Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

Nursing ORIGINAL Children ARTICLE and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management Blackwell Malden, Journal JCAP 1744-6171 1073-6077 XXX 2006 of by USA Publishing Child Nursecom, and Adolescent Inc Inc. Psychiatric Nursing

Tim McDougall, RN, Dip Nursing (Mental Health), BSc (Hons) (Psychotherapeutic Interventions), ENB Specialist Practitioner (Mental Health)

TOPIC: The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings. PURPOSE: In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder. SOURCES: This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality. CONCLUSIONS: Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.

Tim McDougall, RN, Dip Nursing (Mental Health), BSc (Hons) (Psychotherapeutic Interventions), ENB Specialist Practitioner (Mental Health), is Nurse Consultant (Tier 4 CAMHS) and Lead Nurse (Specialist CAMHS), Cheshire & Wirral Foundation NHS Trust, Cheshire, UK. Introduction
Bipolar disorder is a chronic and recurrent serious mental disorder affecting up to 1% of the general population (Mackin & Young, 2005). Despite being relatively common, this disorder often goes unrecognized, misdiagnosed, and untreated. While bipolar disorder is characterized by episodes of both depressed and elated mood, the predominant experience is of low mood (Judd et al., 2002; Lewinsohn, Seeley, & Klein, 2003; Post et al., 2003). The peak age of onset is during adolescence and early adulthood (Johnson, Cohen, & Schettler, 2000; Weissman et al., 1996) and although followup reports are limited (Geller et al., 2002), outcome studies have shown that up to 20% of adults with bipolar disorder have experienced initial symptoms before the age of 19 (Harrington et al., 1994). While as many as 1% of adolescents are affected, the number of prepubertal children with bipolar disorder is very small (Lewinsohn, Klein, & Seeley, 1995; Lewinsohn, Seeley, & Klein, 2003). Children and adolescents tend to suffer from longer episodes, are more likely to have a mixed presentation (Geller et al., 2001), and experience higher rates of rapid cycling than those with late onset bipolar disorder (Geller & Luby, 1997). Nurses play a crucial role in managing acute episodes, promoting recovery, and helping prevent relapse for children and adolescents with bipolar disorder (Hamrin & Pachler, 2006; Taylor, McDougall, & Wellman, 2006). The neuroanatomy, neurobiology, and psychopharmacological management of pediatric bipolar has been reviewed by Hamrin and Pachler; however, they did not include psychosocial interventions in their review. The purpose of this paper is to provide an emphasis on the role of the nurse in assessment, treatment, and management interventions.

Search terms: Adolescents, bipolar disorder, child and

adolescent mental health services, children
doi: 10.1111/j.1744-6171.2008.00167.x Journal of Child and Adolescent Psychiatric Nursing, Volume 22, Number 1, pp. 3339
JCAPN Volume 22, Number 1, February, 2009

Diagnosing Children and Adolescents

The diagnosis of children and adolescents with bipolar disorder is an area of controversy and debate. This is due to the considerable evidence of comorbidity (Geller &
33

Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

Table 1. DSMIVTR Criteria for a Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli) 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for negative consequences C. Symptoms do not meet criteria for mixed episode D. The mood disturbance is sufficiently severe to cause marked impairment in educational functioning or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features E. The symptoms are not due to the direct physiological effects of a substance or a general medical condition
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment should not count towards a diagnosis of bipolar I disorder.

Luby, 1997), overlap with symptoms indicative of other disorders, including attention-deficit/hyperactivity disorder (ADHD) (Biederman et al., 1996; Geller & Luby, 1997; Geller et al., 1998), and low base rates for child and adolescent bipolar disorder in its most severe form (Emslie et al., 1994). Research suggests that the symptoms with most discriminatory validity are elated mood and grandiosity (Geller et al., 2002). The diagnosis of bipolar disorder in children or adolescents should only be made by child and adolescent mental health specialists with training and expertise in bipolar disorder. In severely mentally ill children and adolescents, early diagnosis is important and this should be subject to regular specialist review by a child mental health specialist with expertise in bipolar disorder. Both the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSMIVTR; American Psychiatric Association, 2000) and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (World Health Organization, 1993), outline diagnostic criteria for bipolar disorder. While both classification systems define criteria that are broadly similar, there are differences in relation to number of episodes required for a diagnosis and the distinction between bipolar I and II disorders and the criteria for a manic episode. In the DSMIVTR, symptoms have to be present for the previous week for mania, and for the previous 4 days for hypomania (see Table 1). Despite cautions, there is general consensus that bipolar I disorder can be diagnosed in both children and adolescents (National Collaborating Centre for Mental Health [NCCMH], 2006). However, the evidence base for making a diagnosis of
34

bipolar II disorders is lacking. An exception to this is in relation to older or developmentally mature adolescents where the criteria for diagnosing bipolar II disorder in adults can apply.

