020 - Pediatric Bipolar Disorder

This episode highlights the significant controversy surrounding the diagnosis of bipolar disorder in children, pointing out issues of both over and underdiagnosis and the challenges in differentiating it from conditions like ADHD and Disruptive Mood Dysregulation Disorder (DMDD). Key takeaways include understanding the diagnostic criteria, including the critical role of thorough assessment beyond just symptom checklists, and the importance of evidence-based treatment involving both medications (like lithium and mood stabilizers) and psychosocial therapies.

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com

Feedback can be emailed to feedback@psydactic.com OR submitted via a form at https://psydactic.com.

This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

PsyDactic - Pediatric Bipolar Disorder


Resources

Pediatric Bipolar Disorder - Challenges and Updates

Controversies Surrounding the Pediatric Bipolar Diagnosis & Treatment (Bioethics Briefs)

My Child Has Mood Swings: How Do I Know if It’s Bipolar Disorder, and What Do I Do?

How Can We Reliably Diagnosis Children With Bipolar Disorder At Such A Young Age?

2017 Keynote: Myth-busting Pediatric Bipolar Disorder - Eric Youngstrom, Ph.D.

https://youtube.com/playlist?list=PLYNJbyJdEK4xFfVDhwO-VmVQTzW6YWMZm&si=MNajjOaRoPM33puo

Barton, Jessica, Megan Mio, Vanessa Timmins, Rachel H. B. Mitchell, and Benjamin I. Goldstein. 2023. “Prevalence and Correlates of Childhood-Onset Bipolar Disorder among Adolescents.” Early Intervention in Psychiatry 17 (4): 385–93.

Blok, Elisabet, and Tonya White. 2020. “Editorial: White Matter Matters: Neurobiological Differences between Pediatric Bipolar Disorder and Disruptive Mood Dysregulation Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 59 (10): 1128–29.

Chauhan, Vinay S., Markanday Sharma, Kaushik Chatterjee, Jyoti Prakash, Kalpana Srivastava, and Suprakash Chaudhury. 2023. “Childhood Trauma and Bipolar Affective Disorder: Is There a Linkage?” Industrial Psychiatry Journal 32 (Suppl 1): S9–14.

Findling, Robert L., Xiaofeng Zhou, Prethibha George, and Phillip B. Chappell. 2022. “Diagnostic Trends and Prescription Patterns in Disruptive Mood Dysregulation Disorder and Bipolar Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 61 (3): 434–45.

Havens, Jennifer F., Mollie C. Marr, and Emily Hirsch. 2022. “Editorial: From Bipolar Disorder to Disruptive Mood Dysregulation Disorder: Challenges to Diagnostic and Treatment Specificity in Traumatized Youths.” Journal of the American Academy of Child and Adolescent Psychiatry 61 (3): 364–65.

Hendrickson, Brian, Mahlet Girma, and Leslie Miller. 2020. “Review of the Clinical Approach to the Treatment of Disruptive Mood Dysregulation Disorder.” International Review of Psychiatry (Abingdon, England) 32 (3): 202–11.

Linke, Julia O., Nancy E. Adleman, Joelle Sarlls, Andrew Ross, Samantha Perlstein, Heather R. Frank, Kenneth E. Towbin, Daniel S. Pine, Ellen Leibenluft, and Melissa A. Brotman. 2020. “White Matter Microstructure in Pediatric Bipolar Disorder and Disruptive Mood Dysregulation Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 59 (10): 1135–45.

McIntyre, Roger S., Michael Berk, Elisa Brietzke, Benjamin I. Goldstein, Carlos López-Jaramillo, Lars Vedel Kessing, Gin S. Malhi, et al. 2020. “Bipolar Disorders.” Lancet 396 (10265): 1841–56.

Post, Robert M., and Heinz Grunze. 2021. “The Challenges of Children with Bipolar Disorder.” Medicina (Kaunas, Lithuania) 57 (6): 601.

Scott, Madeline R., and Colleen A. McClung. 2023. “Bipolar Disorder.” Current Opinion in Neurobiology 83 (102801): 102801.


