BY ROB FRIEDMAN, M.D.

If you are a parent and have suspected or been told that your child may be suffering from bipolar disorder, you are likely somewhere in the process of trying to understand what that means for you, your child, and the rest of your family, now and in the future. However, it’s important to remember that not every child with a mood swing or tantrum has bipolar disorder. But pediatric bipolar disorder can be a challenging diagnosis for both children and their families.

With proper guidance and treatment, you will be providing your child with the best chance of living a happy, healthy, fulfilling, and successful life.

In fact, the entire topic of bipolar disorder in children and adolescents is a confusing one, even within the medical community. It is understandable then, that as a parent, you may be confused as well. Skepticism and disbelief are common initial reactions, sometimes with good reason. On the other hand, it is important for parents not to allow their own confusion and fears to interfere with finding the proper help for your child. With so much information readily accessible from the reliable resources referred to elsewhere in this guide, a little self-education can go a long way in helping your child and family.

In this chapter, we will examine why there is so much confusion about bipolar disorder in children and adolescents, help to clarify some of the issues surrounding this confusion, and attempt to provide some guidance for you and your family. With the correct information, you will be prepared to seek and obtain the most appropriate intervention and treatment for your child and family.  With proper guidance and treatment, you will be providing your child with the best chance of living a happy, healthy, fulfilling, and successful life.

Bipolar Disorder Is a Brain Disorder

It is very difficult for us to think of the brain in the same way that we think about any other organ in our body, like the heart, skin, pancreas, or lungs. When one of these organs malfunctions as the result of illness, there is no negative stigma attached to the physical illness. If people suffer from high blood pressure, friends and relatives do not suggest that they simply lower their blood pressure by thinking about it. If someone suffers from skin cancer, no one expects that he or she can make the cancer go away by willpower. If someone suffers from diabetes, we don’t suggest that the person just use their brain to get their pancreas to regulate the levels of sugar in their blood. Of course, we have proven medical therapies to help these physical illnesses. For high blood pressure, we can decrease our salt intake. For diabetes, we can modify our diet, exercise, and sugar intake. We all know that when our bodies need to fight cancer or an infection, we need to rest so that the body can use its resources for healing.

But when someone suffers from an illness of the brain, it can be more difficult to quantify or measure the changes in one’s thoughts, feelings and behaviors. Just like in the examples above, these alterations in someone’s thoughts, feelings, and behaviors are often beyond a person’s control.  We are raised, however, to believe that we have the power and ability to exercise control over our own thoughts, feelings, and behaviors. When we don’t do this, we are held accountable, with sometimes serious consequences.  For children and adolescents who experience behavioral symptoms of a bipolar disorder, the consequences may have far-reaching effects, impacting every area of their family’s life.

For children and adolescents who experience behavioral symptoms of a bipolar disorder, the consequences may have far-reaching effects, impacting every area of their family’s life. 

Accountability for actions is reasonable in the absence of a brain illness. When there is an illness of the brain, however, there are chemical, cellular, and structural changes caused by the illness that, up until very recently, have been difficult to observe and measure. Since these changes are difficult to observe and measure, people have traditionally had a difficult time believing such changes were real. The belief that we should be able to control our thoughts, feelings, and behaviors, coupled with the lack of quantifiable evidence that anything was physically altered in the brains of people with disordered thoughts, feelings, and behaviors, resulted in the bias and stigma that people with a brain or mental illness should somehow be able to control their abnormal thoughts, feelings, and behaviors. This stigma becomes fueled by our own fears of not being able to control our own thoughts, feelings or behaviors while failing to make the distinction between a normally functioning brain, and a brain suffering from an illness.

During the last two decades, however, with advances in technology and the development of sophisticated brain imaging techniques, the changes in the brains of people who suffer from mental illnesses are more able to be observed, measured, and studied. These techniques, as well as advances in our understanding of the role that genetics plays in mental illness, are increasingly available for examining the brains of individuals for the purposes of assessing, diagnosing and treating individual people who suffer from some form of mental, or brain illness.

After years of research, although we still probably know relatively little about the functioning of the brain, there are some things we have learned about brain illnesses such as bipolar disorder.  We know that in bipolar disorder, there are often underlying genetic determinants found in the DNA that modulate the production and release of chemicals within and between our brain cells, which have an impact upon how the brain works. Depending upon which areas of the brain are affected, changes in one’s thoughts, feelings and behaviors can be the result. While there are likely many other chemicals involved, some of these chemicals are called neurotransmitters.  Some of the commonly known neurotransmitters include serotonin, dopamine, acetylcholine and norepinephrine.