Prepubescent Children
Much of the existing published literature in relation to the diagnosis of prepubertal children with bipolar disorder is based on research in the United States, where diagnosis of very young children is more common than in the United Kingdom. When diagnosing bipolar I disorder in prepubescent children, the same criteria should be used as for adults except that mania must be present and euphoria must be present most days, for most of the time. Irritability should not be considered as a core diagnostic criterion as it is present in many other psychiatric disorders of childhood, including oppositional defiant disorder, ADHD, and autistic spectrum disorders (NCCMH, 2006). Bipolar I disorder in prepubescent children should not be diagnosed solely on the basis of a major depressive episode in a child with a family history of bipolar disorder. However, children presenting with depression who have a family history of bipolar disorder should be closely monitored by child and adolescent mental health services.

Adolescents
For older or developmentally advanced adolescents, the same criteria should be used for diagnosing bipolar I disorder in adults. For younger adolescents, the same
JCAPN Volume 22, Number 1, February, 2009

criteria for adults should be applied, except that mania must be present; euphoria must be present most days, for most of the time; and irritability is diagnostically significant if it is episodic or severe, results in impaired function, and is out of keeping or not in character. However, irritability should not be considered as a core diagnostic criterion for adolescents.

little overlap in symptomatology, and manic symptoms such as grandiosity, reduced need for sleep, and racing thoughts are not part of conduct disorder (Reddy & Srinath, 2000). Like ADHD, conduct disorder is not an episodic condition.

Schizophrenia
Schizophrenia is a major differential diagnosis because of the perceptual distortions experienced by children and adolescents with bipolar disorder. Schizophrenia in children and adolescents tends to have a different developmental course than bipolar disorder, with a gradual decline in functioning rather than an episodic course. The presence of mood cycles should be used to distinguish bipolar disorder from schizophrenia, which is considerably rarer than bipolar I disorder in prepubertal children and rarer than bipolar I disorder adolescents (NCCMH, 2006).

Comorbidity
Considering differential diagnosis is important when nurses and other professionals are assessing children and adolescents. This is because comorbidity is the norm rather than the exception with bipolar disorder (McElroy et al., 2001). The accurate diagnosis of children and adolescents is also difficult because features such as grandiosity, overactivity, and involvement in pleasurable activities vary according to age and developmental level. What may be considered as pathological in an adult may not be considered so in a child. For example, children and adolescents are often elated, expansive, and grandiose, and judging the inappropriateness of the context can be difficult. Thus, there is a need for caution in distinguishing between mild elated states and high spirits in younger children.

Depression
Although a previous depressive episode is not necessary to make a diagnosis of bipolar disorder, previous severe or psychotic depression may indicate that the child or adolescent belongs to a small but high-risk group for whom major depression precedes bipolar disorder (NCCMH, 2006). Children or adolescents who have had a major depressive episode and who have a family history of bipolar disorder are at increased risk and require careful monitoring.

Differential Diagnosis
Before diagnosing bipolar disorder in a child or adolescent, other explanations for the symptoms and behavior should be considered. For example, if a child or adolescent presents with disinhibition, hypersexuality, or hypervigilance, consideration should be given to whether the young person has experienced sexual or physical abuse (Geller & Luby, 1997).

Substance Misuse
The effects of substance misuse during adolescence, particularly stimulants and marijuana, can produce manic-like symptoms and perceptual distortions similar to those seen in a bipolar episode. For this reason, nurses should take a full history of drug and alcohol use and consider asking young people to provide urine sample for drug screening.

ADHD
ADHD is the most common comorbid condition with bipolar disorder. (Geller, Craney, & Bolhofner, 2003). The presence of clear-cut episodes of elated mood, inappropriate and impairing grandiosity, and cycles of mood should be used to distinguish bipolar I disorder from ADHD. While bipolar disorder and ADHD share common diagnostic criteria, including distractibility, restlessness, and overtalkativeness, bipolar disorder is episodic or cyclical whereas ADHD is not.

