Bipolar disorder and disruptive mood dysregulation in children and adolescents: assessment, diagnosis and treatment

Bipolar disorder (BD) is a heritable psychiatric condition, that is, associated with lifelong distress and impairment. There has been a long-standing interest in the early-life origins of BD, not least because as many as 50% of adults with BD report onset of their symptoms during childhood and adolescence.1 In this article, we present evidence on the assessment and treatment of BD and related conditions in young people. We also discuss the recent controversy about BD in children and adolescents that has led to the introduction of the diagnosis of disruptive mood dysregulation disorder (DMDD) by the Diagnostic and Statistical Manual for Mental Disorders (DSM)-5. ### Diagnostic features BD is characterised by episodes, that is, distinct periods of abnormally and persistently elevated, expansive or irritable mood. During these episodes, patients experience symptoms such as grandiosity, distractibility, decreased need for sleep, pressure of speech, an increase in activity, flight of ideas and psychomotor agitation. These episodes are required to last by at least 4 days to diagnose hypomania or at least 7 days to diagnose mania. The insistence on episodic mood changes is crucial and prevents clinicians from rating symptoms such as the chronic concentration problems of a child with attention deficit hyperactivity disorder (ADHD) as evidence for mania.2 Manic episodes are extremely rare in children and relatively rare in adolescents according to epidemiological studies in the UK and the USA.3 ### Acute treatment Pharmacotherapy is the mainstay of treatment for acute mania. Aripiprazole, quetiapine and risperidone are approved by the US Food and Drug Administration (FDA) for the treatment of mania in children and adolescents, and olanzapine in approved only for adolescents. A comparative analysis of randomised, placebo-controlled trials in youth BD established that atypical antipsychotics have better efficacy and tolerability compared with anticonvulsants and lithium (effect size atypical antipsychotics 0.65, CI 0.53 to 0.78 vs …