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Section 18
Diagnosing Pediatric Bipolar Disorder

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Until recently, bipolar disorder was rarely diagnosed in adolescence. Due to developmental issues and overlapping symptoms with other disorders, diagnosing bipolar disorder is often a confusing and complex process. It is a serious, but treatable mental illness that is characterized by recurrent episodes of depression and mania. These episodes are manifested by unusual and extreme shifts in moods, energy, and behavior that interfere with effective functioning. There is limited empirical data about the efficacy and safety of the use of psychotropic medications and psychotherapy with adolescents. If bipolar disorder is not diagnosed or is left untreated, the effects on the patient, family, and community can be devastating.

A few years ago, mental health counselors and other professionals rarely diagnosed bipolar disorder in adolescence. The American Academy of Child and Adolescent Psychiatry reports that up to one third of the 3.4 million children and adolescents with depression in the United States may actually be suffering from the onset of bipolar disorder. In addition, it has been estimated that one third of the children and adolescents diagnosed with attention deficit hyperactive disorder (ADHD) may be suffering from emerging bipolar disorder (Papolos & Papolos). School absenteeism, poor academic performance, impaired social functioning, and a greater risk of substance abuse are associated with bipolar disorder in adolescence (Hussain, Chaudry, & Hussain). Left untreated, the disorder can lead to suicide, expensive hospitalizations, legal difficulties, and disastrous consequences for families (Waltz). Early intervention may aid in preventing future symptoms or serious consequences (Hussain et al.).

Diagnostic Criteria
The criteria for diagnosing bipolar disorder in adolescence are the same as those for adults. Defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association) are several variations of bipolar disorder which vary in combinations of mood strength and frequency of mood shift (Lynn). In the bipolar I form, the individual experiences one or more manic episodes, or mixed episodes and possibly one or more major depressive episodes. There can be periods of relative or complete wellness between the episodes. Mania is defined as an elevated, expansive, or irritable mood that is both abnormal and persistent and lasts for at least one week. Symptoms of mania include elevated or irritable mood, a decreased need for sleep, racing speech, grandiose delusions, excessive involvement in pleasurable but risky activities, increased physical and mental activity, and poor judgment. In severe cases, hallucinations and/or delusions may be present often causing marked impairment in functioning and necessitating hospitalization.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association), depressive symptoms include pervasive sadness nearly every day for a 2-week period (in children and adolescents this can be identified as an irritable mood); notable diminished interest or pleasure in all activities for most of the day; sleeping too much or an inability to sleep; weight loss when not dieting or weight gain (in children and adolescents this can be considered a failure to make expected weight gains); psychomotor agitation or retardation; fatigue or decreased energy level; feelings of worthlessness or excessive guilt; the inability to make decisions or concentrate; and recurrent thoughts of death and suicide. A mixed episode lasts for at least one week, and the criteria for both mania and depression are met nearly every day during that time period (APA).

In the bipolar II form of the disorder, an individual experiences hypomania between one or more episodes of major depression. Hypomania is described in the DSM (APA) as a markedly elevated, expansive or irritable mood that lasts for at least 4 days. The symptoms are the same as for mania except that the duration is shorter, and there are no hallucinations or delusions. Hypomania does not significantly impair occupational, social, or relationship functioning; and there are no psychotic features (APA).

The least severe form of this disorder is cyclothymia. It is characterized by periods of hypomanic symptoms and numerous periods of depression that do not meet the criteria for major depressive episode. These symptoms must be present for one year in children and adolescents. Mood swings are present, but they are less intense. When a professional is unable to determine which type bipolar disorder is emerging, it may be classified as bipolar disorder not otherwise specified (Child and Adolescent Bipolar Foundation).

Symptoms And Behaviors
Adolescents may initially exhibit either a manic or depressive episode. Of those with major depression, 20% to 30% subsequently have manic episodes. A loss or other traumatic event may trigger the episode of depression or mania in adolescents. Additional episodes may occur independently or may be precipitated by stress. The onset of puberty is often thought to trigger the disorder. Symptoms in females may vary with their monthly menstrual cycle (Child and Adolescent Bipolar Foundation).

