Difficulties in Diagnosing Manic Disorders among Children and Adolescents MARGARET ANN BOWRING, M.D.,
AND
MARIA KOYACS, PH.D.
Abstract. Four factors are delineated that account for the difficulties in identifying and diagnosing manic disorders among children and adolescents. These factors are the low base rate of the disorder, its variable clinical presentation within and across episodes, its symptomatic overlap with more common disorders of childhood, and the constraints placed on symptom expression by the developmental stage of a child. Each of these factors is discussed in terms of its impact on the likelihood of recognizing mania, and strategies are proposed to improve diagnostic accuracy. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,4:611-614. Key Words: mania in childhood, differential diagnosis. Episodes of mania tend to be underdiagnosed or misdiagnosed in childhood and early adolescence (Carlson, 1984; Strober et aI., 1989; Weller et aI., 1986). One factor that may account for this phenomenon is its often confusing clinical presentation (Carlson, 1990). For example, the symptoms of mania in the adolescent years may appear to be more typical of schizophrenia than affective illness (e.g., Ballenger et aI., 1982; McGlashan, 1988). The abnormal mental and physical excitement that characterize this syndrome may also be confused with symptoms of attention deficit disorder of childhood (Carlson, 1990; Strober et aI., 1989). Another factor that may contribute to misdiagnosis is that existing diagnostic criteria do not take into account age-related changes in the presentation of manic illness (Carlson, 1983). Finally, it is widely believed that this disorder does not occur before puberty (Weller et aI., 1986). Childhood-onset manic disorders need to be accurately diagnosed for several reasons. To start with, their prevalence may be on the rise as suggested by convergent data on adults and children. There is increasing evidence, for example, that among adults, later birth cohorts are characterized both by earlier ages of onset and increasing rates of affective illness (Gershon et aI., 1987; Klerman et aI., 1985; Lavori et aI., 1987; Wickramaratne et aI., 1989). That is, more individuals are developing affective disorders and at younger ages. In addition, juvenile-onset depression, the rate of which may also be increasing, appears to be a risk factor for early bipolar illness (Kovacs and Gatsonis, 1989; Strober and Carlson, 1982). Accurate diagnosis also has treatment implications. For example, double-blind studies of adults with bipolar illness indicate that prophylactic pharmacotherapy is critical in reducing eventual morbidity and impairment (Goodwin and Jamison, 1990). Finally, accurate diagnosis at the onset may make it easier for young patients and
Accepted Januaty 9. 1992. From the Department ofPsychiatry, University ofPittsburgh School of Medicine, and the Western Psychiatric Institute and Clinic, Pittsburgh, PA. Preparation of this article was supported in part by NIMH grant MH 33990 and a grant from the W. T. Grant Foundation. Reprint requests to Dr. Bowring. WPiC, 3811 O'Hara Street, Pittsburgh, PA 15213. 0890-8567/92/3104-0611$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
their families to accept psychoeducation about the disorder's lifelong management. The purpose of the present article is to further discuss issues that have been noted to contribute to the misdiagnosis of mania, to identify additional variables that hinder the diagnostic process, and to outline possible solutions. It is proposed that there are four interacting factors that account for the difficulties in diagnosing a manic episode in the juvenile years, namely, its low base rate, its variable clinical presentation within and across episodes, its symptomatic overlap with more common disorders of childhood, and the effect of developmental age on symptom expression. The discussion that follows rests on the premise that clinical diagnosis is a problem-solving process wherein patterns of illness are differentiated from one another. Illness patterns, in turn, are generally conceptualized as diagnostic prototypes, that is, clusters of characteristic signs and symptoms and their evolution over time. To diagnose a disorder, the clinician has to have a mental representation (mental template) of it, which is a synthesis of previously accumulated knowledge and prior exposure to the syndrome and its variants. It is particularly difficult for clinicians to form a mental template of mania in childhood because of the above noted four factors, each of which is now discussed in detail. I. Base rate problem. Although the prevalence and incidence of psychiatric disorders in childhood have not yet been firmly established, there is consensus about a number of general issues. Among younger age groups, "externalizing" disorders are more prevalent than "internalizing" disorders. The relative rates of disorders shift with the onset of adolescence, and overall rates rise in the middle and late teens (Costello, 1989; Rutter, 1989). Among younger and early adolescent children, manic or bipolar disorders are rare (Strober et aI., 1989), whereas "acting-out" or disruptive behavior disorders, including attention deficit disorder and conduct disorder, are prevalent (Costello, 1989). For example, in a large epidemiological sample of 11year-olds, altogether less than 8% were diagnosed (using more than one information source) as having had any psychiatric disorder in the previous year (Anderson et aI., 1987). The most prevalent disorder, attention deficit disorder, only had a rate of 4.4%, 1.5% of the children had conduct disorder, and 0.8% had depression dysthymia. Mania and bipolar disorders were not even mentioned by the authors. Another 611
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epidemiological study of a representative community sample of 14- to 16-year-olds illustrates that the rates of psychiatric diagnoses increase with age but that mania still remains rare. In this sample of adolescents, altogether 18.7% had some disorder; 8.7% of the youth had conduct disorder, 8.0% met diagnostic criteria for depression dysthymia, 2% had attention deficit disorder, and 0.7% met criteria for "mania" (Kashani et a!., 1987). In other words, at any given point in time, less than 1% of pediatric population samples could be expected to have a manic disorder. However, only about 20% to 30% of youngsters who have a psychiatric disturbance are referred for or receive professional help (Anderson et a!., 1987; Lewinsohn et a!., 1991). Therefore, the typical clinician is likely to have a very low rate of exposure to youths with mania, which makes it difficult to form the initial mental "template" of the diagnostic prototype. 