Learning Difficulties
Previously undiagnosed learning difficulties, neurological and neurodevelopmental disorders, and organic causes such as excited confusional states in young people with epilepsy, brain tumors, and thyroid disease should also be considered when making an assessment of manic symptoms. This will always require collaboration between the nurse and a range of other neuropsychiatric and neurological professionals.

Conduct Disorder
Comorbidity with bipolar disorder is common during childhood and adolescence, occurring in about 20% of children and 18% of adolescents (Geller et al., 2003). However, there is
JCAPN Volume 22, Number 1, February, 2009

Assessment and Treatment

A thorough multidisciplinary assessment is the foundation on which an accurate diagnosis of bipolar disorder can be made, and is essential before planning care, treatment, and
35

Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

management. A detailed developmental and neurodevelopmental history, including birth history, speech and language development, as well as information about attachment, behavior, and any sexual, physical, or emotional abuse, is required. A thorough multidisciplinary assessment should include a comprehensive mental state examination, a medical assessment to exclude organic causes, and further neuropsychological and neurological evaluation as appropriate. Nurses should offer children and adolescents separate individual appointments in addition to joint meetings with their parents or carers and other significant adults such as teachers. Stressors and vulnerabilities in the child or adolescents social, educational, and family environments, including the quality of interpersonal relationships should be explored. The impact of any comorbidities, most commonly substance misuse, ADHD, and anxiety disorders, should also be assessed.

Risk Management and Care Planning

Pediatric bipolar disorder can cause severe disturbances in global functioning (Hamrin & Pachler, 2006). Nurses should therefore make an assessment of the impact of bipolar disorder on the child or adolescents social functioning, education, and family life. As children and adolescents are vulnerable to exploitation or abuse, particularly during manic episodes, their levels of disinhibition and risk from others should also be assessed. If a child or adolescent is at risk of suicide, exploitation, or severe self-neglect, a crisis plan should be developed in conjunction with the young person as well as their parents or carers. This should cover a list of potential personal, social, and environmental triggers, and early warning signs of relapse. The ways in which the child or adolescent can access help and by whom should also be clearly identified in the crisis plan.

A thorough multidisciplinary assessment is the foundation on which an accurate diagnosis of bipolar disorder can be made.

Suicide Risk
At every stage of the assessment and treatment process, it is essential that children and adolescents with bipolar disorder have clear plans of care. This is particularly important for children and young people who are at risk of suicide, exploitation, or severe self-neglect and those who present a risk to others. International research shows that people with bipolar disorder suffer from more depressive episodes than manic episodes and are at increased risk of suicide (Rihmer & Kiss, 2002). Nurses should undertake a thorough evaluation of risk when assessing for bipolar disorder in children and adolescents. They should be aware that just as mood can change rapidly, so too can suicide risk. It is also important to assess risk to others arising from disinhibited, reckless, and impulsive behavior during manic episodes. Self-harm is more common in young people with bipolar disorder than in most other psychiatric disorders and nurses should assess for this (NCCMH, 2006).

Assessment Tools
A range of diagnostic instruments and assessment methods can assist the assessment process. These include specialist diagnostic tools such as the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) (Geller, Williams, & Zimerman, 1996), which includes prepubertal-specific mania items and a section on rapid cycling. To assist differential diagnosis, a number of general scales can be completed by parents or carers such as the Conners Abbreviated Rating Scale (Hirschfield, 2005) and the Child Behaviour Checklist (Achenbach & Edelbrock, 1991). However, it is important to note that the Child Behaviour Checklist does not distinguish episodic symptoms from continuous symptoms, and this is an important factor when considering differential diagnosis. As well as general measures, nurses have access to a battery of specific rating scales. These include the Parent Young Mania Rating Scale (Gracious, Youngstrom, Findling, & Calabrese, 2002), Parent General Behaviour Inventory (Depue, Krauss, & Spoont, 1989), and Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version (Kaufman et al., 1997). All assessment and outcome measures have their limitations, and the use of assessment tools and diagnostic instruments should not replace a full clinical interview with the child and adolescent and their parents or carers.
36

