Also called: Manic Depression in Children, Pediatric Manic Depressive Disorder
Bipolar disorder, formerly called manic depression, is a mental health illness characterized by one or more episodes of mania (emotional highs) or mixed episodes (in which manic episodes coincide with episodes of major depression on a daily basis for at least a week). The onset of bipolar disorder usually happens in late adolescence or early adulthood, but it can occur at any age, including during childhood.
Most people with bipolar disorder experience distinct, alternating periods of extreme energy and impulsivity (mania) and sadness, hopelessness and loss of interest in activities (depression). This is true of children with bipolar disorder as well, although symptoms may differ somewhat in children.
For example, during manic episodes children and teenagers are more likely than adults to become irritable and to engage in destructive behavior rather than to be euphoric. In addition, children are more likely than adults under age 60 to experience these moods at the same time, a condition known as a mixed state. Children and adolescents also cycle rapidly between mania and depression, sometimes within the same day. Among adults with bipolar disorder, these changes typically occur over a period of weeks or months.
The cause of bipolar disorder is not well understood. However, it appears that brain chemistry plays a major role in its development. Bipolar disorder appears to have a genetic component, and children are at greater risk for bipolar disorder if their parents or siblings have the disorder.
Parents who observe behaviors associated with bipolar disorder in their children for at least two weeks are urged to seek medical advice. Diagnosing bipolar disorder in children can be difficult and controversial. There are no separate diagnostic criteria for children with bipolar disorder, although the mood cycles most children experience occur more rapidly than the criteria allow. However, many people diagnosed as adults report that their symptoms began in childhood. Bipolar disorder may also be initially diagnosed as depression, before a manic episode is identified.
Treatment of bipolar disorder often involves a combination of medications and psychotherapy. For some children or adolescents, inpatient psychiatric care may be required for a time to prevent them from harming themselves or others. There is no cure for bipolar disorder, although treatments usually control the symptoms and enable sufferers to function normally. Bipolar disorder that begins in childhood or adolescence is frequently more severe than cases that begin in adulthood.
About bipolar disorder in children
Bipolar disorder is a mental illness characterized by one or more episodes of mania (emotional highs) or mixed episodes (in which manic episodes coincide with episodes of major depression on a daily basis for at least a week). The condition was formerly called manic-depressive illness. The onset of bipolar disorder usually occurs in late adolescence or early adulthood, and the average age of onset is 20 years. However, the disorder can occur at any age, including during childhood. Many people who are diagnosed with bipolar disorder in their 20s report experiencing symptoms during childhood.
Most healthy people experience swings in mood. This is true of children as well. However, people with bipolar disorder experience severe shifts in mood that alternate between periods of extreme energy and impulsive behavior (mania) and periods of sadness, hopelessness and loss of interest in activities (depression). These severe mood swings typically impair a patient’s functioning at work or school and affect relationships with family and peers.
Children with bipolar disorder also experience these mood swings, although in many cases they are more likely than adults to experience these moods at the same time, a condition known as a mixed state. Among adults, the mood swings take place over a period of weeks or months. Children with bipolar disorder may cycle rapidly between moods within the same day.
Approximately one-third of the 3.4 million children and adolescents diagnosed with depression in the United States may be experiencing the early stages of bipolar disorder, according to the American Academy of Child and Adolescent Psychiatry.
Children with bipolar disorder may display behavior that changes rapidly and unpredictably. They may be aggressive at one point, then suddenly appear withdrawn later on. These mood changes significantly interfere with a child’s ability to function and to enjoy life. Academic performance, friendships and especially family relationships can all be affected.
Bipolar disorder typically does not affect a person until late adolescence or early adulthood. Although physicians and other mental health professionals are now more aware of the role of this disorder in childhood, many experts believe it is still underdiagnosed in children and adolescents. The symptoms associated with bipolar disorder are also associated with other mental health disorders in children, including attention deficit hyperactivity disorder (ADHD) and anxiety disorders.
In addition, parents and others often view unpredictable behavior as a normal part of childhood and adolescence, and as a result may be less likely to identify problem behavior. However, bipolar behavior may have serious consequences if not addressed with treatment. People with bipolar disorder, including children, have an increased risk of suicide. Children with the condition may also engage in risk-taking behaviors, such as attempting to fly. Their behavior may also be extremely disruptive in school and at home.
A recent study conducted by the U.S. National Institute of Mental Health (NIMH) found that bipolar children and adolescents tended to misread neutral facial expressions as hostile, which may account for the poor social skills, aggression and irritability often seen in children with the disorder.
