Ms. Favis is currently a staff nurse, Cardiovascular Progressive Care Unit, Wellstar Kennestone Hospital, Marietta, Georgia. This article was written for her master’s degree capstone project in the family nurse practitioner program, University of Cincinnati.
The author has disclosed no potential conflicts of interest, financial or otherwise. The author acknowledges Linda Quinlin, MS, RN, ACNS-BC, NP-C; Tara Crabtree, MS, RN, WHNP-C; and Kevin Wolfe, BSN, RN, for their assistance and guidance in creating this article.
Address correspondence to Tara Favis, MSN, RN, NP-C, 2027 Ferry Drive, Marietta, GA 30066; e-mail: firstname.lastname@example.org.
Pediatric bipolar disorder (PBD) is a serious, chronic mental illness causing devastating psychosocial effects to both the child and his or her loved ones. Maniscalco and Hamrin (2008) asserted that a diagnosis of PBD places a child at higher risk for suicide and impairs the level of functioning in the home, at school, and with friends. Disagreement over the classification of symptoms, subjective differences between clinicians and researchers, and the presence of comorbid psychiatric disorders make PBD difficult to diagnose and treat (Maniscalco & Hamrin, 2008).
Despite these difficulties, the diagnosis of PBD in American youth age 19 and younger increased 40-fold from 1994 to 2003 (National Institute of Mental Health [NIMH], 2007). The factors contributing to such an alarming increase in the diagnosis of PBD are unclear. Although a diagnosis of PBD is well acknowledged in the medical community, Carbray and McGuinness (2009) reported that the increase may be the result of overdiagnosis and confounded by other comorbid mental illnesses. Thus, an accurate assessment and an appropriate diagnosis may lead to better outcomes for the child. This article will describe the present understanding of PBD based on a literature review and describe the current practices of screening for the disorder. Based on these findings, screening suggestions will be made.
A literature review was performed to investigate the current understanding of PBD and practices of screening for the disorder in the primary care setting. The Summon search engine was used to search multiple databases in the library archive of the author’s university. An initial search of pediatric bipolar produced 35,462 sources sorted by relevancy, which reduced to 444 sources when combined with screening in primary care. Inclusion criteria consisted of peer-reviewed journal articles published no earlier than 2007 and written in English. Fifteen of these full articles were read, and eight of them, further narrowed by relevancy, were included in this review. Additional statistical data were referenced from government agency reports.
According to the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), bipolar disorder (BD) is classified as bipolar I disorder (BD-I), bipolar II disorder (BD-II), BD not otherwise specified (BD-NOS), and cyclothymic disorder or cyclothymia (American Psychiatric Association [APA], 2000). The NIMH (2008) describes the differences as follows: BD-I consists of one or more manic or mixed episodes lasting at least 7 days, resulting in extremely impaired functioning, and is often seen in conjunction with a depressive episode of at least 2 weeks duration. BD-II is defined as a major depressive episode of at least 2 weeks and shifting into hypomanic episodes. Cyclothymia is a mild form of BD in which the person shifts between mild depression and hypomania over a period of 2 years but does not meet the requirements for BD-I or BD-II (NIMH, 2008).
According to Townsend, Demeter, Wilson, and Findling (2007), PBD is difficult to diagnose because children and adolescents tend to exhibit chronic, less delineated episodes of mood swings. Maniscalco and Hamrin (2008) further noted that children with PBD tend to have rapid cycling and episodes of mixed mania. Adults typically exhibit more recognizable manic symptoms of euphoria and grandiosity, whereas a child or adolescent would more likely show irritability or explosive anger during a manic episode (Townsend et al., 2007). There is currently no specific subtype of BD for children.
The National Comorbidity Study found a lifetime prevalence rate of BD to be approximately 4% (Centers for Disease Control and Prevention [CDC], 2011). Other estimates have ranged from 0.4% to 3% among adults, while an estimation of a 1% prevalence rate was suggested for adolescents ages 14 to 18 (Maniscalco & Hamrin, 2008). Despite the controversy surrounding the diagnosis, there has been an astounding increase in PBD diagnosis among children and adolescents. Between 1994–1995 and 2002–2003, Moreno et al. (2007) found a 40-fold increase of PBD based on the National Ambulatory Medical Care Survey. Those researchers suggested several possibilities for the increase: (a) greater awareness of PBD by the medical community and general public; (b) a lack of age-specific diagnostic criteria for PBD, leading to sub-threshold manic symptoms being labeled PBD; (c) low concordance among teachers, parents, and youth themselves as to what symptoms constitute manic symptoms; and (d) high rates of co-existing disorders. Additionally, Moreno et al. (2007) stated that perhaps billing for a diagnosis of PBD would more likely result in service provision compared with a diagnosis of conduct disorder or oppositional defiant disorder.