Whether caused completely by genetics, or by an interaction between something in the environment and our genetically inherited DNA, the result can be structural and chemical changes in the brain that can affect the way we think, feel, and behave. When these altered thoughts, feelings, and behaviors are recognized as abnormal, they are called “symptoms.” When a collection of symptoms has a negative impact on a person’s successful functioning, we call it an illness, a disease, or a disorder. In the past, before we had a way to link these symptoms of impaired thoughts, feelings and behavior to the physical structure of the brain, we attributed them to the “mind” and understood them to be a result of a “mental disorder.” Much of the confusion and stigma surrounding these illnesses could be resolved if we began to understand these illnesses for what they are: illnesses of the brain, or brain disorders.

Genetics and the Environment

Bipolar disorder is understood as a genetically determined disorder of the brain that results in an alteration in one’s thoughts, feelings and behaviors that are not readily controlled by an individual’s will or desire to control them. According to the American Academy of Child and Adolescent Psychiatry, identical twin studies have demonstrated that if one twin has bipolar disorder, there is a 70% chance that the other twin will develop it as well. There is a four to six  times increased risk of a child developing bipolar disorder if that child has a parent or sibling with bipolar disorder.

Despite the increased risk of developing bipolar disorder when their parent or sibling has bipolar disorder compared to the general population, most children whose parents or sibling have bipolar disorder will not develop bipolar disorder themselves. Proper nutrition, exercise, an adequate amount of sleep, avoiding overly stressful life situations, the absence of trauma, and avoiding substances that can be toxic to the brain such as abusing drugs or alcohol, may possibly prevent, help delay the onset, or minimize the impact of bipolar disorder in some genetically vulnerable people.

Despite the increased risk of developing bipolar disorder when their parent or sibling has bipolar disorder compared to the general population, most children whose parents or sibling have bipolar disorder will not develop bipolar disorder themselves.

As I noted previously, it is difficult to argue against the idea that people are responsible and accountable for their behavior. However, if we can understand that children or adolescents whose behaviors are the result of, or at least influenced by, an illness affecting their brains, through no fault of their own, this knowledge can help parents, siblings, teachers, friends, and clinicians maintain an attitude of empathy and compassion, while minimizing the tendencies toward frustration, anger and rejection that can cause even more damage to children. These negative emotions may ultimately become a part of the environmental stresses negatively impacting a child or adolescent with bipolar disorder, thereby possibly contributing to a less positive outcome for them and the family.

In order for caregivers to successfully maintain a calm and supportive attitude, much patience and self-control is required, highlighting the need for self-care and supportive resources. It is important to understand that reaching such a level of composure in the face of your child’s challenges may not always be possible to achieve and maintain, but it is helpful to recognize the importance of your role as you strive to be the best parent you can be for your child or adolescent who lives with bipolar disorder.

Diagnosing Bipolar Disorder in Children and Adolescents

As is true for medical conditions of any kind, an understanding of the condition, how to treat it, and what to expect in the future begins with a proper diagnosis. The diagnosis of bipolar disorder in children is where most of the confusion regarding bipolar disorder in children and adolescents begins. Thirty years ago, a diagnosis of bipolar disorder in children and adolescents was a rarity. According to Mitzi Walt, author of Bipolar Disorders: A Guide to Helping Children and Adolescents, beginning in the late 1990s, the number of children and adolescents diagnosed with this condition increased fortyfold . In 2010, the prevalence of bipolar disorder among teenagers in the United States was estimated at 2.9% of the population, with 2.6% of these reporting severe impairment.

There is some controversy as to whether these statistics reflect better recognition of a disorder that has always been there, an actual increase in incidence of the disorder, an over inclusiveness with regard to what we define as bipolar disorder in children and adolescents, or some combination of these three factors.

Nevertheless, it is very difficult for a parent to hear and accept that their child’s mood or behavior may be the result of a serious psychiatric condition. As parents, we want our children to be “normal,” and we struggle with accepting the news that our child’s behavior may fall outside of the range of what is considered “normal,” regardless of what the diagnosis may be. Suddenly, our hopes, dreams and wishes for our child are threatened. Even worse, as is true with most medical science and research, the more we learn, the more we realize how much we don’t know about this condition. This is why it is important that your child be assessed by a qualified, well-trained clinician whom you and your child trust.