2. Cross-sectional and longitudinal variability of symptoms. Carlson (1984) and Strober et a!. (1989), among others, have commented on the wide range of clinical characterizations of childhood mania in the literature. As one approach to this dilemma, they suggested that the disorder might have several variants. However, a more paI'simonious explanation is that the symptoms of mania in childhood are intrinsically labile and that there exist gradients of severity within any given episode. Consideration of these two factors renders the clinical descriptions less confusing. Labile, unstable, and changeable mood is particularly striking among young patients under 10 years of age (Carlson, 1983). Clinically, this phenomenon can be observed as rapid shifts in affect that often cause parents to describe their children as unpredictable, belligerent, nasty, uncontrollable, a "Dr. Jekyll and Mr. Hyde." Such descriptions also suggest irritability, that together with belligerence, appears to be more prominent than euphoria in childhood-onset manic illness. Along with the labile, changeable mood, the extent of mental excitement and psychomotor agitation also may wax and wane. This kaleidoscopic picture should not be surprising given that the disorder is superimposed on a developing child that has yet to achieve emotional, cognitive, neuropsychological, and physical maturity. A related factor is that an episode may have its own progression. Carlson and Goodwin (1973), who have eloquently described such a phenomenon in adults, identified three stages of acute mania. Stage I entails euphoric mood, grandiosity, racing thoughts, and increased psychomotor activity. Stage 2 encompasses a more dysphoric presentation with increasingly explosive behavior, grandiose delusions, pressured speech, and flight of ideas. Stage 3 resembles acute delirium or acute psychotic disorganization. It is very possible that mania in childhood has similar stages. In fact, descriptions of manic youths with presumably "atypical" features (e.g., McGlashan, 1988) strongly resemble Stage 3 mania. According to Carlson and Goodwin's (1973) paradigm, such cases are not atypical but have progressed to the most severe stage of the illness. The above noted cross-sectional and longitudinal symptomatic features of mania in childhood have implications for diagnosis. To begin with, a manic episode may be unrec612
ognized if the changeable and labile presentation is not viewed as a salient characteristic of the disorder. In contrast to existing diagnostic criteria that require persistence of symptoms, a more fitting prototype of a manic episode in childhood would incorporate its unstable arid variable clinical presentation. Furthermore, diagnostic criteria should take into consideration gradients of symptom severity to facilitate recognition of the stages of the disorder. 3. Symptomatic overlap of mania with other disorders. As several authors have noted, mania may be misdiagnosed because its clinical presentation is similar to more common psychiatric disorders of childhood (Carlson, 1990; Strober et a!., 1989). Attention-deficit hyperactivity disorder (ADHD) and conduct disorder are the most likely to be considered in differential diagnosis because they have salient symptoms in common with mania. A young patient may also have any combination of the three conditions, making diagnosis even more difficult. However, the presence of a syndromatic picture, characteristic ages-at-onset, and differences in prodrome and course are clues to accurate diagnosis. For the diagnosis of a manic episode, both DSM-III and DSM-III-R (American Psychiatric Association, 1980, 1987) require at least a I-week duration of elated, expansive, or irritable mood, and three or four of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, rapid or pressured speech, flight of ideas, distractibility, increased goal-directed activity, and excessive involvement in pleasurable activities that have a high potential for painful consequences. As Kendell (1985) has suggested, behaviors such as indiscriminate sexuality, that reflect impaired judgment, can be readily explained by the social disinhibition of manic patients. Distractibility and high levels of motor activity are two prominent features of mania as well as ADHD. Both ADHD and manic disorders also are characterized by behavioral dysregulation that may include impulsive or reckless acts. For example, children with mania and those with ADHD have difficulty maintaining attention, are easily distracted by external stimuli, and may have rapid or pressured speech. They may be socially intrusive and impulsively engage in dangerous activities. Although the foregoing symptoms do not distinguish mania from ADHD, the two conditions differ in syndromatic presentation, age of onset, and course. ADHD is primarily a disorder of attention and behavioral regulation, and it includes a broader range of symptoms than the ones it shares with mania. ADHD is also operationally defined as having an onset before age 6 and often is apparent by age 4 or 5 (Barkley, 1990). The disorder is persistent, with as many as 50% to 80% of affected children continuing to display significant symptoms into adolescence (Barkley, 1990). In contrast, mania is primarily a mood disorder that is characterized by abnormal emotional and mental excitement. The disorder rarely has an onset before the elementary school years. Finally, a manic episode represents a change in the patient's functioning, and the course of the illness is phasic with often lengthy symptom-free intervals. A manic episode may be superimposed on ADHD. In such a case, the diagnostic dilemma is whether the shared J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
DIAGNOSIS OF MANIA
symptoms should be "counted" toward one or the other disorder. Given its age-at-onset, ADHD would be the preexisting disorder in such a comorbid presentation. Shared symptoms, such as impaired attention and distractibility, may be "counted" as part of mania if these symptoms have clearly exacerbated since the onset of the affective episode. The overlap between mania and conduct disorder may not be readily apparent. Children with either of these diagnoses may present with a negative, irritable mood, including belligerence and hostility. They also may exhibit poor judgment, such as "borrowing" parents' credit cards, impaired impulse control, such as inappropriate sexual behavior and disinhibited social interactions. However, conduct and manic disorders do differ with regard to the quality of the disturbed mood, the syndromatic picture, age at onset, prodrome, and course. In mania, the irritable, expansive, or giddy affect has a labile and uncontrollable quality and represents a change in mood. In contrast, the irritability and belligerence of conduct disordered youths usually reflect a chronic pattern of affective response to rules and authority. Children with conduct disorder do not exhibit certain symptoms of mania such as grandiosity, flight of ideas, reduced need for sleep, or loss of reality testing. Conduct disorder often emerges in the preschool or elementary school period, has an insidious onset and lengthy prodrome, and entails a progression from less severe to more serious rule-breaking (Kazdin, 1987; Loeber, 1982, 1991). Although the severity of the disorder may fluctuate, it is typically chronic and persistent. In contrast, antisocial and impulsive behaviors that are part of a manic episode usually begin abruptly. They may also remit rapidly, paralleling the course of the manic episode. It is, however, difficult to diagnose mania in the context of a history of ADHD or conduct disorder. As already noted, sudden exacerbation of "overlapping" symptoms (e.g., agitation or hyperactivity) together with new manic symptoms can be indicative of a dual diagnosis. For example, an adolescent whose conduct disorder started in elementary school may develop intense irritability alternating with elation as well as boastfulness, flight of ideas, grandiosity, and a burst of antisocial behaviors. This presentation would be consistent with the diagnosis of a manic episode superimposed on a preexisting conduct disorder. Alternatively, a young patient with a history of ADHD may show improvement during early adolescence, and then abruptly develop irritable, labile mood, pressured speech, hyperactivity, impulsivity, and social disinhibition, among others. Such a presentation would be consistent with a manic episode rather than a "reemergence" of ADHD. 4. Developmental stage and symptom expression. The diagnosis of mania among juveniles is also made difficult by the fact that a patient's age influences symptom expression. Developmental mediation of (or constraint on) symptoms may occur in several ways. Some of the "classic" manic symptoms are not yet part of the behavior repertoire of children. Symptom expression may also be limited by the relatively strict familial-social regulation of youths. Other J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