One factor that likely complicates an accurate diagnosis of PBD is the frequent comorbidity of conditions in youth with PBD. The most commonly encountered conditions include attention-deficit/hyperactivity disorder, as well as conduct disorder, anxiety disorder, or substance abuse (Townsend et al., 2007). Cummings and Fristad (2008) reported conduct problems to be common among adolescents with PBD, where approximately half had committed an offense prior to the hospitalization. Most offenses were related to larceny, domestic violence, or drug offenses.
According to Townsend et al. (2007), genetic studies do present a strong argument that BD is an inherited illness, with earlier onset and increasing severity for each successive generation. They suggested that BD occurs more frequently in first-degree relatives and that children who have parents with BD exhibit greater incidence of the disorder and often display symptoms of early-onset BD (Townsend et al., 2007).
The CDC (2011) reported BD to be the most costly behavioral health diagnosis, nearly double the expense of unipolar depression per individual when considering both direct and indirect costs of the illness. For a population of insured individuals, a diagnosis of BD incurs more annual insurance payments for medical services than any other psychiatric diagnosis. For every $1 spent treating outpatient care, $1.80 is spent on inpatient care (CDC, 2011). Early diagnosis and treatment of BD in an outpatient setting could help ease a large portion of the economic burden of mental illness by avoiding inpatient hospitalizations during acute episodes.
Screening Tools and Diagnosis
Due to the complex nature of this disorder, clinicians lack consistency in diagnosis. Although screening tools are available, some have suggested they lack specificity when it comes to PBD. Diler et al. (2009) investigated the validity of the Child Behavior Checklist (CBCL; perhaps the most widely used screening tool for child behavior) and the CBCL-Bipolar Phenotype screening tools for identifying children with PBD. They found no significant differences between the checklist scores of normal children, children with PBD, and children with other psychiatric illnesses. Maniscalco and Hamrin (2008) discussed the efficacy of tools used to screen for PBD: Parent version, Young Mania Rating Scale (P-YMRS); General Behavior Inventory; Parent Version, General Behavior Inventory; CBCL; Youth Self-Report; and Teacher’s Report Form. Specifically, the P-YMRS and the Parent Version of the General Behavior Inventory were found to be more effective than teacher or self-reports among the six instruments compared.
Jenkins, Youngstrom, Washburn, and Youngstrom (2011) studied the use of a probability nomogram to quantify the risk of a patient having PBD while displaying symptoms. The nomogram is a decision support tool that improves interpretation of symptoms when added to family history and other assessment data. Jenkins et al. found that the use of the nomogram required brief training (less than 30 minutes) and improved diagnostic accuracy of PBD and decreased inconsistencies among community-based clinicians. This method shows great promise in providing a comprehensive approach in diagnosing PBD.
The diagnosis of PBD is dependent on a set of criteria identified in the DSM-IV-TR (APA, 2000) and on the clinician’s subjective assessment. The APA (2010) released a statement describing a new diagnostic category to be included in the Mood Disorders section of the upcoming DSM-V. Temper dysregulation with dysphoria (TDD) aims to describe children who have severe, recurring, and disproportionate temper outbursts and exhibit a persistently negative mood in between such outbursts. Essentially, TDD would be appropriate for children with severe mood dysregulation. Jenkins et al. (2011) asserted that the probability nomogram can still be used, and be used more accurately, despite changes in the definition of PBD.
The diagnosis of TDD will not replace the diagnosis of PBD. The goal is to improve the accuracy of diagnosing PBD by offering a more appropriate diagnosis to children with severe mood dysregulation but who do not fully meet the criteria for a diagnosis of PBD.
Nurse practitioners in primary care and psychiatric nurse practitioners should use every opportunity to screen for PBD in their patients by performing a thorough interview and assessment and applying evidence-based strategies to screen for PBD. For children suspected of having PBD, it is essential that the primary care nurse practitioner collaborate with the patient, the family, and a mental health specialist, such as a psychiatric nurse practitioner. The psychiatric nurse practitioner should empower the patient and family members by educating and involving them in the care of the youth with BD.
