Considerations for Diagnosing BD in Children and Adolescents When you are considering giving a diagnosis of bipolar disorder for a young person, the following needs to be considered: 1. We cannot diagnose bipolar disorder until a manic/light manic episode is present. By definition, a diagnosis of bipolar I disorder requires a manic episode, while a diagnosis of bipolar II disorder requires a hypomanic + depressive episode. Diagnosing bipolar disorder unspecified is more lenient and allows for some flexibility. We will discuss this point later. In any case, manic episodes remain the primary event for the diagnosis of bipolar disorder. However, in the case of children, they usually present with depression, anxiety, and attention-deficit/hyperactivity disorder-type symptoms, which are often puzzling until they eventually develop manic symptoms. 2. Substance abuse may precede the first episode; more importantly, the first year after the first episode of mania is a high-risk period for the onset of substance abuse, so it is necessary to monitor for changes in symptoms over time. Although the DSM-5 was developed primarily for adult patients, it is also the gold standard for diagnosing BD in children. To make a diagnosis of BD, the child needs to meet the diagnostic criteria. Two important criteria include: 3. The presence of well-defined mood changes. Usually, irritability and high mood are more common; however, keep in mind that irritability is also a common and recognized symptom of adolescent depression, making the differential diagnosis more complex. 4. The presence of a significant change in activity or energy level. This change should be more than a continuation of the underlying hyperactivity symptoms of ADHD. Differences between BD in children and adolescents and BD in adults There are a number of differences between diagnosing BD in children and diagnosing it in adults. For example, the child’s symptomatology may be more subdued and the composition of symptoms may be less “structured”; he or she may be more likely to have mixed episodes or more depressive symptoms; and by definition, given that irritability is also a symptom of depression in children, the likelihood of meeting criteria for both depression and mania is naturally higher. Despite inconsistent findings, children with BD may have more psychotic symptoms compared to adult patients; this makes sense from a developmental perspective, but in fact is often difficult to identify. The degree of vegetative signs or symptoms, especially sleep disturbances, may be relatively mild in children with BD; these functions are better protected in children and adolescents compared to adult patients. Finally, the onset may be less unexpected and acute in adolescents than in adults. More often than not, children first experience a gradual “introductory phase” of symptoms, during which the episodes are less distinct, but eventually a definite episode must occur, otherwise it is difficult to distinguish bipolar disorder from more chronic disorders. This is especially important when making the diagnosis. Differential diagnosis of BD in children and adolescents 1. Depression: When you think about the differential points for BD in children or adolescents, the first and probably most commonly confused diagnosis that comes to mind is depression. Irritability is a symptom of depression in children, and agitation is not uncommon in depression in children and adolescents. Both make it difficult for physicians to determine whether a patient is BD or monophasic depressed. An early age of onset, especially with a more severe degree of depression, is a predictor, but not a defining factor, for the development of BD. Here again, family history is very important for the diagnosis when the criteria for mania are fully met. It is also critical to make sure that symptoms are present according to the DSM-5 diagnostic criteria. The reality is that it is often unlikely to be given with certainty, so follow-up of the child to closely monitor the progression of his or her bipolar disorder symptoms over time is the best way to go. 2. ADHD: ADHD is another confounding condition for the diagnosis of BD due to hyperactivity, distractibility, and other symptoms. However, in general, children with ADHD have a chronic course and no episodic events that could serve as defining differences. Also, although depression is more common, mania is not, so we can look for those discrepancy factors. 3. Substance abuse disorders: especially when occurring in adolescents, can lead to many symptoms of BD. The use of alcohol, cocaine and opium can all cause mood symptoms, even mania and depression. Therefore, substance use history is also very important. 4. Disruptive dysregulation disorder” (DMDD): Ellen Leibenluft and her team at the National Institutes of Health (NIH) have done a lot of excellent work recently. They noted that many children with chronic irritable presentations were diagnosed with BD, while follow-up studies showed that these children did not develop BD, but rather exhibited a recurrent depressive course. This clinical condition became the new diagnosis of “disruptive mood disorder” in the DSM-5, which is characterized by chronic irritability rather than episodic mood symptoms. 5. Disruptive and impulsive behavior disorder: Some of the manifestations of this disorder may resemble the behavior of a manic individual, but generally, the child’s manifestations are not as extensive and comprehensive as the manic symptoms expected by the DSM-5.