Planning Care
Parents and carers should be involved in developing care plans so that they can give informed consent, support the psychological goals of treatment, and help ensure treatment adherence. The care plan should identify any personal, social, and environmental risk and protective factors, and should identify the steps to be taken to access help in a crisis. For children and adolescents at risk of rapid onset of mania, and for whom clear early warning signs can be identified, the care plan should include a protocol for increasing the dose of medication or taking additional medication. Nurses can enable children and adolescents and their parents or carers to monitor bipolar disorder through the
JCAPN Volume 22, Number 1, February, 2009

Table 2. Types and Frequency of Laboratory Tests Required for Monitoring of Children and Adolescents on Long-Term Medication Medication Lithium Laboratory test Serum lithium concentration Blood urea and electrolytes Thyroid function Full blood count Liver panel Glucose test Lipid profile test Glucose test Frequency Three times over 6 weeks following initiation of treatment; every 3 months thereafter At initiation; every 6 months thereafter At initiation; every 6 months thereafter At initiation and over the first 6 months At initiation and over the first 6 months At initiation and at 3 months; annually thereafter At initiation and at 3 months; annually thereafter Annually

Valproate semisodium Olanzapine Common to all medications

use of a mood diary. This can help identify early warning signs, such as high energy levels, sleeplessness, or recurring depression. Nurses should encourage young people to use their mood diary to record changes in severity and frequency of symptoms, and the impact of treatment interventions. Where appropriate, the diary can also be a useful way of empowering young people to take control of their medication. This is by tracking how many tablets they have taken and reporting any side effects that they might be experiencing.

Physical Health
Assessing physical health needs is also important. Mental health service users including those with bipolar disorder have higher levels of physical morbidity and mortality than the general population (McDougall & Brimblecombe, 2006; Osby, Brandt, Correia, Ekbom, & Sparn, 2001). Nurses routinely provide physical health monitoring and are well placed to perform regular health checks for children and adolescents with bipolar disorder. This is to assess thyroid function, lipid levels, plasma glucose levels, weight and height, smoking and alcohol status, and blood pressure. Nurses should ensure that children and adolescents who are taking long-term medication for bipolar disorder should receive a range of blood tests in order to help safely monitor treatment (see Table 2).

Treatment
Drugs including antipsychotic and mood stabilizers are the mainstay of treatment for bipolar disorder in children and adolescents (Hamrin & Pachler, 2006; National Institute for Health and Clinical Excellence, 2006). Issues of comorbidity not only make the diagnosis of children and adolescents a challenge, but subsequent psychopharmacological treatment may also become problematic.
JCAPN Volume 22, Number 1, February, 2009

Whether an antipsychotic or mood stabilizer is used depends on a range of factors, including preferences for future prophylactic use, side-effect profile, relative balance and severity of manic or depressive symptoms, and previous response to treatment. Sodium valproate should not be prescribed routinely for girls and young women of childbearing age, including those who are planning pregnancy, are pregnant, or breastfeeding. This is due to the risk of polycystic ovary syndrome and because valproate is teratogenic and can damage the fetus during pregnancy (Ragson, 2004; Ragson et al., 2005). If no adequate alternative to valproate can be identified, young people should be encouraged to use adequate contraception, and the risks of taking valproate during pregnancy should be fully explained. For adolescent girls who become pregnant, the absolute and relative risks of the problems associated with both treating and not treating the bipolar disorder during pregnancy should be discussed. Lithium, olanzapine, or valproate should be considered for long-term treatment of child or adolescent bipolar disorder. The choice should depend on gender, previous response to treatment, what is known about manic versus depressive relapse, history of adherence, and physical factors, such as presence of obesity, renal disease, and diabetes. Notwithstanding issues of age and consent, the risks and benefits of treatments for bipolar disorder should be fully discussed with the young person themselves, as well as their parents or carers. Many of the drugs that are used to treat bipolar disorder can result in weight gain (Hamrin & Pachler, 2006). For children and adolescents, this presents additional health risks and personal issues about body image. Nurses should ensure that children and adolescents who are taking medication have their weight carefully monitored, and access to health-promotion information and healthy lifestyle choices should be encouraged.
37

Nursing Children and Adolescents With Bipolar Disorder: Assessment, Diagnosis, Treatment, and Management

