Pediatric Bipolar Part 1: Introduction, Prevalence Rates, and Research Links

One of the more complex differential diagnostic questions in working with children concerns those kids who are exceptionally emotionally and behaviorally dysregulated. You know these kids. The ones who are diagnosed with ADHD plus ODD, or ADHD plus depression, or Disruptive Mood Dysregulation Disorder. Or maybe they've even been diagnosed with the "pathological demand avoidance" subtype of autism, if that diagnosis is starting to get traction where you're located. Often, no diagnosis or combination of diagnoses professionals have considered so far seems to fit the child perfectly. On the strengths side, these children are often imaginative, dramatic, outgoing, and even charismatic. They often draw others to them. They are skilled at getting others to do what they want, in one way or another. These children can be bright, articulate, and wildly inventive. And they have energy to spare. However, these strengths are often obscured by the challenges these kids face. Diagnostically, these children are typically highly impulsive, inattentive, and hyperactive. On paper, they easily meet criteria for ADHD. However, there is also a mood and self-regulation component. These children are often irritable and emotionally fragile. They have behavior problems across settings. These children are easily overwhelmed by their emotions. Parents may say their emotions "change on a dime" or "go from 0 to 60 in 1 second flat."

These children also have a broad range of other symptoms that go beyond expectations even for children with complex ADHD or "ADHD plus" (e.g., ADHD and depression or behavior disorder). For example, these kids often have social problems despite their charm. They often have clear boundary issues, like trouble recognizing status differences between children and adults. These children may even seem to have an inflated sense of themselves, their opinions, and their own importance. They can be very demanding. They may even be aggressive, violent, or disruptive when they do not get their way. However, these children also often have anxiety, too. In my experience, this anxiety is often atypical, or unusual for their age. For example, you might see an 11 year-old with separation anxiety. Or, they may also have unusual anxieties (often related to a fear of harm, but it will typically be an anxiety you rarely encounter in other children). They may also have mild paranoia, or even unusual thought patterns. These are the kids where you might be wondering - is this pediatric bipolar disorder? We once thought pediatric bipolar disorder did not exist, and that only adults could have bipolar disorder. Then we thought, hmm... maybe pediatric bipolar disorder exists, but it's very rare. More recently, the research has become quite clearer: pediatric bipolar disorder exists, and it's not that uncommon. If you only have time to read one author's work on pediatric bipolar disorder, my recommendation would be to look at the work of Eric Youngstrom and his colleagues. Here's a good article by this group on evidence-based assessment of pediatric bipolar: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915577/ This article reviews the ever-growing body of current research showing that bipolar does present in children and adolescents. This article reviews the prevalence, which is probably around 1-2% in kids and adolescents (though prevalence rates in inpatient settings are much higher). The article also reviews evidence-based ways to assess for pediatric bipolar disorder, following their Evidence-Based Assessment model. The article also reviews a "3P" model for the assessment process - with the goals of the assessment being to Predict, to Prescribe treatment options, and to Process information with and for the child and family.

For more Youngstrom, here's another meta-analysis of prevalence data, again showing a prevalence of around 1-2% in children and adolescents: https://www.psychiatrist.com/.../2011/v72n09/v72n0914.aspx

And here's another review by Youngstrom and colleagues: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600605/

The articles linked above provide a comprehensive overview of pediatric bipolar and an evidence-based method of assessment. As such, these articles are really required reading for assessing this population, in my opinion. For anyone interested, in Part 2 of this series, I'll also briefly review what I personally include in an assessment where one of my potential differentials is pediatric bipolar disorder. In part 3, I'll address the behavioral observations I look for during an evaluation that raise my index of suspicion for this diagnosis.