symptoms of a manic episode may be difficult to distinguish from developmentally appropriate behaviors. For example, the expression of symptoms such as poor judgment, "increased goal-directed activity," and "excessive involvement in pleasurable activities" are shaped by both the youngster's stage of social-cognitive development and constraints imposed by the family and the social milieu. During an episode of mania, an adult may charge thousands of dollars on credit cards, go bankrupt because of impulsive business deals, phone every news media in the city about imagined injustices, indiscriminately engage in multiple sexual encounters, or gamble for 5 nights in a row. In contrast, the poor judgment and disinhibition of a 10- or ll-year-old may manifest as the sudden emergence of new dysfunctional behaviors, such as cheating in school, picking fights with teachers, running away from home, dressing flamboyantly, or intrusively touching peers. Manic youngsters may give away all the food in the family's refrigerator, impulsively buy magic markers for the children in their class, invite strangers into their house, or color their hair green. Excessive involvement in pleasurable activities for a 10-year-old manic child may mean staying up all night counting baseball cards, whereas for a 16-year-old, it may involve driving his parent's car without permission or without a driver's license. Symptom expression in the juvenile years is, therefore, best evaluated in the context of the child's prior history because the behaviors in isolation may not be obvious expressions of psychopathology. The symptoms of grandiosity or inflated self-esteem must also be considered from a developmental perspective. More specifically, during childhood and early adolescence, it is "normal" to have an active imagination and to brag about real or imagined positive attributes. In a clinical interview, it may, therefore, be extremely difficult to determine if the young patient has crossed the boundary into psychotic thinking. This problem is exacerbated by the fact that the cognitive content may not be altogether different from developmentally normal preoccupations. For example, a 10year-old boy in a manic episode may maintain with conviction that he is an undercover policeman who apprehends criminals in the neighborhood. He may, however, also play this role in a game of "cops" and robbers with his friends. Such continuity or fluidity across psychopathological and normal cognitive themes is unique to children. In other words, an adult who believes himself to be the President of the United States or Jesus Christ during a manic episode does not "play" such roles as part of his normal life and interactions. Conclusions It has been proposed in the present article that four factors account for the problems in diagnosing a manic disorder among juveniles, namely, the low base rate of the disorder, its variable clinical presentation, its symptomatic overlap with more common disorders, and the effects of developmental age on symptoms. These factors have made it difficult for clinicians to form a mental representation (template) of mania and, coincidentally, have hindered research in this area. Recognition of mania in childhood could be improved 613
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by developing special training opportumtles, approaching clinical assessment in a more longitudinal manner, and improving existing diagnostic criteria. Ultimately, such attempts must be supported by systematic empirical data. To begin with, the consequence of the low base rate of mania in childhood is that most professionals may have only read about it. Increased exposure would help clinicians to develop a mental template of the disorder and to sharpen diagnostic skills. This goal could be accomplished through systematic training opportunities for visiting professionals in academic-clinical institutions where bipolar youths are evaluated and treated. Training videotapes from such sites could also be developed and made available for distribution. The frequent misdiagnosis of mania in childhood cannot be solely due to its low base rate, but it also is a function of the disorder's variable presentation and its fuzzy diagnostic boundaries. The resultant diagnostic uncertainties can only be resolved by repeated assessments of young patients, which should include a detailed history. Particular attention must be paid to the age at which symptoms emerge, the vicissitudes of the symptoms, the temporal relationship among them, and the evolution of the syndrome. Historical information should be obtained from adult informants who are able to describe the young patient's behavior, mood, and functioning over time. The foregoing diagnostic difficulties are compounded by the DSM-/ll and DSM-ll/-R. Whereas persistence of symptoms is currently required for a manic episode, it would be more accurate to specify an unstable and variable clinical presentation as its defining feature among youths. Additionally, as Carlson (1983) noted, the existing criteria do not take into account or specify age-variant features of the syndrome. To help clinicians, diagnostic manuals should include systematic and standardized descriptions of how symptom expression changes as a function of age. For example, the way in which grandiosity may be expressed in a 9-year-old versus a 14-year-old should be made clear. Such a developmental approach to pathology has long been accepted in pediatrics and is exemplified by various sections of the Harriet Lane Handbook (Schuberth and Zitelli, 1978). By combining special training opportunities, improved methods of clinical assessment, and developmentally descriptive diagnostic criteria, buttressed by systematic empirical research, the rate of misdiagnosing mania in childhood should be much reduced. References American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III). Washington, DC: American Psychiatric Association. American Psychiatric Association (1987), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised (DSM-III-R). Washington, DC: American Psychiatric Association. Anderson, J. C., Williams, S., McGee R. & Silva, P. A. (1987), DSMIII disorders in preadolescent children. Arch. Gen. Psychiatry, 44:69-76.
