Well, as far as trying to design, assessment or phenomenology studies or treatment intervention studies with kids and teenagers, it’s almost doubly hard in some ways because one, you’re really – to get something that’s feasible, you really have to think about is the child and the parents/family members going to be capable of doing this and what is the impact of whatever research is going to be on their life. So for instance, you can’t expect so much when a parent also has three other children. They may be a single mom who has to work as well, so expecting them to spend hours with you, coming back multiple times may be unrealistic.

The other thing that is a research challenge with this population is that since we’re dealing with young people, we’re, by definition, catching them early in their illness process, and sort of the prodromal or early manifestations of bipolar disorder can look a lot like other child psychiatric disorders and are fairly nonspecific. Things like irritability, sleep problems, hyperactivity, impulsivity, mood lability, that can describe a number of different psychiatric illnesses in kids, and so there’s a very difficult diagnostic challenge.

And kids, although you can interview them and some of them can give you a lot of insight into what they’re experiencing, many of them can’t. So you can’t rely on their report specifically all the time to make the diagnosis. You are relying quite a bit on parent or caregiver information, which can be good because they are an outside observer and can discuss behaviors and things that they see. But on the other hand, their viewpoint can be biased at times and can lead to difficult or misdiagnoses. So in some ways, just getting the patient population in sort of an accurate way is an extra challenge.

The other methodologic issue is you really have to convince both a young person and a parent or caregiver to participate in the research, and if one or the other doesn’t want to do it, it’s not going to happen. And, you know, kids that are healthy have short attention spans and are going to have moodiness and are going to have difficulty filling out questionnaires or taking medicine or things like that. So imagine somebody who’s got a lot of affect dysregulation, energy changes, impulsivity, that’s asking quite a lot. So those are really significant methodologic issues that we have to deal with when we’re dealing with kids and teenagers with bipolar disorder.