Evidence-based assessment/Rx4DxTx of bipolar in youths

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A Primer on Bipolar Disorders in Children and Adolescents

The diagnosis of bipolar disorder (BD) in youth has historically been controversial, with some clinicians and researchers debating its validity as a disorder that manifests in children. However, decades of research offer evidence that youth do experience bipolar disorder and benefit from the relevant evidence-based treatments. BD comprises a "spectrum" of disorders (i.e., BD-I, BD-II, cyclothymic disorder, and other specified bipolar and related disorders) and symptom presentations vary across individuals. Regardless of subtype, BD is associated with significant consequences for affected youth. Early diagnosis and intervention can help improve prognosis, but lack of knowledge and misperceptions about BD in youth may cause delays in seeking or receiving appropriate treatment. This paper will outline current evidence related to the prevalence, risk factors, assessment, comorbidity, and treatment of BD in youth.

Diagnostic Criteria, Prevalence, and Comorbidity

Diagnostic Criteria

Graphic depicting the differences between bipolar I disorder, bipolar II disorder, and cyclothymia.

There are four primary diagnoses that fall within the category of Bipolar Spectrum Disorders: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and other specified bipolar and related disorder.  A bipolar I disorder diagnosis requires a patient to have had at least one manic episode. Manic episodes are a period of extreme elated or irritable mood accompanied by a change in energy.  Individuals must also experience three or more concurrent manic symptoms to meet diagnostic criteria (four or more if the mood is irritable rather than elated). The symptoms of mania that are most commonly experienced in youth are increased energy, irritability, mood lability, distractibility, and increased goal-directed activity. Major depressive episodes are common but are not required for a diagnosis of bipolar I disorder. Major depressive episodes are characterized by a period of depressed mood plus five or more other depressive symptoms for a period of at least two weeks (such as lack of sleep, fatigue, worthlessness, or suicidal ideation). To be diagnosed with bipolar II disorder, a patient must experience at least one hypomanic episode and at least one major depressive episode. A hypomanic episode is characterized by elated or irritable mood, plus three (four if mood is irritable) additional manic symptoms for at least four consecutive days. Hypomanic episodes are less severe than manic episodes; the duration criterion is shorter and impairment is minimal or nonexistent (hospitalization qualifies an episode as mania). Cyclothymic disorder is diagnosed when an individual experiences chronic (for at least one year with no more than two months symptom-free) hypomanic symptoms and depressive symptoms, but never meets full criteria for a hypomanic episode or an episode of major depression. If an individual presents with episodic bipolar mood symptoms but does not meet full criteria for any of the described classifications, the diagnosis of Other Specified Bipolar and Related Disorder may be given. Further, if bipolar symptoms cannot be fully evaluated or other circumstances prevent definitive diagnosis (e.g., current substance use), a diagnosis of Bipolar Disorder Unspecified may be given. The table below describes the core features of all bipolar spectrum disorders.

Click here for Bipolar Disorder diagnostic criteria

Bipolar Type I Disorder Bipolar type I disorder is an episodic mood disorder defined by the occurrence of one or more manic or mixed episodes. A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention. It is characterized by euphoria, irritability, or expansiveness, and increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least 2 weeks. Although the diagnosis can be made based on evidence of a single manic or mixed episode, typically manic or mixed episodes alternate with depressive episodes over the course of the disorder. Note: The ICD-11 lists 18 additional subcategories of Bipolar type I disorder. They can be found here. Bipolar Type II Disorder Bipolar type II disorder is an episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. A hypomanic episode is a persistent mood state characterized by euphoria, irritability, or expansiveness, and excessive psychomotor activation or increased energy, accompanied by other characteristic symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, and impulsive or reckless behavior lasting for at least four consecutive days and present most of the day. The symptoms represent a change from the individual’s typical behavior that is are observable to others and are not severe enough to cause marked impairment in functioning. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least 2 weeks accompanied by other symptoms such as changes in appetite or sleep, psychomotor agitation or retardation, fatigue, feelings of worthless or excessive or inappropriate guilt, feelings or hopelessness, difficulty concentrating, and suicidality. Bipolar II does not have a history of manic or mixed episodes. Note: The ICD-11 lists 13 additional subcategories of Bipolar type II disorder. They can be found here. Cyclothymic Disorder Cyclothymic disorder is characterized by a persistent instability of mood over a period of at least 2 years with symptoms present at least half of the time, involving numerous periods of hypomanic (e.g., euphoria, irritability, or expansiveness, psychomotor activation) and depressive (e.g., feeling down, diminished interest in activities, fatigue) symptoms that are present during more of the time than not. The hypomanic and depressive symptoms are not severe or prolonged enough to meet the full definitional requirements of a hypomanic or depressive episode (see Bipolar type II disorder). There is no history of manic or mixed episodes (see Bipolar type I disorder). The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Changes in DSM-5 The diagnostic criteria for Bipolar Disorder changed slightly from DSM-IV to DSM-5. This includes the removal of the not otherwise specified subtype. Summaries are available here and here.

Prevalence

Graphic depicting the world prevalence of bipolar disorder.

Bipolar spectrum disorders are more common in youth than autism and schizophrenia but less common than Attention-Deficit/Hyperactivity Disorder (ADHD) or unipolar depression (Goldstein et al., 2017). A meta-analysis estimated that the prevalence rate of bipolar spectrum disorders in youth is 3.9%. Bipolar I has a prevalence rate of 0.6%. Moreover, the risk of BD roughly triples with the onset of puberty.  There are several reasons that puberty could be associated with risk, including changes in hormones, shifts in sleep patterns, and changes in interpersonal relationships.

Community prevalence of BD in youth in the United States compared to other countries (mainly in Central America, South America, and Europe) is relatively consistent. However, there is significant heterogeneity across individual studies and the availability of data across regions varies widely; more research is needed in non-Western regions especially. Data from international epidemiological studies also show that the prevalence of BD in youth has been largely stable over time. This is in contrast to clinical diagnoses of BD in youth, which increased in the 1990s and early 2000s - likely in response to the fact that, historically, BD had been diagnosed only in adults.

