Diagnosis of Pediatric Bipolar Disorder

September, 2008

The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV-TR)
defines bipolar I disorder as having a clinical course that is characterized by the occurrence of one or more manic episodes, (defined as a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood, lasting for at least one week.) 
There are also mixed episodes, (in which criteria for a manic episode and a major depressive episode are met nearly everyday for at least a one week period); and Bipolar II Disorder as having at least one or more major depressive episodes, accompanied by at least one hypomanic episode. 

A hypomanic episode is a distinct period of persistently elevated, expansive or irritable mood lasting throughout at least 4 days, which is clearly different from the usual non-depressed mood.  

The diagnosis of the cyclothymic disorder requires a chronic, fluctuating mood disturbance, involving numerous periods of hypomanic symptoms, alternating or mixed with depressive symptoms.  To meet the diagnostic criteria for cyclothymia, the individual must not experience any symptom free intervals lasting longer than 2 months during a one-year period. 
The diagnosis of Bipolar Disorder (NOS) not otherwise specified or the term Bipolar Spectrum Disorder, is used when an individual possesses some, but not all of the symptoms, or doesn’t meet the duration or severity criteria that is necessary to be classified as Bipolar I or Bipolar II.  While these individuals may not meet the full diagnostic criteria for Bipolar I or Bipolar II disorder, they still suffer from highly impairing elements of the disorder which require intervention.  The earlier treatment is initiated, the more responsive children seem to be to medications and other treatments.  Whether or not children and adolescents with bipolar disorder NOS will go on to develop bipolar disorder I or II is not clear at this time. 

Studies of populations at high-risk for BD development have indicated that children with strong family histories of BD who are themselves experiencing symptoms of attention-deficit/hyperactive disorder (ADHD) and/or depression or have early mood dysregulation may be experiencing prodromal states of BD. 

Many children and adolescents with bipolar disorder present with the following symptoms: 1) chronic irritability; 2) psychosis; 3) mixed episodes with rapid cycling, with little inter-episodic recovery; and 4) high rates of co-morbidity with ADHD, oppositional defiant disorder and conduct disorder. 

Episodes tend to be long in duration, often with rapid cycling and mixed mania, and include symptoms of impulse control or conduct problems.  Mixed episodes are described as rapid shifting moods, ranging from irritability or elation to depression; usually with manic symptoms coexisting with depressive symptoms for at least 4 hours per day.   

Core Features of Bipolar Disorder in prepubertal and early-adolescent bipolar disorder phenotype   

DSM-IV-TR Diagnostic Criteria for Manic/Hypomanic Episode

  • Mood Symptoms: Elevated, Expansive or Irritable
  • Associated Symptoms: 3 out of 7 or 4 out of 7 if mood is primarily irritable  
  • Inflated self esteem/grandiosity
  • Decreased need for sleep  
  • Flight of Ideas or Racing Thoughts 
  • Poor Judgment and hypersexuality 
  • Distractibility
  • Goal Directed Activity
  • Talkative/Pressured Speech

Findings from research studies report that sub-threshold PBD, sometimes referred to as bipolar spectrum disorder or bipolar disorder NOS (BP-NOS), is common, clinically significant and under-detected in treatment settings.    Despite the fact that sub-threshold cases of PBD do not meet the full criteria for bipolar disorder I (BP-I) or bipolar disorder II (BP-II), most of these children and adolescents have moderate to severe clinical severity and role impairment.

Screening Instruments
Some of the screening instruments which are easy to use that pediatricians and nurses might find helpful in their practice are: 1) the Child Mania Rating Scale-Parent Version; 2) the Young Mania Rating Scale-Parent Version; 3) The Mood Disorders Questionnaire; and 4) The Child Behavior Checklist.


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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.

- Dr. Howard King, M.D.