The validity of bipolar disorder in children and adolescents has long been debated, and the history surrounding this diagnosis is controversial to say the least. In this podcast, we will discuss the evidence supporting whether bipolar disorder presents in youth, and how clinicians can best assess this disorder.

Published On: 05/30/2022

Duration: 29 minutes, 17 seconds

Referenced Article: “Assessing Bipolar Disorder in Children and Adolescents,” The Carlat Child Psychiatry Report, October/November/December 2021

Transcript:

Dr. Feder: The validity of bipolar disorder in children and adolescents has long been debated, and the history surrounding this diagnosis is controversial to say the least. In this podcast, Mara and I will discuss the evidence supporting whether bipolar disorder presents in youth, and how clinicians can best assess this disorder. Dr. Anna Van Meter joins us today to help us unpack this topic. She is an Assistant professor at the Institute of Behavioral Science at Feinstein Institutes for Medical Research, associated with Northwell Health, in Manhasset, NY. She is also an Assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. 

Welcome to The Carlat Psychiatry Podcast.

This is a special episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice. 

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

In the 1990s there was increased attention and research on bipolar disorder in youth. The research groups led by Barbara Geller and Joe Biederman published work showing that youth, including prepubertal children, could experience the symptoms of bipolar disorder, and others started studying bipolar disorder in youth as well.  

Dr. Feder: This early work coincided with an increase in clinical diagnoses and, subsequently, a fair amount of controversy regarding the validity of the diagnosis of bipolar disorder in youth.

Dr. Van Meter, can you tell us a little bit about what happened after we started to see an increase in clinical diagnosing of bipolar disorder in youth? And how this increase further fueled the controversy surrounding bipolar in children and adolescents?

Dr. Van Meter: There was this sort of associated increase in clinical diagnoses and then there were some sad events that happened where kids were being treated with maybe too many medications. Some ended up dying and so, there was this kind of backlash against the diagnosis. And there’s been this controversy all along as to whether young people can be affected by bipolar disorder, whether the diagnostic criteria should be the same as in adults, or if the presentation is qualitatively different. And I think because it’s not in the news any more, certainly not in the mainstream media, a lot of the evidence that’s been gathered more recently that I think has addressed many of these controversies hasn’t been disseminated or hasn’t reached as many people as the more hyped up controversies that were present earlier.

Mara: You and your colleagues performed a study to investigate whether the prevalence of bipolar disorder in youth actually increased, right? What was concluded from that study?

Dr. Van Meter: One of the projects that I did that was kind of my first foray into research was doing a meta analysis looking at the community prevalence of bipolar disorder in youth around the world and the goal of that was to address two main questions, one of which was, is the actual prevalence of bipolar disorder increasing? Is that why we see this increase in clinical diagnoses and is this something that’s specific to the United States, because in other countries they weren’t seeing the same increase in clinical diagnoses.

And what we found in that meta analysis – and then also in a subsequent meta analysis that we published a couple of years ago that was just sort of updating the data – is that the community prevalence has been stable since the eighties, since this was something that people were assessing for and that there really aren’t big differences between the prevalence in the United States and other countries once you account for the fact that in the United States, some studies take a broader perspective of what bipolar disorder is. So, if you’re using non-DSM or non-ICD criteria and you’re saying, well, if you were ever hypomanic even just for a few hours, we’re going to count you. Then, of course, the diagnostic boundaries expand, and more people meet criteria.

Dr. Feder: Speaking of diagnosing criteria, how does the relationship between extreme irritability and disruptive mood dysregulation disorder (DMMD), as well as the irritability we see in other psychiatric disorders, affect the validity of bipolar disorder in children and adolescents?

Dr. Van Meter: Extreme irritability for a while was being diagnosed as bipolar disorder. And I think that the fact that that was happening definitely did damage to the validity of this diagnosis. You know, most kids who have a mental health disorder are pretty irritable and some of them also get enraged, and I think that relates a little bit to what I was saying earlier about how there’s sort of a series of diagnoses that gets tried and then it’s like, this kid is sort of out of control, this must be something really serious. You know, maybe it’s bipolar disorder. But I think looking just a kids with tantrums or extreme irritability without other symptoms that are episodic shouldn’t be diagnosed as bipolar disorder. And the diagnosis of disruptive mood dysregulation disorder was intended to kind of provide a diagnostic home for kids like that who had this severe chronic irritability.

But in the research that’s been done since DSM-5 came out and that diagnosis was included, I think hasn’t really supported the idea that DMDD is a distinct diagnostic entity. In most studies, it overlaps almost entirely with ODD, ADHD or other sort of disruptive behavior disorders. So, I don’t think that that solved the problem. But there’s an awareness that there are these kids who are very reactive and irritable, and we don’t necessarily have the best understanding of that, I don’t think.