Common Comorbidities & Overlapping Symptoms

Bipolar disorder is often comorbid with other conditions; more than half of youth with BD also meet criteria for ADHD or Oppositional Defiant Disorder (ODD) and more than a quarter have an anxiety disorder. These comorbid conditions impact the prognosis, course, and treatment options for youth with BD and may make it difficult for a youth to achieve symptomatic remission if not addressed. Generally, the presence of comorbidities results in a more severe presentation, including more intense mood episodes and faster mood cycling. It is unclear if these conditions commonly co-occur with BD because of a shared, underlying diathesis, or if some disorders are early manifestations, or prodromes, of BD.

BD and ADHD have many overlapping symptoms, including irritability, distractibility, and impulsivity, which can make them difficult to distinguish.  Youth with comorbid ADHD and BD tend to have more intense symptoms than peers with BD alone. In one study, youth with BD who were hospitalized four or more times with mood episodes were more likely to have comorbid ADHD versus those who were hospitalized three times or less. Another study found that youth  diagnosed with both ADHD and BD had poorer overall functioning and more severe symptoms compared to youth with BD alone. Patients with both ADHD and BD are also more likely to meet criteria for additional comorbidities compared to patients with BD or ADHD alone.

Like ADHD, ODD is a common comorbidity of BD that shares several symptoms such as irritability and impulsivity. Unlike ADHD, ODD lacks complete diagnostic specificity from BD such that all of its symptoms could be present in youth with BD. As a result of this diagnostic overlap, some researchers have hypothesized that ODD may be a prodrome or a secondary consequence of BD. However, not all youth who are diagnosed with ODD subsequently develop BD. One study found that, for youth with BD, an additional diagnosis of ODD was not associated with a greater necessary level of care, which also suggests that impairment may not be incrementally greater for youth with both diagnoses.

Youth with comorbid BD and anxiety disorders tend to exhibit more severe depressive symptoms and manifest manic symtpoms earlier than those with BD alone. Additionally, youth with comorbid anxiety disorders had longer and/or a greater number of affective episodes as well as more severe global impairment. One aspect of this greater impairment is that youth with comorbid anxiety disorders are more likely to have been hospitalized for a psychiatric reason. Estimated comorbidity rates of BD with any anxiety disorder range widely from 12.5% to 76%, though multiple studies suggest that panic disorder is the most likely to cooccur with BD. This relationship is especially pronounced in children and adolescence as 52% with BD are estimated to also have panic disorder (compared to 21-33% of adults).      

Youth with BD are at elevated risk for substance use disorders (SUDs) with prevalence rates ranging from 16 to 48%. A large clinical study found that the lifetime prevalence of alcohol and drug use disorders among those with childhood onset of BD is greater than those with adult onset of BD. Studies have also found that for the majority of youth with BD and a SUD, BD precedes the development of a SUD by approximately 2 years. This may be due to the fact that some youth with BD use symptoms to help manage their mood symptoms or attempt to prolong the high mood associated with mania. Having comorbid SUD is associated with slower recovery from mood episodes, as well as shorter time between mood episodes.

Risk Factors

Although the etiology of BD is not fully understood, it is a highly heritable psychiatric disorder. The rate of BD among people with an affected first degree relative is roughly five times higher than that of the general population (approximately 5 to 15%). Environmental factors may also increase one’s risk for developing BD. For example, concordance rates of BD are only 50-60% for monozygotic twins, indicating that non-genetic, environmental factors are also at play.

There is some evidence that certain prenatal maternal infections may increase risk for BD, specifically, the T. gondii infection. The role of other prenatal factors have been investigated, but have not been as well supported. There is more support for postnatal environmental risk factors, including stress/trauma and substance use. Childhood adversity, particularly emotional abuse, is associated with increased risk for developing BD. Early life stressors can also trigger earlier onset of BD and a more severe course of the illness. Relatedly, youth with BD who have a history of trauma also tend to have a worse course and outcomes than youth who have not experienced trauma. In fact, early adversity and abuse is associated with an increased severity and frequency of mood episodes. Substance use may also increase one’s likelihood of developing BD. Particular evidence has been found for the role of cannabis in addition to other drugs such as cocaine, opioids, stimulants, and sedatives.    

Developmental Course & Outcomes

Symptoms of BD can manifest at a young age with 60-70% of people who eventually meet criteria for BD experiencing their first mood symptoms before the age of 18. The Course and Outcome of Bipolar Youth (COBY) study, a longitudinal study of the course and outcomes of youth aged 7-17 with BD, found that on average, mood symptoms presented at 8.4 years old and the first clinical mood episode occurred at 9.3 years old. After the first mood episode, 80% of youth with BD experience a mood recurrence within the next 3 to 5 years.

Although onset of symptoms can occur in childhood, the average age of onset of BD is in adolescence. Individuals who experience the onset of BD before puberty are likely to have a more severe course, including intense mood fluctuations, compared to adolescent or adult onset. Youth and young adults 7-21 years old are more likely than older adults to experience mixed episodes, characterized by the presence of both (hypo)mania and depression at the same time, which can be associated with high impairment and suicide risk. The polarity of the first mood episode may also differ depending on age of onset. Prepubertal children will generally experience manic or hypomanic symptoms first, while those with adolescent-onset BD tend to experience depressive symptoms or a major depressive episode first. Additionally, the polarity (manic or depressive) of a person's index episode is related to the predominant polarity of subsequent mood episodes. In the COBY study, participants with an index episode of mania were more likely to experience mania in their next episode (59%) wen compared to those whose index episode was another mood state (i.e., depressed, mixed, hypomanic.

Youth with bipolar disorder tend to be symptomatic more often than not. The COBY study found that youth with BD were symptomatic 60% of the time. Additionally, youth with BD tend to spend more time with depressive or mixed symptoms than manic or hypomanic symptoms. Changes in mood polarity can occur frequently. The COBY study found that mood changes occurred five or more times per year in 51.1% of their sample, ten or more times per year in 38.7% of their sample, and greater than twenty times per year in 23.7% of the study’s sample, with only 31.2% of the study’s sample reporting one or fewer changes in mood polarity per year. However, a recent follow-up study to COBY found 29.9-41% of adolescents recovered within 6 months after a mood episode and maintained euthymic mood for approximately 18 months.