Bipolar Disorder Types Explained

In the past (until the early to mid 1990s), bipolar disorder was called “manic depression” or “manic depressive disorder.”   These terms are synonymous, but today, we refer to the condition as “bipolar disorder.” Bipolar disorder is suspected when there are symptoms suggestive of a “manic episode” or “mania.” as well as “depressive episodes,” or “depression.” These episodes can be mild, moderate or severe. When very severe, the depressive or manic episodes may be accompanied by misperceptions of reality, or psychotic symptoms, such as delusional beliefs or hallucinations.

It may be helpful to think of bipolar disorder as a spectrum. One of the problems with recognizing and diagnosing bipolar disorder is that for some period of time, a person appears to be manic, while at other times, that same person may appear to be depressed, and at still other times,  that same person may have a normal or “euthymic” mood. This pattern is called bipolar disorder, type 1.

If the manic episode is on the mild side, it may not reach the diagnostic threshold of a manic episode. These hypomanic episodes may lead to a diagnosis of bipolar disorder, type 2.  When there are mild depressive episodes alternating with hypomanic episodes, this is sometimes diagnosed as cyclothymia. When a child has symptoms suggestive of a bipolar disorder, but the symptoms do not fit any of the above subtypes, the illness may be categorized as bipolar disorder not otherwise specified (NOS).

Regardless of the type, sometimes these mood shifts can last for weeks or months, but at other times, these mood shifts can occur with a greater frequency, and are referred to as “rapid cycling” bipolar disorder. When the mood shifts happen very frequently, such as several times per day for several days in a row, the patient is diagnozed with “ultra rapid cycling” bipolar disorder. Some people can have both manic and depressive mood states overlapping and present at the same time. This is called a “mixed” episode of bipolar disorder.

It appears that there is a developmental trajectory of the symptoms of bipolar disorder from childhood to adulthood. In early childhood, it is more common to have mixed states and ultra-rapidly cycling symptoms. As children with bipolar disorder become older, the pattern is likely to shift to a rapid cycling pattern. As age increases toward late childhood and early adolescence, there is likely to be some separation of the mixed states toward the more classic manic and depressive episodic pattern of hypomanic or manic episodes alternating with normal mood and depressive episodes, the pattern which continues to be more common in adulthood.

Symptoms of Manic and Depressive Episodes

• an elevated, expansive, overly joyful, overly silly or irritable mood
• a decreased need for sleep

• racing thoughts
• rapid speech
• inflated self-esteem or “grandiosity”
• excessive involvement in pleasurable but risky activities
• increased physical or mental activity and energy

• an increase in sexual ideation or interest
• a decrease in the ability to concentrate and stay focused.

The symptoms of depression or a depressive episode include the following:

• frequent sadness, tearfulness, crying or persistent irritability
• a decrease in interest in activities that used to be interesting, or an inability to enjoy those activities

• a sense of boredom, feelings of hopelessness, feeling worthless or feeling inappropriately guilty
• decreased energy
• social isolation and withdrawal from others
• feeling sensitive to perceived or real rejection or failure
• low self-esteem, anger, or hostility

• trouble concentrating
• poor school performance
• changes in eating habits with an increase or decrease in weight
• changes in sleeping habits, with an increase or decrease in sleep duration, headaches, stomachaches or other physical complaints
• thoughts of death and/or suicide.

Why Is It So Hard to Diagnose Bipolar Disorder in Children?

In order to accurately diagnose bipolar disorder in children and adolescents, a clinician must take all of the above information into account and put it into the context of the degree, duration, and frequency of symptoms. It is important to differentiate whether or not the moods and behaviors being reported or experienced fall within the normal range of a child’s behaviors or cross the threshold into the realm of abnormality. Medical conditions as well as supplement or medication side effects that could mimic the symptoms of bipolar disorder must be considered and ruled out. Other mood or psychiatric disorders as well as illicit drug and alcohol use may also have symptoms that can be confused with, or co-occur with the symptoms of bipolar disorder in children and adolescents.