Adolescents may consume illegal drugs in an attempt to control their mood swings and insomnia. Sudden development of the disorder following puberty often results in addiction to drugs and alcohol in these vulnerable adolescents. It then becomes necessary to treat both the bipolar disorder and the substance abuse (Child and Adolescent Bipolar Foundation). In children and younger adolescents, the disorder is more continuous than in adults with few asymptomatic periods between episodes of depression and mania. Some children and adolescents cycle between depression and mania as few as several times per year, while others cycle within a week or month. However, most bipolar children cycle between depression to mania several times throughout the day. This mixed state can cause them to feel full of energy, restless, worthless, and self-destructive simultaneously (Papolos & Papolos).

Mania is not always characterized by euphoria. Adolescents often exhibit irritability and outbursts of destructive rage (Biederman). Rages that are violent and often result in exhaustion are common in adolescents experiencing this disorder. These rages are frequently precipitated by a requirement to follow a rule or by a denial of a request. Often the individual does not remember what transpired during the rage (Lynn). Another common feature of adolescents with bipolar disorder is their oppositional and tyrannical behavior. They many times defy authority and dictate to their parents how they should relate to and discipline their siblings. The adolescent displays an outburst of rage when told he or she cannot engage in a requested activity, and often becomes verbally abusive (Stanard). Another characteristic of bipolar disorder in adolescents is akathesia, a restless inner tension. Akathesia, coupled with anxiety, produces irritability and hyperactivity. Adolescents with bipolar disorder typically cycle through periods of hyperactivity that is oddly magnified at night. Due to this uncomfortable agitation, adolescents frequently attempt risky and dangerous behavior such as sneaking out of the house after everyone is asleep or driving without a license. This disorder can have a profound effect on the sleep cycles of adolescents. They usually cannot fall asleep until very late and then prefer to sleep most of the day. Episodes of mania occur more frequently from late afternoon throughout the night in the rapid cycling form of the disorder. Impulsivity is another common trait associated with bipolar disorder. Adolescents with bipolar disorder act impulsively to energize themselves when depressed. Good judgment may fade when in a manic phase, leading them to act impulsively. This impulsivity may be associated with hypersexuality and/or hyperreligiosity, often causing extreme confusion. When hypomania is present, the ability of adolescents to focus increases. They can exhibit extreme self­-centeredness and combative behavior. These adolescents seem unable to display empathy (Lynn).

When adolescents become depressed, often they lose cognitive abilities, causing them to be unable to focus or concentrate. Many of them have thoughts that they have difficulty controlling. These thoughts may lead to suicidal thinking, which is common among adolescents in depressed states. The suicidal thoughts of adolescents warrant close attention as suicide is the leading cause of death of those with bipolar disorder (Lynn). Suicide associated with bipolar disorder is consistent with the Center for Disease Control’s findings that suicide is responsible for more deaths in youth 15—19 years of age than any other mental or physical illness. Equally alarming is the finding that it is the fourth leading cause of death in children 10—14 years of age (Stanard).

Some unique temperament traits are often associated with bipolar disorder in children and adolescents (Lynn). One peculiar trait is excessive sensitivity to various types of physical stimuli. Pockets in clothes, labels on shirts, and ill-fitting socks can be very bothersome to a child or adolescent with this sensitivity. In addition, certain odors and strange noises can also be bothersome. Extreme reaction to cold and heat is another unusual characteristic response to physical stimuli. Some children and adolescents are very heat intolerant and wear no coats in the winter. Even food must be a certain temperature or it will not be eaten. Some bipolar children and adolescents have insatiable cravings for carbohydrates and sweets. They may hoard chocolate and cookies in their bedrooms and eat large amounts of pasta, cereal, and bread (Papolos & Papolos).

