BiPolar Dx



 Very important Dx issues to keep in mind about BPD Dx in children & adolescents:


  1. “Mania” is very uncommon under age 15.
  2. “Extreme irritability” is the typical feature of BPD in children; this is the child equivalent of mania.
  3. Very rapid & dramatic changes in mood are characteristic of BPD children.  Very giddy and “whoop tee do!” moods followed by profound sorrow 7 (often) suicidal thoughts and threats over trivial frustrations are common in BPD children.
  4. Decreased need for sleep, especially extreme difficulty getting to bed, characterize many BPD children.
  5. Precocious sexual activity is often found in BPD children.  When a child is especially aggressive perpetrating these behaviors, a Dx of BPD should always be strongly suspected.
  6. Family history in BPD children usually is positive for at least one primary relative having a major depressive disorder, most commonly BPD.  I am far more confident in a Dx of BPD in a child when this condition has affected a parent, and yet more confident when more than one relative has BPD.  Faroane, Wozniak, and Biederman, in a large survey, found no primary BPD relatives in children with ADHD only, but found 80% of children Dx with BPD and ADHD had a relative with BPD.
  7. Most studies have shown about 10-15% of ADHD children also have BPD, while 95% of BPD children (and adolescents) have co morbid ADHD. Therefore, in most cases, the diagnostic question and primary clinical concern is which condition is most impairing now.
  8. I disagree with Dr. Wagners’ comment on page 2 of the handout (area bracketed) in the sense most children and adolescents with combined ADHD/BPD, in my experience, do not present with psychosis nor require psychiatric hospitalization.


I agree:


A.     These children and adolescents are much more difficult to parent and cause intense friction between parents (often leading to divorce);

B.     Their clinical course is far more problematic and requires careful, expert psychological and psychiatric Rx;

C.     Management of medications effective in treating ADHD/BPD children is usually difficult, at best, since adolescents are historically non-compliant with meds and side effects of effective BPD Rx medications can be severe.

  1. Bear in mind Geller, Wozniak, and others have all described cases of severe BPD in children as young as two.  We have made this Dx in several 3 year olds and many 4 year olds.  Early Dx and Rx can be life-saving for these children, who are very often nearly impossible to effectively manage while in emotional “melt down” mode, thus invite abuse (by caretakers as well as parents!).
  2. The standard wisdom that Rx with TCA’s and SSRI’s “precipitates” latent manic episodes has not been borne out when re-examined in recent, large long-term studies.
  3. It is important to note BPD II is very different, presenting as commonly in girls as boys, and usually with repeated episodes of deep depression.

Important: The reason SSRI’s often seemingly fail to effectively treat depressed teenaged girls is because the girl has BPD-II.  In these cases, combined Rx with a mood stabilizer and an anti-D medication is necessary, undoubtedly-in-part accounting for why additions of Lithium to augment anti-D Rx has been so often so effective in so-called “treatment-resistant depressions.”