Diagnosis Of Pediatric Bipolar Disorder Research Articles

Pediatric Bipolar Disorder: A Practical Guide for Clinicians.

Pediatric bipolar disorder (PBD) is a controversial clinical entity and it still needs to be satisfactorily defined. Having a polymorphous presentation and associated with numerous symptoms of comorbid psychiatric illnesses often diagnosed during childhood and adolescence, including attention deficit hyperactivity disorder, its symptoms do not completely parallel those of bipolar disorder in adults. The clinician must be able to reach a diagnosis of PBD in the presence of fluctuating and atypical symptoms, especially in children, who tend to experience mixed episodes and very rapid cycles. Historically a key symptom for diagnosing PBD is episodic irritability. Proper diagnosis is critical due to the gravity of its prognosis. Clinicians may find supporting evidence for a diagnosis through careful study of the medical and developmental history of the young patient in addition to psychometric data. Treatment prioritizes psychotherapeutic intervention and assigns important roles to family involvement and a healthy lifestyle.

Psychiatric Comorbidity in patients with Pediatric Bipolar Disorder - a Systematic Review.

A growing body of evidence suggests that pediatric bipolar disorder (PBD) frequently co-occurs with comorbid psychiatric disorders that may impact functioning. To review existing literature on the prevalence of psychiatric comorbidity and general functioning in patients with a primary diagnosis of PBD. We performed a systematic literature search on the PubMed, Embase and PsycInfo databases on November 16th, 2022. We included original papers on patients ≤18 years with primary PBD and any comorbid psychiatric disorder, diagnosed according to a validated diagnostic tool. Risk of bias of the individual studies was assessed using the STROBE checklist. We calculated weighted means to assess the comorbidity prevalence. The review complied with PRISMA statement guidelines. 20 studies with a total study population of 2722 patients with PBD were included (mean age=12.2 years). We found an overall high prevalence of comorbidity in patients with PBD. The most common comorbidities were attention-deficit-hyperactivity disorder (ADHD) (60%) and oppositional defiant disorder (ODD) (47%). Anxiety disorders, obsessive-compulsive disorder, conduct disorder, tic disorders and substance-related disorders affected between 13.2% and 29% of patients, while one in ten had comorbid mental retardation or autism spectrum disorder (ASD). The prevalence of comorbid disorders was lower in studies that assessed the current prevalence in patients in full or partial remission. General functioning was overall not specifically decreased in patients with comorbidity. Comorbidity across a broad range of disorders was high in children diagnosed with PBD, especially regarding ADHD, ASD, behavioural and anxiety disorders including OCD. Future original studies should assess current prevalence of comorbidities in patients with PBD who are in remission to obtain more reliable estimates of psychiatric comorbidity in this patient group. The review highlights the clinical and scientific importance of comorbidity in PBD. This article is protected by copyright. All rights reserved.

Further Evidence of an Association Between a Positive Child Behavior Checklist-Bipolar Profile and a Diagnosis of Pediatric Bipolar Disorder: A Meta-Analysis.

