Here, consistent with the data presented above, we provide guidelines for assessing manic episodes. Before discussing details of the assessment, we note that it is important that child and parent (or caregiver) be interviewed both separately and together. Basically the same set of questions should be asked to both. Then, a meeting with parent and child together can be used to resolve any inconsistencies (for example, a parent may report that a child was euphoric because he was giggling excessively when punished, while the child may report that he was giggling from embarrassment). While this recommendation is in keeping with standard practice in child psychiatry (AACAP, 2007
), only limited data exist regarding the impact of informant on diagnosis in the assessment of pediatric mania. Some data indicate that parents’ reports are more valid than youth's or teachers’ in establishing the occurrence of manic symptoms (Youngstrom, Meyers, Youngstrom, Calabrese, & Findling, 2006
), while others find that parents may be less likely than youths to report that the youth is experiencing characteristic manic symptoms such as elation, grandiosity, flight of ideas, and racing thoughts (Tillman et al., 2004
). In addition, youth can provide important information about their suicidal or homicidal ideation or attempts, hallucinations or delusions, and about abuse that they may have suffered (AACAP, 2001
; Youngstrom et al., 2006
). In our clinical experience, parents are more likely than their children to describe the child's irritability, while parents often underestimate the severity of their child's anxiety symptoms, grandiose thinking, racing thoughts, and, less commonly, the extent of their child's psychotic symptoms.
Consistent with the diagnostic criteria and recommendations described above, screening questions for mania (or depression) should inquire about distinct periods of mood change associated with the other symptoms of a mood episode (i.e., sleep disturbances, psychomotor activation, and other changes in behavior and cognition) (APA, 2001
; Kaufman et al., 1997
Specifically, to determine the occurrence of a manic episode, the clinician should ascertain whether the child and parent can identify a period of time, lasting at least 4 days for hypomania or 7 days for mania, during which the youth displayed euphoria or increased irritability that was unusual for him or her, and accompanied by a sufficient number of ‘B’ criteria (see ) that were uncharacteristic or distinctly more severe than usual during this time. Euphoria and/or irritability must be highly conspicuous during this period, meaning it is present most, but not necessarily all, of the time during the episode.
Whether the severity of a symptom is severe enough to be considered above diagnostic threshold is an important and potentially thorny decision. Also, when evaluating pediatric patients, clinicians should consider developmental differences: how does euphoria in an 8-year-old differ from euphoria in a 12-, 16-, 25-, or 40-year-old, and how do all the latter groups differ from each other? The decision is further complicated because developmental age is not synonymous with chronological age, and such assessments are particularly challenging in children with atypical development. However, in this instance, the fact that an episode must represent a distinct change from that youth's own baseline provides a helpful framework for the clinician. The evaluator should ask parents to compare the youth's current state (or state during the putative episode) to the youth's typical mood, behavior, and level of function. In addition, the episode should be severely impairing in the case of mania, and noticeable to others in the case of hypomania. Therefore, one would expect that it would be difficult for a child to continue in an ordinary school program during a manic episode, and a hypomanic episode should have received comment from teachers and/or peers, as well as from parents.
With regard to the threshold for elation, it may help to consider whether the youth's elation is any greater than his or her positive affect during a trip to Disneyland or on Christmas morning. In mania, elation should be inappropriate to context, unusual for that child, and having its onset at about the same time as criteria ‘B’ symptoms. Similarly, in a youth with chronic irritability, irritable mood would only count toward the ‘A’ criterion of mania if, during the specified episode, the youth was distinctly more irritable than at his/her baseline. Questions that can be asked about mood changes include ‘Was Johnny different from way he usually is? Was he uncharacteristically and inappropriately happy? Or much more irritable than usual? Did teachers notice the change? Did it cause problems?’ It is always important to get details in order to increase reliability, e.g., ‘Did you have more fights than usual at school? Did your family complain that you were crankier that usual? Did your friends say that you were getting really crabby?’
Once episodes are identified, the interviewer should inquire whether criterion ‘B’ symptoms occurred at the same time as the mood changes. Three symptoms are required if the predominant mood is elation, four symptoms if the mood is irritable. As with elation, increased self esteem or grandiosity should represent a change from baseline, be developmentally inappropriate, and either noticeable to others (in the case of hypomania) or impairing (in the case of mania). There are many instances where a young child who pretends to be an astronaut or says he could become an astronaut in the future would not be considered grandiose. However a child who is usually cautious but, at a time when his mood and activity level are different from usual, wants to jump from the top of a flight of stairs believing ‘he can fly and nothing can hurt him’ can be considered grandiose.
A common clinical question is whether a youth who, as a clear manifestation of psychopathology challenges the teacher, or claims to be smarter than the teacher, is exhibiting grandiosity or oppositional behavior. Here again, it is important to weigh: 1) whether the behavior constitutes a distinct change from baseline, and 2) whether there are a sufficient number of new-onset concurrent symptoms. Thus, if a youth often defies his or her teacher, this is more likely to be oppositional behavior than a symptom of mania. On the other hand, if a typically shy youth begins openly challenging his or her teacher, at the same time that he or she begins to exhibit a decreased need for sleep and increased motor activity, that is much more likely to be a symptom of mania or hypomania.