Bipolar disorder is associated with greater risk of suicide compared to other mood disorders. Anywhere between 50 and 60% of youth with BD report suicidal ideation, while 20 to 25% of youth with BD attempt suicide at some point. Furthermore, those with BD who experienceonset before the age of 18 are more likely to attempt suicide. The relative frequency of mixed mood episodes in youth also puts them at higher risk for suicidal ideation and attempt. Comorbid mental health disorders, especially SUD and panic disorder, or a family history of a suicide attempt also increase the risk of suicidal behavior. Factors that are not associated with an increase in suicide attempt are bipolar subtype, sex, race, or socioeconomic status.

Youth with BD tend to have less frequent manic symptoms, largely due to the fact that manic symptoms are more responsive to pharmacological treatments than depressive symptoms. Those with a greater quality of life at baseline were more likely to have a favorable course of BD. Quality of life also continued to relate to the course of illness and symptom severity at 2 year follow up. Adolescents who perceive their family environment as more positive, may have a buffer against worsening mood symptoms and a more favorable course of illness. Earlier treatment in youth with BD, has shown to have better course of illness. Youth with BD that belong to a minority group, typically have a poorer course of illness.

Psychosocial functioning is a major concern in youth with BD. Studies have shown that those who spend more time symptomatic had greater psychosocial impairment across various domains of functioning. Interpersonal relationships with family members and interpersonal functioning worsens in youth with BD except when they are predominantly euthymic. Those who were euthymic were little of the time had worsening outcomes in school and recreational activities. Overall, early age of onset, disability, and low SES predicted psychosocial impairment across all domains.

Evidence-Based Assessment

Symptoms that overlap with other disorders and difficulty distinguishing typical from problematic mood and behavior changes make the diagnosis of BD in youth challenging. Following evidence-based assessment strategies results in more accurate and reliable diagnoses. Starting with a valid measure to screen for symptoms of bipolar disorder allows the clinician to gauge if the patient has had spontaneous changes in mood for defined periods of time and assess personal and family history of mood disorders. It is important to use a  scale that covers the symptoms of mania. Some of the most effective scales for assessing bipolar disorder in youth are the Mood Disorder Questionnaire (MDQ), Child Mania Rating Scale (CMRS), and the General Behavior Inventory (GBI). These assessments, which specifically ask about symptoms of mania, perform better than broad symptom measures like the Achenbach System of Empirically Based Assessment (ASEBA). Additionally, caregiver report tends to be more informative than youth report, and much more informative than teacher report, when considering a BD diagnosis.  

If the initial screen for BD symptoms is positive, it is important to follow with a structured or semi-structured interview to assess all symptoms and evaluate for comorbid disorders. Relying on limited information, like a positive screen alone, does not sufficiently account for other key factors such as episodicity and comorbidity.

Evidence-Based Treatment

After a child or adolescent has received a comprehensive, evidence-based assessment and is diagnosed with PBD, the clinician should devise the most appropriate evidence-based treatment plan specific to the patient. There are numerous treatment options for PBD, and research has demonstrated efficacy in pharmacotherapy, psychotherapy, and the combination of the two.

Medication

Medication is often the first line of treatment for children and adults with BD, though current recommendations suggest a combination of medication and therapy is most effective (Look at review by Kowatch; AACAP practice parameters- need EAY to send to JJ; Correll has meta-analyses about efficacy and side effects). Before medication is prescribed to pediatric patients, their medical history and the possibility of comorbidity must be considered. Lithium can only be prescribed to children who are 12 years of age or older. Lithium and Divalproex have been recommended as a first line for treatment, specifically for nonpsychotic manic episodes. A combination of medications such as lithium with Divalproex or lithium with an atypical antipsychotic can also be efficacious, but typically this treatment approach is only used if the use of a singular medication is unsuccessful. Overall, patients who are prescribed medication must be thoroughly monitored for adverse side effects (especially for lithium, which can be toxic if blood lithium levels are too high).

Mood Stabilizers

Lithium

Though there are variety of pharmacological treatment options for BD, lithium is a commonly used mood stabilizer. According to Harrison et al. (2016), lithium is the most effective treatment to prevent relapse of mood episodes. Lithium works by inhibiting inositol monophosphate and other enzymes signaling to calcium channels, inhibiting mitochondrial function, and G-protein activated potassium channels. Lithium use must be carefully monitored, because there is a delicate balance between a dosage that is helpful and one that is toxic or even deadly .

A meta-analysis completed by Nolen et al. (2019) found that optimal lithium dosages were around the lower end of 0.45-0.60 mmol/L and the higher end of 0.80-1.00 mmol/L. Individuals at the higher end of dosage (0.80-1.00 mmol/L) relapsed more often than those in the lower end of dosage . Patients who were given less than 0.45 mmol/L had a relapse rate of 61.5%, demonstrating that there is a minimum dosage in which lithium can be effective. Patients outside the two ranges did not see any benefit, especially if the individual was prescribed more than 1.00 mmol/L .

Lithium is a popular pharmacological treatment option because it can prevent mood episodes from reoccurring in patients with BD. Lithium may prevent manic episodes and decrease the risk of suicide (a notable benefit given that BD has one of the highest suicide rates in comparison to the general population) . A study by Song et al. (2017) demonstrated a 14% decrease in suicide-related events (in patients with BD?) in comparison to a group with BD that was not receiving lithium (were they receiving anything else?). Because lithium may reduce manic episodes, it may subsequently reduce impulsivity. Decreased impulsivity can lead to decreased rates of self-harm in individuals with BD .

Though lithium's effectiveness makes it a frontline treatment for BD, it may also be a dangerous treatment option. The thyroid, kidneys, and the parathyroid glands are three large and important organ systems that may sustain damage from lithium intake . Most people experience mild side effects when actively taking lithium, all of which are related to organ damage over time. For example, lithium use can structurally damage kidney tubules, resulting in polyuria (increased urination) . Symptoms of lithium toxicity must be closely monitored, and dosages of lithium must be adjusted based on a person’s sensitivity.