Welcome to PsyDactic - Child and Adolescent Psychiatry Edition.  Today is Monday, March 31, 2025.  I am your host, Dr. O'Leary, a child and adolescent psychiatry fellow in the national capital region.  This is a podcast I designed to help myself and other Child and Adolescent Psychiatry fellows study for their boards.  Anyone interested in human development and mental health will likely also get something out of it.  I am using AI to assist me with the content creation.  The tool that I used to create this episode allows me to feed it papers I found during a literature search of peer reviewed and reputable sources.  Then I create a prompt to guide the discussion.  I usually have to create 2-3 different prompts and explore the output of each, fact check it, then pick the best parts, edit out problem parts, and paste it all together.  Even though I am using AI, all the content in the podcast should be considered my opinion and no one else's.  At the very least, it is compiled by me and released to you, so I take editorial responsibility for that. If you find errors in the content or have suggestions for improvement, I would love it if you could go to PsyDactic.Com and fill out a form there to let me know.  You can also email me at feedback@psydactic.com. 

Today’s episode covers pediatric bipolar disorder.  There is some controversy surrounding this diagnosis and interestingly it regards both over and under diagnosis.  The general term for this is misdiagnosis, where many true cases are missed while many diagnoses are simultaneously being given erroneously.  Many cases of bipolar, especially bipolar 2 disorder can take years to diagnose.  In the meantime patients are getting no treatment or the wrong treatment and this treatment might be making things worse.  On the flip-side, kids with early traumatic experiences or neglect may be misdiagnosed with bipolar disorder and be put on high risk medications with escalating doses that don’t seem to work or that merely tranquilize them into oblivion.  I tried to feed my A.I. friends a wide range of perspectives, so that they could synthesize a complete and fair picture of pediatric bipolar disorder, what is commonly mistaken for pediatric bipolar disorder, what little we know about the neurobiology of bipolar disorder, and what are the evidence-based treatments.

A quick note:  When referring to bipolar disorder without designating type 1 or type 2, the speaker is generally referring to type 1.  The A.I. was not smart enough to figure out that a single capital “I” meant “1” but, oddly, it was able to figure out that two consecutive I’s meant “2.”  I’m sure you’ll have some fun noting other odd A.I. contrivances while listening.  So without further ado…

