Updated: Aug 8, 2019
In Part 1 of this series, we reviewed the prevalence of pediatric bipolar disorder and linked some articles on empirically-based assessment of this complex condition. In this post, I'll outline my general assessment process for this diagnosis. When I am seeing a child where one of the differentials is possible pediatric bipolar disorder, following my 8 step model, I go through the following steps: 1. Review demographic info, referral source, base rates, and other info to get a prior estimate of probability of bipolar disorder.
Here, I'm thinking about:
The general prevalence of pediatric bipolar disorder (1-2%)
My "local" prevalence rate(about 6-8% in my practice)
Who referred the child to me (I have a few psychologists who refer to me specifically when they suspect pediatric bipolar), and
The age of the child.
I'm trying to get a general sense of how likely is it that I need to carefully assess this specific child for pediatric bipolar disorder.
2. Gather information during the intake about possible risk factors and moderators. Specifically, I include the following 5 steps:
A. Interview questions that ask about the primary mood symptoms of bipolar disorder
Youngstrom and colleagues have a great 2009 article on the 15 items from the General Behavior Inventory that best differentiate pediatric bipolar disorder from other childhood disorders. The specific questions can be found in Table 2.
I often use these questions in interview form as a way of asking about manic, mixed, and depressed moods and overall mood lability.
B. Interview questions that look at additional symptoms of bipolar disorder as well as related challenges. Here I am looking for the following:
Precocious interests (e.g., hypersexuality; excessive interest in money/fashion/ brands/fame; teenager-like interests in a young child)
Aggressive behavior or violent/overly intense themes in play
Atypical social behavior (e.g., social problems despite good social skills, charisma, and strong social interest)
Psychotic-like experiences (e.g., hallucinations; delusions of grandeur or paranoia)
C. Assessment of family history of bipolar disorder
As reviewed in the articles by Youngstrom and colleagues I've linked in this post series, having a parent with bipolar disorder increases the child's risk of developing bipolar disorder by a factor of 5 to 10.
D. Assessment of sleep disturbance and appetite disturbances or changes
E. Assessment of what else might better explain the symptoms other than pediatric bipolar disorder.
Important differentials in my opinion, in rough prevalence order, include:
Unrecognized intellectual disability or language disorder
Oppositional defiant disorder
Chaotic family structure
(If very acute onset) rare medical disorders like a neoplasm or anti-NMDA encephalitis.
I also sometimes see young children with NVLD who look 'on paper' like they have pediatric bipolar disorder
Is there anything you can think of that I've forgotten?
3. Obtain information about contextual factors.
Here I am looking at:
Family social support
The child's coping skills
His or her temperament and personality (and match with parent temperament)
The child's strengths and interests
I'm also asking questions about what intervention strategies have already been tried, and how well those worked.
I want to ensure my interview and other info I gather will place the whole child in his or her context. This info will help me prioritize recommendations. It will also help me personalize and tailor those recommendations.
4. Design a test battery
I want to have a test battery that will assess for pediatric bipolar. However, I also want to test for other concerns that might better explain the child's presentations. I also want to test for concerns that might be comorbid with bipolar disorder.
Because I set my threshold at 10%, if I do not have any info that raises my index of suspicion based on the steps listed above, I am typically only screening (if anything) for pediatric bipolar disorder.
However, if I feel there is a 10% or greater chance of pediatric bipolar - e.g., a child referred to me by a psychologist for suspected bipolar with a family history of bipolar disorder - I do a thorough assessment for this condition.
I typically complete the following battery:
Usually, IQ is average to above in pediatric bipolar. I still assess it, for a few reasons:
To have a standardized observation period during which to observe how the child responds to demands on her attention, motivation, social cooperation, and ability to handle novelty
To have an appreciation of her strengths, and
I see many children who have severe emotional and behavioral dysregulation who also show a profile of much stronger verbal skills than nonverbal skills on a standard IQ test. I find having this info helps me make recommendations for these kids.
Attention and Executive Functioning
Research shows individuals with bipolar disorder have clear executive functioning deficits. For example, about 95% of adults with bipolar disorder met childhood criteria for ADHD.
In my evals, I've noticed the following three findings most often:
Performance on continuous performance tests is wildly variable, ranging from intact to incredibly poor.
Cognitive inhibition is often poor For example, scores might be poor on a Stroop-type test (e.g. DKEFS Color-Word or NEPSY-II Inhibition). Or, there may be rule-breaking errors on planning tasks (e.g. on the Tower of London-2 or Trails X).
Challenges maintaining set. This might include losses of set on trail-making tasks. Or, it might include intrusions, neologisms, or clang associations on verbal fluency (e.g., for S-words, a child might say "soup, super, superduper, sluperpooper, supertrooper, trooper, clooper, smooper").