Mara: And what’s your take on the current state of diagnosing bipolar in youth? Are clinicians screening for it enough, or are people just writing it off?

Dr. Van Meter: My sense is that it’s not typically assessed for, which I think is a problem, obviously, and hopefully, we’ll get into more details about how one might go about doing that. But as somebody who studies bipolar disorder in youth, it’s always at the top of my mind and so, it’s interesting to me when I interact with clinicians in the community or even going into conferences and things and I hear people reluctant to acknowledge that bipolar disorder affects young people; or I hear opinions that I think are sort of outdated at this point, given that we have a couple of decades of good research demonstrating that young people are affected by bipolar disorder.

I think that when it is assessed in the community, it’s often sort of a diagnosis of last resort when other diagnoses have been made and the treatments for those aren’t effective. So for example, somebody might be diagnosed initially with major depressive disorder treated with an antidepressant. It doesn’t help them or in some cases, people might get more agitated. Sometimes people will have a diagnosis of ADHD, as well, and so they’re sort of trying different medications to address the symptoms, and then when those aren’t working, might move to a diagnosis of bipolar disorder.

Mara: So, Dr. Feder, how common is bipolar in children and adolescents?

Dr. Feder: Well, it’s difficult to say, but the current data indicates that more than 10% of adolescents have experienced an episode of major depression. Of those who have had an episode of major depression, about 10% will develop an episode of mania or hypomania.

Mara: Dr. Van Meter, is there a specific age range where bipolar symptoms begin to emerge in youth? And what criteria should clinicians use when diagnosing bipolar in this population?

Dr. Van Meter: I think the most common age of onset is around 15, so I do think it’s unusual to see in prepubertal youth; but a colleague of mine, Ben Goldstein, who’s from Toronto, had sort of the best response to the idea that it doesn’t happen in children which is that strokes are extremely rare in children, but it doesn’t mean that it can’t happen, and if it does happen, you want to treat it. And so, I think we can take a similar kind of perspective with bipolar disorder and that in children it is rare, but it does happen and should be addressed when it occurs.

So, using DSM or ICD criteria unmodified is the recommended way to make a diagnosis of bipolar disorder in young people. Of course, the presentation of grandiosity in a 13-year-old is going to look different than someone who’s 33, but you can still look for grandiosity and understand what that is in the developmental level that you’re working with. 

Dr. Feder: Are there any hallmark symptoms that are common amongst youth with bipolar disorders, that help us to identify this disorder more readily? And how can we differentiate between bipolar and other disorders? 

Dr. Van Meter: It’s definitely challenging. I was involved in another meta-analysis where we were looking at the most common manic symptoms in youth and the hope was that some clear signals would come through that these are kind of the hallmark symptoms that you can look for in young people and that just wasn’t really the case. The most common manic symptoms that we found overlapped a lot with other childhood disorders like irritability, like distractibility, high energy, so I think the main thing to think about is whether this is episodic. So, for example, with ADHD, we expect to see more of a chronic course of illness and over the day the symptoms may change in terms of their intensity. But it’s not like a child is hyperactive and has poor attention for a month and then they’re doing much better for a couple of months. So, I think looking for the change in functioning and sort of this episodic presentation is really important.

Dr. Feder: Now, there are many disorders that are comorbid with bipolar. Do you have any tips for distinguishing between the presence of a single disorder, say ADHD, versus the presence of numerous disorders, like a child presenting with ADHD and bipolar?

Dr. Van Meter: The thing that I personally find most informative and helpful is really trying to create that timeline and so, I’m always trying to anchor symptoms to different events that happened. So, was it summer or were you in school? Was it winter break? You know, it really helps me kind of figure out when different symptoms stopped and started because if you say, was there ever a time when you had a lot of mood variability? And they say, yeah. And then you say, was there ever a time when the child was talking too much or talking too fast? And they say, yeah. You don’t know if those happened at the same time or if it was because it was their birthday or whatever. And so, I think as much as you can and as much detail as the family can provide, just trying to kind of lay things out in order like that is helpful.

You can sometimes start to see a timeline emerge where there were some symptoms of ADHD that were present earlier and then the mood symptoms started later. And that can be helpful for saying, okay, you’ve been distractible since you were five, so we’re not going to count distractibility as one of your manic symptoms. We need to see other symptoms that help us to make a diagnosis of bipolar disorder.