With regard to sleep patterns, it is important to differentiate decreased need for sleep (i.e., the patient sleeps less than usual for him or her, is not tired, and does not nap to compensate for decreased nighttime sleep), from insomnia (i.e., an individual wants to sleep but cannot, and is tired the next day). Decreased need for sleep is rather specific to mania, whereas insomnia is common in a number of psychiatric illnesses. Decreased need for sleep was present in the majority (83.2%) of youth with BDI in the COBY study (Axelson et al., 2006
) and, in another study, discriminated children with ADHD from those with BD (Geller et al., 2002
). Often, children are quite active in the middle of the night when they are in a manic or hypomanic episode (rearranging furniture, playing videogames, etc.). Again, a sleep pattern that is a symptom of mania can be differentiated from typical adolescent sleep phase delay when it is a change from the adolescent's typical pattern, and when the adolescent sleeps less than is typical for him or her and is not tired over the next day or so.
Overlap between ADHD and mania, and the assessment of co-occurring conditions
A number of the remaining ‘B’ criteria of mania (distractibility, agitation, increased goal-directed activity, pleasure-seeking, racing thoughts, pressured speech) can be viewed as overlapping with the diagnostic criteria for ADHD. This complicates the differential diagnosis of mania in youth while also raising important questions as to how one can diagnose co-occurring ADHD when distinct manic episodes are clearly present. However, the historical view (operationalized in the DSM) that BD is an episodic illness makes both of these issues significantly more tractable. Specifically, in a youth with BD, the diagnosis of co-occurring ADHD (or any other co-occurring illness, such as an anxiety disorder) is made based on symptoms present during a time when the patient is not hypomanic, manic, or depressed. Thus, when interviewing families, the clinician should identify, in addition to putative episodes of mania and depression, a period when the youth was euthymic or had only subsyndromal mood symptoms. The clinician should then inquire about whether the symptoms of anxiety disorders, ADHD, and other possible co-occurring illnesses were evident during this euthymic period. Reports in the literature suggest that up to 70–90% of children and 30–40% of adolescents with BD present with co-occurring ADHD (Singh, DelBello, Kowatch, & Strakowski, 2006
). However, it is often unclear whether the guidelines described above were followed in assessing co-occurring illnesses, or instead whether these data might be confounded by overlap between the symptoms of ADHD and those of mania and/or depression. Research is needed to compare the validity of different techniques for identifying comorbid illnesses.
Conversely, in a youth with ADHD, a symptom such as distractibility or ‘pleasure seeking’, in the form of engaging in risky behavior, should ‘count’ toward the diagnosis of mania only if the severity of the symptom increased significantly at the same time that the child's mood was abnormal. Once again, because BD is characterized by distinct episodes, this differentiation becomes more feasible; the youth's symptoms during a putative episode can be compared to his or her usual behavior. In addition, the severe behavioral problems that adolescents with ADHD can develop in response to the combined stress of social pressures, academic demands, and puberty should be distinguished from the onset of mania. The latter should be more abrupt and characterized by the onset of a number of new symptoms at once.
It is important to differentiate BD from ADHD, psychotic disorders, and substance use disorders. Using the techniques described above, chronic conditions such as ADHD and ODD, even when characterized by severe irritability and oppositionality, can be differentiated from an episodic one (mania). Psychosis in the context of BD can be differentiated from schizophrenia and schizoaffective disorder if one is mindful that, in BD, psychotic symptoms must appear exclusively during the same time as severe mood symptoms. However, it must be acknowledged that this determination (i.e., whether psychotic and mood symptoms occurred concurrently) can be a difficult one to make retrospectively. In BD, delusions are often mood congruent (i.e., grandiose delusions during mania in about 50% of cases) (Pavuluri, Herbener, & Sweeney, 2004
), but need not be (Goes et al., 2007
). Children with psychotic mood disorders are often misdiagnosed with schizophrenia, since depressive states may be misinterpreted as negative symptoms, while agitation and flight of ideas due to a manic episode can resemble the disorganization of schizophrenia.
Children who experience extreme stress may have changes in behavior that resemble mania; alternatively, extreme stress may trigger a manic episode in a child who is genetically vulnerable. Sleep loss can precipitate manic episodes in individuals with BD, and there is evidence that sleep loss mediates the link between stress and the onset of mania (Malkoff-Schwartz et al., 1998
). Therefore, in a youth who has recently encountered a severe stress, clinicians should be alert to the symptoms of post-traumatic stress disorder and particularly wary of assigning the diagnosis of BD.
In a child presenting with a major depressive episode, previous (hypo)manic symptoms should always be assessed, and the child should be observed for the emergence of such symptoms over time, or with antidepressant treatment. The risk of converting from major depressive disorder to BD may be higher in younger cohorts than in adults, with studies reporting rates of developing (hypo)mania ranging from 19 to 49% (Geller, Zimerman, Williams, Bolhofner, & Craney, 2001
; Kovacs, 1996
; Rao et al., 1995
). Young, severely depressed patients with psychotic features may be at especially high risk for developing mania (Goldberg, Harrow, & Whiteside, 2001
). Nonetheless, in general one diagnoses and treats the illness with which the child presents, albeit with caution and close monitoring, rather than the one for which he or she may be at risk.
