A 12-year-old boy with no psychiatric history and no evidence of substance use presents with his first manic episode. Throughout the past 4 weeks, his family, school, and friends have noted distinct changes in his mood and behavior. His mood has oscillated between euphoria and severe irritability, with little or no provocation. He has been awake much of the past several nights, running up significant charges on pornography Web sites using his parents' credit cards. He recently sexually propositioned a female teacher at school. On interview, he is extremely grandiose, with racing thoughts and rapid pressured speech. He has a family history of bipolar disorder in his mother, maternal grandfather, and maternal uncle. Several expert clinicians discuss their practical approaches for this case. Their responses are not meant to be practice guidelines but rather examples of thought processes that may go into pharmacotherapy decision making.