Lithium is widely used for BD treatment in adults, but its use in children is understudied. CoLT studies have found an optimal dosage in children of 0.3 and 1.3 mEq/L, which is much lower than the dosage for adults . In another research study in children with BD, some children who were taking lithium achieved remission. Those who were not considered "in remission" experienced stabilization of symptoms, a promising direction for future research .

Anticonvulsants (Antiepileptic Agents)

Antiepileptic agents are used for the treatment of BD in both youth and adults. The specific antiepileptic agents that have been studied in children and adolescents with BD are carbamazepine, divalproex sodium, lamotrigine, oxcarbazepine, and topiramate .

Antipsychotics

Antipsychotics (also known as neuroleptics) may be used in conjunction with lithium when someone is undergoing an acute, severe manic episode. However, there are concerns over neurotoxicity with a prolonged use of lithium and antipsychotics together . The FDA has approved antipsychotics for treatment of BD, mania and mixed states, and as maintenance to treat depressive, manic or mixed episodes. A common practice is also to use antipsychotics over a prolonged period. However, antipsychotics may cause several undesired side effects such as weight gain, late dyskinesia, sedation, sexual dysfunction and depression. Antipsychotics may be further classified into typical or atypical.

First Generation Antipsychotics (FGA; "Typical")

Typical antipsychotics, or first generation antipsychotics, are useful in treating manic symptoms even in the absence of psychotic symptoms. However, their use has drastically decreased in the treatment of BD due to the risk of extrapyramidal symptoms (drug-induced movement disorders).

Second Generation Antipsychotics (SGA; "Atypical")

Atypical antipsychotics, or second generation antipsychotics, are equally effective as typical antipsychotics in the treatment of manic symptoms, but they do not cause extrapyramidal symptoms. Since 2000, there have been several aytipcal psychotics that have been approved for treatment by the FDA. Olanzapine (generic form available) was approved in 2000, Risperidone was approved in 2003, Quetiapine, Aripiprazole, and Ziprasidone were approved in 2004, Olanzapine/fluoxetine combination was approved in 2012, Lurasidone was approved in 2013, and Cariprazine and Asenapine were approved in 2015.

Antidepressants

Depressive episodes within patients with BD are often difficult to treat pharmacologically, because elevating mood via antidepressants may lead to manic episodes.

Psychosocial Therapy

Another approach to treatment is psychosocial therapy. Cognitive-behavioral therapy (CBT) emphasizes the psychosocial factors of PBD and helps the pediatric patient change their thinking patterns and learn coping skills to manage their cognitions and emotions. An adaption of combined family-focused treatment and CBT called Child- and Family-Focused CBT (CFF-CBT), or the RAINBOW program, was established specifically for children with PBD between the ages of 8-12 and their families. This 12-session program focuses on teaching parents and children self-efficacy and behavioral management, engaging problem-solving skills, and increasing or maintaining social support. CBT and its many variations may be useful to help families and children learn to manage bipolar disorder as well as reduce the negative conflict and affect likely existent within a household.

Interpersonal Social Rhythms Therapy (IPSRT) has also been demonstrated as an effective treatment for adolescents with PBD, specifically to manage symptoms related to sleep dysfunction. IPSRT can help youth stabilize their moods, improve social functioning, and regulate their sleep patterns. It can also help clinicians establish the relationship between the beginning of mood episodes and sleep dysfunction patterns. When combined with medication, IPSRT has been shown to increase time between mood episodes.

Psychosocial Therapies for Bipolar Disorder

Therapy	Key components	Duration	Results
Child- and Family-Focused Cognitive-Behavioral Therapy	Develop consistent routines Learn to regulate emotions Improve child's self-esteem and parent's self efficacy Reduce negativity Build social skills and networks Teach parents self-care Family-based problem solving and communication skill building	12 weeks long 60-90 minute weekly sessions	Decrease intensity of manic episodes Decrease depressive symptoms in child Overall improvement in client's functioning
Interpersonal and Social Rhythm Therapy	Develop understanding of disruptions in routine and manic/depressive episodes Build skills for creating consistent routines, aka, social rhythms Build self-efficacy and phase out of therapy	Varies dependent on client need	Increases time between manic/depressive episodes
Mindfulness-Based Cognitive Therapy	Utilizes mindfulness-based practices such as mindfulness meditation Focus on awareness of client's thoughts, feelings and behaviors Learn to recognize how to monitor one's own thoughts Increase self-care practices	8 weeks long 60-120 minute weekly sessions	Decrease in anxiety symptoms Decrease in depressive symptoms Increase mood regulation Increase attention ability
Multi-Family Psychoeducational Psychotherapy	Group therapy using treatment components from: Psychoeducation Family Systems therapy Cognitive-behavioral therapy	8 weeks long 60-90 minute weekly sessions	Decrease in severity of mood symptoms Increase in caregiver understanding of child's disorder and how to seek mental health care Children report feeling more social support from caregivers

Exercise as a Treatment Component

Exercise can be beneficial in the treatment process for bipolar disorder.

Exercise has been credited for its tremendous benefits in cardiovascular systems, the brain, sleep, and even mood. Although it is not a first-line treatment for PBD, there may be benefits to including an exercise regimen as an adjunctive treatment with medication and/or psychotherapy. There is limited research examining exercise's benefits in PBD, but studies in adults with BD demonstrate promising results. Consequently, adults with BD tend to have more sedentary lifestyles, which may lead to increased comorbidities and depressive symptoms.

One such promising study investigated the impact of exercise on adults with BD, examining improvements in quality of life and mood symptoms. 40% of participants reported not exercising at all, and the less participants exercised (of those who did), the more likely their quality of life and overall functioning was to be lower. Consequently, exercising more often corresponded to more frequent manic symptoms and mixed episodes.

Though the above studies observe adults with BD, it is likely that exercise is associated with the same effects on mood symptoms and quality of life in children, and additionally, one’s long-term trajectory of BD into adulthood. A study of adolescents demonstrated that when adolescents with BD participate in short-term, aerobic exercise, neural activity in the nucleus accumbens is different after exercising (measured by performing an executive task both before and after exercise). This suggests for adolescents, and possibly extending into younger children, exercise can increase concentration, an impairment that is often seen in youth with PBD.

