PRACTICE PARAMETERS FOR THE ASSESSMENT AND
TREATMENT OF CHILDREN AND ADOLESCENTS WITH BIPOLAR DISORDER
- Diagnostic assessment.
- Premorbid history.
- Cognitive, motor, sensory, social, or other developmental
- Premorbid personality characteristics; i.e., temperament,
mood, anxiety, and/or behavioral problems.
- History of present illness.
- Document DSM-IV (APA,
1994b) target symptoms (both manic and depressive symptoms), as
well as associated phenomena (e.g., psychotic symptoms,
suicidality). The symptoms should represent a significant change
from baseline functioning, with associated changes in the
child's mental status. Rapidity of onset and any precipitating
stressors should be noted.
- Examine the longitudinal course of illness. It is often
helpful to create a life chart to identify cyclical and/or
- Assessment for associated or confounding symptoms, especially
substance abuse, organic factors, and/or behavioral disorders.
- Family history.
- Obtain a thorough family history of mood, anxiety and
psychotic disorders, suicidality, impulse control disorders,
neurological and medical conditions, and substance abuse.
- Family emotional, communicative, interactional, and coping
styles and resources.
- School information.
- Obtain information about school functioning, both premorbid
and subsequent to the onset of symptoms, either directly or from
written reports from appropriate staff, such as the principal,
school psychologist/counselor, teacher, and/or nurse after
release of information is granted.
- Neuropsychological functioning.
- Suspected disabilities in either intellectual functioning,
communication abilities, and/or motor skills should be evaluated
to help with the differential diagnosis and/or to identify
comorbid problems. Assessments to consider include psychological
testing (IQ, neuropsychological testing, adaptive functioning,
and/or academic testing), speech and language assessment, and/
or an occupational/physical therapy evaluation.
- Consultation and collaboration with other mental health and/or
social service providers as necessary.
- Physical evaluation of the child. A thorough evaluation is needed
to rule out organic conditions.
- A pediatric examination is needed, including a thorough
neurological evaluation, especially in the presence of either
psychotic symptoms and/or catatonia, with consideration of
neurological consultation, EEG, and computed tomographic and
magnetic resonance imaging head scans. This may be done in
collaboration with the primary family physician or other health
- Medical conditions that mimic either mania or depression,
such as metabolic, endocrine, infectious disorders, or acute
intoxication/withdrawal, need to be evaluated as indicated.
Routine laboratory tests (i.e., blood counts, renal and liver
functions, thyroid functions, toxicology screen, pregnancy test,
and urinalysis) are usually indicated, both as part of the
organic workup and also as baseline assessments for medication
therapy. If the risk factors are present, testing for HIV should
be done, with appropriate informed consent.
- Diagnostic formulation.
- A diagnosis of bipolar disorder is made when the required DSM-IV
(APA, 1994b) target symptoms for
mania/mixed state are present, either currently or by history, and
other disorders, such as schizophrenia or organic affective
disturbances, have been adequately ruled out. Once the diagnosis has
been established, it should be reassessed longitudinally to ensure
- In the assessment of children and adolescents presenting with
symptoms suggestive of bipolar disorder, evaluation includes
- Recent onset of biopsychosocial stresses.
- Educational and vocational potential, disabilities, and
- Peer, sibling, family, and sociocultural problems and
- Environmental factors, including disorganized home, presence
of child abuse/neglect, and/or mental illness in parents or
- Developmental abnormalities (motor and language delays).
- Child/adolescent interpersonal strengths, especially the
ability to form adult and peer relationships.
- Differential diagnosis.
- The following conditions may be misdiagnosed as bipolar
- Schizoaffective disorder or other psychotic disorders
(delusional disorders, schizophreniform disorder, psychosis
not otherwise specified).
- Organic affective disorders.
- Childhood disruptive behavior disorders.
- Borderline personality disorder (or other personality
disorders/traits that present with affective instability and
- Posttraumatic stress disorder.
- The following conditions often occur comorbidly with bipolar
- Substance abuse disorders.