Medical conditions can mimic manic symptoms and must be considered carefully. Conditions that can display manic symptoms are neurological diseases (e.g., head trauma, seizures, multiple sclerosis, stroke), endocrine diseases (e.g., hyperthyroidism, Cushing Syndrome) or reactions to medications or illegal drugs (e.g., steroids, sympathicomimetics, antidepressants, cocaine, methylendioxymethamine) (James & Javaloyes, 2001
). Any adolescent presenting with manic symptoms should be screened for substance abuse. Substance abuse disorders are present in nearly 60% of adults with BD (Cassidy, Ahearn, & Carroll, 2001a
) but have received little attention in pediatric BD studies. One study found that 32% of youth with BD had lifetime substance use disorder (N = 57, mean age 13.3 ± 2.4y) (Wilens et al., 2004
). This is an important area for future research.
Other clinical considerations
Once at least one (hypo)manic episode has been established, the overall course of the illness (number and type of previous episodes) should be evaluated for both diagnostic and clinical purposes. As noted above, the ICD-10 requires at least two mood episodes for the diagnosis of BD, of which one must be a (hypo)manic episode, while DSM-IV requires at least one manic or mixed episode for the diagnosis of BD I, or a hypomanic episode plus a major depressive episode in BD II. Depressive symptoms and previous or current episodes of major depression should always be assessed. In addition, even though the literature on pediatric BD has focused predominately on mania, children with BD spend more time depressed than manic, and have more depressive (57.5%) than (hypo)manic and mixed recurrences (42.5%) (Axelson et al., 2006
; Birmaher et al., 2006
Suicidality can be seen in manic, mixed, or depressive episodes, and should always be assessed. Suicide attempts are extremely common in youth with BD. In the COBY study, 35% of patients with BD I had a lifetime history of suicide attempts (Axelson et al., 2006
), and BD is a serious risk factor for completed suicide in adolescents (Goldstein et al., 2005
; Welner, Welner, & Fishman, 1979
). Other important risk factors for suicide attempts in BD youth are history of mixed episodes, psychotic symptoms, non-suicidal self-injuries, hospitalizations, panic disorders, and substance abuse disorders (Goldstein et al., 2005
Severe aggression may be observed in BD. As with suicide, aggression should always be evaluated with direct questions to establish whether the child has experienced homicidal ideation or hallucinations or delusions that could lead to aggressive acts. Parental reports are usually more reliable for a history of aggressive behavior, while child reports are more useful to learn about aggressive impulses and thoughts. As with all other putative manic symptoms, it is important to ascertain whether the aggression, suicidal, or homicidal behavior occurred in the context of a mood episode (i.e., change in mood and associated symptoms).
For both treatment and diagnosis, it is important to follow the youth's symptoms longitudinally. Therefore, it is advisable to have parents and, where appropriate, youth, rate their most prominent symptoms daily. Many instruments are available to allow parents to collect daily or weekly information on mood, sleep pattern, appetite, level of energy/activities, etc. (AACAP, 2007
). An example of such a life chart can be found at http://www.dbsalliance.org/pdfs/calendarforweb.pdf
(Youngstrom et al., 2005
Because expert-clinical assessment will always be key in the diagnostic process for BD, all screening should be approached with caution. There is no consensus on a standardized screening instrument for BD. Most recent studies have focused on the Child Behavior Checklist (CBCL; Biederman et al., 1995
; Faraone, Althoff, Hudziak, Monuteaux, & Biederman, 2005
; Mick, Biederman, Pandina, & Faraone, 2003
). Children with BD may have high scores (T > 70) on the CBCL Attention Problem, Aggression and Depression/Anxiety subscales (Mick et al., 2003
), although this profile is not unique to pediatric BD (Volk & Todd, 2007
; Youngstrom et al., 2006
). Possibly, the uneven data on the utility of the CBCL in screening for BD may arise because it does not ascertain episodic symptoms. The Parent Mood Disorder Questionnaire (P-MDQ), the Child Mania Rating Scale (Pauvulun et al., 2006
) and the 10-item short form of the Parent General Behavior Inventory (PGBI-SF10) have some potential for screening for BD (Wagner et al., 2006
; Youngstrom et al., 2004
). For example, in one study the P-MDQ had a sensitivity of 72% and a specificity of 81% (Wagner et al., 2006
). The Parent General Behavior Inventory Short Form (PGBI-SF10) has a sensitivity of 75% and specificity of 85%, but performs somewhat less well than the P-MDQ in children 5–10 years old (Youngstrom et al., 2005
). When examining the utility of screening measures, it is important to consider whether the setting in which the screening measure was tested (inpatient, specialty clinic, community clinic, etc.) resembles that in which the clinician wishes to employ it (Youngstrom et al., 2005