Resources

Resource	Description
National Institute of Mental Health	This website includes a section for each mental disorder listed in the DSM-5. There is a section dedicated to bipolar disorder in children and teens comprised of the definition of bipolar disorder, symptoms, diagnosis, comorbidities, and common treatments.
Effective Child Therapy	Effective Child Therapy is a resource for evidence-based information about bipolar disorder and other mental illnesses diagnosed in children.
National Suicide Prevention Lifeline	National Suicide Prevention Lifeline provides a hotline number (1-800-273-8255), an online chat, and an informational website for individuals who are experiencing suicidal thoughts.
Psychology Today	Psychology Today provides information for individuals and families who are seeking local, face-to-face therapy options for treatment of psychiatric symptoms, including treatment centers for bipolar disorder in and around Raleigh.
NC Health Info	NC Health Info provides additional resources including local therapists, support groups, and more that are specifically for individuals with bipolar disorder in North Carolina.
Depression and Bipolar Support Alliance (DBSA)	The DBSA is a non-profit organization providing support for people with bipolar disorder, their caregivers, and clinicians. Individuals can search for in-person support groups by zip code or participate in online support chats or groups.

Archived content from original draft (to be moved to talk page)

Pediatric bipolar disorder (PBD) has been acknowledged by clinicians and researchers alike for centuries, but the diagnosis of Bipolar Disorder in children has historically been controversial. There is a long-standing debate over whether or not bipolar disorder (BD) should be diagnosed in children at all, and if it should, at what age is it appropriate to begin to diagnose children with the disorder. According to meta-analytic evidence, the community prevalence of PBD is 3.9%, without a significant increase in prevalence over time. There is large variability demonstrated within the symptom presentation of children with PBD, partly due to the fact that BD is a "spectrum" of disorders with no clear qualitative boundaries separating the different types (i.e., BD-I, BD-II, cyclothymia, and Other Specified Bipolar and Related Disorder)identified by current classification systems. To combat this variability within symptoms and allow for a concrete diagnosis, it is important to evaluate the most appropriate plan for assessment, diagnosis, and treatment while also keeping in mind the risk factors and long-term prognosis for children with PBD.

A bipolar I disorder diagnosis requires the patient to have at least one manic episode within their lifetime. Manic episodes are best described as a period of extreme elated mood/energy and irritability, and individuals must experience three or more of the symptoms provided; among the most commonly experienced are grandiosity, racing thoughts, decreased/dysfunctional sleep, and being easily distracted . Major depressive episodes are common but not required for a diagnosis of bipolar disorder. Major depressive episodes are characterized by a period of either anhedonia or depressed mood in addition to having five or more of the classified symptoms within a period of 2 weeks such as lack of sleep, fatigue, worthlessness, or suicidal ideation. To be diagnosed with bipolar II disorder, a patient must demonstrate at least one hypomanic episode paired with at least one major depressive episode. The criteria are still the same for a depressive episode, but a hypomanic episode is a change in mood present for at least 4 consecutive days for a majority of the day. Three or more of the similar symptoms experienced for manic episodes are required. The DSM-5 specifies manic, hypomanic, and depressed as the three types of episodes of BD.

A recent meta-analysis estimated the prevalence rate of PBD overall as 3.9% (when BD is defined as a spectrum diagnosis). Although this represents an increase in the rate as compared to an earlier meta-analysis's prevalence rate of 1.8% , this may be the result of a shift from the DSM-IV to the DSM-5 and subsequent changes to diagnostic specificity. It is also consistent with prevalence rates of other recent meta-analyses. Compared to the overall rate, Bipolar I has a prevalence rate of of 0.6%. These rates indicate that bipolar disorder in youth is more common than autism and schizophrenia but not more common than ADHD or unipolar depression.

Another study compared diagnostic rates of PBD in the United States to other countries and identified that U.S. children are just as likely to be diagnosed with PBD as children in any other country. This suggests that cultural and ethnic factors do not present risk factors for PBD or biases in the interpretation of bipolar symptoms. Older adolescents also have significantly higher prevalence rates compared to pre-pubertal youth.

Sex Differences

Studies of Bipolar I in adults have demonstrated that it occurs equally in men and women. No significant differences in PBD prevalence based on gender have been demonstrated after accounting for the fact that generally, more young males present to clinics for externalizing problems than females , although earlier studies have reported a higher percentage of females with bipolar II disorder than males.

Many symptoms of PBD overlap with symptoms of other diagnoses that are common in childhood (e.g., ADHD, conduct disorder, oppositional defiant disorder), and bipolar disorder is often comorbid with other conditions. Comorbid psychopathology may also exacerbate bipolar symptoms in pediatric patients, complicating accurate diagnosis. A meta-analytic study investigating the phenomenology of mania in children, including the most common comorbidities, determined that ADHD is the most common comorbid diagnosis (62% of participants) in children with PBD, followed by Oppositional Defiant Disorder (ODD; 53%), psychosis (42%), and anxiety (27%).

In addition to being commonly comorbid, overlapping symptoms between PBD and ADHD include irritability, distractibility, and impulsivity. When pediatric patients are diagnosed with both ADHD and PBD, they may be more susceptible to an increased severity of shared symptoms. One study investigated the effect a comorbid diagnosis of both ADHD and bipolar spectrum disorder (BPSD) had on pediatric patients when compared to pediatric patients with only BD. When pediatric patients were diagnosed with both ADHD and BPSD, they were more likely to experience decreased overall functioning and increased severity of symptoms. Patients with both ADHD and BPSD also experienced higher rates of additional comorbidities when compared to patients with only BPSD or ADHD alone. Age of onset did not differ between the BPSD only group and the combination of ADHD and BPSD.

There have also been cases of patients with PBD and comorbid Autism Spectrum Disorder (ASD). Researchers have studied individuals diagnosed with ASD and experiencing bipolar symptoms to investigate neurocognitive and clinical impairment compared to individuals only with ASD, and discovered that the ASD + BD group experienced an increased rate of externalizing behaviors (e.g., aggression, delinquency) and behavioral inhibition. The ASD + BD group also experienced increased internalizing behaviors such as depression, suicidal ideation, and anxiety.