- Childhood disruptive behavioral disorders.
- Anxiety disorders.
- The following medical conditions may mimic bipolar disorder:
- Organic mania:
- Organic mania due to substance abuse or withdrawal
(amphetamines, cocaine, phencyclidine, inhalants,
- Organic mania due to prescribed medications, such as
antidepressant agents (induced mania), sympathomimetics,
bromocriptine, stimulants, and/or corticosteroids.
- Neurological disorders (e.g., brain tumors, posttrauma,
CNS infections, including HIV, multiple sclerosis, temporal
lobe seizures, Kleine-Levin syndrome).
- Metabolic conditions (e.g., hyperthyroidism, urermia,
Wilson's disease, collagen vascular disorders, delirium).
- Substantial scientific evidence suggests that the only specific
treatment of bipolar disorder is medication therapy using a mood
stabilizer. However, medications need to be used in conjunction with
a multimodal treatment model that also includes psychoeducational
services, individual and family supportive and psychotherapeutic
interventions, educational programs, and community support services.
Psychotherapeutic interventions must be sensitive to cultural
Most of the treatment recommendations are based on studies of
adults. However, the limited available research on early-onset
bipolar disorder, plus clinical consensus within the field,
suggests that these findings can be applied to youth as long as
pertinent developmental factors are incorporated into the
The following elements are necessary to develop a multimodal
- Thorough diagnostic assessment. Acute mania or severe
depression (especially psychotic depression) may require
hospitalization, depending on the severity and potential danger
of the symptomatology, as well as the social supports of the
family. Hospitalization may be necessary because of the
extensive array of psychiatric and neurological evaluation
resources required to complete the initial assessment, and the
need for a more structured, safe environment in which to
evaluate the patient.
- Assessment for suicide potential, since this population is at
significant risk for attempting/completing suicide.
- Identification of other pertinent issues, i.e., family
dysfunction, school difficulties, and premorbid and/or comorbid
disorders, requiring ongoing treatment.
- Evaluation and initiation of medication therapy.
- Education of the patient and family as to the nature of the
illness, potential prognostic issues, and treatment needs.
- Development of a long-term treatment plan, including
medication management, appropriate psychotherapy and
psychoeducational services for the patient, supportive services
for the family (advocacy groups, support groups), appropriate
educational and vocational services, and residential services
- Designation of a case manager for chronically disabled
individuals because of the wide range of services needed.
- Provisions for long-term periodic diagnostic reassessments to
ensure accuracy of diagnosis.
- Psychopharmacology. The phase of the illness needs to be
considered when making decisions on medication therapy.
- Acute mania/mixed mania.
- Prior to initiating medications, a thorough psychiatric
evaluation is needed, including documentation of the
symptoms targeted for therapy. Informed consent is needed
from the parents and adolescent patients, and assent, when
possible, should be obtained from preadolescents.
- In adults, lithium has been the most extensively
researched antimanic agent, and its efficacy has been
documented. The anticonvulsants valproate and carbamazepine
are also used, with greater evidence supporting the efficacy
of valproate. During the acute phase, it may be necessary to
augment the antimanic agent with either an antipsychotic
agent or a benzodiazepine to address the associated
psychomotor agitation and/or psychotic symptoms.
- To determine whether or not an antimanic medication is
effective, it must be used for at least 4 to 6 weeks at
adequate dosages and blood levels. If no effects are seen at
that point, consideration should be given to either adding
or changing to a different antimanic medication.
- As the acute manic symptoms stabilize, the patient may
cycle through a period of confusion and disorganization.
These symptoms may also progress into a depressive episode.
It is important to recognize these as phases of the
disorder; otherwise, the tendency may be to make significant
changes in the medication regimen that may, in fact, only
prolong recovery. The antimanic agent should be maintained
through this phase, with modifications in dosage or
augmenting agents to further ameliorate the presenting
- Depressed phase.