Previous research has found that a unique profile of the Child Behavior Checklist comprising of aggregate elevations of the Attention, Anxiety/Depression and Aggression scales (A-A-A profile, CBCL-Bipolar (BP) profile, CBCL-Dysregulation profile (DP); henceforth CBCL-BP/DP profile) is associated with a clinical diagnosis of pediatric bipolar (BP) disorder. The main aim of the study is to evaluate the strength of the association between the CBCL-BP/DP profile and the clinical diagnosis of pediatric BP disorder through a meta-analysis. A literature search was performed to identify studies that examined the association between a positive CBCL-BP/DP profile and a clinical diagnosis of pediatric BP disorder. The meta-analyses first examined studies assessing the rates of a positive CBCL-BP/DP profile in youth with BP disorder versus those with 1) ADHD, anxiety/depression, or disruptive behavior disorders (DBDs), and 2) non-bipolar controls. The second analysis evaluated studies examining the rates of pediatric BP disorder in youth with and without a positive CBCL-BP/DP profile. Eighteen articles met our inclusion and exclusion criteria, and fifteen articles had adequate data for meta-analysis. Results showed that BP youth were at significantly increased odds of having a positive CBCL-BP/DP profile compared to those with other psychiatric disorders (i.e., ADHD, anxiety/depression, or DBDs) (pooled OR=4.34, 95% CI=2.82, 8.27; p<0.001) and healthy control groups (pooled OR=34.77, 95% CI=2.87, 420.95; p=0.005). Further, meta-analysis results showed that youth with a positive CBCL-BP/DP profile were at significantly increased odds of having a BP disorder diagnosis compared to those without (pooled OR=4.25, 95% CI=2.12, 8.52; p<0.001). Our systematic review and meta-analysis of the extant literature provides strong support for the association between the CBCL-BP/DP profile and pediatric BP disorder.

31.4 Continuity of Pediatric Bipolar Disorder With Mania/Hypomania in Young Adulthood

In recent years, there has been substantial controversy regarding the diagnosis of pediatric bipolar disorder (PBD) and the continuity of this diagnosis with adult bipolar I disorder (BD-I) and bipolar II disorder (BD-II). A better understanding about the prospective course of youth with PBD (especially prepubertal youth) is critical to address this clinically important controversy. In this Symposium, we present a recent analysis of the Course and Outcome of Bipolar Youth (COBY) study, which assessed the course of PBD in youth and predictors of mania/hypomania in young adulthood.

Patients' opinions on the validity of the diagnosis of pediatric bipolar disorder.

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A commentary on youth onset bipolar disorder.

Given ongoing disagreement about the diagnosis of pediatric bipolar disorder, we sought to illuminate key empirical findings regarding the condition in children and adolescents. We conducted a review of extant studies of the diagnosis, course, and treatment of bipolar disorder in children and adolescents. Bipolar disorder is a lifelong, familial condition with frequent onset in childhood or adolescence. Secular trends indicate that globally, the onset of puberty is occurring earlier, which may contribute to increased identification of mood disorders in younger populations. Despite opinions to the contrary, bipolar disorder has been observed in youth around the world, not just in the U.S. Discrete and episodic manic symptoms occur on a continuum/spectrum of severity and duration. Clinicians may be just as likely to miss mania (false negatives) as overcall it (false positives). As is true in adults, periodicity and heterogeneity are defining features of early onset bipolar disorder. Youth who are misdiagnosed and undiagnosed tend to do poorly over the long term. Youth with and at risk for bipolar disorder are frequently exposed to maltreatment, abuse, and bullying. Fortunately, there are now many evidence-based interventions that have been studied in thousands of youth with or at high risk for bipolar disorder, demonstrating large effect sizes for evaluated treatments versus comparative treatments. Identifying optimal methods for the evaluation and treatment of bipolar disorder in children and adolescents represents important advances in the field. Recognizing the occurrence of mania symptoms in youth is pivotal for improving outcomes in patients living with bipolar disorder.

Occurrence and accuracy of a register-based diagnosis of pediatric bipolar disorder: A nationwide cohort study.

