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J Can Acad Child Adolesc Psychiatry. 2009 August; 18(3): 198–199.
PMCID: PMC2732724

International Perspectives of Pediatric Bipolar Disorder

Dr. Kirti Saxena, MD, Guest Editor1,2

Pediatric bipolar disorder (PBD) is a serious, chronic illness significantly affecting the global functioning of the individual affected. In the past decade there has been significant research undertaken to understand the phenomenology, neurobiology and treatments for PBD. Indeed, in clinical practices, the diagnosis of bipolar disorder in children and adolescents has increased markedly (Youngstrom et al., 2005; Blader and Carlson et al., 2006; Case et al., 2007).

As bipolar disorder may present differently in children and adolescents due to developmental variations in manic symptom expression, researchers continue to discuss the appropriate diagnostic criteria for PBD (Leibenluft et al., 2008, McClellan et al., 2007). Thus, research to date has focused on studying the phenomenology and pathophysiology for PBD in an effort to inform the diagnosis of this disorder in youth.

As there is evidence suggesting that children and adolescents who have a parent with bipolar disorder are at a high risk for developing a mood disorder, longitudinal follow up of these high–risk youth may provide phenomenological, temperamental, and biological clues to early presentations of bipolar disorder (Chang et al., 2003). Dr. Anne Duffy, an esteemed Canadian researcher at the Dalhousie University, Halifax, begins our theme issue with providing an expert’s perspective on selected bipolar offspring studies and discusses the implications of these regarding the diagnosis of PBD. She discusses the prodromal symptoms of early onset bipolar disorder and the difficulty of using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in making an accurate diagnosis of bipolar disorder in children.

Our next article by Dr. Inal-Emiroglu at the Dokuz Eylul University Medical School, Izmir, Turkey and Dr. Diler at the Western Psychiatric Institute and Clinic, University of Pittsburgh reveals the significant research conducted in bipolar Turkish youth. The authors discuss their findings which are similar to what other researchers have found in regards to difficulties encountered in diagnosing PBD and in Turkish bipolar offspring having a higher risk of receiving a psychiatric diagnosis than offspring of healthy parents.

The ultimate goal of clinical research is its applicability to regular clinical practices, which brings us to the next article by Dr. Saxena and colleagues at the University of Texas Southwestern Medical School in Dallas, TX. As many children and adolescents do not fit the classic DSM-IV-TR criteria for Bipolar Disorder, Type I., Bipolar Disorder, Not Otherwise Specified (BPNOS) is often the “catch all” diagnosis. In this article Dr. Saxena and colleagues discuss a recent study, The Course and Outcome of Bipolar Youth (COBY) which provided research definitions for BPNOS. Using these research definitions for BPNOS, which provided preliminary validation for BPNOS, Saxena and colleagues examined the clinical presentation of youth with BPI vs. BPNOS presenting to an outpatient clinic. This study was able to demonstrate that research diagnostic criteria may be effectively utilized in a clinical setting, which may serve to improve the precision of diagnosis and thus future treatment outcomes.

To be able to improve the diagnostic assessment of PBD, researchers are searching for endophenotypic markers for bipolar disorder. Because bipolar disorder is associated with cognitive impairments such as attention deficits, difficulties in executive functioning and verbal memory deficits, studies have looked at the neurocognitive profiles of bipolar subjects to determine if these could be endophenotypes for the illness. Cahill and colleagues at the University of Sydney in Australia provide an overview of studies looking at the cognitive deficits associated with bipolar disorder in youth.

Kowatch et al., (2005) have published treatment guidelines for bipolar disorder which provide guidelines to clinicians regarding the best treatment approaches for bipolar youth. As noted above, clinical research and guidelines are developed so they can be applied to clinical practice. Towards this end, Drs. Consoli and Cohen at the Laboratoire “Psychologie et Neurosciences Cognitives” in Paris, France describe the pharmacological treatment prescribed in an inpatient setting for acute manic or mixed episodes in adolescents and compare their results with evidence-based data.

Researchers have recognized that treatment of PBD with psychotropics alone is not sufficient, since PBD is associated with significant psychosocial impairments. Thus, psychosocial treatment adjunctive to medication is becoming an important component of the comprehensive treatment for PBD, and research has been conducted to develop evidence-based psychosocial treatments for PBD. Indeed, Fristad MA (2006) and Miklowitz et al., (2008) have developed family-based psychoeducational interventions for the treatment of bipolar youth. To add to this literature, Amy West and her colleagues at the University of Illinois in Chicago explored the feasibility of child and family-focused cognitive behavioral therapy for PBD. This study consisted of group psychotherapy as an adjunct to pharmacotherapy.

Pediatric bipolar disorder is a recognized global illness. The aim of this international theme issue on PBD is to reinforce to the readers that researchers worldwide are struggling with the same dilemmas regarding the diagnosis and treatments for PBD. One way to gain more insight into the development, causes and treatments for this illness is to conduct multicenter international studies on PBD.

These six articles complete this theme issue on International Perspectives of Pediatric Bipolar Disorder. Our hope is that the readers will benefit from an understanding that PBD is recognized globally as a serious illness which is difficult to diagnose, and for which the treatments and biological markers remain a challenge. The guest editors and the Journal invite you to participate in an ongoing dialogue by either submitting further articles on the theme issue or a commentary via letters to the editor.


Dr. Kirti Saxena MD
Guest Editor


  • Blader JC, Carlson GA. BPD diagnosis among child and adolescent U.S. psychiatric inpatients, 1996–2003. Presented at NIMH Pediatric Bipolar Disorder Conference; Chicago, Ill. 2006.
  • Case BG, Olfson M, Marcus S, Siegel C. Trends in the inpatient mental health treatment of children and adolescents in US community hospitals between 1990 and 2000. Archives of General Psychiatry. 2007;64:89–96. [PubMed]
  • Chang K, Steiner H, Dienes K, Adleman N, Ketter T. Bipolar offspring: A window into bipolar disorder evolution. Biological Psychiatry. 2007;53:945–51. [PubMed]
  • Fristad MA. Psychoeducational treatment for school-aged children with bipolar disorder. Developmental Psychopathology. 2006;18:1289–306. [PubMed]
  • Kowatch RA, Fristad M, Birmaher B, Wagner KD, Findling RL, Hellander M, Child Psychiatric Workgroup on Bipolar Disorder Treatment guidelines for children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44:213–35. [PubMed]
  • Leibenluft E, Rich BA. Pediatric Bipolar Disorder. Annual Review of Clinical Psychology. 2008;4:163–87. [PubMed]
  • McClellan J, Kowatch R, Findling RL, et al. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46:107–125. [PubMed]
  • Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, Beresford CA, Dickinson LM, Craighead WE, Brent DA. Family-focused treatment for adolescents with bipolar disorder: Results of a 2-year randomized trial. Archives of General Psychiatry. 2008;65:1053–61. [PMC free article] [PubMed]
  • Youngstrom E, Youngstrom JK, Starr M. Bipolar diagnoses in community mental health: Achenbach Child Behavior Checklist profiles and patterns of comorbidity. Biological Psychiatry. 2005;58:569–75. [PubMed]

Articles from Journal of the Canadian Academy of Child and Adolescent Psychiatry are provided here courtesy of Canadian Academy of Child and Adolescent Psychiatry