- Care must be taken in using antidepressant agents because
they may induce a manic episode. Patients with established
bipolar disorder should be maintained on an antimanic agent
prior to initiating antidepressant therapy.
- As patients recover from mania, it is common for them to
cycle through a depressive phase. This phase often resolves
with continued antimanic treatment; therefore, the addition
of an antidepressant may not be necessary unless the
depressed phase persists or becomes severe.
- Long-term maintenance therapy with an antimanic agent is
indicated to prevent relapse. Data are inadequate to specify
how long prophylactic treatment should be maintained.
However, one study of youth suggests at least 18 months of
therapy is necessary, and, undoubtedly, some patients will
need lifelong treatment.
- If multiple psychotropic agents were needed to treat the
patient's acute symptoms, attempts to taper adjunctive
agents (e.g., antipsychotic agents, benzodiazepines) should
be made once remission has been achieved and the patient is
clinically stable. Patients with bipolar disorder may be at
increased risk for tardive dyskinesia with long-term
neuroleptic use. Similarly, if more than one antimanic agent
has been used to control manic symptoms, an assessment is
needed to determine if remission can be maintained with a
single agent. Close monitoring for relapse is necessary
during these changes.
- Relapse of symptoms.
- When symptoms relapse, it should first be determined
whether or not the patient was compliant with prophylactic
therapy. If nor, resumption of the antimanic medication
should occur. If the patient was compliant and had been
previously responding to the agent (without significant side
effects), an increase in the medication dose may stabilize
the symptoms (keeping in mind the standard dosage ranges and
- If symptoms relapse and the patient is not adequately
responding to the current antimanic agent (at adequate
dosages), a trial of a different antimanic, either alone or
in addition, should then be undertaken. Adjunctive agents
(e.g., antipsychotics, benzodiazepines, antidepressants) may
also be indicated, depending on the symptom presentation.
- Patients who relapse may require acute hospitalization.
This decision should be based on the severity of affective
and psychotic symptoms, potential danger to self or others,
degree of impairment in the patient's ability to maintain
basic self care, and availability of supportive services in
- Patients who do not respond to standard therapy.
- Before it is decided that the patient is a nonresponder,
the patient should receive at least two adequate trials of
different antimanic agents, one of which should be lithium.
An adequate trial is defined both by duration (4 to 6 weeks)
and dosage (using maximal levels if necessary and
- In adults, other agents with reported antimanic activity
include clozapine, benzodiazepines, calcium channel
blockers, and thyroid hormones. However, these have not been
studied in children and adolescents. If clozapine is to be
used, close monitoring for potential seizures,
agranulocytosis (with periodic blood cell counts), and
weight gain is necessary.
- The efficacy of ECT for bipolar disorder, both mania and
depression, is well established for adults. There is also some
literature supporting its use in youth with bipolar disorder. It
is generally used only for medication-resistant cases. However,
it may be considered as an Initial treatment for severe
psychotic depression and/or catatonia.
- Psychosocial therapy.
- Psychoeducational therapy for the patient, including ongoing
education about the illness, medication effects, social skills
training, problem-solving skills strategies, and basic life
skills training. Part of the focus should be on relapse
prevention, including compliance with medications.
- Psychoeducational therapy for the family, focusing on
increasing the understanding of the illness, treatment options
and prognosis, relapse prevention, and effective coping and
parenting intervention strategies.
- Specialized education programs and/or vocational training
- Individual (usually supportive rather than insight-oriented),
group, or family psychotherapy to address associated
psychosocial problems that increase morbidity.
- Treatment of associated disorders or symptoms, such as substance
abuse disorders, disruptive behavior disorders, and/or suicidality.
- Partial hospitalization or day treatment programs.
- Many patients will need the specialized educational and
psychiatric services available in either a partial
hospitalization or day treatment program to be maintained at
home within their community.
- Residential treatment.
- In some cases, the severity of the individual's illness or
lack of effective response to treatment (often in conjunction
with chaotic social situations) may necessitate long-term
hospitalization or residential treatment. This option should
only be considered after less restrictive alternatives have been
unsuccessful. Once in a long-term residential setting, the
patient's status needs to be reassessed at regular intervals,
with the goal of returning to a less restrictive setting when
- Flexible models of care.