Risk factors and causes
The cause of bipolar disorder is not well understood. However, it appears that brain chemistry plays a major role in its development. Brain chemicals called neurotransmitters convey messages between the nerves. Too many or too few neurotransmitters are believed to cause alterations in mood.
Bipolar disorder appears to have a genetic component, although the specific gene that may be linked to this condition has not been identified. Children are at greater risk for bipolar disorder if one or both parents have the disorder. In addition, a family history of substance abuse appears to be associated with a higher risk of developing bipolar disorder.
Some researchers believe that some people inherit a tendency to develop the illness, which may be then triggered by environmental factors (e.g., stressful life events, disturbances in circadian or seasonal rhythms). Other possible triggers include sleep deprivation and treatment with antidepressants and certain herbal and dietary supplements (e.g., St. John’s wort). Many drugs and other substances can produce the symptoms of bipolar disorder.
Signs and symptoms in children
Many of the symptoms of bipolar disorder in children are similar to those of adults with the condition. However, children may experience some symptoms slightly differently than adults. Symptoms of bipolar disorder are typically divided into two categories – mania and depression.
Symptoms of manic episodes include:
- Euphoria and elevated, “high” feelings or irritability. The patient may be in a good mood that remains even when things happen that would normally dampen the mood. For example, a child may appear extremely elated, even when waiting in a principal’s office for a reprimand. During mania, children and teenagers are more likely than adults to become irritable and to engage in destructive behavior rather than to be euphoric.
- Uncharacteristically elevated self-esteem, feelings of grandiosity or unrealistic confidence. Patients often feel very good about themselves, or feel like they can take on the world. Children may feel that they can defy logic, by being able to fly or not being subject to rules or laws.
- Decreased need for sleep. The patient may wake up feeling rested after only a few hours of sleep. Children may stay up late at night, but be extremely difficult to awaken in the morning.
- Rapid talking, talking more than usual or feeling a need to keep talking. Patients may be excessively talkative. They may be loud or talk too fast.
- “Flight” of ideas, feeling as though thoughts are racing, distraction or agitation. Patients may be easily distracted or restless. They may have rapidly shifting thoughts that may be revealed in conversation as the patient constantly changes the subject.
- Increased goal-directed activity. Productivity may be increased.
- Intrusive or aggressive behavior. The patient may seem nosy or aggressive, sometimes with destructive outbursts. Children with bipolar disorder may physically attack peers or family members during manic outbursts. This may prevent them from establishing solid peer relationships. Children may also become enraged when they are disciplined or told “no.”
- Unaware that anything is wrong. Because patients feel good and are often more productive, they may be unaware or in denial of their condition.
- Seeking pleasure without regard to consequences, reckless behavior or poor judgment. Patients may engage in sexually precocious behavior, substance abuse or other behavior when they would normally exercise better judgment. Adolescents may be sexually promiscuous, whereas younger children may use sexually explicit language or touch themselves or other people inappropriately. Bipolar children may also engage in daredevil type behavior, such as reckless driving among adolescents.
Major depressive episodes are the most common of the depressive disorders occurring in bipolar disorder. Nearly all patients will have one at some point during their lifetimes.
The symptoms of major depressive episodes include:
- Altered mood. The patient may experience sadness, anxiety, anger, irritability or apathy (lack of emotion). They may be pessimistic (feel that everything in life will turn out badly) or discouraged and may experience crying spells or excessive emotional sensitivity. Crying and irritability are common among children with bipolar disorder.
- Anhedonia. Reduction or loss of interest in activities the patient formerly found pleasurable, such as food, school, friends, hobbies and entertainment.
- Significant change in appetite or weight. Reduced or increased appetite or significant weight loss or gain.
- Changes in sleep patterns. The patient may sleep too much (hypersomnia) or not enough (insomnia). Often, the patient wakes up early in the morning and cannot get back to sleep.
- Physical or verbal activity. The patient may be agitated and anxious. They may wring their hands, pace or not be able to sit still. Conversely, the patient may have sluggish movements or speech. There may be a pause before answering questions or starting actions. The patient may speak quietly or not be able to be heard. They may not speak except in response to a direct question or may become completely mute (not talking at all).
- Fatigue and loss of energy.
- Diminished self-worth. The patient may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.
- Impaired concentration. There may be a diminished ability to concentrate.
- Death thoughts. The patient may have recurrent thoughts of death and death wishes. They may think about committing suicide (suicidal ideation) or exhibit suicidal actions. The patient may even attempt or complete suicide.
