AssessmentGuidelines for the assess

Assessment
Guidelines for the assessment and management
of bipolar disorder in adults and children have
been produced by a variety of authoritative groups
[92–99].
Clinicians should expect a base rate of bipolar
disorder of 1% in school settings; 5% in nonspecialist
clinical settings; and a rate that is 5-times
higher where the referred child has a parent with a
diagnosis of bipolar disorder [99]. In routine clinical
assessment where there is evidence of parental
bipolar disorder, mania or hypomania occurring in
response to anti-depressant treatment, delusions
and/or hallucinations associated with mood disturbance,
rapid cycling depressive and manic symptoms,
episodic or unplanned highly aggressive
behaviour, then a thorough evaluation for paediatric
bipolar disorder should be conducted [99].
The diagnosis of mood disorder is based on the
lifetime history of episodes of mood disorders and
not simply on the clinical presentation. In assessing
young people who may have bipolar disorder, data
should be gathered from multiple informants over a
series of appointments. Extending assessment over
time is important for tracking the course of mood
fluctuations. Self-report data from young people is
particularly useful is documenting depressive symptoms
and internalizing behaviour problems, while
parent reports are useful in documenting symptoms
of mania and externalizing behaviour problems.
Teacher reports provide information on academic
and social functioning in a school and peer group
context.
The process of assessment is a critical opportunity
for forming a strong working alliance with the young
person and their parents, since a strong working
alliance has been shown to predict treatment
response in adults with bipolar disorder [100].
A preliminary screening should be conducted,
followed by a thorough psychiatric and psychological
assessment. This should cover all of the symptoms
listed in Table I and also include a detailed personal
and family history. The following brief screening
instruments may be useful in detecting cases of
paediatric bipolar disorder [99]: the externalizing
sub-scale of the Achenbach Empirically Based
Assessment instruments (ASEBA) [101] including
the Child Behaviour Checklist, Teacher Report
Form and Youth Self-report form; the self-report
[102] and parent [103] versions of the Young Mania
Rating Scale (YMRS); and the hypomanic/biphaic
scale of the self-report [104] and parent [105]
versions of the General Behaviour Inventory (GBI).
Detailed probabilistic data for all of these instruments
useful in screening for paediatric bipolar
disorder are available [99, 106].
The Kiddie Schedule for Affective Disorders and
Schizophrenia (KSADS) [107, 108] has been used
extensively in research on paediatric bipolar disorder,
but may be impractical to use in routine
clinical settings, because it takes a number or hours
to administer. The Children’s Interview for
Psychiatric Syndromes [109] is a much briefer
structured interview that covers a range of DSM
IV diagnoses including bipolar disorder and is useful
in clinical practice.
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 main alternatives to include in the differential
diagnosis of bipolar disorder are ADHD, conduct
disorder, schizophrenia, drug abuse, endocrinopathies
such as hypertyroidism and neurological conditions
such as temporal lobe epilepsy [92, 112,
113]. Youngsters with bipolar disorder, like those
with ADHD, may show distractibility, impulsivity
and over-activity. However, ADHD has an earlier
onset than bipolar disorder; the symptoms of
distractibility, impulsivity and over-activity are persistent,
not episodic; and elated mood rarely occurs
in ADHD. Children with bipolar disorder, like those
with conduct disorder, may show oppositional
behaviour, tantrums, defiance, sexual promiscuity
and a pattern of rule-breaking and socially deviant
behaviour. However, in bipolar disorder, this overall
pattern of behaviour is episodic rather than persistent
and usually there is a family history of mood
disorder. With bipolar disorder, guilt or remorse may
be expressed for rule-breaking, which is rare in
434 A. Carr
conduct disorder. Neither flight of ideas nor
pressured speech are present in conduct disorder
or ADHD, but both occur in bipolar disorder.
Delusions and hallucinations may occur during
manic episodes, making children with this type of
presentation difficult to distinguish from youngsters
with schizophrenia. In such cases extended periods
of observation may be required. A family history of
schizophrenia rather than mood disorder and an
insidious onset of current difficulties suggest a
diagnosis of schizophrenia rather than bipolar disorder.
Youngsters who abuse amphetamines or
hallucinogenic drugs may present with hypomaniclike
behaviour. However, this typically abates over
time. A thorough medical and neurological assessment
(including an EEG if seizure disorder is
suspected) is essential to outrule endocrinopathies
such as hypertyroidism and neurological conditions
such as temporal lobe epilepsy which can contribute
to a hypomanic-like presentation.
Differential diagnosis of bipolar disorder is complicated
by the fact that in young people this
condition rarely occurs alone. 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. While data on
suicide risks associated with paediatric bipolar disorder
are unavailable, in adults bipolar disorder is
associated with suicide risk. Consequently suicide
risk assessment should be routinely conducted.
Guidelines for such interviews are given in Carr
[114, 115] and elsewhere [116, 117].
The level of critical and hostile emotions
expressed by parents (a central aspect of expressed
emotion) affects the course of paediatric bipolar
disorder and so is a focus for psychosocial intervention
[87]. In view of this, the periodic assessment
of parental attitudes towards young people with
bipolar disorder is important. In routine clinical
settings it is not practical to administer the
Camberwell Family Interview [118] to assess the
construct of expressed emotion. However, brief
alternatives that may be useful in assessing relevant
parental attitudes in routine practice are the Family
Attitudes Scale [119] and the Level of Expressed
Emotion scale [120].
The YMRS [102], the Children’s Depression
rating Scale [121] and the KSADS Mania and
Depression rating scales [122] are brief sensitive
rating scales which may be used to periodically
monitor symptomatic improvement in young people
with bipolar disorder.