To investigate the accuracy of a diagnosis of pediatric bipolar disorder in the Danish National Register compared to the patient charts. Second, we reported on the occurrence of a diagnosis of pediatric bipolar disorder during the study period. All persons appearing in the Danish nationwide registers between 1995 and 2014 with an incident ICD-10 diagnosis of single hypomanic/manic episode or a diagnosis of bipolar disorder (summarized as bipolar disorder [BD]) before turning 18 years were identified (n = 521) and a random sample (n = 131) hereof was selected for chart review. Each chart was reviewed by two independent Schedules for Clinical Assessment in Neuropsychiatry (SCAN) certified raters to assess whether symptoms documented in the chart were consistent with a formal diagnosis of BD according to the ICD-10 criteria or not. The formal diagnostic criteria for BD according to the ICD-10 were fulfilled in 48 charts (45.3%, 95% CI: [36.1%, 54.8%]) out of 106 reviewable charts, age at index = 16.4 ± 1.6 (range = 9.1-18.3) years. Cohen's Kappa ranged from 94.4% to 100%. The estimate of a lifetime prevalence up till the current age for bipolar disorder for those of aged 5-18 years, was 0.019% in 2014. Less than half of the register-based pediatric BD diagnoses were confirmed by chart review, which was lower than expected. The occurrence of a register diagnosis of pediatric BD was relatively low.

26.1 HISTORICAL PERSPECTIVE: BIPOLAR DISORDER, TEMPER TANTRUMS, AND DMDD

Cathryn Galanter, MD, will review the literature examining the increased diagnosis of pediatric bipolar disorder (BD), its overdiagnosis, and the eventual revisions to DSM-5.

45.2 ARE THERE ALTERNATIVE WAYS TO IDENTIFY CHILDREN WITH BIPOLAR DISORDER?

Although structured diagnostic interviews have been developed for research studies to aid in the diagnosis of pediatric bipolar disorder (BD), these tools are not practical to use in clinical practice, because they are lengthy, costly, and not widely available. As a result, simpler diagnostic aids are needed to help identify children who may have pediatric BD. This presentation aims to discuss alternative ways of identifying children with BD.

Debate: Looking forward: choose data over opinions to best serve youth with bipolar spectrum disorders - commentary on Parry etal. (2018).

Over the past two decades, research on pediatric bipolar disorder has grown geometrically. The diagnosis of pediatric bipolar disorder was met with enthusiasm, which in healthy doses catalyzed change, and skepticism, which in good measure pushes for rigor. Skepticism led to productive questions about the phenomenology of pediatric bipolar disorder and how best to diagnose and treat it. With regard to prevalence, key questions included whether it was increasing over time, and whether it was limited to the United States. In 2011, we published a meta-analysis addressing the prevalence questions; results indicated that bipolar disorder manifested at statistically indistinguishable rates in youth community samples across the world. In their recent paper, Parry etal. examine the studies included in the 2011 meta-analysis using a qualitative approach. Their opinion piece represents a step backwards; every study has shortcomings, but in focusing on a dozen individual studies, Parry etal. fail to take into account the preponderance of evidence - literally thousands of articles across countries, cohorts and methodologies - that support the existence of bipolar disorder in both prepubescent youth and adolescents. This commentary addresses misperceptions regarding the diagnosis of bipolar disorder in youth, particularly with regard to cross-informant agreement, to present converging data from international sources regarding the onset of bipolar disorder in childhood, and to correct the false claim that pediatric bipolar disorder is controversial. As clinicians and researchers, we have an obligation to do what we can to improve the lives of youth affected by mental illness. Denying the existence of a serious mood disorder will not serve the best interests of young people and will perpetuate the long delays many experience before getting an accurate diagnosis, appropriate treatment, and a fair chance at a good quality of life.

Further Evidence of the Diagnostic Utility of the Child Behavior Checklist for Identifying Pediatric Bipolar I Disorder.