For example, many of the symptoms of ADHD, another disorder common in childhood,  overlap with the symptoms of bipolar disorder in children and adolescents. Impulsivity, hyperactivity, and distractibility, the hallmark symptoms of ADHD, are a subset of the symptoms found in bipolar disorder. Irritability, as well as oppositional and defiant behaviors, is commonly present in children with ADHD as well as bipolar disorder. It is helpful to recognize that mood elevation, grandiosity, decreased need for sleep and an increase in sexual interest or behavior are features strongly suggestive of bipolar disorder, as they are not generally part of the presentation of ADHD.

Another clue is that for children with ADHD, the symptoms of ADHD are generally always present, while the symptoms of inattention, distractibility, hyperactivity and impulsivity when present in bipolar disorder tend to fluctuate as the episodes of mania and depression fluctuate. However, since 85% of children and adolescents with bipolar disorder are likely to also suffer from ADHD, this distinction is not always helpful.

In addition to ADHD, anxiety disorders, major depressive disorder, schizophrenia, autism spectrum disorders, and post-traumatic stress disorder (now called post-traumatic stress) are some of the other common psychiatric conditions that cause patients to  present with symptoms that may be confused with, or co-occur with bipolar disorder in children and adolescents.

Another dilemma that causes confusion in diagnosis involves drug and alcohol use, especially in adolescents. Sometimes the effects of drugs and alcohol can mimic the symptoms of the manic or depressive episodes of bipolar disorder. When teenagers are in the midst of a manic or depressive episode, they  may be more likely to experiment with or use drugs or alcohol, adding yet another layer to the difficulty in accurately diagnosing bipolar disorder in adolescents as well as young adults.

One thing is very clear. Patients with bipolar disorder must completely avoid the use of any illicit drugs and alcohol.  Not only do these substances complicate the diagnostic picture, but their use is also like adding “fuel to the fire” of a brain already impaired by a severe illness, and alcohol or drugs will undoubtedly worsen the symptoms and outcome of the illness.

A thorough and complete diagnostic assessment, including a physical examination, blood tests, drug screens, a thorough medical history, supplement and medication history, a thorough psychosocial and behavioral history of functioning at home, school and the community throughout the lifecycle, with special attention paid to fluctuations in moods, behaviors, feelings, performance, sleep, appetite, energy and activity level across the lifespan, are essential parts of arriving at a proper and accurate diagnosis. Interviewing the child, as well as his or her parents, with collateral input from teachers, friends, and other relatives, is also likely to prove helpful in determining the correct diagnosis.

Controversy in the Medical Community

As noted above, the diagnosis of bipolar disorder in children and adolescents is not without controversy within the medical community. In the last decade, there has been a dramatic increase in the diagnosis of childhood onset bipolar disorder. While some parents resist the identification of bipolar disorder in their children, other parents may seek such a diagnosis as a means of explaining their child’s behavior, when the issues may have more to do with behavior problems and parenting issues as opposed to bipolar disorder.  Still other children may be diagnosed with bipolar disorder because of the presence of severe tantrums and outbursts along with other disruptive behaviors that warrant intervention when there is no other diagnostic category that is a better fit in categorizing their symptoms.

Researchers are examining the subset of children who may be given a diagnosis of bipolar disorder, but who lack clearly defined episodes of mania and depression. Perhaps some of these children overlap with ultra-rapid and rapid cycling presentations of bipolar disorder in children and adolescents, while others may present differently. Some children present with persistent and continuous severe irritability along with a low frustration tolerance, leading to frequent and severe emotional outbursts that are no longer developmentally appropriate for their age, and may be accompanied by additional symptoms of sadness, anxiety, distractibility, racing thoughts, insomnia and agitation. These children may be on a different developmental trajectory than children with classic bipolar disorder. They may be at risk for developing depressive and anxiety disorders and not bipolar disorder when they reach adulthood. A new diagnostic entity called disruptive mood dysregulation disorder (DMDD) to identify and describe these children was included in the DSM-5, the manual that clinicians use to diagnose patients.

Regardless of the label, the children who manifest these symptoms, as well as their parents, siblings and others around them, suffer greatly, and the impairments from which these children suffer are serious. A better understanding of these children, as well as effective interventions and treatments to improve the symptoms from which they suffer, is clearly needed.