Because the bipolar symptoms pediatric patients experience can be variable and unpredictable in nature (especially in terms of duration and frequency), it is difficult to determine if there is a concrete age of onset for PBD. According to a study by Leverich et al. (2007), when surveying 480 individuals with bipolar disorder, 14% reported their age of onset was between 0-12 years old, with the average age around 9.57. Patients with earlier onset of PBD were reported to have the highest incidence of parental history of depression and/or BD and greater environmental stressors. Earlier onset of bipolar disorder corresponded with longer time to treatment. Additionally, adult patients with earlier onset experienced a more convoluted developmental course of BD, including faster cycling periods, substance abuse, depressive episodes, and suicide attempts, demonstrating the importance of early intervention for PBD.

The family environment of a child with PBD can also affect overall functioning and symptom severity. Pediatric patients that experience greater impairment in a variety of contexts (at home, in school, and other social settings) are more likely to have reduced overall functioning, a history of being admitted to a mental health institution, and/or a suicide attempt. Additionally, reduced functional and social impairment for children with PBD can ultimately lead to a reduced quality of life. Cotrena et al. (2020) measured the value of ‘quality of life’ (QoL) for patients with PBD based on how their personal QoL (how they view their lives) and social QoL (how they perceive the world) compared to how the patient managed their depression symptoms and their PBD diagnosis, and both were found to negatively affect outcomes. In particular, such factors (which factors?) influenced one’s personal QoL and cognitive performance. Because the presence of manic and depressive symptoms can impair function and, consequently, cognitive performance, children with PBD may experience lower self-esteem and reduced quality of life compared to healthy children.

PBD is considered a spectrum disorder, suggesting that children with PBD are likely to experience a range of symptoms. This can make PBD especially difficult to diagnose and, consequently, treat. Establishing a clear and well-defined assessment strategy for clinicians to use can provide a more accurate and reliable way to diagnose PBD and prevent misdiagnoses. Clinicians are recommended to use screening questions as an initial step in evidence-based assessment (EBA). Screening questions allow the clinician to gauge if the patient has had spontaneous changes in mood for defined periods of time and assess personal and family history of mood disorders. Symptom reports from family members, school, and peers are necessary to gauge the behavioral and emotional challenges a child is experiencing. Other potential medical conditions or comorbid disorders must be reported to determine the most appropriate treatment plan, especially if there is a presence of suicidal ideation and/or substance abuse. Following the screening, the use of a questionnaire and checklists are the next logical step in EBA.

Questionnaires like K-SADS, WASH-U-KSADS, and the Young Mania Rating Scale are pivotal for determining mania severity as well as feedback for treatment, but not for diagnosing a patient with PBD. One of the most effective assessment checklists for diagnosis is the Achenbach System of Empirically Based Assessment (also Child Behavior Checklist, CBCL). The CBCL represents a pediatric patient’s symptoms on a scale, conveying both externalizing and internalizing symptoms. The CBCL shows a higher sensitivity for externalizing scores for PBD, which is helpful in differentiating PBD from other disorders like ADHD. Such measures indicate what the appropriate approach for treatment is as well as the patient’s overall functioning level. However, in general, questionnaires are observed to be more effective when paired with a diagnostic structured interview.

Bayesian approaches, or nomograms, may also be used with checklists or questionnaires. Bayesian approaches identify the probability that a patient has a certain disorder using a patient's diagnostic likelihood and their test results on performance-based exams. The nomogram allows clinicians to create probabilities that are unbiased, efficient, and produce no variability, reducing the chance that PBD would be misdiagnosed.

Table: Recommended starter kits for assessing potential bipolar spectrum disorder

Identified Patient Age Tool School Aged (5 to 10 years old) Adolescent (11 to 18 years) Parent About Youth Adult Client or Parent About Self Anchor probability Very rare in general population Uncommon Uncommon Uncommon Bipolar spectrum benchmark probability ~1% general ~5% clinical (<1% bipolar I) ~4% general population ~10% clinical Use age of youth to pick ~4% general population ~20% of clinical Broad screen N/A (reading level) YSR, BASC, SDQ, or ASI CBCL, BASC, CSI, or SDQ YASR Follow up measures PPDS (puberty) N/A for self-report questionnaires (reading level) PPDS (puberty) GBI-10M or 7 Up PPDS (puberty) PGBI-10M or CMRS10 FIRM FIRM HCL, BSDS, MDQ, or ISS Diagnostic Interview MINI-Kid MINI-Kid or MINI MINI MINI Severity Interview: KMRS, KDRS Rating Scale: None (reading) Interview: KMRS, KDRS Rating Scale: GBI10M, GBI10Da/Db Interview: KMRS, KDRS Rating Scale: PGBI10M, PGBI10Da/Db Interview: YMRS, HDRS Rating Scale: Altman Global Functioning: CGAS (1 to 100) CGAS (1 to 100) CGAS (1 to 100) GAF Quality of Life: Kiddy KINDL KINDL Parent KINDL QoL.BSD Sleep See Meltzer (2020) See Meltzer, (2020) PGBI-Sleep See Meltzer (2020) Chronotype (SMEQ), sleep problems (PSQI) Mood change N/A Mood charting app Mood charting app Mood charting app Note. Bipolar Disorder is extremely rare before the age of 5; do not consider as a possible diagnosis except under highly extenuating circumstances. Glossary: YSR = Youth Self Report; BASC = Behavioral Assessment Scale for Children; SDQ = Strengths and Difficulties Questionnaire; ASI = Adolescent Symptom Inventory; CSI = Child Symptom Inventory; YASR = Young Adult Self-Report; PPDS = Petersen Pubertal Developmental Screen; FIRM = Family Index of Risk for Mood disorders; GBI = General Behavior Inventory; 7 Up = 7 Up; PGBI-10M, 10Da, 10Db = 10 item forms of parent-reported GBI; HCL = Hypomania Checklist; BSDS = Bipolar Spectrum Diagnostic Scale; MDQ = Mood Disorder Questionnaire; ISS = Internal States Scale; MINI = Mini International Neuropsychiatric Interview; MINI-Kid = MINI for Children and Adolescents; KMRS = KSADS Mania Rating Scale; KDRS = KSADS Depression Rating Scale; YMRS = Young Mania Rating Scale; HDRS = Hamilton Depression Rating Scale; CGAS = Children’s Global Assessment Scale; GAF = Global Assessment of Functioning; KINDL = quality of life scale (not an acronym); QoL.BSD = Quality of Life for Bipolar Disorder; PGBI Sleep = sleep scale carved from parent GBI; SMEQ = Student Morningness-Eveningness Questionnaire; PSQI = Pittsburgh Sleep Quality Index.