We know from research that all mood disorders are associated with memory impairments. This could be a direct effect of mood on encoding, storage, or retrieval. More likely, it reflects problems with attention and motivation secondary to mood challenges.
For that reason, I like to administer a list-learning task like the CVLT-C or CVLT-3. What I most typically find is a very high level of intrusions (e.g., 15 or more intrusions, ranging from common intrusions like 'sweatshirt', to much less common intrusions like 'necklace').
Other common list-learning task findings include failure to acquire more words on each trial and poor primacy recall. Both of these might reflect problems with attention or motivation. I also see a lot of irritation during these list-learning tasks.
Mood disorders are also associated with psychomotor slowing. Depression in particular associated with slowed motor and processing speed. So, I'm assessing psychomotor speed as part of the process of determining if depression better explains the child's proile.
However, I'm also looking at speed-accuracy trade-off during these tasks. Slow overall speed due to many impulsive mistakes may point me more towards a disorder with significant impulse control problems, like pediatric bipolar or ADHD, rather than depression.
If the child makes few errors but slows down a lot after each error (that is, shows post-error slowing), I'm less likely to suspect pediatric bipolar. I'm now more suspicious of anxiety.
Social communication and social perception
Here, I am first and foremost ruling out a social developmental disorder that might better explain the child's presentation. However, I have also noticed students with suspected pediatric bipolar are often exceptionally socially motivated, empathetic, and socially skilled, yet still show atypical social behavior and deficits on social perception testing.
Most often, I see problems with accurate perception of or memory of faces. I am not sure why I see this finding. It could reflect motivation problems, a hostile attribution bias, mood-congruent perceptual problems, or true subtle social difficulties comorbid with the mood disorder.
I find it helpful to assess for these concerns to ensure I'm making good recommendations if there are social perception problems. I also find it helpful to administer these tasks (typically, NEPSY-II Affect Recognition and Memory for Faces) because the social-emotional content of them contributes to emotional dysregulation in the child that I can actually observe. That is, children with likely bipolar disorder can get really "silly" or excited during these tasks. They can also express frank paranoia that is important to observe.
Any other neurocognitive testing needed to answer the referral question
Something I've noticed but am not yet able to explain is a high degree of comorbidity between severe emotional dysregulation and unexpectedly poor reading. For this reason, I often assess reading skills when evaluating these children because it is often one of the referral questions.
If the child is old enough, I administer self-report questionnaires. For younger children, these are usually questionnaires related to emotional symptoms. Examples include the CDI-2, MASC-2, CMOCS if there are OCD-like concerns, or the TSCC if trauma is a concern.
In adolescents, I typically use the BASC-3 because it has a mania content scale. I also use the MMPI-2-RF. I also interview directly around the specific symptoms of mood disorders (including bipolar disorder), anxiety disorders, PTSD/trauma, and anger or impulse-control problems.
Parent Rating Scales
I find the Pediatric Behavior Rating Scale (PBRS) to be the most helpful rating scale for gathering info about the symptoms of pediatric bipolar disorder, so that is my go-to.
In my opinion, however, all rating scales specific to pediatric bipolar disorder have a high false-positive rate. So, I'd recommend interpreting these rating scales with caution. The linked Youngsrom article also includes lots of good info on the available questionnaires to assess pediatric bipolar disorder.
I also almost always give the parent BASC-3 and BRIEF-2. Much of the time I'm also giving the SRS-2 to see if there are social concerns.
As I look at the scores on the rating scales, I am looking for both what I might expect for pediatric bipolar disorder. In my experience, this is ALL (or almost all) scales extremely elevated, with T scores in the 80s or above. As I look at the scores, I'm also for info that might point me away from bipolar disorder and towards a more likely explanation for the child's problem.
While I do not rely on them for diagnosis, I find storytelling tasks (e.g., the Roberts or TAT) to be really helpful. In my experience, usually the child has difficulty "holding it together" when faced with an ambiguous emotion-provoking task, even if they were somewhat more able to self-regulate during the rest of the test session.
As a result, you get stories that are loose, grandiose, sometimes scatological, sometimes very violent, and often disorganized. Often, the stories derail easily, go on at great length, and are difficult to follow. Many children I have assessed appear frankly manic during storytelling tasks. This helps me feel more comfortable with my diagnosis.
In contrast, sometimes the storytelling task gives me hypotheses about what diagnosis would better explain the child's presentation. For example, I may be more likely to suspect ASD, depression, anxiety, trauma, or psychosis based on their stories, and will follow up more extensively on those hypotheses.
Here, I am also looking for the primary and related symptoms of pediatric bipolar disorder. In my experience, these behaviors often stand out very clearly in the context of a relatively structured, standardized evaluation session.
