Toward an Evidence-Based Assessment of Pediatric Bipolar Disorder

Abstract

This article outlines a provisional evidence-based approach to the assessment of pediatric bipolar disorder (PBD). Public attention to PBD and the rate of diagnosis have both increased substantially in the past decade. Accurate diagnosis is crucial to avoid harm due to mislabeling or unnecessary medication exposure. Because there are no proven efficacious or effective treatments for PBD, the role of assessment is heightened to demonstrate efficacy in individual cases as well as to identify cases for participation in clinical trials. This review discusses (a) the state of psychopathology research regarding PBD; (b) the likely base rate of PBD in multiple clinical settings; (c) the diagnostic value of family history; (d) challenges to differential diagnosis, including comorbidity and symptom overlap with other diagnoses, shortcomings in contemporary assessment methods, and the cyclical nature of PBD; (e) practical methods for improving diagnosis, focusing on the most discriminative symptoms, extending the temporal window of assessment to capture mood changes, and using screening tools within an actuarial framework; and (f) monitoring response to treatment using a variety of assessment methods. Twelve recommendations are offered to move toward an evidence-based assessment model for PBD.

Animal models of bipolar disorder and mood stabilizer efficacy: A critical need for improvement

“…Bipolar disorder commonly first appears in young adulthood, though early and late onset is not uncommon (Young, 2005;Youngstrom et al, 2005). The differentiation between bipolar disorder type I and II is based on clinical presentation, and not neurobiology, epidemiology, genetics, or response to medications.…”

Evidence-Based Treatment

“…In making a diagnosis, while rages, irritability, distractibility and hyperactivity may be the symptoms of greatest concern to parents and teachers and greatest familiarity to most clinicians, the presence of elevated mood (happiness that is inappropriate in intensity, duration and context), grandiosity, pressured speech and racing thoughts are symptoms that alert clinician's to the possibility of bipolar disorder [110]. It is important to retrospectively reconstruct from history or prospectively chart over time constellations of symptoms present in each episode of mood disturbance [111].…”

“…The most common comorbid disorders are ADHD, oppositional defiant disorder, conduct disorder and learning disorders, all of which are more common and more familiar to most practicing clinicians and all of which have symptoms that overlap with bipolar disorder [110]. In adolescents, co-morbid substance abuse may occur and so deserves assessment.…”

Symptoms Leading to a Bipolar Diagnosis: A Phone Survey of Child and Adolescent Psychiatrists

“…revalence rates of pediatric bipolar disorder (BPD) vary in population-based (Carlson and Kashani 1988;Lewinsohn et al 1995;Costello et al 1996;Reich et al 2005) and clinical samples (Wozniak et al 1995;Youngstrom et al 2005). Although much variation can be attributed to differences in study methodology and the conceptualization of BPD, some variation is likely due to clinicians' diagnostic decision making.…”

“…Although part of diagnostic variability may be due to the shifting conceptualization of pediatric BPD, apart from the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000), there is no other accepted ''gold standard'' for diagnosing BPD in the community (Setterberg et al 1991; National Institute of Mental Health Research Roundtable on Prepubertal Bipolar Disorder 2001; Youngstrom et al 2005). Given the recent rise in BPD diagnoses (Blader and Carlson 2007;Moreno et al 2007), we were interested to determine whether CAPs apply DSM criteria consistently or instead rely on other criteria or their clinical judgment.…”