Background:Pediatric bipolar (BP) disorder is a prevalent and highly morbid disorder. While structured diagnostic interviews have been developed to aid in the diagnosis of pediatric BP disorder, these tools are lengthy, costly and not widely available. One possible diagnostic aid is the Child Behavior Checklist (CBCL).Objective:To assess the diagnostic utility of the CBCL-BP profile to identify children with a diagnosis of BP-I disorder.Method:Subjects were derived from four independent data sets of children and adolescents with and without attention deficit hyperactivity disorder and BP-I. Subjects were recruited from pediatric and psychiatric clinics and the community. All subjects had structured clinical interviews with raters blinded to subject ascertainment status. We used an empirically derived profile from the CBCL consisting of an aggregate t-score from the Attention, Anxiety/Depression and Aggression subscales (CBCL-BP profile) to operationalize the presence or absence of BP symptoms. Receiver operating characteristic (ROC) curves were used to examine the ability of the CBCL-BP profile to identify children with and without a structured interview diagnosis of BP-I disorder.Results:The sample consisted of 661 subjects (mean age: 11.7 ± 3.3 years, 57% male and 94% Caucasian). In total, 20 percent of participants (n = 130) met structured interview criteria for a full diagnosis of BP-I disorder. The ROC analysis of the CBCL-BP profile yielded an area under the curve (AUC) of 0.91. A t-score of ≥ 195 on the CBCL-BP profile correctly classified 86% of subjects with BP-I disorder with 80% sensitivity, 87% specificity, 61% positive predictive value (PPV) and 95% negative predictive value (NPV).Conclusion:The CBCL-BP profile efficiently discriminated pediatric subjects with and without a structured interview diagnosis of BP-I disorder. Findings suggest that the CBCL-BP profile may be an efficient tool to help identify children who are very likely to suffer from BP-I disorder.

1.6 Polypharmacy, Maintenance, and Depression Beyond Elementary Management of Pediatric Bipolar Disorder

Pediatric bipolar disorder has been more widely recognized and diagnosed over the past 10 years, with up to 3% of youth on the bipolar spectrum. As the diagnosis of pediatric bipolar disorder has been more widely recognized, the need for treatment options that are pediatric-specific has increased.

Trastorno bipolar infantil: A propósito de un caso

Introducción: Existe evidencia creciente sobre la validez del diagnóstico de trastorno bipolar infantil. Existen múltiples factores que contribuyen a que la enfermedad esté infradiagnosticada y se confunda con facilidad con otros trastornos con conductas de externalización patológica, como el trastorno por déficit de atención con hiperactividad. Caso clínico: Se presenta el caso clínico de un niño con sospecha de trastorno bipolar infantil con el que se ha llevado a cabo un seguimiento semanal desde los 3 hasta los 5 años, con la finalidad de observar su conducta y llevar a cabo un buen diagnóstico diferencial. Conclusiones: El diagnóstico de trastorno bipolar infantil debe ser considerado en aquellos menores con síntomas graves de hiperactividad, distraibilidad, impulsividad y alteración de la conducta, especialmente en aquellos casos en los que encontremos antecedentes familiares de trastorno bipolar, fluctuaciones anímicas llamativas, episodios de agresividad graves y alteración del sueño.

Infections and Childhood Psychiatric Disorders: Tick-Borne Illness and Bipolar Disorder in Youth

Objective: To explore possible links between tick-borne illness (TBI) and pediatric bipolar disorder (PBD) in a retrospective series of youth from a Northeast U.S. psychiatric private practice. Methods: PBD diagnosis in 27 youth (15 Bipolar I and 12 Bipolar II) was based on DSM-IV TR criteria following interviews with parents and children, questionnaires and school reports. Testing for Borrelia burgdorferi (Lyme disease), Babesia, Bartonella, Mycoplasma pneumoniae, Anaplasma and Ehrlichia occurred between February 2013 and July 2015. Lyme testing included an ELISA and Western Blot IgM/IgG and cultures; Babesia and Bartonella were ascertained by IgM/IgG antibody titers and fluorescent in-situ hybridization (FISH) tests. Other pathogen exposure was determined by IgM/IgG antibody titers. Testing was performed at LabCorp, Mayo Medical, IgeneX, Advanced Labs and/or Galaxy Diagnostics Laboratories. Clinical diagnoses were confirmed by physicians familiar with TBI. Data was summarized using descriptive statistics. Results: Eighty-one percent of the sample was male and 19% was female. Mean age at PBD diagnosis was 7.3 years. Exposure to one or more pathogens was found in 24/27 (89%) of the patients. Frequency of positive serology included: Babesia (n=16), Mycoplasma pneumoniae (n=11), Bartonella (N=8), and Lyme (n=6). Twenty-two of these 24 agreed to clinical evaluation and 92% (20/22) were diagnosed with TBI. Conclusion: The high rate of TBI in PBD patients presented here is provocative. If confirmed, this association may suggest gene-environment interactions and has implications for the prevention and treatment of PBD. Research evaluating TBI in bipolar cases vs. matched controls with other psychopathology and without psychiatric disease using standardized serological testing is needed.