when we talk about bipolar disorder in children, what are the core diagnostic features we should be looking for?
So if we look at the DSM5, the main thing for bipolar disorder is experiencing at least one full manic episode.
A manic episode. Okay.
Yeah, that's the hallmark. Now, this might be followed by periods of hypomomania, sort of a less intense high or depression. But interestingly, you don't strictly need a depressive episode or even psychosis for a bipolar diagnosis.
And here we mean bipolar type one.
Oh, okay. That's interesting.
Then you have bipolar 2 disorder that involves a different pattern. You need at least one episode of hypomomania and at least one major depressive episode. But crucially, no full-blown manic episodes.
Got it. Hypomomania plus depression, no full mania.
Exactly. And then there's also psychotheric disorder. Think of this as a more persistent kind of lower grade mood instability. It's like ongoing ups and downs symptoms of hypomomania and depression, but they don't quite meet the full criteria for those major episodes.
And how long does that have to go on for?
In kids and adolescences, that pattern needs to last for at least a year.
So, it definitely sounds like more than just, you know, typical childhood moodiness. We're talking about specific periods of really significant shifts.
That's the key.
And I remember reading somewhere that just ticking off symptoms from a list isn't really enough, especially when you're dealing with kids.
Oh, that's a really critical point. You're absolutely right. Diagnos ing bipolar disorder, especially in younger people, needs a very thorough assessment. Identifying a clear manic or hypom manic episode is just fundamental.
But what does that assessment look like?
Well, you have to look really closely at the quality of these mood states. Is it genuinely elevated or expansive? Or is it more reactive? How long do these periods last? What are the specific changes in energy, sleep, thinking, activity that go along with the mood shift?
Right?
Even something like irritability needs careful evaluation. Is it that explosive out of proportion anger or more of a constant simmering agitation? Is it episodic coming in distinct periods or is it just always there chronic? All these details are vital for distinguishing bipolar from other things.
That makes a lot of sense. So, okay, we have these definitions. Where does the controversy really kick in? Why is there this big debate about overdiagnosis versus underdiagnosis in children?
Right? This is where things get well quite debated. If you look at diagnostic trends, there was a noticeable rise in diagnoses of disruptive mood dysregulation disorder, DMD, in young people between about 2016 and 2018.
Okay. DMD went up.
Exactly. And what's really interesting is that during that same period, the number of pediatric bipolar disorder diagnoses actually decreased.
Oh, okay. So, one goes up, the other goes down.
Precisely. And this has led to some concern, you know, that DMD, which was a relatively new diagnosis added in DSM5 back in 2013, might now be getting applied to some kids who maybe before D and DDD existed would have received a bipolar diagnosis based on similar issues like severe irritability and mood swings.
So it's like the diagnostic goalpost shifted a bit and some kids landed in a different category.
That's one way to think about it. Yeah.
But it's not just about potential overdiagnosis shuffling kids around. Underdagnosis of bipolar disorder is also a really significant concern.
Oh, so
well our sources consistently point out that many people who eventually get a bipolar diagnosis face a huge delay in getting there. Somes Sometimes it takes a decade, maybe even longer.
A decade. Wow.
Yeah. And along the way, they often get multiple wrong diagnoses. Unipolar depression is a really common misdiagnosis initially.
And that delay must have consequences.
Huge consequences. It means potentially years without the right kind of treatment, often during really critical developmental periods.
That's a really long time to be sort of on the wrong track. But despite all these shifts and the controversies, is there any common ground among researchers when bipolar disorder is diagnosed in childhood, does it tend to stick?
That's a good question. And what's quite noteworthy is yes. Despite all the debate about criteria and trends, there seems to be pretty good agreement across different research sites that when bipolar disorder is diagnosed in childhood, it often persists.
Okay.
For instance, there was one study that directly compared kids who developed bipolar early in childhood versus those who developed it later in adolescence.
And what did they find?
They found that the childhood onset type was actually just as common among adolescence who had bipolar disorder. And importantly, it was linked to what they called a higher familial loading of psychopathology,
meaning more mental health issues in the family.
Exactly. More relatives with mental health conditions. So, it suggests that when bipolar disorder does show up early, it's often a pretty significant enduring condition, frequently with the strong family link.
Okay, so we've got the definitions, the debate around diagnosis rates, and the challenge of actually identifying it accurately. This brings us naturally to the overlap with other conditions. Let's start with ADHD. How do clinicians tell the difference? Can a child have both?
This is a super common clinical challenge because yes, ADHD and bipolar disorder absolutely can occur together. It's definitely not just a case of dismissing it as moody ADHD,
right?
