112 Chapter 11
Classical and juvenile-specific criteria
for bipolar disorder
In any discussion of bipolar disorder affecting children and adolescents, it is
crucial to distinguish between ‘classical criteria’ for mania and hypomania,
on the one hand, and controversial ‘juvenile-specific criteria’, on the other
hand:
1 Classicalcriteria involve episodes of mania or hypomania that fully meet
the official ICD-10 or DSM-IV criteria, with these criteria being applied
in exactly the same way to children and adolescents as to adults.
2 Juvenile-specificcriteria involve a wide variety of controversial semi-
official or unofficial definitions of manic episodes that have been spe-
cially adjusted for use with children and adolescents. There are certainly
precedents for adjusting diagnostic criteria for different age ranges. For
example, although adults should only be diagnosed with obsessive-
compulsive disorder if they resist their obsessions and compulsions,
both ICD and DSM drop this requirement for children and adolescents.
Similarly, the DSM-IV criteria for major depression in adults stipulate
that depressed mood must be present, whereas irritable mood is an
acceptable alternative to depressed mood in the case of children and
adolescents. Thus the principle that diagnostic criteria can be adjusted
for age is not controversial. What is controversial is whether such
adjustment is needed in the specific instance of bipolar disorder, and
if so, how it should be done. There are many opposing suggestions
from different experts – the only certainty is that they cannot all be
right. In the rest of this chapter, classically defined bipolar disorder
is considered first, turning subsequently to the debate about bipolar
disorder diagnosed on the basis of juvenile-specific criteria.
Epidemiology
In adolescence, classically defined bipolar disorder is uncommon until the
late teens, with community surveys suggesting a prevalence of between
0.1% and 1% – and a fairly even gender ratio. Mania and depression
are probably equally common as first episodes of bipolar disorders in
adolescence, with mania being more common thereafter. Bipolar disorder
that begins in childhood or adolescence rather than adulthood seems to be
associated with a particularly high rate of mixed episodes and rapid cycling
(i.e. four or more episodes per year).
Clinical reports make it clear that classically defined bipolar disorder does
also occur in prepubertal children, but only rarely. Why might prepubertal
mania be rare? Perhaps the neural substrate for going high is particularly
late to mature – something that could make evolutionary sense if mania-
like behaviours are usually only adaptive in dominant adults (see above).