Ten-year updated meta-analysis of the clinical characteristics of pediatric mania and hypomania.

The phenomenology and diagnosis of pediatric bipolar disorder has been controversial. We aimed to update a 2005 meta analysis of the prevalence of manic symptoms in youth, in order to determine whether the picture of pediatric mania has changed as research on pediatric bipolar disorder has grown. We conducted literature reviews in PsycINFO and PubMed; studies with the prevalence of manic symptoms in youth were included. Two raters coded each study; kappa was 0.86-1.0. Twenty studies were meta-analyzed (N = 2,226 youths). The most common symptoms across bipolar subtypes, using a random-effects model, were: increased energy 79%, irritability 77%, mood lability 76%, distractibility 74%, goal-directed activity 72%, euphoric/elated mood 64%, pressured speech 63%, hyperactive 62%, racing thoughts 61%, poor judgment 61%, grandiosity 57%, inappropriate laughter 57%, decreased need for sleep 56%, and flight of ideas 54%. Symptom rates were heterogeneous across samples; potential predictors were explored but no clear patterns were found. Debate continues about the definitions of pediatric bipolar disorder; the results of this meta-analysis suggest that there is significant heterogeneity of symptom prevalence between studies, and that symptoms vary widely across individuals. Understanding the roots of this heterogeneity could broaden understanding of the complex clinical presentation of pediatric mania, and aid in diagnosis.

Pediatric Bipolar Disorder: Subtype Trend and Impact of Behavioral Comorbidities.

The diagnosis of pediatric bipolar disorder (PBD) has increased dramatically in community-treated youth in the past 20 years. No previous study has assessed the trend in PBD subtype diagnoses or the impact of clinician-reported behavioral comorbidities (BC) on psychotropic medication prescribing patterns. This study aims: (1) to characterize national trends in PBD visits in relation to PBD subtypes; and (2) to assess differences in socio-demographic PBD subtype diagnostic patterns and psychotropic medications prescribed in PBD visits with and without behavioral comorbidities (w/w/o BC). PBD visits for 1999–2010 from the National Ambulatory Medical Care Survey (NAMCS) data were assessed using population-weighted chi-square and logistic regression analyses. While PBD visit rates were stable across 12 years, the proportional shift of subtype diagnosis from Bipolar I (89.0%) in 1999–2002 to Bipolar Not Otherwise Specified (NOS) (74.1%) in 2007–2010 was notable. Compared with PBD without behavioral comorbidities (w/o BC), PBD visits w/BC had greater proportions of the bipolar-NOS subtype, more males, 2–14-year-olds, and more publicly-insured visits. The prescription of antipsychotics (60% vs. 61%) was common in PBD visits regardless of the presence of behavioral comorbidities. Stimulants were the predominant class prescribed for PBD visits with BC (67.8% vs. 9.4%). Antidepressants were significantly greater in PBD visits without BC (41.6% vs. 21.0%). Overall one-third of PBD youth visits were prescribed antipsychotics concomitant with other psychotropic classes. Behavioral conditions accompanying PBD visits were prominent, suggesting the need for monitoring and evaluating the outcomes of complex medication regimens in community populations.

A Comparison of American and English Hospital Discharge Rates for Pediatric Bipolar Disorder, 2000 to 2010

Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years. We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD). There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1-103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4-1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England. The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.