And in terms of the actual verbiage, I try to get examples because I have definitely found that what I’m thinking of isn’t necessarily what other people are thinking about. Like racing thoughts could be a good example. What we’re looking for is somebody who’s having lots of ideas, they’re planning things, they’re coming up with different schemes and things. But for a lot of the patients I’ve talked to, they’re thinking of ruminations or anxiety, which wouldn’t necessarily be a criteria that I’m assessing. So, I’m just saying, okay, so you do have those fast thoughts. Can you tell me a little about the content of the thoughts? I think just getting examples when people do endorse the questions that you’re asking about.

Mara: So, how does the large degree of symptom overlap between bipolar and other disorders impact accurate diagnosis and the timely deliverance of treatment?

Dr. Van Meter: I think in a huge way. On average, people go about 10 years from when they first seek services to when they get a diagnosis of bipolar disorder. And those data aren’t specific to children, but if we accept that the average age is around 15 when people start having symptoms, then it’s early to mid-twenties before they would get the right diagnosis and the best treatment. So, it definitely affects it. 

I think another factor is that usually the first episode is depression, not mania or hypomania and so, somebody may have bipolar disorder. You know, that’s their trajectory, but they haven’t yet manifested the symptoms that would enable you to make the diagnosis. And so, I think that when you are working with somebody who has depression, it’s very important to find out as much as you can about their family history, and also inquire about any personal history they have of any hypomanic symptoms. This can be difficult to do because people aren’t thinking about times that they felt better than usual when they’re coming for a mental health visit.

But I think just getting a sense for whether there have been times when there was mood lability, decreased need for sleep, any symptoms that might help you to see or help you to predict that maybe they’re going to be on a bipolar spectrum. Similarly, if they have close family history of bipolar disorder, then they would be more likely to be on that trajectory. And I think that can help inform some treatment decisions that you would make, even if they don’t yet meet diagnostic criteria for bipolar disorder.

Dr. Feder: Are there any sociocultural factors that can delay the treatment of bipolar in youth, too? Perhaps, any cultural differences that clinicians should be aware of?

Dr. Van Meter: So, there has been some research showing that black individuals are more likely to be diagnosed with a psychotic disorder like schizophrenia, rather than bipolar disorder. And so I think that’s something to be aware of. And I think that people from some cultural backgrounds are more hesitant to seek mental health treatment, which affects more than just bipolar disorder. But I think that that can result in more delays to treatment seeking and perhaps make the diagnostic process more difficult if families aren’t as open about what may have been happening with the child. So, I think trying to be really sensitive to that when you’re talking with them and helping them to understand the process and what the goal of the process is.

I know, too, from some epidemiological work that I’ve done just in different cultures, different behaviors may be considered symptomatic or not. Or symptoms can sort of manifest in different ways. So, I think that’s also important to take into consideration.

I think if you’re working with somebody who grew up in a different culture, you can ask, is this typical of people you grew up with, of your peers? If it’s not a culture that you’re familiar with.

Dr. Feder: From everything we’ve discussed so far, it seems like diagnosing bipolar in adolescents is quite convoluted and strenuous. Do you have any advice on how we screen for bipolar in children and adolescents better? What’s your process?

Dr. Van Meter: The most important thing is to do it. Like I really strongly encourage clinicians to screen people broadly and sort of the approach that is recommended if you take an evidence-based approach to assessment is to start with kind of a broad screening tool, like the CDCL or the strengths and difficulties questioning or something that’s going to touch on a lot of different symptom domains; and then based on which symptom domains are elevated, you can then do some more disorder-specific symptom checklists.

So, for example, the one that I use for manic symptoms is called the General Behavior Inventory Ten-Item Mania Reading Scale and it’s ten items. It’s very quick, but it can help you to see and help the family to start thinking about whether or not this child has had symptoms of mania or hypomania. And if not, then you can move forward with your diagnostic assessment and not worry as much about it. But if some of those questions are coming up positive, then it’s important to do a more thorough assessment. And if they’re there because the kid is depressed, those symptoms aren’t going to be the ones that they would have brought to your attention. So, I think that having that extra information is really valuable.

Mara: Do you use any algorithms to help you in your screening process?

Dr. Van Meter: I’m a fan of using the nomogram, which some people may be familiar with, but it’s based on Bayes’s theorem and it’s a simple paper and pencil tool, or there are some apps that will do the same thing for you. But basically, on the left side, you put the pretest probability of a bipolar diagnosis and depending on your setting, that would change. So, if you’re in an outpatient clinic, it might be around 10%. If you’re working on an inpatient unit, it would be significantly higher than that.

Dr. Feder: That’s amazing! Can you walk us through how to use the nomogram?

Dr. Van Meter: So, you sort of figure out what’s the prevalence in my setting that’s the probability that any kid who walks in the door would have bipolar disorder, and then based on the outcome of the screening measure, you put a dot sort of in the middle of this box that’s the nomogram for the likelihood ratio that’s associated with that score and then you just literally connect the dots and then it gives you the posterior probability. The thing that’s kind of cool about the nomogram is that you can incorporate more information, so if you know that they have a family history of bipolar disorder as well, that’s something that you can incorporate. And you sort of keep updating the posterior probability with all of information that you have.

