Pediatric Bipolar Disorder Part 3: Behavior Observations

As discussed in Part 1, we once thought bipolar disorder in children was rare. However, ever-growing body of research shows it definitely presents in children. Meta-analyses show a prevalence rate for pediatric bipolar of around 1-2%.

Depending on the presenting problems you typically see, your local base rate may be lower, or even higher. For instance, inpatient settings sometimes report local base rates up to 30%! However, even if your local base rate is lower, unless you are in a very specialized setting, you almost certainly see children with it on occasion.


My base rate for pediatric bipolar is around 8%. In other words, I think I see about 8 kids with likely pediatric bipolar disorder for every 100 kids I assess. I base my diagnoses on a combination of (1) parent report of the cardinal symptoms of bipolar disorder, (2) parent/teacher rating scales, (3) direct test scores, and (4) behavior observations during testing. [To see how I write up bipolar disorder in a report, feel free to email me and ask for the link to my Sample Reports page.]


Of course, behavior observations are only one piece of data. Research shows behavior observations do not correlate all that well with other raters' assessments (of course, almost all correlations between different raters are very low). Behavior observations also do not correlate that well with any other source of data, such as direct test scores, just like parent or teacher ratings do not correlate that well with direct test scores. Nevertheless, behavior observations are data. While you don't want to rely on behavior observations alone, seeing extremely dysregulated emotions and behavior during testing can help confirm a diagnosis. Seeing this behavior during testing can also help you feel more confident about a diagnosis you are making. I feel like this is more important than it sounds -- I suspect that clinician confidence in and comfort with their diagnostic formulation helps feedbacks go more smoothly. Data from behavioral observations can also help you explain "what you're seeing" to parents during the feedback. Over the years, I've developed an informal list of behaviors during testing that raise my index of suspicion for a mood dysregulation disorder like pediatric bipolar disorder. Note: Absolutely none of these behaviors are diagnostic, and many of these behaviors can be seen in children with disorders other than an episodic mood disorder. These behaviors can also be displayed by typically developing children, especially under stress. However, seeing many of these behaviors during a highly structured test session suggests that emotional and behavioral regulation is very difficult for the child. And one possible reason for that level of dysregulation could be pediatric bipolar disorder. Here are the categories of behavior I look for, as well as sample behaviors in those categories:


Possible Grandiosity

  • Makes more than 1 statement saying "I'm so amazing/great/awesome at this" when discussing his or her interests or activities (softer version might be "I'm not the most amazing person in the world at this")

  • Highly unrealistically assesses his or her skill on a test (e.g., states he or she is doing well above average, when scoring at or below the 10th percentile)

  • Brags about making successful demands or negotiations with teachers or parents (e.g., "I get my parents to do what I want all the time")

  • Reports or brags that he or she has "lots of friends," but cannot provide details about friends, or seems disinterested in discussing their friends

  • Asks for your business card or asks a lot of questions about your framed diplomas or awards

  • Asks to "have" or "keep" something in the office or some part of the testing materials, such as your stopwatch or a test stimulus book

  • Claims to have “invented” something or tells story where someone invented something (or other highly improbable claim to fame)

  • Believes he or she has special powers or a special destiny

Demanding Behavior During Testing:

  • Makes more than 2 attempts to demand or negotiate around testing

  • Attempts to leave the testing room if he or she does not get his or her way

  • Attempts to open off-access area, like a locked file cabinet, window, or drawer

  • Attempts to negotiate special privileges during testing (e.g., "Can you do it this way, just for me?")

  • Makes more than 3 complaints of being bored

  • Destroys something, or threatens to destroy something if he or she does not get his or her way

  • Threatens you with violence, or threatens you with their anger (e.g., "You don't want to make me angry, because when I'm angry I hit people")

  • “Sneaky” behavior when thinks you are not looking (or observed theft or lying)

  • Makes up “own” way of responding to testing and demands you adhere to it (e.g., “If I say ‘beep’ it means yes, and if I say ‘boop’ it means no”)

Very High Levels of Inattention, Impulsivity, and Hyperactivity:

  • Frequently misses very easy test items (e.g., possibly even sample items) but passes more difficult ones easily