Online Assessment Resources

There are a number of online assessment resources available for the general public (adolescents, parents, etc.) as well as clinicians. The Helping Give Away Psychological Science (HGAPS) Assessment Center offers a free, confidential platform to help you safely explore your mental health symptoms and determine if you should seek assistance from a mental health professional. Upon finishing an assessment, you will be given your results and offered recommended resources based on the symptoms you have endorsed.

The following links are to specific assessment batteries for adults, adolescents, and caregivers:

This survey contains self-report assessments used by mental health professionals to measure ADHD, depression, anxiety, PTSD, bipolar disorder, and substance use in adults. These questionnaires are designed to be taken by an adult about themselves.

This survey contains self-report assessments used by mental health professionals to measure depression, anxiety, PTSD, bipolar disorder, substance use, and oppositional defiant disorder/conduct disorder in youth. These questionnaires are designed to be taken by a child or adolescent about themselves.

This survey contains assessments used by mental health professionals to measure ADHD, depression, anxiety, PTSD, bipolar disorder, substance use, and oppositional defiant disorder/conduct disorder in youth. These questionnaires are designed to be taken by a caregiver about a child or adolescent.

The HGAPS Assessment Center also offers specific measures for clinician use.

Clinician Assessments for Bipolar Disorder

Assessment	Language	For Parent/Child/Adult	Link
7 Up-7 Down	English	Adult and Adolescent	7up-7down
BSDS: Bipolar Spectrum Diagnostic Scale	English	Adult	BSDS
CMRS: Child Mania Rating Scale	English	Parent	CMRS
Family Index of Risk for Mood (FIRM)	English	Parent	FIRM
Hypomania Checklist (HCL)	English	Adult	HCL
General Behavior Inventory	English	Parent	GBI
General Behavior Inventory	Spanish	Parent	GBI
General Behavior Inventory	English	Adult/Adolescent	GBI
General Behavior Inventory 10M	English	Parent	GBI 10M
General Behavior Inventory Da	English	Parent	GBI Da
General Behavior Inventory Da	Spanish	Parent	GBI Da
General Behavior Inventory Db	English	Parent	GBI Db

Table: Criteria for Manic or Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive or irritable mood, clearly different from usual mood; increased energy Duration: At least one week present every day, at least most of the day (unless treatment cuts it short) for mania; at least 4 consecutive days present every day, at least most of the day for hypomanic episode (though data suggest that two day periods are more common and still impairing) B. During the mood episode, at least 3 of the following symptoms are also present to a significant degree (4 or more if mood is mostly irritable): 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (such as feeling rested with only three hours of sleep) 3. Pressured speech or more talkative than usual 4. Flight of ideas or racing thoughts 5. Distractibility, either reported or observed 6. Increased goal-directed activity (either socially, at work, at school, or sexually) or psychomotor agitation 7. Excessive activities with a high risk for painful or damaging consequences (ie. unrestrained spending sprees, sexual indiscretions, or risky business investments) C. Mania: Causes marked impairment in school, at home, or with peers; may also require hospitalization to prevent harm to self or others; may also have psychotic features Hypomania: An unequivocal change in functioning from typical for person when not symptomatic, observable by others; but not severe enough to cause marked impairment, and with no psychotic features. D. Symptoms are not due to physiological effects of a substance (including stimulant or antidepressant medication), or symptoms due to a general medical condition. E. Hypomania: The episode is not severe enough to cause major impairment in functioning or to require hospitalization. By definition psychotic features is manic. F. Hypomania: Symptoms are not due to physiological effects of a substance (e.g. an abused drug, medication, or other treatment) Adapted from DSM-5; ICD-11; ISBSD Child Diagnosis Task Force.