Sleep architecture disturbances in children with bipolar disorder versus attention deficit and hyperactivity disorder: a pilot study

Introduction Sleep disturbances on Bipolar Disorder have been widely described and, bidirectionally, some reports point on sleep role on Bipolar Disorder physiopathology. Pediatric Bipolar Disorder (PBD) and Attention Deficit and Hyperactivity Disorder (ADHD) comorbidity is common. Useful biological markers should be found in order to achieve the correct management of both diseases. The aim of this study is to describe sleep architecture on PBD patients and compare to ADHD children. Materials and methods Participants: 4 PBD children (3 males; 4 European Hispanic) and 4 ADHD children (4 males; 3 European Hispanic) aged from 7 to 18 years were recruited from the Child and Adolescent Mental Health Services. Instruments: International Neuropsychiatric Interview for Kids and Adolescents (MINI-Kid) was used for diagnostic purposes. WISC-IV below 70 was an exclusion criterion. Socio-demographic data were recorded. BEARS Algorithm and Sleep Disturbance Scale for Children (SDSC) were applied for sleep disturbances screening. Child Depression Inventory (CDI), Child Mania Rating Scale (CMRS) and Young Mania Rating Scale parent’s version (p-YMRS) were measured the same day of Nocturnal Polysomnography (NPSG) was performed. Hypnogram characteristics were manually scored. Parameters analyzed were Sleep Efficiency, Sleep Time in N1, N2, N3 and REM stages, NoREM and REM Sleep Latencies, duration and number of REM cycles and REM density values. Results All PBD and ADHD participants had at least one current comorbid Axis I disorder. Sleep architecture showed a wide diversity. Significant differences in NPSG values according to PBD or ADHD conditions were not found. Only REM density showed a higher mean value on PBD than on ADHD children. 100% of PBD and 75% of ADHD participants were taking psychotropic medication. Correlations between sleep architecture and current medical treatments could not be established. No correlation between scales for the assessment of mood and sleep variables was found. Conclusion Sleep architecture in PBD and ADHD patients presents heterogeneous patterns. REM density seems to play an important role as biological marker in differential diagnosis of PBD and ADHD. New trials should be applied in order to establish correlations between NPSG variables and PBD or ADHD conditions, psychotropic drugs effects and mood disturbances. Acknowledgement Neurophysiology Department, Hospital del Mar.

2666 – How pediatric bipolar disorder and pandas/pans symptoms overlap and can cause diagnostic confusion

In recent years the number of youth given the diagnosis of pediatric bipolar disorder (PBD) has escalated and the question of overdiagnosis has been raised. The existence of the diagnoses on Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome PANS) has also been the subject of controversy. This poster compares the symptoms of these two groups of disorders and presents one case to demonstrate how these disorders may confound the diagnostic presentation of a youngster with mood and behavioral symptoms. The goal is to familiarize the reader with the symptomatic presentations of PBPD, vs. PANDAS and PANS and how to approach assessment and treatment issues. Similarities and differences in the diagnostic criteria for all three disorders will be compared. A case demonstrating the importance of recognizing both groups of diagnoses for maximizing therapeutic interventions will be presented. Comparison will indicate how one or both of these disorders may be responsible for a child's mood and behavioral symptoms. The importance of this in determining the approach to treatment will be discussed. It is hypothesized that part of the significant rise in the number of youngsters being given the diagnosis of Pediatric Bipolar Disorder, may be due to the lack of recognition of PANS and / or PANDAS. Detailed history of symptomatology, past medical history, laboratory testing, family history of psychiatric illness as well as autoimmune disorders, may play an important role in the approach to treatment.

P.7.c.009 Maintenance of efficacy of lisdexamfetamine dimesylate in children and adolescents with ADHD: randomised withdrawal design

Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years.We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD).There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1–103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4–1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England.The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.