  • Utilization behavior - seems to “have” to touch anything in front of them

  • Unusual and striking levels of hyperactivity

  • Consistently and repeatedly tries to respond too soon

  • Expresses or shows significant impatience with test directions

Atypical Social Behavior:

  • Difficult to interrupt (or clear pressured speech)

  • Becomes offended if you use hyperbole or exaggeration for humor

  • Unusually poor ability to read facial expressions or to remember faces

  • Highly dramatic tone of voice and/or extremely dramatic gestures

  • Attempts to "snuggle" with you, especially if done to get his or her way

  • Significant difficulty maintaining personal space

  • Responses seem silly/random and follow own train of thought

Mood Problems:

  • Highly irritable (not captured by behavior already mentioned)

  • Cries

  • Mood changes quickly during testing

  • Seems emotionally "fragile" - e.g., anything seems to set him or her into a rage or despair

  • Unusually positive (or can only express positive affect even when talking about sad things)

Atypical Anxiety:

  • Expression of separation anxiety during testing, yet without anxious affect

  • Expresses paranoia about the purpose of testing

  • Talks about a specific phobia (e.g., of the dark or snakes) without prompting or questioning

  • Complains that testing is physically hurting him or her in some way (e.g., says that the CPT is making his or her eyes hurt)

  • High level of fixation on harm (e.g., talks a lot about or expresses anxiety about hurt, pain, injury, others being injured, "emotional pain")


Possible Precocious Interests:

  • In pre-teen children, seems "like a teenager" in terms of interests and/or attitude

  • Brags about committing a crime (or in young children, tells a story about committing a crime in positive tone of voice)

  • Unusually violent themes in a drawing or a story

  • Talks about self as an adult, or talks about how much he or she dislikes "children" even though he or she is a child

  • In young children, talks about wanting to use alcohol or drugs, "partying", being attractive/beautiful, and/or not being able to wait until they get to do what they want as an adult

  • Noticeable amount of talk about money (how much something costs; lots of use of words like "expensive", "rich", or "afford" in conversation or stories)

  • Stories or drawings where people are rich, famous, catered to, or become rich and famous (or best in the world at something) with relatively minimal effort

  • Refers to a preference for a certain fashion brand, wanting to be fashionable or a fashion designer, or makes references to other luxury items (especially if this is not typical for the child's SES)

  • Noticeable amount of talk about wanting to be famous or people who are famous (and/or clear "name-dropping")

  • Cursing (or, especially in young children, statements about enjoying cursing) - may get overwhelmed by urge to use curse words on verbal fluency tests

  • Scatological references

  • Any reference to sex (outside of adult-initiated conversations about this topic with older teens) or genitals (softer version might be a pre-teen who becomes unusually upset when seeing adults be affectionate)

Signs in the test results:

  • Many intrusions on a list-learning test

  • 2 or more made-up words and/or clang association on verbal fluency test

  • Crosses out a more neutral word on a questionnaire to change it to a massively more positive word (e.g., changes "I look OK" to "I look AWESOME")

  • Combination of: 2 or more T-scores >80 on parent rating scale of behavior, 6 or more T-scores > 70 on parent rating of executive functioning, and 3 or more T-scores > 80 on a continuous performance test

I would estimate that for children who are not experiencing any emotional or behavioral concerns in their daily life, I see 0 to 2 of these behaviors during the "average" 3-5 hour test session. For children where emotional, behavioral, or social problems are a primary referral concern, I see 3 to 5 of these behaviors during the average test session. In the vast majority of those cases, I find those behaviors are better explained by another disorder. For example, I see a handful of these behaviors when I'm assessing the "average" child with depression, anxiety, ADHD, ASD, ODD, NVLD, PTSD, etc, over 3-5 hours. However, 6 to 10 of the above behaviors places the child in the "elevated risk" category, in my professional opinion. When I see children who appear to have clear pediatric bipolar disorder, with discrete manic or mixed episodes and discrete depressed episodes, I almost always see more than 10 of the behaviors listed above during the test session. In my mind, I classify this as "very high risk." When I assess children who I believe have an "elevated" or "very high" risk based on my behavioral observations, I focus the evaluation more directly on the possibility of pediatric bipolar. I also make sure my feedback, report, and recommendations directly address strategies for reducing emotional and behavioral dysregulation, regardless of my ultimate diagnosis.


©2018 by Stephanie Nelson, Ph.D.