Table: Symptoms and associated features of BSD based on meta-analysis

Symptom Sensitivity to BSDa Specificity to BSD Features Suggesting BSD Features Suggesting Other Diagnoses Recommendation Handle Symptoms (High Specificity) A.1. Elated, expansive, euphoric mood Mweighted= 64% (95% CI: 53 to 75%) 19 studies High Extreme, causes impairment, situationally inappropriate, extreme duration Transient, more responsive to redirection, more situationally driven Substance abuse Highly specific feature – Presence helps rule in diagnosis. Assess even though family may not consider it part of presenting problem A.2. Irritable mood 77% (64 to 88%) 17 studies Low Irritability in context of other mood symptoms; high versus low energy irritability Chronic oppositional behavior in absence of changes in mood or energy; Might be unipolar depression Assess via collateral informant – self report underestimates. If collaterals deny irritability, effectively rule out BSD because of high sensitivity. Embed in context of changes in mood & energy B.1. Grandiosity 57% (44 to 69%) 19 studies Moderately high – much lower if conduct disorder included Episodic quality, and should fluctuate with mood. Periods of grandiosity contrasted with low self-esteem, worthlessness More chronic, arrogant, not associated with mood is suggestive of CD/APD or adolescent overconfidence Substance abuse Worth emphasizing, but probably not specific enough to elevate to required feature. Fluctuations a key feature in discerning from CD/APD. Increased Energy 79% (61 to 93%) 8 studies Highest sensitivity in meta-analysis Low for “high energy” – which is also common in ADHD; episodic periods of high energy would be more specific to mood disorder Higher if ask about fluctuation or change; low if ask about chronic (b/c common feature with ADHD) Chronic high motor activity Need to assess as change in functioning from youth’s typical behavior. Episodic quality is more specific to bipolar. Focus on energy versus motor activity for self-report (2002); change in motor activity for collaterals. Nonspecific Symptoms (in Descending Order of Sensitivity to BSD) Pressured Speech 63% (49 to 77%) 18 studies Unclear. Carlson (Carlson, 2002) raises issue of expressive language problems; but not evaluated yet in published samples Episodic quality, change from typical for youth; set against slowed or impoverished speech during depression Chronically “chatty” or talkative more suggestive of ADHD Emphasize changes from typical functioning embedded in shifts of mood or energy Racing Thoughts 61% (45 to 76%) 15 studies Good if embedded in mood context Ask about imagery as well as words Distinguish from expressive language disorder Substance abuse, meds Decreased need for sleep 56% (46 to 67%) 19 studies High if framed as decreased need, not insomnia. Low if just focus on trouble falling asleep. High energy, actively engaged in activities, does not miss sleep the next day Decreased sleep due to stimulant use (ADHD), use of substances or medications; difficulty falling asleep with unipolar depression (versus decreased need for sleep). Depressed persons want to sleep, but cannot Emphasize decreased need for sleep, as distinct from difficulty falling asleep (particularly due to stress or rumination). High energy, little diminution of energy despite decreased sleep Mood swings/lability 76% (55 to 95%) 6 studies High – based on PGBI, CBCL, Conners items Frequent, intense, with periods of long duration May be induced by substance abuse , medications, medical/neurological illnesses, borderline personality traits, disruptive disorders Parent report highly sensitive. BSD unlikely if parent denies. Specificity appears promising, based on multiple scales. Conceptualize as mixed state with volatile mood. Hypersexuality 32% (23 to 42%) 12 studies High – typically either pediatric BSD or sexual abuse Hypersexuality not characteristic, embedded in episodes of energy/mood; has pleasure-seeking quality Sexual Abuse—linked to trauma, perhaps more seductive/re-enacting quality than sensation-seeking; pornography exposure; actual sex Insensitive to BSD, so absence not informative. Highly specific: Presence should trigger careful assessment of BSD and abuse (recognize that they could co-occur) Distractibility 74% (61 to 85%) 17 studies Low – ADHD, unipolar, anxiety, PTSD, and low cognitive functioning all show this, too Higher if ask about change from typical, embed in context of mood Chronic problems much more suggestive of ADHD or neurological impairment Probably important to assess via collateral instead of self-report. High sensitivity could make negative collateral helpful at ruling out bipolar. Poor judgment 61% (45 to 76%) 17 studies Moderate Episodic, embedded in mood/energy Impulsive or accident-prone, clumsy Episodic, sensation-seeking may be most specific presentation Flight of Ideas 54% (42 to 66%) 12 studies Moderate (Speech problems again) substance abuse, medication-induced Increased sociability/people-seeking/overfamiliarity (ICD10, p. 113); Added to WASH-U KSADS; 41% (27 to 56%) 7 studies Unknown Could be the positive affect, could be sensation seeking Needs investigation a Sensitivity estimates from Van Meter, Burke, Kowatch, et al. (2016) meta-analysis.

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rates of PBD that they are likely to see in their clinical practices.

• To find prevalence rates across multiple disorders, click here.

^p Parent interviewed as component of diagnostic assessment; ^y youth interviewed as part of diagnostic assessment.

Note: KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia, PL = Present and Lifetime version, WASH-U = Washington University version, -E = Epidemiological version of the KSADS; DISC = Diagnostic Interview Schedule for Children; DICA = Diagnostic Interview for Children and Adolescents. Table modified from Wikiversity.

Demography	Setting	Base Rate	Diagnostic Method
All of U.S.A.	Community epidemiological (NCS-A)	3.0%	CIDI 3.0
U.S.A., Netherlands, U.K., Spain, Mexico, Ireland, New Zealand	Community epidemiologic samples	mean= 1.8% (95% CI, 1.1%–3.0%), bipolar I (mean =1.2%; 95% CI, 0.7%–1.9%)	Structured and semi-structured diagnostic interviews, Combination of broad and specific diagnostic criteria (Meta-Analysis)
U.S.A., Midwestern Urban, 80% non-white, low-income	Community mental health center	6%	Parent and youth clinical assessment & treatment
Urban academic research centers	General outpatient clinic	6-8%	WASH-U-KSADS (parent and youth)
Boston area, U. S. A.	Specialty outpatient service	15-17%	KSADS-E
All of Germany	Inpatient Services/Diagnoses	0.3%	International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
Oregon	Community sample	2.9%	LIFE, SCID, DSM-IV
New York City Metro Region	Inpatient service	30% manic symptoms, <2% strict BP I	DICA; KSADS
U.S.A, NCS-A	NCS-A Clinical Reappraisal Sample p y	6.2% and SE=1.7 (bipolar I and II and sub-threshold bipolar spectrum disorder)	K-SADS, DSM-IV criteria were modified from published version for purpose of the study, broad criteria for not otherwise specified
U.S.A, NCS-A	NCS-A Clinical Reappraisal Sample p y	6.6% and SE=1.7 (bipolar I and II and sub-threshold bipolar spectrum disorder)	CIDI, DSM-IV criteria were modified from published version for purpose of the study, broad criteria for not otherwise specified,
United Kingdom	National Cross‐sectional epidemiological sample p y	1.2% (bipolar I and II and not otherwise specified)	DAWBA, DSM-IV criteria, broad criteria for not otherwise specified
Mexico City	Community epidemiological samples y	2.5% (bipolar I and II)	CIDI, DSM-IV Criteria
Ireland	2-stage epidemiological study p y	0.0% (bipolar I and II, cyclothymia, not otherwise specified	K-SADS, DSM-IV Criteria

^p:Parent interviewed as component of diagnostic assessment; ^y:Youth interviewed as part of diagnostic assessment.

Note:

• KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia,
• WASH-U = Washington University version, -PL = Present and Lifetime Version, -E = Epidemiological version of the KSADS
• LIFE = Longitudinal Interval Follow-Up Evaluation,
• DICA = Diagnostic Interview for Children and Adolescents
• CIDI = Composite International Diagnostic Interview
• DAWBA= The Development and Well-Being Assessment

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