The differential diagnosis of a manic episode may include a broad range of psychiatric conditions depending upon the age of the child. For example, sexual abuse is especially important in the differential diagnosis during the childhood years, because manic hypersexuality is often manifested in children by self-stimulatory behaviours including frequent masturbation. Thus, obtaining a careful history of whether the child could have been abused or exposed to adult sexual behaviours is important. Specific language disorders need to be differentiated from flight of ideas. Because of greater perceptual distortions in bipolar illness during adolescence, schizophrenia is a major differential diagnosis . Differentiation is greatly aided by a family history of mania, which is more probable for bipolar disorder than schizophrenia .
Substance abuse begins to be an important comorbid condition during the teenage years and is to be considered in differential diagnosis [53,54]. For example, laughing fits may be due to smoking marijuana rather than being a manifestation of elation. Furthermore, very rapid cycling, which is according to some researchers a hallmark of child and adolescent bipolarity , can easily be mimicked by amphetamine highs followed by withdrawal ''crashes''. Hallucinogens can mimic the perceptual distortions of bipolar disorder [53,54].
Bipolar youths exhibit significantly higher rates of comorbid psychiatric conditions, including disruptive behaviour disorders (especially ADHD, conduct disorder and oppositional defiant disorder), anxiety disorders (especially separation anxiety and panic disorder) and eating disorders. The relationship between ADHD and mania is of interest. A very high comor-bidity between paediatric bipolar disorder and ADHD has been reported. As many as 60-90% of the paediatric bipolar disorder cases have been diagnosed with concurrent ADHD [55,56,48]. Careful assessment is needed to clarify whether children have ADHD, bipolar disorder or both. There is an overlap of symptoms between mania and ADHD. These symptoms include increased motor activity, distractibility, rapid or pressured speech, impaired attention, racing thoughts and irritability.
Geller et al.  have suggested that ADHD is an age-dependent manifestation of bipolar disorder, as normal pre-pubertal children are more hyperactive than their post-pubertal counterparts. Thus, they assert that hyperactivity can be seen as the child analogue to the intense energy surges seen in the manic episodes of adults.
One prospective study  followed males who met, at the baseline assessment, criteria for mania+ADHD (n = 15), ADHD without mania (n = 65) or no psychiatric diagnosis (n = 17). These subjects were re-evaluated 6 years later. There were no group differences in the prevalence of Axis I or Axis II disorders, with the exception of alcohol abuse, which was higher in controls. Manic symptoms persisted in only one mania+ ADHD subject, while three (5%) of the ADHD subjects had new onset of manic symptoms. There were no clear cases of bipolar disorder. Levels of service utilization or criminal behaviour did not differentiate the groups. However, global functioning was significantly lower at follow-up in the mania+ADHD group compared with controls. Although a pilot study in scope, the findings cast doubt on a link between manic symptoms associated with ADHD in childhood and follow-up bipolar disorder.
High levels of comorbidity with disruptive behaviour disorders have been observed in paediatric bipolar disorder. The overlap between paedia-tric bipolar disorder and conduct disorder is not surprising, considering that severe irritability with ''affective storms'' or aggressive temper outbursts is a common presentation . This relationship was systematically examined by Biederman et al.  in 186 children and adolescents who met DSM-III-R diagnostic criteria for conduct disorder and mania on structured diagnostic interview. The investigators found that 116 subjects met criteria for conduct disorder, 110 for mania and 76 for both. The comorbid group represented 40% of subjects with an initial diagnosis of conduct disorder and 41% of subjects with an initial diagnosis of mania.
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