Symptoms of depression that are especially characteristic of children include physical ailments such as various body aches and fatigue. Children are also likely to encounter academic difficulties when depressed, including regular absences from school and poor academic performance. They may threaten to run away from home and may follow through on such threats. Other characteristic symptoms of depression in children with bipolar disorder include:
- Constant complaints
- Difficulty with relationships
- Extreme difficulty handling rejection or failure
- Poor communication
- Social isolation
Children with bipolar disorder sometimes display symptoms of hallucinations and delusions, which are more commonly associated with disorders such as schizophrenia.
Studies suggest that children and teens with bipolar disorder may have a more severe form of the condition than that experienced by older patients. This may include more continuous and rapid cycling between moods and greater tendency for symptoms to be “mixed” – partially depressed and partially manic. Though adults are likely to have clearly defined and separated periods of depression and mania, children may cycle between the two states several times daily.
Children with bipolar disorder are also more likely than adults to experience other mental health disorders, including attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD) and anxiety disorders.
Teens and children who have bipolar disorder are at higher risk than other youths for developing substance abuse disorders. The use of recreational drugs and alcohol may help these youths to numb themselves from the emotional imbalance and unsettled behavior associated with bipolar disorder.
Diagnosis of bipolar disorder in children
Parents who observe behaviors associated with bipolar disorder in their children for at least two weeks are urged to schedule an examination with their child’s primary physician. The onset of bipolar disorder may begin with either a depressive or a manic episode.
Diagnosing bipolar disorder in children can be difficult. In addition, some symptoms that appear to be related to bipolar disorder may actually be the result of another disorder such as anxiety disorders and attention deficit hyperactivity disorder. Children exposed to physical abuse, sexual abuse or domestic violence may display severe shifts in mood. In such cases, a diagnosis of post-traumatic stress disorder may be more appropriate than a diagnosis of bipolar disorder. Many drugs, both legal and illegal, can produce the symptoms of bipolar disorder.
Children with bipolar disorder often do not fully meet the diagnostic criteria established for adults. However, the condition in children may be more severe than in adults. It may be characterized by a continuous state of rapid cycling, mixed symptoms of mania and depression.
Bipolar disorder is often underdiagnosed and misdiagnosed in patients of all ages. According to the National Mental Health Association (NMHA), up to 80 percent of patients with the condition go undiagnosed or misdiagnosed for up to 10 years. However, there may be an overrepresentation of bipolar disorder in higher social-economic and education groups. This may be because these groups may be more aware of the disorder and are more likely to acknowledge and accept mental health disorders.
Before bipolar disorder can be diagnosed, a physician must perform a physical examination of the child to rule out other potential causes of the symptoms. Many medications or medical conditions (e.g., viral infections) can cause symptoms similar to those of bipolar disorder. Lab tests may also be ordered, particularly to check for thyroid dysfunction, which can produce the symptoms of bipolar disorder or make the symptoms of bipolar disorder worse in people with the disorder. Urine toxicology may be ordered to detect mood-altering drugs that can cause similar changes in mood.
The actual diagnosis of bipolar disorder begins with a mental health evaluation performed either by a primary care physician or by referral to a mental health professional, typically a child and adolescent psychiatrist. This evaluation includes a complete history of symptoms, including when they started, how long they have lasted and how severe they are. It is also noted whether the child has had these symptoms before and, if so, whether and how they were treated. The Mood Disorder Questionnaire (MDQ) may be used, as well. This is a set of questions for the patient to answer that helps to determine if the child has had any previous manic symptoms.
The physician or mental health professional will also ask about whether the child has thought about death or suicide and whether other family members have had a mood disorder or history of alcohol and drug use. The family’s medical history is especially important in identifying bipolar disorder in children. Many children with the condition have a bipolar parent or other family member, although the parent’s condition may remain undiagnosed.
Bipolar disorder is generally characterized by many separate episodes of mania. For an episode to be considered a new episode, the following criteria must exist:
- There must be a shift in mood or lapse of time. The patient must display a drastic shift in mood, such as from major depression to mania. A new episode may also be diagnosed if it is separated from the previous episode by at least two months of normal mood. However, most children with bipolar disorder do not meet this standard because their mood swings occur more rapidly.
- Episodes must occur spontaneously. They cannot be directly caused by a general medical condition or the use of prescription or illegal substances.
- Psychotic disorders (e.g., schizophrenia) must be ruled out.
Diagnosis of bipolar disorder in children is largely dependent on symptoms. It is especially difficult because the symptoms change rapidly and may only occur at home and be observed only by family members or caregivers.
Treatment options for bipolar disorder
Bipolar disorder in children and adolescents is frequently more severe than the condition is in adults. It can be treated, but not cured, with a combination of medication and psychosocial care.