Part 3 of this series is a post detailing the types of behaviors I am looking for.
5. Add testing and other forms of assessment as needed to clarify diagnosis.
I may feel very comfortable with my diagnosis after gathering the data above. However, if I still need to clarify the diagnostic picture, this is the stage where I will add in other forms of assessment as needed.
Typically, here I'm considering a school observation, additional collateral informants (e.g., interviews with the child's therapist), and/or a functional behavior assessment.
6. Interpret cross-informant and cross-domain data patterns.
This step is no different from how I conduct any other type of evaluation. Except that I'm trying to interpret the data within the context of the known neurocognitive profile of individuals with bipolar disorder and the known developmental course of bipolar disorder across the lifespan.
At this stage, I almost always re-read review articles about bipolar disorder to help protect me against relying too much on my own impressions, rather than on the actual assessment data in front of me and the existing literature base.
7. Review step 3 to finalize case formulation and generate treatment recommendations that consider the "whole child" In general, my top 6 recommendations for pediatric bipolar disorder are:
Ensuring there are no untreated medical conditions that could be contributing to the child's current difficulties
Strongly considering pharmacological treatment options (since research shows early intervention is essential for optimal outcomes)
Promoting healthy lifestyle factors like regular exercise and good sleep patterns
Reducing triggers to the fullest extent possible through a high level of routine and structure at home and school
Individual therapy that focuses on teaching strong emotion-regulation skills, and
Family therapy that supports the parents’ ability to help the child practice her emotion-regulation skills as much as possible so she can contribute positively to family life
In this stage of the assessment process, I am personalizing these recommendations based on what I know about the child and her context. For example, I might more strongly recommend a sleep study to rule out sleep as a possible etiological factor if I know she is not sleeping regularly. Or, if the child is already receiving therapy, I may provide more specific feedback for the therapist on what seems to be working and what skills might need additional focus.
Of course, if I know the family is not going to consider medication, this is the stage at which I think hard about how to best present the data in a way that empowers the family to make a good medical decision that fits with their values. For example, this might be talking with the family about "what would be our red flags that tell us we have to consider medication even if we don't want to?" Depending on what I know about a teen, I might also be including recommendations about substance use, safety planning, and possible times when he might need a higher level of care such as hospitalization.
If I know there is a family history of bipolar disorder, I might be thinking about how to best talk about the family's history with this disorder during the feedback, as this history can often ripple down to affect how the parents address the child's current problems.
These are just examples - each child is different and of course the goal of a good evaluation is to personalize evidence-based recommendations to the child's unique needs and context.
8. Present findings using therapeutic techniques, including seeking out and incorporating client preferences in the treatment plan.
Much of what I am doing in this stage overlaps step 7 above. But here I also wanted to talk about two other things I have found helpful during the feedback process:
First, spend whatever time you need to be comfortable and confident in your diagnosis.
If you have a lot of discomfort with the diagnosis of pediatric bipolar disorder, you will be tense and anxious during the feedback. Parents will sense this. Take time to review the case, discuss with your supervisor or a consultant, and learn as much as you can about pediatric bipolar, interventions for this disorder, and long-term outcomes. Convey this information to parents simply, respectfully, and with hope.
The second and last tip I have is to talk openly with the parents about their experience.
Having a child with significant emotional and behavioral dysregulation is traumatizing for parents. They are coping with their child's often overwhelming needs. They are also almost certainly coping with some or all of the following:
Their grief over the loss of their 'perfect' child
Their despair or shame over not being able to perfectly parent their child (or even in some cases to just provide basic soothing to the child)
Their hurt that their child does not seem to delight in their presence the way most children do with their parents
Their frustration with the broken mental health care system
Their worry that they passed this difficult condition on to their child
Their memories of a parent or other relative who struggled with this disorder, and/or
Their fear that their child will experience a disastrously negative outcome
I used to think I was being "sensitive" to these concerns during feedback, even though I was not directly mentioning any of them. Then, during one feedback, I actually used the word "trauma" to describe some of what a parent was experiencing. The result transformed how I give feedback to these families. The parent sobbed in sheer relief.
She told me no one seemed to understand what she was going through, and she felt so much shame about her feelings about her experience. Once we'd processed her initial reaction, her entire demeanor changed. She seemed so much less burdened and so much more hopeful.
This experience completely changed the way I do feedback for a child with pediatric bipolar. I discuss the parents' experience openly, and 9 times out of 10, the simple effect of naming and bringing to the light these emotions and experiences is truly awe-inspiring. Now it's your turn.
Leave a comment about your assessments for pediatric bipolar disorder and what you've found most helpful. Or read on for Part 3.