Research actually shows that kids who have both ADHD and bipolar disorder tend to have much higher rates of other serious problems like psychosis or conduct disorder compared to kids who only have ADHD. So the combination is often more severe.
It often presents with more complexity. Yes.
A key concept here that pops up in both ADHD and also DMD is dysregulation.
Disregulation.
In ADHD that often looks like trouble with attention, hyperactivity, impulsivity. But in bipolar disorder, the dysregulation really extends profoundly to mood. These distinct, often intense, sometimes quite long shifts in emotional state.
So it's not just about energy levels or focus. It's these clear mood episodes. that are way beyond typical kid stuff.
That's the core difference we look for. And when it comes to treatment for a child who might have both conditions, the general clinical wisdom is to prioritize stabilizing the mood first
before treating the ADHD symptoms.
Yes. Before considering stimulants for any leftover ADHD symptoms. Interestingly, studies suggest that if you get the mood stable first and then you carefully add stimulants at appropriate doses, it usually doesn't make the bipolar symptoms worse.
But the The reverse isn't true.
Well, the concern is that if you go in first with highdose stimulants or even certain anti-depressants before the mood is stable, you might get a poor response or it could potentially worsen the mood symptoms.
That's a really crucial point for treatment planning. Okay, now let's shift to DMD. This newer diagnosis we mentioned, it was created partly to address some of these issues, right? How does DMDD fit in, especially with all the talk about chronic irritability,
right? DMD, disruptive mood dysregulation disorder. It was put into the DSM5 to try and better capture kids who have these really severe frequent temper outbursts, but also importantly a persistently irritable or angry mood in between the outbursts.
Okay, so outbursts plus chronic irritability.
Exactly. The criteria specify the outbursts have to be way out of proportion, happen frequently, like three or more times a week, and this generally irritable mood has to be noticeable by others, last at least a year, and show up in different settings like home and school.
And where does it fit in the diagnostic manual.
It's actually placed in the depressive disorders chapter of DSM5. And crucially, it's what we call a diagnosis of exclusion.
Meaning,
meaning if a child actually meets the full criteria for a manic or hypom manic episode, key features of bipolar disorder, then you wouldn't diagnose DMD. Bipolar disorder essentially trumps DMD if its criteria are met.
Okay. So, the idea was to separate out these chronically irritable kids from those with more episodic mood swings of bipolar. But it sounds like in practice That distinction is still causing some debate.
You've absolutely hit the nail on the head. That's a central point of ongoing discussion. Generally, chronic irritability by itself is thought less likely to signal bipolar disorder. But
but the picture gets fuzzier when you have episodes of really explosive irritability happening alongside other symptoms that might hint at mania or hypomomania like decreased need for sleep, racing thoughts, risky behavior. If those other symptoms add up to meet the criteria for a full manic episode then bipolar might still be the right diagnosis even with the explosive irritability.
So irritability can be part of both but the pattern matters.
Exactly. The pattern and the accompanying symptoms. So while both involve irritability, the key difference is supposed to be those distinct episodes of mania or hypomomania in bipolar which aren't part of DMD. In DMDD the irritability is more of a constant baseline. Although fascinatingly even using advanced techniques like brain imaging and machineing learning algorithms. Researchers have found it difficult sometimes to reliably tell BD and DMBD apart based just on the brain's white matter structure.
So even the biology shows some overlap.
It suggests there might be some shared neurobiological features. Yes. Even if the clinical picture looks different.
That is fascinating. Okay. What about other behavioral issues? Things like oppositional defiant disorder, ODD, or the more severe conduct disorder. How do they fit in?
Well, our sources point out that it's quite common for kids diagnosed with DMD to also have other disruptive behavior disorders like OD.
Okay. High co-occurrence there.
Yes. And conduct disorder, which involves more serious behaviors that violate rules or others rights, is also known to co-occur with bipolar disorder.
But again, the mood component is key for bipolar.
Exactly. While irritability might be part of OD, it's those distinct episodes of mania or hypomomania that really point towards a bipolar diagnosis rather than just OD or conduct disorder alone. Okay. And what about autism spectrum disorder ASD? Any important overlaps there to consider?
Yeah, briefly on ASD, there can definitely be some overlap in symptoms which makes it important for clinicians to consider in the differential diagnosis process.
Like what kind of overlap?
Well, for instance, significant irritability can be a major challenge for some individuals with ASD just like it can be in mood disorders. It's actually noteworthy that two antiscychotic medications, Arapiprazole and Respperadone are FDA approved specifically for treating irritability associated with autism even in kids as young as six.
So irritability isn't exclusive to mood disorders.
Not at all. It highlights that this symptom while common in mood disorders can definitely be prominent in other neurodedevelopmental conditions too.
That's a really helpful point.
Yeah.