Psychological Interventions
As well as monitoring medication, nurses provide structured psychological interventions for young people with bipolar disorder. This is primarily cognitive behavioral therapy for moderate depressive episodes, or psychological interventions in conjunction with an antidepressant for severe or persistent depressive symptoms (National Institute for Health and Clinical Excellence, 2005). Cognitive behavioral interventions should focus on depressive symptoms, problem solving, and social functioning. Psychoeducation should also include advice and guidance about lifestyle choices and the need to take medication as prescribed. To cope with mild depressive symptoms, nurses should encourage children and adolescents to exercise, to participate in pleasurable and goaldirected activities, and to ensure adequate diet and sleep. Many people with bipolar disorder experience early warning signs for several days or weeks before becoming seriously unwell (Taylor et al., 2006). One of the most important interventions that nurses undertake is in relation to relapse prevention. This involves helping young people and their parents or carers to recognize early warning signs, and monitoring medication. This includes ensuring that children and adolescents understand their medication, the reasons for taking it, any potential side effects, and the possible implications of stopping their medication. Early warning signs of relapse should be clearly identified in the child or adolescents care plan.

Consent to Treatment
Within the normal bounds of confidentiality, nurses should establish and maintain collaborative relationships with children and adolescents, as well as their parents or carers. Not withstanding issues of capacity and consent, nurses should be respectful of the child or young persons knowledge, understanding, and experience of his or her illness. They should provide verbal and written information at every stage of assessment and treatment and this should include the proper use and likely side-effect profile of medication. Parents and carers should also be involved in the assessment and treatment process. This is to provide informed consent where appropriate, and in order to support the psychological goals of treatment and help ensure treatment adherence.

Conclusion
This paper has summarized the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder. Mental health nurses have more contact with service users than any other professional group. They are well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services and in accessing early intervention and crisis services. Author contact: tim.mcdougall@cwp.nhs.uk, with a copy to the Editor: poster@uta.edu References
Achenbach, T., & Edelbrock, C. (1991). Manual for the child behavior checklist and revised child behavior profile. Texas: University Associates in Psychiatry. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author. Biederman, J., Farone, S., Mick, E., Wozniak, J., Chen, L., Ouellette, C., et al. (1996). Attention deficit hyperactivity disorder and juvenile mania: An overlooked comorbidity? Journal of Child and Adolescent Psychiatry, 35(8), 9971008. Depue, R., Krauss, S., & Spoont, M. (1989). General behaviour inventory identification of unipolar and bipolar affective conditions in a non clinical university population. Journal of Abnormal Psychology, 98(2), 117126. Emslie, G., Kennar, B., & Kowatch, R. (1994). Affective disorders in children: Diagnosis and management. Journal of Child Neurology, 10, S42S49. Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 11681176. Geller, B., Craney, J., Bolhofner, K., DelBello, M. P., Williams, M., & Zimerman, B. (2001). One-year recovery and relapse rates of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 158, 303305. Geller, B., Craney, J., Bolhofner, K., Nichelsburg, M. J., Williams, M., & Zimerman, B. (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 159(6), 927933. JCAPN Volume 22, Number 1, February, 2009

Management
Nurses also support children and adolescents during the management of behavioral disturbance associated with manic episodes. To help reduce the negative consequences of manic symptoms, nurses should advise children and adolescents to avoid excessive stimulation, to delay important decisions, and to establish a structured routine in which levels of activity are reduced. During acutely disturbed manic phases, nurses should review the risk the child or adolescent presents to themselves or others, and should assess physical status including hydration levels. Nurses should consider using distraction techniques, and attempt to divert the young persons energy into low stimulus activities to reduce behavioral disturbance. Children and adolescents who exhibit seriously disturbed behavior should be cared for in the least stimulating and confrontational, and most supportive environment. Children and adolescents with bipolar disorder should only be admitted to hospital if the risks associated with community treatment are too high. This is to help avoid disruption to family, education, and social functioning. However, if the young person is suicidal, vulnerable to exploitation, or presenting a risk to others, an inpatient admission may be the safest alternative.
38