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Ballenger, J. C, Reus, V. I. & Post, R. M. (1982), The "atypical" clinical picture of adolescent mania. Am. J. Psychiatry, 139:602606. Barkley, R. A. (1990), Attention Deficit Hyperactivity Disorder. New York: Guilford Press. Carlson, G. A. (1983), Bipolar affective disorders in childhood and adolescence. In: Affective Disorders in Childhood and Adolescence, eds. D. P. Cantwell & G. A. Carlson. New York: Spectrum Publications, pp. 61-83. - - (1984), Classification issues of bipolar disorders in childhood. Psychiatr. Dev., 4:273-285. - - (1990), Annotation: child and adolescent mania-diagnostic considerations. J. Child Psycho!. Psychiatry, 31 :331-341. - - & Goodwin, F. K. (1973), The stages of mania. Arch. Gen. Psychiatry, 28:221-228. Costello, E. J. (1989), Developments in child psychiatric epidemiology. J. Am. A cad. Child Adolesc. Psychiatry, 28:836-841. Gershon, E. S., Hamovit, J. H., Guroff, J. J. & Nurnberger, J. I. (1987), Birth-cohort changes in manic and depressive disorders in relatives of bipolar and schizo-affective patients. Arch. Gen. Psychiatry, 44:314-319. Goodwin, F. K. & Jamison, K. R. (1990), Manic-Depressive Illness. New York: Oxford University Press. Kashani, J. H., Beck, N. C., Hoeper, E. W. et al. (1987), Psychiatric disorders in a community sample of adolescents. Am. J. Psychiatry, 144:584-589. Kazdin, A. E. (1987), Conduct Disorders in Childhood and Adolescence. California: Sage Publications. Kendell, R. E. (1985), The diagnosis of mania. J. Aflective Disord., 8:207-213. Klerman, G. L., Lavori, P. W., Rice, J. et al. (1985), Birth-cohort trends in rates of major depressive disorder among relatives of patients with affective disorder. Arch. Gen. Psychiatry, 42:689-693. Kovacs, M. & Gatsonis, C. (1989), Stability and change in childhoodonset depressive disorders: longitudinal course as a diagnostic validator. In: The Validity of Psychiatric Diagnosis, eds. L. N. Robins & J. E. Barrett. New York: Raven Press, pp. 57-75. Lavori, P. W., Klerman, G. L., Keller, M. B., Reich, T., Rice, J. & Endicott, J. (1987), Age-period-cohort analysis of secular trends in onset of major depression: findings in siblings of patients with major affective disorder. J. Psychiatr. Res., 21 :23-35. Lewinsohn, P. M., Rohde, P., Seeley, J. R. & Hops, H. (1991), Comorbidity of unipolar depresson: 1. major depression with dysthymia. J. Abnorm. Psychol., 100:205-213. Loeber, R. (1982), The stability of antisocial and delinquent child behavior: a review. Child Dev., 53:1431-1446. -~ (1991), Antisocial behavior: more enduring than changeable. J. Am. Acad. Child Adolesc. Psychiatry, 30:393-397. McGlashan, T. H. (1988), Adolescent versus adult onset of mania. Am. J. Psychiatry, 145:221-223. Rutter, M. (1989), Isle of Wight revisited: twenty-five years of child psychiatric epidemiology. J. Am. Acad. Child Adolesc. Psychiatry, 28:633-653. Schuberth, K. C. & Zitelli, B. J. (1978), The Harriet Lane Handbook, 8th edition. Chicago: Year Book Medical Publishers. Strober, M. & Carlson, G. (1982), Bipolar illness in adolescents with major depression. Arch. Gen. Psychiatry, 39:549-555. - - Hanna, G. & McCracken, J. (1989), Bipolar disorder. In: Handbook of Child Psychiatric Diagnosis, eds. C. Last & M. Hersen. New York: Wiley, pp. 299-316. Weller, R. A., Weller, E. B., Tucker, S. G. & Fristad, M. A. (1986), Mania in prepubertal children: has it been underdiagnosed? J. Affective Disord., II: 151-154. Wickramaratne, P. J., Weissman, M. M., Leaf, P. J. & Holford, T. R. (1989), Age, period and cohort effects on the risk of major depression: results from five United States communities. J. Clin. Epidemiol., 42:333-343.
