Early into the evaluation of a 10-year-old boy, you note the following symptoms: inattention, hyperactivity, impulsivity, sleep problems, racing thoughts, and moodiness. The boy’s parents came to your office convinced that their son has ADHD, but thinking through the case, you recognize that the same symptoms could signal bipolar disorder (BD).

You are evaluating a 16-year-old boy referred for mandated substance use treatment by his high school, where he was found drinking alcohol and smoking cannabis with a friend in the restroom.

It’s a vexing question: At what point do you consider prescribing antipsychotics for aggressive children? The potential side effects—weight gain, sedation, possible movement side effects, and metabolic abnormalities—encourage us to think long and hard about this, and there are few good evidence-based guidelines.