Geller, B., Craney, J., Bolhofner, K., Delbello, M., Axelson, D., & Luby, J. (2003). Phenomenology and longitudinal course of children with a prepubertal and early adolescent bipolar disorder phenotype. In B. Geller & M. Delbello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 2550). New York: Guilford Press. Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 11681176. Geller, B., Williams, M., & Zimerman, B. (1996). Washington University in St Louis Kiddie Schedule for affective disorders and schizophrenia (WASH-U-KSADS). St. Louis, MO: Washington University. Geller, B., Williams, M., Zimerman, B., Frazier, J., Beringer, L., & Warner, K. L. (1998). Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective Disorders, 51(2), 8191. Gracious, B., Youngstrom, E., & Findling, R., & Calabrese, J. R. (2002). Discriminative validity of a parent version of the Young Mania Rating Scale. Journal of the American Academy of Child and Adolescent Psychiatry, 41(11), 13501359. Hamrin, V., & Pachler, M. (2006). Pediatric bipolar disorder: Evidence based psychopharmacological treatments. Journal of Child and Adolescent Psychiatric Nursing, 20(1), 4058. Harrington, R., Bredenkamp, D., Groothues, C., Rutter, M., Fudge, H., & Pickles, A. (1994). Adult outcomes of childhood and adolescent depression. III. Links with suicidal behaviours. Journal of Child Psychology and Psychiatry, 35(7), 13091319. Hirschfield, R. (2005). Are depression and bipolar disorder the same illness? American Journal of Psychiatry, 162(7), 12411242. Johnson, J., Cohen, P., & Brooks, J. (2000). Associations between bipolar disorder and other psychiatric disorders during adolescence and early adulthood: A community-based longitudinal investigation. American Journal of Psychiatry, 157(10), 16791681. Judd, L., Akiskal, H., Schettler, P., Endicott, J., Maser, J., Solomon, D. A., et al. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59(6), 530537. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for Affective Disorders and Schizophrenia for School-age ChildrenPresent and Lifetime version (K-SADSPL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980988. Lewinsohn, P., Klein, D., & Seeley, J. (1995). Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenology, comorbidity, and course. Journal of American Academy of Child and Adolescent Psychiatry, 34(4), 454463.

Lewinsohn, P., Seeley, J., & Klein, D. (2003). Bipolar disorders during adolescence. Acta Psychiatrica Scandinavica, (418), 4750. Mackin, P., & Young, A. (2005). Bipolar disorders. In P. Wright, M. Stern & M. Phelan (Eds.), Core psychiatry (pp. 6480). Edinburgh, UK: Elsevier Saunders . McDougall, T., & Brimblecombe, N. (2006). Turning values into action. Mental Health Practice, 9(8), 1012. McElroy, S., Altshuler, L., Suppes, T., Keck, P. E. Jr., Frye, M. A., Denicoff, K. D., et al. (2001). Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. American Journal of Psychiatry, 158(3), 420 426. National Collaborating Centre for Mental Health. (2006). Bipolar disorder: The management of bipolar disorder in adults, children and adolescents in primary and secondary care. Appendix 19: consensus conference on the diagnosis of bipolar I disorder in children and adolescents. London: BPS. National Institute for Health and Clinical Excellence. (2005). Depression in children and young people: Identification and management in primary, community and secondary care. London: Author. Osby, U., Brandt, L., Correia, N., Ekbom, A., & Sparn, P. (2001). Excess mortality in bipolar and unipolar disorder in Sweden. Archives of General Psychiatry, 58(9), 844850. Post, R., Denicoff, K., Leverich, G. S., Altshuler, L. L., Frye, M. A., Suppes, T. M., et al. (2003). Morbidity in 258 bipolar outpatients followed for 1 year with daily prospective ratings on the NIMH life chart method. Journal of Clinical Psychiatry, 64(6), 680690. Ragson, N. (2004). The relationship between polycystic ovary syndrome and antiepileptic drugs: A review of the evidence. Journal of Clinical Psychopharmacology, 24(3), 322334. Ragson, N., Altshuler, L., Fairbanks, L., Elman, S., Bitman, J., Labarca, R., et al. (2005). Reproductive function and risk for PCOS in women treated for bipolar disorder. Bipolar Disorders, 7(3), 246259. Reddy, Y., & Srinath, S. (2000). Juvenile bipolar disorder. Acta Psychiatrica Scandinavica, 102(3), 162170. Rihmer, Z., & Kiss, K. (2002). Bipolar disorders and suicidal behaviour. Bipolar Disorders, 4(Suppl. 1), 2125. Taylor, C., McDougall, T., & Wellman, N. (2006). Bipolar disorder: The nurses role. Mental Health Practice, 10(2), 1012. Weissman, M., Bland, R. & Canino, G. (1996). Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association, 276, 393399. World Health Organization. (1993). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author.

JCAPN Volume 22, Number 1, February, 2009

39