A thorough and extensive evaluation is necessary before diagnosing bipolar disorder in a child or adolescent. Such an evaluation requires a detailed history of both mood and non-mood symptoms and an appraisal of risk factors for bipolar disorder. A comprehensive face-to-face assessment of the child, including a mental status examination, is necessary to rule out pervasive developmental disorders, language and thought disorders, and psychotic symptoms. This assessment may take several hours to complete and could be done by a multidisciplinary team in one day or over several days. A detailed lifeline or timeline including onset, offset and duration of symptoms, stressful life events and history of treatment is helpful in establishing diagnosis. The diagnostic accuracy for bipolar illness in children and adolescents improves when DSM criteria are applied .
Several structured and semi-structured interviews may also be used to help assess mania in children. Structured interviews include the Diagnostic Interview for Children and Adolescents, Revised (DICA-R) , the Diagnostic Interview Schedule for Children (DISC)  and the Children's Interview for Psychiatric Syndromes (ChIPS) . Semi-structured interviews include the Schedule for Affective Disorders and Schizophrenia for School Age Children (KSADS) , the Washington University Kiddie and Young Adult Schedule for Affective Disorders and Schizophrenia, Lifetime and Present Episode Version for DSM-IV (WASH-U-KSADS) [70,71] and the Interview Schedule for Children (ISC) . When using standardized assessment instruments, a comprehensive evaluation by a well-trained clinician with extensive experience in diagnosing children and adolescents with psychiatric disorders should be performed to improve diagnostic accuracy.
Clinical rating scales may be helpful in tracking the severity and course of target symptoms of mania. Such rating scales for bipolar disorder used to be underdeveloped and understudied, but at the present time several investigators are looking into the usefulness of various scales. Strober et al.  used the Beigel-Murphy Scale  in assessing severity of mania in adolescents and reported the instrument to be helpful. Fristad et al.  modified the Mania Rating Scale  for use in pre-pubertal manic children. A preliminary study found that it was helpful in differentiating manic children from hyperactive children . The Child Behavior Checklist (CBCL) has been reported to distinguish children with mania from those with ADHD [70,77]. Such rating scales can be used to supplement clinical evaluation.
The diagnostic work-up should be done in a systematic manner. First and foremost, mania secondary to drug use or general medical conditions should be ruled out. Currently, there are no specific laboratory or biological tests that can diagnose bipolar disorder in children and adolescents. Hence, diagnosis is established by considering all data from history, family history and mental status examination. Once the diagnosis has been established, a baseline laboratory assessment that includes a complete blood count with differential, thyroid function tests (including T3, free T4 and TSH), electrolytes, blood urea nitrogen, creatinine, creatinine clearance, liver function tests and electrocardiogram should be performed. These tests are necessary because there are medical conditions that can present with manic symptoms and often children with bipolar disorder require treatment with psychotropic medications.
Medical conditions which may present with manic symptoms include infectious diseases (encephalitis, influenza, syphilis, AIDS), endocrine disorders (hyperthyroidism), tumours, and neurological conditions (temporal lobe epilepsy, multiple sclerosis, Wilson's disease, closed or open head injury). Manic symptoms may be induced by medications (steroids, isoniazid, sympathomimetics) and alcohol or drug abuse.
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