Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What are the performance characteristics (e.g., sensitivity, specificity) of approaches and/or clinical features/symptoms to diagnose bipolar disorder in children? How do diagnostic methods compare in different subpopulations of children (e.g., by age, comorbidities, and other characteristics)?

What biomarkers are valid for bipolar disorder and how do they differ by population characteristics?

What are the harms of diagnosis for the child and family?

What is the effectiveness of interventions intended to treat bipolar disorder (manic and depressive phases) in children (<18 years of age)?

What characteristics of the child (severity/type of bipolar disorder, age, family history, etc.) modify treatment effectiveness?

What are the effects of treatment on common medical and mental health comorbidities (ADHD, anxiety, conduct disorder, etc.)?

What are the effects of antimanic treatment on management of depressive symptoms in children with bipolar disorder?

What are the harms of treatments for bipolar disorder in children?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Pharmacologic, psychosocial/behavioral, allied health, complementary and other approaches to treating bipolar disorder

Approaches to diagnosing the disorder including specific scales, interviewing approaches.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Children (<18 yrs of age) with bipolar disorder or at risk for diagnosis

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Children with bipolar disorder and comorbidities including ADHD, anxiety disorders, ODD; age ranges (e.g., younger children, adolescents; SES and patient history (e.g., history of trauma, family history of mood disorder)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

-Improve ability to diagnose bipolar disorder accurately in children -Improvement in patient symptoms and family functioning

-Increase understanding of presentation of bipolar disorder in children as symptoms may mimic typical childhood behavior

Describe any health-related risks, side effects, or harms that you are concerned about.

-Medication side effects, particularly potential cardiovascular effects given associations between adult bipolar disorder and metabolic disturbances -Unintended consequences/harms potentially associated with psychosocial, behavioral, or other therapies

-Family and child distress associated with delayed diagnosis or inaccurate diagnosis

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders

AHRQ Priority Populations

• Children

Federal Health Care Program

• Medicaid
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

The prevalence of bipolar disorder in children has increased dramatically since 2000, though controversy exists regarding the true prevalence and potential for overdiagnosis. Over 50% of adults with bipolar disorder report onset in childhood or adolescence; however, diagnosis is complicated as symptoms of bipolar disorder may mimic typical childhood behavior (e.g., periods of silliness or impulsive behavior) and vary based on developmental age. Firm consensus on the symptoms constituting a pediatric bipolar diagnosis is lacking as is understanding of potential biomarkers or risk factors.

Early diagnosis and appropriate treatment can minimize morbidity and mortality. While pharmacotherapy is the mainstay of treatment, RCTs in the area have tended to address the manic phase of the condition, and questions remain regarding optimal treatment for the disorder in the presence of comorbidities including ADHD, conduct disorder, depression, and anxiety. Psychotropic medications used to treat bipolar disorder have significant side effects, and potential effects in young children are not well understood. Pediatric health care providers may lack training in recognizing or differentiating bipolar disorder from other psychiatric disorders.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

clinical practice dilemma

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Need for evidence-based approaches to diagnosis and treatment, particularly differentiating bipolar disorder from other disorders and effects of treatment on comorbidities and harms of treatment ; training for pediatric care providers and educating families about the disorder.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Increased understanding of diagnostic features and biomarkers can improve the accuracy and timeliness of diagnosis. Understanding treatment effects and harms and instituting appropriate treatment can reduce morbidity and mortality in this chronic and potentially debilitating condition.

Describe the timeframe in which an answer to your question is needed.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Synthesis of the literature can help to educate pediatric providers in recognizing and differentiating symptoms related to bipolar disorder in children, potentially leading to accurate diagnosis and appropriate treatment.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Increased understanding of diagnostic features and biomarkers can improve the accuracy and timeliness of diagnosis. Understanding treatment effects and harms and instituting appropriate treatment can reduce morbidity and mortality in this chronic and potentially debilitating condition.

Are you making a suggestion as an individual or on behalf of an organization?

Please tell us how you heard about the Effective Health Care Program