Differential Diagnosis
The mental health counselor making the diagnosis does so by a process referred to as differential diagnosis, a process of elimination (Waltz). As a first step in the elimination process, medical conditions that can mimic the symptoms of mania and depression must be ruled out. These conditions include hormonal disorders, infectious disease, neurological disorders, blood disease, malignancies, and nutritional disorders (Papolos & Papolos). Symptoms of mania can be induced by prescription medications including antidepressant agents, stimulants, steroids, sympathomimetics, and bromocriptine. Abuse of substances including amphetamines, cocaine, phencyclidine, inhalants, and methylenedioxymethamphetamine (ecstasy) may also trigger mania in adolescents (McClellan & Werry). The most important factors to consider in diagnosing bipolar disorder are medical and psychiatric history, family psychiatric history, direct observation, physical exam, and personal interviews. In some situations, a psychiatrist, psychologist, or neurologist may administer psychiatric, neurological and/or academic tests (Waltz).

The age of the individual and the developmental stage are important considerations in making a differential diagnosis. Due to the fact that bipolar disorder is rarely diagnosed in childhood or adolescence, the symptoms are often attributed to developmental issues or to another disorder (Cantor). The symptoms of bipolar disorder may be mistaken for normal emotions and behaviors of adolescence. However, unlike normal mood changes, bipolar disorder can seriously affect an adolescent’s functioning in school, with peers, and at home (National Institute of Mental Health, n.d.). A manic episode lasting a few weeks in adolescence may be mistaken by parents as a normal phase of development, especially if the symptoms do not severely influence school performance (Geller & Luby).

The mental health counselor is presented with a challenge in accurately determining the diagnosis due to the clusters of overlapping psychiatric symptoms and the unique manifestations of the symptoms (Waltz). Manic symptoms such as distractibility, irritability, impulsivity, and hyperactivity may mimic symptoms of ADHD (Biederman). Although the symptoms of bipolar disorder and ADHD may be similar, there are a few distinguishing features. Whereas oppositional behavior in bipolar adolescents is intentional, in ADHD adolescents, it is a result of carelessness and inattention. The physical outbursts and temper tantrums often seen in both disorders are believed to be triggered by sensory and emotional stimulation in those with ADHD, but are triggered by adult limit-setting in those with bipolar disorder. Another feature that separates ADHD from bipolar disorder is that adolescents with ADHD tend to calm themselves shortly after the outbursts, while those with bipolar disorder may take hours to become calm (Papolos & Papolos). Manic episodes may have debilitating extremes that include psychotic symptoms of hallucination, paranoia, and marked thought disorder. These manic extremes have led to a misdiagnosis of schizophrenia as well as an underdiagnosis of bipolar disorder in adolescents. Many symptoms of mania are also shared with conduct disorder, oppositional defiant disorder, and major depression. These symptoms include aggression, irritability, hyperactivity, provocative and risk-taking behaviors, sleep disturbances, distractibility, and antisocial behavior (McClellan & Werry). To meet the criteria for mania, the adolescent must exhibit additional symptoms such as a decreased need for sleep, flight of ideas, pressured speech, grandiosity, elated mood, and hypersexuality (Leibenluft).

Other important differential diagnoses or combined conditions that should be considered are trauma from sexual abuse, specific language disorders, and substance abuse (Geller & Luby; Remschmidt). Bipolar disorder is often associated with or preceded by conduct disorder, ADHD, and/or oppositional disorder (Chang). Approximately 90% of the children who later develop bipolar disorder were first diagnosed with ADHD (Chandler). Studies have found that as many as 57% to 86% of children and adolescents with bipolar disorder have comorbid ADHD and 69% have comorbid conduct disorder. It is unknown whether these are comorbid conditions, prodromal, or concurrent representations of the bipolar disorder itself (Chang).

In summary, diagnosing mood disorders in adolescents is a complex undertaking. However, there are several factors that are unique to bipolar disorder. The temperament and moods of bipolar adolescents are often extreme with no consistency and many fluctuations. Family history of mood disorders and substance abuse is a strong predisposing factor of childhood bipolar disorder. It is important for the client and family to understand that an initial diagnosis is tentative. The adolescent’s behavioral and family history, response to medications, and developmental stage are important considerations in the overall treatment plan (Waltz).

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Personal Reflection Exercise #4
The preceding section contained information about diagnosing pediatric bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 18
According to Wilkinson, what are four characteristic symptoms of mania in adolescents? Record the letter of the correct answer the Answer Booklet.