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Dr. Himanshu Agrawal, MD

Dr. Himanshu Agrawal, MD

by Dr. Himanshu Agrawal, MD.

Disclaimer: This blog is merely a personal opinion about psychiatric issues.It does not equate to a psychiatric consultation and does not imply doctor-patient relationship.

In my humble opinion, in the world of Child Psychiatry, there is nothing murkier than the answer to this question “What does pediatric mania look like?

It seems that there are several differing opinions endorsed by different schools of thought spread across USA. One such school emphasizes the importance of severe irritability as a strong indicator of pediatric mania. I do not belong to this school of thought- I think many clinicians overemphasize the importance of severe irritability. When a child is referred to my clinic to assess for possible bipolar disorder, I screen for a whole range of relatively specific and non-specific symptoms (I say ’ relatively’ because I do not think there is any symptom of pediatric mania that is 100% specific- not even euphoria).

This is how I approach my interview:


1. Decreased need for sleep

  • “I want you to think about Jimmy’s sleep patterns. Is Jimmy the kind of child who fights going to sleep, is up till extremely late hours and then wakes up in the middle of the night- 3 am, 4 am, 5 am, up-and-ready, demanding to play, waking everyone else up?”
  • Does this happen almost every night?
  • When he does have nights like these, how is he the next day? Is he tired or is full of energy at school?”
  • Many parents will tell me that their child fights going to sleep and is up till late hours of the night. If they report that the child is generally tired in school the next day, to me this rules out decreased-need-for-sleep
  • Common reasons why kids have initial insomnia: poor sleep hygiene, anxiety

2. Dare-Devil Acts

  • In my mind, genuine dare-devil acts differ from the impulsive acts seen in ADHD. Here’s how I look at it: if a child with ADHD jumps of a wall, hurts himself and says “that was dumb! What was I thinking?”, in my mind that rules out dare-devil-acts.
  • I ask parents this : Would you say Jimmy is a fearless child? For e.g., have you ever had a situation when Jimmy was about to jump from someplace high and you said’ Jimmy- if you do that you could die” and Jimmy responded ‘I know, and I don’t care! Here I go! Woohoo !!!” (a child with ADHD is more likely to say “ No I won’t mom, I’ll be fine! Watch!”)

3. Psychosis

  • Hearing things, seeing things, delusions. This is extremely rare!

4. Mood lability

Remember :

  • Happy –to- sad in 1 second = emotional reactivity (depression/anxiety/certain personality organizations)
  • Happy-to-sad-to-happy in 2 seconds = true mood lability (maybe Mania)


1. Irritability

  • C Children with mania will show intense rages over trivial matters (the other day Jimmy trashed his entire room because he spilt ink on his shirt!)
  • O Often outbursts will be triggered by hearing the word ‘No’, but a word of caution to the reader- this scenario is not specific and can be seen in kids with ODD, anxiety, depression, Reactive Attachment Disorder, Fetal Alcohol Effects and Pervasive Developmental Disorders!

2. Distractibility/ Racing thoughts

  • I will ask the child this : Jimmy, do you ever feel like there are so many thoughts in your head at the same time that you need a stop sign?
  • More Common reasons for distractibility : Anxiety, ADHD

3. Disinhibition

  • C Children with mania will often talk in a disinhibited manner, like an inebriated person saying non-PC things at a party (usually the comments are about things that would embarrass parents in front of others). This is a non-specific symptom.
  • C Common reasons for disinhibited speech: ADHD(not thinking before one opens one’s mouth), PDD(being clueless about why something would be socially inappropriate and embarrassing for others)

4. Hypersexual behaviors

  • This includes behaviors such as roaming around the house naked, groping others’ private parts and breast areas, and excessive masturbating (Is there any age where masturbating is inappropriate? I don’t think so, but other clinicians may beg to differ)
  • Other reasons that could explain hypersexual behaviors : Sexual abuse, Reactive attachment Disorder, exposure to pornographic material

5. Grandiosity

  • Children with mania will often say things such as “I can do that better than anyone else. I am the best baseball player/student/singer in the world.” Observations from adults may suggest otherwise J
  • Such bravado could also be a defense against poor self esteem or anxiety


check back next week for part 2!
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