J. Am. A cad. Child Adolesc. Psychiatry, 31 :4, July 1992
AND
MARIA KOYACS, PH.D.
Abstract. Four factors are delineated that account for the difficulties in identifying and diagnosing manic disorders among children and adolescents. These factors are the low base rate of the disorder, its variable clinical presentation within and across episodes, its symptomatic overlap with more common disorders of childhood, and the constraints placed on symptom expression by the developmental stage of a child. Each of these factors is discussed in terms of its impact on the likelihood of recognizing mania, and strategies are proposed to improve diagnostic accuracy. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,4:611-614. Key Words: mania in childhood, differential diagnosis. Episodes of mania tend to be underdiagnosed or misdiagnosed in childhood and early adolescence (Carlson, 1984; Strober et aI., 1989; Weller et aI., 1986). One factor that may account for this phenomenon is its often confusing clinical presentation (Carlson, 1990). For example, the symptoms of mania in the adolescent years may appear to be more typical of schizophrenia than affective illness (e.g., Ballenger et aI., 1982; McGlashan, 1988). The abnormal mental and physical excitement that characterize this syndrome may also be confused with symptoms of attention deficit disorder of childhood (Carlson, 1990; Strober et aI., 1989). Another factor that may contribute to misdiagnosis is that existing diagnostic criteria do not take into account age-related changes in the presentation of manic illness (Carlson, 1983). Finally, it is widely believed that this disorder does not occur before puberty (Weller et aI., 1986). Childhood-onset manic disorders need to be accurately diagnosed for several reasons. To start with, their prevalence may be on the rise as suggested by convergent data on adults and children. There is increasing evidence, for example, that among adults, later birth cohorts are characterized both by earlier ages of onset and increasing rates of affective illness (Gershon et aI., 1987; Klerman et aI., 1985; Lavori et aI., 1987; Wickramaratne et aI., 1989). That is, more individuals are developing affective disorders and at younger ages. In addition, juvenile-onset depression, the rate of which may also be increasing, appears to be a risk factor for early bipolar illness (Kovacs and Gatsonis, 1989; Strober and Carlson, 1982). Accurate diagnosis also has treatment implications. For example, double-blind studies of adults with bipolar illness indicate that prophylactic pharmacotherapy is critical in reducing eventual morbidity and impairment (Goodwin and Jamison, 1990). Finally, accurate diagnosis at the onset may make it easier for young patients and
Accepted Januaty 9. 1992. From the Department ofPsychiatry, University ofPittsburgh School of Medicine, and the Western Psychiatric Institute and Clinic, Pittsburgh, PA. Preparation of this article was supported in part by NIMH grant MH 33990 and a grant from the W. T. Grant Foundation. Reprint requests to Dr. Bowring. WPiC, 3811 O'Hara Street, Pittsburgh, PA 15213. 0890-8567/92/3104-0611$03.00/0©1992 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
their families to accept psychoeducation about the disorder's lifelong management. The purpose of the present article is to further discuss issues that have been noted to contribute to the misdiagnosis of mania, to identify additional variables that hinder the diagnostic process, and to outline possible solutions. It is proposed that there are four interacting factors that account for the difficulties in diagnosing a manic episode in the juvenile years, namely, its low base rate, its variable clinical presentation within and across episodes, its symptomatic overlap with more common disorders of childhood, and the effect of developmental age on symptom expression. The discussion that follows rests on the premise that clinical diagnosis is a problem-solving process wherein patterns of illness are differentiated from one another. Illness patterns, in turn, are generally conceptualized as diagnostic prototypes, that is, clusters of characteristic signs and symptoms and their evolution over time. To diagnose a disorder, the clinician has to have a mental representation (mental template) of it, which is a synthesis of previously accumulated knowledge and prior exposure to the syndrome and its variants. It is particularly difficult for clinicians to form a mental template of mania in childhood because of the above noted four factors, each of which is now discussed in detail. I. Base rate problem. Although the prevalence and incidence of psychiatric disorders in childhood have not yet been firmly established, there is consensus about a number of general issues. Among younger age groups, "externalizing" disorders are more prevalent than "internalizing" disorders. The relative rates of disorders shift with the onset of adolescence, and overall rates rise in the middle and late teens (Costello, 1989; Rutter, 1989). Among younger and early adolescent children, manic or bipolar disorders are rare (Strober et aI., 1989), whereas "acting-out" or disruptive behavior disorders, including attention deficit disorder and conduct disorder, are prevalent (Costello, 1989). For example, in a large epidemiological sample of 11year-olds, altogether less than 8% were diagnosed (using more than one information source) as having had any psychiatric disorder in the previous year (Anderson et aI., 1987). The most prevalent disorder, attention deficit disorder, only had a rate of 4.4%, 1.5% of the children had conduct disorder, and 0.8% had depression dysthymia. Mania and bipolar disorders were not even mentioned by the authors. Another 611
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epidemiological study of a representative community sample of 14- to 16-year-olds illustrates that the rates of psychiatric diagnoses increase with age but that mania still remains rare. In this sample of adolescents, altogether 18.7% had some disorder; 8.7% of the youth had conduct disorder, 8.0% met diagnostic criteria for depression dysthymia, 2% had attention deficit disorder, and 0.7% met criteria for "mania" (Kashani et a!., 1987). In other words, at any given point in time, less than 1% of pediatric population samples could be expected to have a manic disorder. However, only about 20% to 30% of youngsters who have a psychiatric disturbance are referred for or receive professional help (Anderson et a!., 1987; Lewinsohn et a!., 1991). Therefore, the typical clinician is likely to have a very low rate of exposure to youths with mania, which makes it difficult to form the initial mental "template" of the diagnostic prototype. 