Now shifting gears slightly, but something you mentioned earlier, the role of trauma and difficult experiences. This seems incredibly important. How can adverse childhood experiences or trauma exposure complicate diagnosing mood disorders in kids.
Oh, this is absolutely critical. And unfortunately, trauma exposure is far too common among young people, especially those who end up in psychiatric care or involved with child welfare or juvenile justice systems.
And how does trauma manifest?
Well, traumatic experiences can lead to major difficulties with emotional regulation, behavioral control, things like increased irritability, being much more sensitive to stress, and actual changes in how the brain processes emotions and information. which could look like a mood disorder.
Exactly. These trauma responses can sometimes mimic symptoms of mood disorders or they can certainly complicate the picture if a mood disorder is also present.
Is there a direct link shown between trauma and developing bipolar disorder?
Yes, the sources strongly emphasize this link. Various forms of childhood trauma, physical, emotional, sexual abuse, neglect are associated with an elevated risk of developing bipolar disorder later on.
Wow.
And not only that, but trauma exposure has also been linked to an earlier age of onset for bipolar disorder and often more severe symptoms when it does develop.
So screening for trauma seems essential then
absolutely essential. Clinicians really need to systematically ask about trauma history when evaluating kids with significant mood and behavior issues. Why? Because symptoms that look like they fit a mood disorder might actually be at least in part a direct result of trauma. It's estimated that adverse childhood experiences contribute significantly to the onset of many mental illnesses.
And if you miss that history,
you risk making an inaccurate diagnosis and recommending treatments that might not be the most effective or might even miss the core issue.
What about genetics or other biological factors?
Genetics definitely plays a role in bipolar disorder. It's considered highly heritable, but also complex, likely involving many genes interacting rather than a single gene. And there's shared genetic risk with other conditions, too, like schizophrenia and major depression. Researchers are also looking into other biological processes, things like potential disturbances in how neurons communicate with supporting cells called GA, imbalances in neurotransmitters, the role of inflammation in the body and brain, and even how mitochondria, the cells powerhouses, function. There's even research using stem cells suggesting mitochondrial issues, might be involved.
A lot of different potential pathways.
Absolutely. And another huge area is sleep and circadian rhythms, the body's internal clock. Disruptions here are really common in bipolar disorder, ranging from the obvious sleep problems people experience right down to abnormalities at the molecular level within cells.
So we understand pediatric bipolar disorder better, how it differs from DMD and ADHD, the role of trauma. Now the big question, what actually works?
What are the evidence-based treatments?
Right? Treatment usually needs a two-pronged approach. Medications or pharmacotherapy and therapy psychosocial interventions.
Let's start with meds. Mood stabilizers.
Mood stabilizers are were really the foundation and lithium often gets called the gold standard.
Gold standard because
it works. It's proven effective for treating mania, for treating depression in bipolar disorder. And this is really significant. It has anti-suicide effects.
That is huge.
Yeah. It seems particularly effective for bipolar. And research has even found some predictors of who might respond best to lithium.
Like what?
Things like having really clear-cut episodes, not having rapid cycling or psychosis mixed in, having family members who responded well to lithium, maybe a shorter time being ill before before starting it later onset, lower BMI, things like that.
Interesting. So, lithium despite being around a while is still a major player. Are there other mood stabilizers?
Oh, yes, others are definitely used. Dvalproax, also known as depicote and carbomasopene or tegretl are effective for treating acute mania.
Okay. For the upfit,
right? Then there's lamatrogene or lameal. That one seems to be more effective for treating and preventing the depressive episodes. Ah, so different tools for different jobs potentially.
Exactly. The choice depends on the main symptoms you're trying to target and whether it's an acute episode or long-term maintenance.
Makes sense. What about antiscychotics? You hear about those being used too.
Yes. Antiscychotics are often very helpful for acute mania. They can quickly calm down agitation, psychosis, racing thoughts.
Okay.
Fewer of them though have strong evidence for treating the depressive side of bipolar disorder.
But some do.
Yes. A few approved for bipolar depression. therapine, laoretone, latuda, cerakquil, and the olanzipene fluoxitine combination symbi. But it's crucial to know they come with potential side effects. Weight gain, metabolic issues like blood sugar or cholesterol changes, sedation or common concerns with some of them. And the side effect profile varies a lot between the different drugs.
All right, always a trade-off.
And availability might be an issue, too. Carapriine is newer. Laorasadone might be particularly good for sleep problems and irritability and pediatric bipolar depression.
Good to know. What about standard anti-depressants like SSRIs?
Yeah,
so common for depression generally. How do they fit in here?
That's where you need to be really cautious. Both McIntyre and the Mass General webinar warned against using anti-depressants alone for bipolar disorder.