Not every child or adolescent who has “mood swings” suffers from bipolar disorder.  Although challenging, a thorough assessment performed by a qualified and competent clinician can help clarify the issues related to the mood swings, and facilitate the establishment of the correct diagnosis or diagnoses, which will lead to recommendations for appropriate interventions and treatment. If it turns out that your child is correctly diagnosed with bipolar disorder, it is very important that your child be treated effectively and appropriately. Untreated or incompletely treated bipolar disorder can lead to terrible consequences for your child. Fortunately, there are very effective treatments available that may improve or control the symptoms of bipolar disorder and allow your child every opportunity to lead a full, productive, and successful life.

Course and Outcome of Children and Adolescents with Bipolar Disorder

New and ongoing research about bipolar disorder in children and adolescents   is taking place and new information is being learned all the time. As of 2005, studies suggest that 40% to 100% of children and adolescents who suffer from a manic episode will usually recover from that episode within one to two years. However, according to a 2005 review of the literature in Journal of American Academy of Child and Adolescent Psychiatry, of those who do not recover, up to 60-70% will experience a recurrence of an episode within 10-12 months .  In addition, many of these young people will experience frequent fluctuations in their moods, most often with depressed or mixed episodes, on an ongoing basis, aside from the recurrent episodes. The factors associated with a worse outcome over time for these children and adolescents include an early age of onset, a long duration of the illness, mixed episodes, rapid cycling, the presence of psychotic symptoms, a lack of treatment, and poor compliance with medication treatment.

About 20-25 % of children and adolescents with bipolar disorder NOS and bipolar type 2 are likely to progress to bipolar disorder type 1  in adulthood. Between episodes, many of these young people experience what are called “subsyndromal” symptoms of bipolar disorder, or mood and behavioral symptoms that are beyond what would be considered normal, but not severe enough to reach the level of a full-blown episode. For children and adolescents, 30% of the time, full blown mood shifts between mania and depression will likely occur one time or less per year, while 50% of the time, the mood shifts will likely occur more than five times per year. Almost 40% of the time, the mood shifts between depression and mania will occur more than 10 times per year, and in 24%, they will occur more than twenty times per year (Birmaher et al., 2009).

Bipolar disorder in children and adolescents is best understood as characterized by shifting episodes between mania and depression,while between these episodes, symptoms of depression, mixed symptoms of depression and mania, as well as rapidly changing moods are common. The challenge for parents and clinicians is to be able   to differentiate what may be a normally moody child from a child who has symptoms of a disorder that warrants treatment.

Treatment of Children and Adolescents with Bipolar Disorder

A variety of treatments may be effective for children and adolescents diagnosed with bipolar disorder.

First, various forms of psychotherapy, or “talk” therapy, to include the child or adolescent and his or her parents and other members of the family are valuable and important. Everyone in the family needs to become educated about bipolar disorder and be kept up to date with current understanding and new findings, as research is ongoing in many countries throughout the world. Counseling and guidance for parents and siblings is essential. Caregivers must keep in mind that although it may appear that the child is in control of their behavior, much of this maladaptive behavior is a manifestation of an illness of the brain, over which the child may actually have little or no control.

Children and adolescents with bipolar disorder may already blame themselves for difficult and disappointing behavior. To experience the anger, frustration, disappointment and rejection of those people whom the child is closest to and relies on for emotional and physical safety and security, may contribute negatively to the outcome of an already challenging course of life. While it is reasonable to expect family members to experience many of these feelings, working together as a family, with the guidance of skilled professional counselors or therapists, can help modulate those feelings and facilitate their expression in a positive and helpful manner.

Second, medication can really make a difference. Although many parents initially experience some resistance to the idea of prescribed medications, these are the mainstay of treatment for stabilizing the moods in children and adolescents with bipolar disorder. Several medications are approved by the Food and Drug Administration for the treatment of bipolar disorder in children and adolescents. They include lithium, and the second-generation antipsychotics (SGAs) Risperdal, Abilify, Seroquel, Zyprexa, Latuda, and Saphris.

If your clinician prescribes an off-label medication or a medication that is approved for adults but not children, it is important to keep in mind that many medications used to treat childhood illnesses, including childhood cancers, may be FDA approved for use in adults, but not for use in children. Treatment providers often extrapolate the use of these medications from adults to children and adolescents. Several other medications besides the ones listed above are used to treat bipolar disorder in children and adolescents with varying degrees of success. These include the anticonvulsants Depakote, Tegretol, Trileptal, Topamax, Neurontin and Lamictal, as well as other SGAs, such as Geodon, Clozaril, Fanapt, Vraylar, and Caplyta. Many of these medications are used alone or in combination, depending upon each individual’s unique circumstances. You should always talk with your prescribing physician if you have any concerns about the medication(s) your child takes to manage their bipolar disorder.