2. Cross-sectional and longitudinal variability of symptoms. Carlson (1984) and Strober et a!. (1989), among others, have commented on the wide range of clinical characterizations of childhood mania in the literature. As one approach to this dilemma, they suggested that the disorder might have several variants. However, a more paI'simonious explanation is that the symptoms of mania in childhood are intrinsically labile and that there exist gradients of severity within any given episode. Consideration of these two factors renders the clinical descriptions less confusing. Labile, unstable, and changeable mood is particularly striking among young patients under 10 years of age (Carlson, 1983). Clinically, this phenomenon can be observed as rapid shifts in affect that often cause parents to describe their children as unpredictable, belligerent, nasty, uncontrollable, a "Dr. Jekyll and Mr. Hyde." Such descriptions also suggest irritability, that together with belligerence, appears to be more prominent than euphoria in childhood-onset manic illness. Along with the labile, changeable mood, the extent of mental excitement and psychomotor agitation also may wax and wane. This kaleidoscopic picture should not be surprising given that the disorder is superimposed on a developing child that has yet to achieve emotional, cognitive, neuropsychological, and physical maturity. A related factor is that an episode may have its own progression. Carlson and Goodwin (1973), who have eloquently described such a phenomenon in adults, identified three stages of acute mania. Stage I entails euphoric mood, grandiosity, racing thoughts, and increased psychomotor activity. Stage 2 encompasses a more dysphoric presentation with increasingly explosive behavior, grandiose delusions, pressured speech, and flight of ideas. Stage 3 resembles acute delirium or acute psychotic disorganization. It is very possible that mania in childhood has similar stages. In fact, descriptions of manic youths with presumably "atypical" features (e.g., McGlashan, 1988) strongly resemble Stage 3 mania. According to Carlson and Goodwin's (1973) paradigm, such cases are not atypical but have progressed to the most severe stage of the illness. The above noted cross-sectional and longitudinal symptomatic features of mania in childhood have implications for diagnosis. To begin with, a manic episode may be unrec612
ognized if the changeable and labile presentation is not viewed as a salient characteristic of the disorder. In contrast to existing diagnostic criteria that require persistence of symptoms, a more fitting prototype of a manic episode in childhood would incorporate its unstable arid variable clinical presentation. Furthermore, diagnostic criteria should take into consideration gradients of symptom severity to facilitate recognition of the stages of the disorder. 3. Symptomatic overlap of mania with other disorders. As several authors have noted, mania may be misdiagnosed because its clinical presentation is similar to more common psychiatric disorders of childhood (Carlson, 1990; Strober et a!., 1989). Attention-deficit hyperactivity disorder (ADHD) and conduct disorder are the most likely to be considered in differential diagnosis because they have salient symptoms in common with mania. A young patient may also have any combination of the three conditions, making diagnosis even more difficult. However, the presence of a syndromatic picture, characteristic ages-at-onset, and differences in prodrome and course are clues to accurate diagnosis. For the diagnosis of a manic episode, both DSM-III and DSM-III-R (American Psychiatric Association, 1980, 1987) require at least a I-week duration of elated, expansive, or irritable mood, and three or four of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, rapid or pressured speech, flight of ideas, distractibility, increased goal-directed activity, and excessive involvement in pleasurable activities that have a high potential for painful consequences. As Kendell (1985) has suggested, behaviors such as indiscriminate sexuality, that reflect impaired judgment, can be readily explained by the social disinhibition of manic patients. Distractibility and high levels of motor activity are two prominent features of mania as well as ADHD. Both ADHD and manic disorders also are characterized by behavioral dysregulation that may include impulsive or reckless acts. For example, children with mania and those with ADHD have difficulty maintaining attention, are easily distracted by external stimuli, and may have rapid or pressured speech. They may be socially intrusive and impulsively engage in dangerous activities. Although the foregoing symptoms do not distinguish mania from ADHD, the two conditions differ in syndromatic presentation, age of onset, and course. ADHD is primarily a disorder of attention and behavioral regulation, and it includes a broader range of symptoms than the ones it shares with mania. ADHD is also operationally defined as having an onset before age 6 and often is apparent by age 4 or 5 (Barkley, 1990). The disorder is persistent, with as many as 50% to 80% of affected children continuing to display significant symptoms into adolescence (Barkley, 1990). In contrast, mania is primarily a mood disorder that is characterized by abnormal emotional and mental excitement. The disorder rarely has an onset before the elementary school years. Finally, a manic episode represents a change in the patient's functioning, and the course of the illness is phasic with often lengthy symptom-free intervals. A manic episode may be superimposed on ADHD. In such a case, the diagnostic dilemma is whether the shared J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
DIAGNOSIS OF MANIA
symptoms should be "counted" toward one or the other disorder. Given its age-at-onset, ADHD would be the preexisting disorder in such a comorbid presentation. Shared symptoms, such as impaired attention and distractibility, may be "counted" as part of mania if these symptoms have clearly exacerbated since the onset of the affective episode. The overlap between mania and conduct disorder may not be readily apparent. Children with either of these diagnoses may present with a negative, irritable mood, including belligerence and hostility. They also may exhibit poor judgment, such as "borrowing" parents' credit cards, impaired impulse control, such as inappropriate sexual behavior and disinhibited social interactions. However, conduct and manic disorders do differ with regard to the quality of the disturbed mood, the syndromatic picture, age at onset, prodrome, and course. In mania, the irritable, expansive, or giddy affect has a labile and uncontrollable quality and represents a change in mood. In contrast, the irritability and belligerence of conduct disordered youths usually reflect a chronic pattern of affective response to rules and authority. Children with conduct disorder do not exhibit certain symptoms of mania such as grandiosity, flight of ideas, reduced need for sleep, or loss of reality testing. Conduct disorder often emerges in the preschool or elementary school period, has an insidious onset and lengthy prodrome, and entails a progression from less severe to more serious rule-breaking (Kazdin, 1987; Loeber, 1982, 1991). Although the severity of the disorder may fluctuate, it is typically chronic and persistent. In contrast, antisocial and impulsive behaviors that are part of a manic episode usually begin abruptly. They may also remit rapidly, paralleling the course of the manic episode. It is, however, difficult to diagnose mania in the context of a history of ADHD or conduct disorder. As already noted, sudden exacerbation of "overlapping" symptoms (e.g., agitation or hyperactivity) together with new manic symptoms can be indicative of a dual diagnosis. For example, an adolescent whose conduct disorder started in elementary school may develop intense irritability alternating with elation as well as boastfulness, flight of ideas, grandiosity, and a burst of antisocial behaviors. This presentation would be consistent with the diagnosis of a manic episode superimposed on a preexisting conduct disorder. Alternatively, a young patient with a history of ADHD may show improvement during early adolescence, and then abruptly develop irritable, labile mood, pressured speech, hyperactivity, impulsivity, and social disinhibition, among others. Such a presentation would be consistent with a manic episode rather than a "reemergence" of ADHD. 4. Developmental stage and symptom expression. The diagnosis of mania among juveniles is also made difficult by the fact that a patient's age influences symptom expression. Developmental mediation of (or constraint on) symptoms may occur in several ways. Some of the "classic" manic symptoms are not yet part of the behavior repertoire of children. Symptom expression may also be limited by the relatively strict familial-social regulation of youths. Other J. Am. Acad. Child Adolesc. Psychiatry, 31 :4, July 1992