Why?
There's just not much evidence they work well long term, and there's a real risk they could actually make things worse, destabilize mood, maybe even trigger mania or hypomomania, especially if someone isn't also on a mood stabilizer. So definitely not a firstline or solo treatment for bipolar.
Generally, no.
Are there other medication related options for really tough cases?
Yes. For severe mania or depression that hasn't responded to other treatments, electrocombulsive therapy, ECT, is still a viable option. McIntyre mentions this.
ECT still gets used.
Yes, it can be very effective in severe cases. There's also growing research on ketamine, which seems to work quickly for treatment resistant bipolar depression in adults. adults and they're looking into it for adolescence too.
Interesting. Okay, so that covers the medication side. Yeah.
What about the other essential piece, psychosocial therapies? How important are they?
Absolutely vital. Can't stress that enough. Using structured manualbased therapies alongside medication, especially for maintenance,
like CVT.
Exactly. Cognitive behavioral therapy is a common one. These therapies help kids and families understand the illness better, stick with medication, learn coping skills for mood swings, recognize warning signs, basically reduce the chance of relapse and improve overall quality of life.
Makes total sense.
And psycho education is huge, too. Just teaching the young person and their family about the disorder, about treatments, tackling stigma, building support systems, peer support can also be really powerful. Connecting with others who get it.
Yeah, that shared experience matters.
Definitely. The ADA webinar talked a lot about family focused therapy, teaching the whole family about managing emotions, identifying feelings, tracking moods, building social skills, solving problems together.
It's really practical.
Yeah. They even mentioned a technique called the family bug box.
Bug box.
Yeah. Like a designated way for the family to bring up and work through things that might trigger mood episodes. A constructive way to handle those potential triggers.
I like that. Very concrete. Are there any sort of guiding principles for managing pediatric bipolar overall?
Yeah, several key ones came up. First, measurement based care. Actually tracking symptoms regular ly with rating scales to see if treatment is working.
Makes sense. Track progress,
right? Prioritizing evidence-based treatments using what we know works. Always thinking about safety and side effects. Using established guidelines, looking at the whole person, mental and physical health, and really critical, involving the patient and their family in every decision, shared decision-m
collaboration is key.
Absolutely. And early intervention is important, too. Trying to catch it early and prevent episodes seems to help minimize longer term issues like cognitive problems or the illness becoming harder to treat. And finally, addressing any other medical or psychiatric conditions they might have.
That holistic view again, it sounds like a lot to manage. Are there still big challenges or areas where we need more research?
Oh, definitely. Bipolar disorder looks different in different kids. Heterogeneity makes a one-sizefits-all treatment tough. We need more personalized strategies.
Also, the long-term effects both of the illness itself, if untreated, and maybe even of early treatment, we still need more more data on that and achieving full recovery like complete remission of symptoms is unfortunately still really difficult for many even with good treatment.
It's tough to hear.
Yeah. And just getting these evidence-based treatments out there accessible to everyone who needs them. That's an ongoing challenge too. Plus, we just need more highquality clinical trials specifically in kids and adolescence with bipolar disorder.
So, still work to do on multiple fronts. What about new directions? Yeah. Technology, novel treatments.
Well, there's interest in computer and mobile apps maybe for screening, tracking symptoms between visits, delivering psycho education
could be helpful.
Yeah, the potential is there, but we don't have solid proof yet that these apps actually prevent relapses. More research needed. And then there's the really cutting edge stuff, research into new treatments targeting those biological pathways we talked about earlier,
like the neuroplasticity, inflammation, mitochondria.
Exactly. Trying to develop therapies that target those underlying mechanisms. That's where a lot of hope for future breakthroughs lies.
Okay, so let's try to wrap this up. We've covered a lot of ground. What are the absolute key takeaways for our listeners?
I think number one, pediatric bipolar disorder is complex. Yes, but it is treatable. It has specific features, especially mania or hypomomania that distinguish it from things like DMD or ADHD. Though overlap can happen
and treatment isn't just one thing,
right? It's usually a combination. Medication, primarily mood stabilizers, sometimes specific antiscychotics working together with evidence-based therapy like family focused therapy or CBT and it has to be tailored to the individual child and family
and underlining all of that is the need for a really good thorough evaluation by professionals who know what they're looking for.
Couldn't agree more that accurate diagnosis is the foundation for everything else.
So, a final thought for people listening,
I'd say just recognizing that these distinctions matter. Telling apart a mood disorder like bipolar from other behavioral issues is the crucial first step. It's what ensures a young person gets the support that's actually right for them.