CCPR: The frst signs of bipolar disorder are often non-specific. When do parents first recognize something is wrong?

Dr. Miklowitz: Childhood bipolar disorder (BD) is diagnosed mostly in adolescence; true mania in children under 12 is exceedingly rare, though many young children are given the label. Younger children may show signs of risk, such as mood instability, rage episodes, sleep problems, and occasional grandiosity, all short of a manic episode, and none of them are definitive. Parents typically need time to determine whether anything is wrong, since mood swings are so common in adolescence. The signal that clinicians and parents both recognize is functional impairment: things like trouble getting through dinner without conflict, homework that is derailed by suicidal thoughts, being full of unrealistic ideas that alienate other people, or risky behavior that leads to contact with the police. These are non-specific to BD. Parents with a family history of BD often recognize the pattern sooner; others wait years.

CCPR: What happens once a family seeks an evaluation?

Dr. Miklowitz: At the CHAMP clinic, our evaluation runs four to five sessions and includes interviews with the teen and parents, a full psychiatric history, a medical workup, and a review of prior medication trials. We rule out physical illnesses before settling on a diagnosis. Feedback for families and teens usually falls into one of three categories: 1) a picture consistent with BD, 2) subthreshold symptoms of risk that need monitoring, or 3) a presentation fitting a different disorder. Treatment ranges from psychotherapy to low-dose medication to, for severe presentations, hospitalization then step-down to partial hospitalization or intensive outpatient care. Access is a barrier; many families have no local clinician experienced with pediatric BD. Generally, telehealth only helps when the family can reach a clinician in the same state. Parents’ reactions vary from relief to feeling dismissed to disagreeing with the diagnosis and treatment plan. Disagreement is common in separated families where one household sees a mood disorder and the other sees conflict within the ex-partner’s home.

“Don’t communicate blame. Having a mental illness does not mean a parent caused the child’s illness or determined its course.” - David J. Miklowitz, PhD

CCPR: How can clinicians respond to the parents’ experience, and to the value judgments they face from others?

Dr. Miklowitz: Start with a diagnostic feedback session after the initial evaluation, with both parents present, and explain the reasoning behind the diagnosis. Acknowledge that parents are in distress. Parents’ irritability during the evaluation usually reflects worry rather than resistance. Parents often describe homes as war zones, with siblings walking on tiptoe around a volatile sibling, and a child who seems to have changed overnight. They also direct frustration at the system: Answers feel too slow, and school problems are unaddressed. Clinicians can help by contacting schools and supporting an Individualized Education Program when appropriate.

CCPR: What should clinicians say about medication and non-pharmacologic treatment?

Dr. Miklowitz: Walk parents through the trade-offs: antipsychotics for more severe presentations, lamotrigine as a milder mood-stabilizing option, and lithium, still the most effective agent for many patients but often unpopular with teens because of stigma and side effects. Medication is part of a larger plan that has to address adherence and, in older teens, co-occurring substance use. On the non-pharmacologic side, family-focused therapy (FFT) combines psychoeducation, communication training, and problem-solving, and gives the teen room to describe to their family what an episode feels like from the inside (Editor’s note: For more on family-based therapies for BD in youth, see article on page 1).

CCPR: How does a parent’s own mental health affect the child’s treatment?

Dr. Miklowitz: Our sessions are mostly conducted with the youth and parents together, but when a parent appears to be struggling, we take that parent aside separately and ask whether they want a referral or already have mental health care. BD runs in families, so we sometimes also treat a parent with BD. Treatment of the child goes more smoothly when the parent is stable; when a parent is unstable, the parent and child can trigger each other and create a chaotic and negative cycle. It is important not to communicate blame. Having a mental illness does not mean a parent caused the child’s illness or determined its course.

CCPR: How do you guide a parent toward getting their own care?

Dr. Miklowitz: Ask directly whether the parent feels stable enough to care for their child right now, and if not, what would help, whether it’s medication, therapy, or at minimum a psychiatric evaluation. Their first response is often resistance (“If my kid weren’t so difficult, I’d be fine”), but many parents can be guided to see that the strain comes from more than the child, including marital differences, unresolved family-of-origin issues, and of course, their own genetic vulnerability. One signal that a parent may need support in addition to family therapy is recursive interaction patterns, in which the child provokes, the parent reacts with anxiety or anger, and the child reacts in turn to that reaction.

CCPR: What differences commonly arise between parents or caregivers?

Dr. Miklowitz: The widest gaps show up after divorce, when marital resentment ends up bleeding into disagreements about the child’s care. A common divide is one parent pushing for psychiatric treatment while the other favors discipline and firmer limits. FFT addresses this through psychoeducation for the whole family, working to reduce the likelihood that one parent will blame the other parent or dismiss the behavior as ordinary teenage conduct.

CCPR: How do you manage a parent who will not engage, or sessions that turn into marital conflict?