symptoms of a manic episode may be difficult to distinguish from developmentally appropriate behaviors. For example, the expression of symptoms such as poor judgment, "increased goal-directed activity," and "excessive involvement in pleasurable activities" are shaped by both the youngster's stage of social-cognitive development and constraints imposed by the family and the social milieu. During an episode of mania, an adult may charge thousands of dollars on credit cards, go bankrupt because of impulsive business deals, phone every news media in the city about imagined injustices, indiscriminately engage in multiple sexual encounters, or gamble for 5 nights in a row. In contrast, the poor judgment and disinhibition of a 10- or ll-year-old may manifest as the sudden emergence of new dysfunctional behaviors, such as cheating in school, picking fights with teachers, running away from home, dressing flamboyantly, or intrusively touching peers. Manic youngsters may give away all the food in the family's refrigerator, impulsively buy magic markers for the children in their class, invite strangers into their house, or color their hair green. Excessive involvement in pleasurable activities for a 10-year-old manic child may mean staying up all night counting baseball cards, whereas for a 16-year-old, it may involve driving his parent's car without permission or without a driver's license. Symptom expression in the juvenile years is, therefore, best evaluated in the context of the child's prior history because the behaviors in isolation may not be obvious expressions of psychopathology. The symptoms of grandiosity or inflated self-esteem must also be considered from a developmental perspective. More specifically, during childhood and early adolescence, it is "normal" to have an active imagination and to brag about real or imagined positive attributes. In a clinical interview, it may, therefore, be extremely difficult to determine if the young patient has crossed the boundary into psychotic thinking. This problem is exacerbated by the fact that the cognitive content may not be altogether different from developmentally normal preoccupations. For example, a 10year-old boy in a manic episode may maintain with conviction that he is an undercover policeman who apprehends criminals in the neighborhood. He may, however, also play this role in a game of "cops" and robbers with his friends. Such continuity or fluidity across psychopathological and normal cognitive themes is unique to children. In other words, an adult who believes himself to be the President of the United States or Jesus Christ during a manic episode does not "play" such roles as part of his normal life and interactions. Conclusions It has been proposed in the present article that four factors account for the problems in diagnosing a manic disorder among juveniles, namely, the low base rate of the disorder, its variable clinical presentation, its symptomatic overlap with more common disorders, and the effects of developmental age on symptoms. These factors have made it difficult for clinicians to form a mental representation (template) of mania and, coincidentally, have hindered research in this area. Recognition of mania in childhood could be improved 613
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by developing special training opportumtles, approaching clinical assessment in a more longitudinal manner, and improving existing diagnostic criteria. Ultimately, such attempts must be supported by systematic empirical data. To begin with, the consequence of the low base rate of mania in childhood is that most professionals may have only read about it. Increased exposure would help clinicians to develop a mental template of the disorder and to sharpen diagnostic skills. This goal could be accomplished through systematic training opportunities for visiting professionals in academic-clinical institutions where bipolar youths are evaluated and treated. Training videotapes from such sites could also be developed and made available for distribution. The frequent misdiagnosis of mania in childhood cannot be solely due to its low base rate, but it also is a function of the disorder's variable presentation and its fuzzy diagnostic boundaries. The resultant diagnostic uncertainties can only be resolved by repeated assessments of young patients, which should include a detailed history. Particular attention must be paid to the age at which symptoms emerge, the vicissitudes of the symptoms, the temporal relationship among them, and the evolution of the syndrome. Historical information should be obtained from adult informants who are able to describe the young patient's behavior, mood, and functioning over time. The foregoing diagnostic difficulties are compounded by the DSM-/ll and DSM-ll/-R. Whereas persistence of symptoms is currently required for a manic episode, it would be more accurate to specify an unstable and variable clinical presentation as its defining feature among youths. Additionally, as Carlson (1983) noted, the existing criteria do not take into account or specify age-variant features of the syndrome. To help clinicians, diagnostic manuals should include systematic and standardized descriptions of how symptom expression changes as a function of age. For example, the way in which grandiosity may be expressed in a 9-year-old versus a 14-year-old should be made clear. Such a developmental approach to pathology has long been accepted in pediatrics and is exemplified by various sections of the Harriet Lane Handbook (Schuberth and Zitelli, 1978). By combining special training opportunities, improved methods of clinical assessment, and developmentally descriptive diagnostic criteria, buttressed by systematic empirical research, the rate of misdiagnosing mania in childhood should be much reduced. References American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III). Washington, DC: American Psychiatric Association. American Psychiatric Association (1987), Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised (DSM-III-R). Washington, DC: American Psychiatric Association. Anderson, J. C., Williams, S., McGee R. & Silva, P. A. (1987), DSMIII disorders in preadolescent children. Arch. Gen. Psychiatry, 44:69-76.