It would be very rare that you would get a posterior probability of 90% or something.

Dr. Feder: As a reminder, basically, what a posterior probability means is that you’re predicting based on the factors that you’ve got, like family history and current symptoms, what the likelihood is that the patient has bipolar disorder.  

Mara: How should we interpret these posterior probabilities? For instance, at what probability should we consider starting treatment for bipolar?

Dr. Van Meter: Eric Youngstrom and I have written about this as sort of different targets. If it’s a low probability, then you can kind of wait and see. You know, you don’t need to address these symptoms immediately. If it’s sort of a medium probability, say, 35 to 70% then you want to do more thorough testing, a more thorough interview. And then, if it’s higher than that, you can treat those symptoms. So, I think it is helpful for organizing the information that you have and making some informed decisions about treatment.

Dr. Feder: And, speaking of treatment, why do you think that people are hesitant to use lithium in children? We know that there’s been plenty of studies demonstrating its safety in children and adolescents, and that it can be helpful when used safely. 

Dr. Van Meter: So, I think the lithium question maybe is the shortest to answer, and I think that a lot of people are reluctant to use lithium in kids because of the need to do blood draws and families might feel like that’s a lot to take on, or just the implication of that I think might be that this is dangerous in some way, or it makes people more reluctant to accept that as a treatment.

But the alternatives typically are atypical antipsychotics which have for many kids really significant side effects and so I think there could be better education of families about making an informed decision because all these medications have drawbacks and initially in most cases, we don’t know what’s going to work best for that individual. So, there may be a few different things that end up getting tried, but I think understanding there may be significant weight gain and metabolic changes with this option, and with lithium there are these other potential consequences with the liver and so forth. I think that’s part of the reason that lithium doesn’t get used more and I think that the treatment guidelines for bipolar disorder recommend that lithium would be a first-line treatment. So, I think it would be good if more people tried it.

Mara: We’ve unpacked a lot over this podcast. Bipolar disorder can be tricky to identify in youth, considering its significant symptom overlap with other disorders. And, not to mention, there are many disorders that are comorbid with bipolar.

Dr. Feder: But a broad spectrum tool can help kick off the assessment for bipolar disorder. Think of your assessment as kind of like a funnel, where you don’t know where the end will be. Start your assessment broad and it'll get more narrow until you’ve isolated the archetypal symptoms, perhaps of bipolar disorder, at the bottom of this metaphorical funnel.

Mara: And don’t forget to really hone in on when specific symptoms started and whether these symptoms present episodically or are more chronic in nature with episodic fluctuation in intensity.

Dr. Feder: Also, we should get a thorough history from our patients and their families to maximize the benefits of our nomogram, which will result in more accurate posterior probabilities. 

Mara: Any final thoughts Dr. Van Meter?

Dr. Van Meter: In terms of a bottom line, I think that I strongly encourage everybody who works with young people to screen for manic and hypomanic symptoms in any child who’s having depressed mood or some externalizing behavior problems and it isn’t only a disorder of extreme irritability and temper tantrums. Not everybody has that presentation at all. And that it may be a controversial diagnosis, but there are multiple decades of evidence now that it does affect young people and it affects them during a really key developmental period when they’re sort of setting the foundation for their adult lives and I think that even though there may be concern about stigma, about labeling somebody with a serious mental illness and what the implications of that are, I think not treating that illness and not giving that young person the best opportunity to be healthy, particularly during that time, is a greater risk.

Dr. Feder: Our printed interview with Dr. Van Meter is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust. 

Mara: As always, thanks for listening and have a great day!

References:

• Van Meter AR et al, J Clin Psychiatry 2019;80(3):18r12180
• Goldstein BI et al, Bipolar Disord 2017;19(7):524–543
• Van Meter AR et al, Bipolar Disord 2016;18(1):19–32
• Bruno A et al, Psychiatry Res 2019;279:323–330
• Marchand WR et al, J Psychiatr Pract 2006;12(2):128–133
• Beesdo K et al, Bipolar Disord 2009;11(6):637–649
• Baldessarini RJ et al, J Affect Disord 2013;148(1):129–135
• Van Meter AR et al, J Abnorm Child Psychol 2013;41(3):367–378
• Jenkins MM et al, Prof Psychol Res Pr 2011;42(2):121–129
• Youngstrom EA et al, Cognitive and Behavioral Practice 2015;22(1):20–35
• Akinhanmi MO et al, Bipolar Disord 2018;20(6):506–514
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