Dr. Miklowitz: If one parent will not participate, we proceed with the parent who will and keep trying to bring the other in, while staying mindful of child custody laws and agreements. If sessions repeatedly turn into marital disputes, we recommend separate couples counseling or mediation, sometimes providing an initial round ourselves while keeping the family sessions focused on the child. Appealing to the part of each parent that wants to be a good parent tends to work better than arguing over who is right.

CCPR: How do you manage high expressed emotion and high conflict?

Dr. Miklowitz: Delivering FFT usually means recognizing and responding to high expressed emotion in parents: high criticism, hostility, or overprotectiveness toward the child, which is linked to higher rates of illness recurrence (Vaughn C. Expressed Emotion in Families: Its Significance for Mental Illness. New York: Guilford Press; 1984). It’s typically assessed via structured interview, though that’s not always feasible clinically. Clinicians can instead learn to spot criticism and overprotectiveness by watching family interactions—for example, a parent raising a conflict topic (eg, smartphone use) and escalating it with critical comments, provoking defensiveness in the child and aggravating existing mood symptoms.

CCPR: How do you handle a hostile, dysregulated, or safety-concerning parent in session?

Dr. Miklowitz: When a parent’s response during a session is over the top, such as when they’re screaming or looking physically intimidating to the child or another family member, we usually stop the session and take a break. We may talk individually with the parent to find out what’s setting them off. Once the parent is calmer and more receptive, we may say “You obviously care a great deal about _____’s health and are worried that their behavior is interfering with their recovery. But I’m concerned that the way you’re saying it is making them (the kid) close down. Let’s work on a different way to get your point across.” That leads us into communication skill training.

CCPR: How do you respond to other parental presentations such as guilt, denial or minimization, or caregiver burnout?

Dr. Miklowitz: Guilt calls for an empathetic response. Normalize the parent’s self-blame (“Many of us think it’s our fault when a child becomes ill”) while clarifying that no one chooses their genes, and we don’t yet know enough about BD to say which parent’s genes contributed. Denial and minimization are subtler: “She’s just going through a teen hormonal phase,” “He’ll get over this once the semester ends.” The clinician should make clear these are biologically based, recurrent disorders that don’t simply resolve. But the clinician should also communicate hope: Coping skills and a supportive family environment can help a biologically vulnerable child stay well over the long term (Editor’s note: See our interview with Aaron Besterman in CCPR April/May/June 2026 on presenting genetic risk without blame).

CCPR: What organizations or resources help parents?

Dr. Miklowitz: The Depression and Bipolar Support Alliance (www.dbsalliance.org), the International Bipolar Foundation (www.ibpf.org), and the National Alliance on Mental Illness (www.nami.org) offer free lectures, groups, and peer support, often via telehealth. Encourage parents to attend even one meeting so that they meet other families managing the same problems. This is usually helpful early in the course of the disorder, when parents may be resistant to the diagnosis.

CCPR: How do you handle outside pressure from extended family, such as grandparents?

Dr. Miklowitz: Bring the grandparent into a session to hear the clinical reasoning and to be heard in turn; this works better than leaving parents to relay messages secondhand. Coach parents to set limits with their own parents, such as asking that the diagnosis not come up at the dinner table (offhand grandparent comments in front of the child can feel stigmatizing).

CCPR: How does sharing outcome data change a parent’s outlook?

Dr. Miklowitz: Roughly 25% to 30% of kids with a reported manic episode in the teen or pre-teen years don’t go on to a chronic adult course (Weintraub MJ et al, J Am Acad Child Adolesc Psychiatry 2020;59(3):381–390). Some stop having episodes; others have infrequent, subthreshold ones. Telling parents that their child may fall into that group changes how they picture the road ahead. The second lever is helping parents sort what’s within the child’s control: how much of an outburst reflects the disorder’s neurophysiology (sleep disruption, shifts in circuit activity) versus willful behavior. We encourage them to see control as a matter of degree, not yes or no (Editor’s note: This underscores the need for rigorous assessment to rule out things like adjustment disorders and avoid overdiagnosing BD in youth).

CCPR: Can you give an example of negotiating limits with a teen?

Dr. Miklowitz: An 18-year-old on a simple lithium regimen had a mother so focused on whether he was taking his pills that she would accuse him of being noncompliant whenever he laughed, spoke too loudly, or became irritable. He began hiding pills around the house as pushback. In FFT, we negotiated a system: She set out his pills each morning, they discussed it only if one was left over or found elsewhere, and he agreed to get his lithium level checked periodically. He said he wanted to keep taking lithium but couldn’t do it if he was constantly watched. This collaborative approach using the teen’s input worked better than simply imposing a plan.

CCPR: Do you have any concluding thoughts?

Dr. Miklowitz: Awareness of pediatric mood and anxiety disorders has grown, but BD still carries stigma; much of the public sees it as wild and dangerous. Parents describe real consequences: Friends or their parents may forbid future get-togethers, or a teen is teased about medication side effects like acne or weight gain. Support groups help, especially when matched to the child’s age and the family’s stage of coping. News stories about public figures with BD are teaching moments, letting us compare a teen’s situation to others’.

CCPR: Thank you for your time, Dr. Miklowitz.