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Ballenger, J. C, Reus, V. I. & Post, R. M. (1982), The "atypical" clinical picture of adolescent mania. Am. J. Psychiatry, 139:602606. Barkley, R. A. (1990), Attention Deficit Hyperactivity Disorder. New York: Guilford Press. Carlson, G. A. (1983), Bipolar affective disorders in childhood and adolescence. In: Affective Disorders in Childhood and Adolescence, eds. D. P. Cantwell & G. A. Carlson. New York: Spectrum Publications, pp. 61-83. - - (1984), Classification issues of bipolar disorders in childhood. Psychiatr. Dev., 4:273-285. - - (1990), Annotation: child and adolescent mania-diagnostic considerations. J. Child Psycho!. Psychiatry, 31 :331-341. - - & Goodwin, F. K. (1973), The stages of mania. Arch. Gen. Psychiatry, 28:221-228. Costello, E. J. (1989), Developments in child psychiatric epidemiology. J. Am. A cad. Child Adolesc. Psychiatry, 28:836-841. Gershon, E. S., Hamovit, J. H., Guroff, J. J. & Nurnberger, J. I. (1987), Birth-cohort changes in manic and depressive disorders in relatives of bipolar and schizo-affective patients. Arch. Gen. Psychiatry, 44:314-319. Goodwin, F. K. & Jamison, K. R. (1990), Manic-Depressive Illness. New York: Oxford University Press. Kashani, J. H., Beck, N. C., Hoeper, E. W. et al. (1987), Psychiatric disorders in a community sample of adolescents. Am. J. Psychiatry, 144:584-589. Kazdin, A. E. (1987), Conduct Disorders in Childhood and Adolescence. California: Sage Publications. Kendell, R. E. (1985), The diagnosis of mania. J. Aflective Disord., 8:207-213. Klerman, G. L., Lavori, P. W., Rice, J. et al. (1985), Birth-cohort trends in rates of major depressive disorder among relatives of patients with affective disorder. Arch. Gen. Psychiatry, 42:689-693. Kovacs, M. & Gatsonis, C. (1989), Stability and change in childhoodonset depressive disorders: longitudinal course as a diagnostic validator. In: The Validity of Psychiatric Diagnosis, eds. L. N. Robins & J. E. Barrett. New York: Raven Press, pp. 57-75. Lavori, P. W., Klerman, G. L., Keller, M. B., Reich, T., Rice, J. & Endicott, J. (1987), Age-period-cohort analysis of secular trends in onset of major depression: findings in siblings of patients with major affective disorder. J. Psychiatr. Res., 21 :23-35. Lewinsohn, P. M., Rohde, P., Seeley, J. R. & Hops, H. (1991), Comorbidity of unipolar depresson: 1. major depression with dysthymia. J. Abnorm. Psychol., 100:205-213. Loeber, R. (1982), The stability of antisocial and delinquent child behavior: a review. Child Dev., 53:1431-1446. -~ (1991), Antisocial behavior: more enduring than changeable. J. Am. Acad. Child Adolesc. Psychiatry, 30:393-397. McGlashan, T. H. (1988), Adolescent versus adult onset of mania. Am. J. Psychiatry, 145:221-223. Rutter, M. (1989), Isle of Wight revisited: twenty-five years of child psychiatric epidemiology. J. Am. Acad. Child Adolesc. Psychiatry, 28:633-653. Schuberth, K. C. & Zitelli, B. J. (1978), The Harriet Lane Handbook, 8th edition. Chicago: Year Book Medical Publishers. Strober, M. & Carlson, G. (1982), Bipolar illness in adolescents with major depression. Arch. Gen. Psychiatry, 39:549-555. - - Hanna, G. & McCracken, J. (1989), Bipolar disorder. In: Handbook of Child Psychiatric Diagnosis, eds. C. Last & M. Hersen. New York: Wiley, pp. 299-316. Weller, R. A., Weller, E. B., Tucker, S. G. & Fristad, M. A. (1986), Mania in prepubertal children: has it been underdiagnosed? J. Affective Disord., II: 151-154. Wickramaratne, P. J., Weissman, M. M., Leaf, P. J. & Holford, T. R. (1989), Age, period and cohort effects on the risk of major depression: results from five United States communities. J. Clin. Epidemiol., 42:333-343.
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