Long-term monitoring is vital as treatment adherence is often low in this population. Depending on the treatment regimen, baseline and periodic measurements of blood pressure, body mass index, waist circumference, liver function, kidney function, lipids, complete blood counts, fasting glucose levels, serum drug levels, and electrolytes should be performed (Cummings & Fristad, 2008). Above all, hope should be instilled; PBD is a treatable disorder, especially after an accurate diagnosis is made.
The increase in diagnosis of PBD is alarming. Maniscalco and Hamrin (2008) reported findings from a study in which 27.7% of a sample of 1,000 adults with BD indicated experiencing their first episode before they were 13 years old. According to Townsend et al. (2007), children with PBD are at higher risk for physical and psychosocial trauma. Risk factors for poor outcomes are low socioeconomic status, family conflict, the presence of rapid cycling, and early age of onset.
With the risk of psychosocial harm, primary care practitioners should consider implementing early evidence-based screening strategies, such as the probability nomogram, into family and pediatric clinical practice. A thorough interview and assessment during well child examinations and at episodic visits pertaining to mood or behavior may allow primary care practitioners to make an expedient mental health referral for appropriate diagnosis and treatment of PBD. It is essential to identify and treat PBD as soon as possible, because for approximately 50% of youth, often 5 years elapse between the first symptoms of PBD and an accurate diagnosis (Jenkins et al., 2011). Implementation of evidence-based strategies for early screening of PBD in primary care practice may assist in accomplishing the goal of early, accurate assessment.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
- American Psychiatric Association. (2010). DSM-5 proposed revisions include new diagnostic category of temper dysregulation with dysphoria (TDD): Criteria to differentiate children with TDD from those with bipolar disorder or oppositional defiant disorder (Release No. 10-14). Retrieved from http://www.dsm5.org/Newsroom/Documents/TDD%20release%202.05%20(1).pdf
- Carbray, J.A. & McGuinness, T.M. (2009). Pediatric bipolar disorder. Journal of Psychosocial Nursing and Mental Health Services, 47(12), 22–26. doi:10.3928/02793695-20091103-02 [CrossRef]
- Centers for Disease Control and Prevention. (2011). Burden of mental illness. Retrieved from http://www.cdc.gov/mentalhealth/basics/burden.htm
- Cummings, C.M. & Fristad, M.A. (2008). Pediatric bipolar disorder: Recognition in primary care. Current Opinion in Pediatrics, 20, 560–565. doi:10.1097/MOP.0b013e-32830fe3d2 [CrossRef]
- Diler, R.S., Birmaher, B., Axelson, D., Goldstein, B., Gill, M., Strober, M. & Keller, M.B. (2009). The Child Behavior Checklist (CBCL) and the CBCL-Bipolar Phenotype are not useful in diagnosing pediatric bipolar disorder. Journal of Child and Adolescent Psychopharmacology, 19, 23–30. doi:10.1089/cap.2008.067 [CrossRef]
- Jenkins, M.M., Youngstrom, E.A., Washburn, J.J. & Youngstrom, J.K. (2011). Evidence-based strategies improve assessment of pediatric bipolar disorder by community practitioners. Professional Psychology: Research and Practice, 42, 121–129. doi:10.1037/a0022506 [CrossRef]
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- Moreno, C., Laje, G., Blanco, C., Jiang, H., Schmidt, A.B. & Olfson, M. (2007). National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Archives of General Psychiatry, 64, 1032–1039. doi:10.1001/archpsyc.64.9.1032 [CrossRef]
- National Institute of Mental Health. (2007). Rates of bipolar diagnosis in youth rapidly climbing, treatment patterns similar to adults. Retrieved from http://www.nimh.nih.gov/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml
- National Institute of Mental Health. (2008). Bipolar disorder. Retrieved from http://mentalhealth.gov/health/publications/bipolar-disorder/complete-index.shtml
- Townsend, L.D., Demeter, C.A., Wilson, M. & Findling, R.L. (2007). Update on pediatric bipolar disorder. Current Psychiatry Reports, 9, 529–534. doi:10.1007/s11920-007-0072-0 [CrossRef]