Be patient, keep track of your child’s symptoms and reactions, and bring any concerns to your prescribing clinician.

One note of caution: The use of antidepressant medications, such as the SSRIs, including Prozac, Paxil, Zoloft, Celexa and Lexapro, while often helpful in treating depressive symptoms in children and adolescents, pose serious risks when used in attempting to treat depressive symptoms of bipolar disorder in children and adolescents. Activation, disinhibition, the triggering of a manic episode, and the worsening of mood symptoms are not uncommon results. If these medications are used, caution and careful monitoring are required.

Since it is not unusual for bipolar disorder to be present along with other psychiatric disorders, most commonly ADHD or anxiety disorders, combinations of medications to treat more than one disorder are sometimes necessary. Treatment can be very challenging, as the symptoms of one disorder may worsen when trying to treat the symptoms of a co-occurring disorder with medication. Be patient, keep track of your child’s symptoms and reactions, and bring any concerns to your prescribing clinician.

Each medication or combination of medications has its risks and benefits. Different medications or combinations of medications may be warranted in different circumstances at different times. Each medication may have an unwanted effect on some other area of the brain or other parts of the body than intended, with the potential for causing unwanted side effects. These side effects can range from short-term temporary annoyances to long-term and permanent problems. However, just because there is a risk of developing a certain side effect does not mean that your child will develop that side effect.

You must also keep in mind that there are serious potential risks in not using medications to treat the symptoms of bipolar disorder. Becoming educated about these medications and discussing the various treatment options and alternatives with a child and adolescent psychiatrist in whom you have trust and confidence are the first steps. If medications are prescribed, you should participate in regular medical follow up visits with the child and adolescent psychiatrist in order to monitor the symptoms and treatment response, as well as unwanted side effects. Medication management is essential in ensuring that your child receives every opportunity to obtain the best treatment available.

Knowledge is Power

Although it may not be obvious, children and adolescents with unstable moods as the result of bipolar disorder are often frightened about how out of control they feel. When faced with their children’s challenging behaviors, it is important for parents to do all that they can to stay in the role of the adult.  Staying calm in the face of upsetting situations and reacting to your child’s out of control behavior in a thoughtful and rational way that models being “in control” is not always easy. However, this approach can have a significant impact on increasing the chances of a positive outcome for your child and your family.

Your child needs you and is relying on you to make the right choices and decisions.  Learn as much as you can from the reliable resources available, and make the best decisions you can for the health, safety and future of your child.

About the Author

Rob Friedman, M.D. is board certified in child and adolescent as well as adult psychiatry. After graduating magna cum laude with distinction in psychology from Duke University, Dr. Friedman received his medical degree from The New York State Program at the Sackler School of Medicine in Tel Aviv, Israel, in 1985. He completed his residency in general psychiatry at Long Island Jewish/ Hillside Medical Center in Great Neck, New York, followed by the completion of a fellowship in child and adolescent psychiatry at the UCSD Medical Center in 1990. Since then, Dr. Friedman has been in private practice in San Diego. He is a founding partner, President and CEO of PsyCare, Inc., a behavioral healthcare provider group with seven offices throughout San Diego. Dr Friedman is an Assistant Clinical Professor of Psychiatry at the UCSD Department of Psychiatry, San Diego, providing clinical supervision to training child and adolescent psychiatrists. Dr. Friedman is a member of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatrists. 

References

Birmaher, B., Axelson, D., Goldstein, B., Strober, M., et al (2009). Four-year longitudinal course of childhood and adolescents with bipolar spectrum disorders: The Course and Outcome of Bipolar Youth (COBY) study.  American Journal of Psychiatry, 166: 795-804. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2009.08101569

Hamrin, V. and DeSanto I. (2010). Psychopharmacology of pediatric bipolar disorder. Expert Review of Neurotherapeutics,10 (7): 1053-1088.

Kowatch, M. and Delgado, S. (2011, February). Not all mood swings are bipolar disorder, Current Psychiatry, 10 (2).

Pavuluri, Mani N., Birmaher, Boris, Naylor, Michael W. (2005, September). Pediatric bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9) 9: 846-871.