pediatric psychiatry clinics have used variations of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age children (Kiddie-SADS-MRS, WASH-U-KSADS, or Kiddie-SADS-E), sometimes adding questions for mania (Axelson, Birnaher, Brent, Wassick, Hoover, et al., 2003; Geller, Williams, Zimerman, Frazier, Beringer, et al., 1998; Wozniak, Monuteaux, Richards, Lail, Faraone, et al., 2003). Wozniak and colleagues found a convergence of structured diagnostic interview and clinical evaluations in 67 of 69 youths studied.

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