- Many youth with bipolar disorder will be chronically
impaired, with complicated clinical and social needs, and may
need an integrated continuum of services, including: case
management, intensive community and family support, in-home
services, out-of-home care (including respite and specialized
foster care), and specialized educational/vocational services.
Conflict of Interest
In keeping with the requirement that practice parameters be developed by
experienced clinicians and researchers, some of the contributors to these
practice parameters are in active clinical practice. Through their
practices, it is likely that most of these child and adolescent
psychiatrists have received income related to treatments discussed in
these parameters. Some contributors are primarily involved in research or
other academic endeavors; it is possible that through such activities,
many of them have also received income related to treatments discussed in
these parameters. A number of mechanisms are in place to minimize the
potential for producing biased recommendations due to conflicts of
interest. First, the development process calls for extensive review of the
document before it is finalized. All members of the Academy have the
opportunity to comment on the parameters before they are approved.
Comments have been solicited and received from a broad group of reviewers
in child and adolescent psychiatry. Second, the contributors and reviewers
have all been asked to base their recommendations on an objective
evaluation of the available evidence. Third, we ask that contributors or
reviewers who believe that they have conflicts of interest that may bias
or appear to bias their work notify the Academy.
Literature Review Process
A National Library of Medicine search was initially done in May 1994,
covering the preceding 5-year period. The following topics were reviewed:
bipolar disorder and adolescents (39 articles), bipolar disorder and
children (105 articles), and bipolar disorder and early onset (21
articles). This search was updated periodically (most recently in December
1995) to identify new articles. Searches were also undertaken to review
specific topics (e.g., the use of lithium, valproate, and carbamazepine in
children and adolescents). The abstracts generated by these MEDLINE
searches were reviewed to identify articles relevant to early-onset
bipolar disorder. Pertinent papers published before the 5-year search
period were also reviewed, as were review articles and texts addressing
the larger adult literature. Finally, the authors also drew from their own
research in this area. Articles most often used are marked with an
asterisk in the reference section.
This literature review was used to develop the initial draft of the
manuscript. After review by the Committee on Quality Issues, this draft
was then distributed to a panel of experts for comment. The panel of
experts included Hagop S. Akiskal, M.D., William Arroyo, M.D., Joseph
Biederman, M.D., Kelly Botteron, M.D., Charles Bowden, M.D., Stacy Bower,
R.N., Ian Canino, M.D., Magda Campbell, M.D., Gabrielle Carlson, M.D.,
Debbie Carter, M.D., Mark DeAntonio, M.D., Mina Dulcan, M.D., Norbert
Enzer, M.D., Robert Freeman, R.N., Mary A. Fristad, Ph.D., Barbara Geller,
M.D., Peter S. Jensen, M.D., Vivian Kafantaris, M.D., P. Keck, M.D., Wun
Jung Kim, M.D., Maria Kovacs, Ph.D., Carlyn Lampert, M.S.W., Benjamin C.P.
Lee, M.D., S. McElroy, M.D., Editha D. Nottelmann, Ph.D., Kambiz Pahlavan,
M.D., Myrna Pollack, M.S.W., Elva Poznanski, M.D., Andres Pumariega, M.D.,
David Rue, M.D., Neal Ryan, M.D., Susan Schmidt-Lackner, M.D., Jeanne
Spurlock, M.D., Michael Strober, Ph.D., Richard D. Todd, M.D., Ph.D.,
Michael W. Vannier, M.D., Elizabeth Weller, M.D., Ronald Weller, M.D., and
Deborah Zarin, M.D. Their comments were then incorporated into the
manuscript, which was then reviewed by the Academy members at large, with
a public forum at the Annual Meeting in New Orleans, October 19, 1995.
After incorporating the membership's input, a final draft was reviewed and
adopted by the Academy's Council June 15, 1996.