In some cases, a child or adolescent is diagnosed during a crisis severe enough to warrant inpatient psychiatric treatment. Such treatment is used to provide and monitor medications for the child and prevent them from harming themselves or others. Inpatient care may be considered when substance abuse is involved or the patient has threatened harm, or has access to potentially harmful items (e.g., firearms).
Medications are generally the first line of treatment for bipolar disorder. They are used to quickly control and eliminate dangerous or disabling symptoms and prevent further episodes. Medications used to treat bipolar disorder include:
- Mood-stabilizing drugs. The primary medications for bipolar disorder. Different types of mood stabilizers may be more effective in different patients and a second mood stabilizer may be added if a single medication is not effective. Lithium is the most common mood stabilizer, and generally the first medication used to treat bipolar disorder. It is typically more effective when started early in the course of the condition. According to the National Mental Health Association (NMHA), lithium is effective in controlling mania in 60 percent of patients with bipolar disorder. It is also effective in preventing new episodes of both mania and depression and appears effective in reducing suicide among patients with bipolar disorder.
There is limited data on the effectiveness of mood-stabilizing drugs in treating bipolar disorder in children. Research continues into how effective and safe these medications are when used in youths. Anticonvulsants are mood-stabilizing drugs that can be helpful for children with bipolar disorder. However, some types have serious side effects, such as weight gain and the risk for girls to develop polycystic ovarian syndrome ([PCOS] a hormonal disorder that causes infertility).
- Antipsychotics. These may be used to treat some children who have aggressive behavior or experience psychotic symptoms.
Some medications must be carefully monitored or discontinued when bipolar disorder is diagnosed. For example, some children with bipolar disorder who use stimulant medications to treat attention deficit hyperactivity disorder (ADHD) may experience increased mania. Antidepressants may cause or worsen manic episodes in bipolar patients. However, they may occasionally be carefully used with mood stabilizers in the treatment of depressive episodes.
Although some children with bipolar disorder may benefit from antidepressant use, these drugs should be used with extreme caution. The U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients – particularly children – and all people being treated with them should be monitored closely for unusual changes in behavior. Antidepressant use in children with bipolar disorder has also been shown to increase mania when these drugs are taken without a mood stabilizer.
Psychotherapy is typically only used when the most severe bipolar symptoms are under control with medication. Children who engage in psychotherapy will learn to understand themselves better and to develop a stronger sense of self-worth. They also will learn techniques to reduce stress and to improve their relationships.
Psychotherapies commonly used in the treatment of bipolar disorder include:
- Cognitive-behavior therapy(CBT). The patient learns to change and control inappropriate thought patterns and behaviors. For younger children, therapy may concentrate on behavior only, until they have a better understanding of their cognitive abilities.
- Psychoeducation. Teaches the patient about bipolar disorder, its treatment and how to recognize early signs of new episodes so that early intervention can take place. This is often helpful for family members of patients with bipolar disorder as well.
- Family therapy. Reduces the levels of distress within the family that may contribute to or result from the symptoms of bipolar disorder. Family therapy can help parents learn to deal with their bipolar child and may help siblings adjust as well.
- Interpersonal and social rhythm therapy. Improves the interpersonal relationships of patients and normalizes their daily routines and sleep schedules to give them more control of their lives and their condition.
- Group therapy. Focuses on acceptance of bipolar disorder and the need for long-term medication. This may include families.
Therapeutic treatment of bipolar disorder in children may extend to the child’s school. Specific individual education plans (IEPs) can be developed for the child in cooperation with teachers and the school system.
Research indicates that left untreated, childhood-onset bipolar disorder can have negative consequences in adulthood, including an increased risk of substance abuse, relationship difficulties and suicide, among others.
Tips for coping with bipolar disorder in children
Bipolar disorder can have a major effect on the lives of children who have the condition. However, with treatment, children can live full lives. Tips for parents or caregivers of children living with bipolar disorder include:
- Make sure children follow the prescribed treatment regimen closely. Children should take medications as directed, without skipping any doses. Primary care physicians or psychiatrists may have to monitor medical compliance closely if the child also has a bipolar parent, who may not monitor the child. If psychotherapy has been recommended, children are urged to attend sessions regularly. Do not make any changes in therapy without consulting a physician or mental health professional.
- Keep an eye out for signs of an upcoming episode. If specific triggers of episodes have been identified, be attentive to them and help children avoid them when possible. Friends and family members can often help with this awareness. As soon as it seems that a mood episode may be developing, contact a physician (e.g., psychiatrist) or other mental health professional.
- Avoid drugs, alcohol or other triggers. Many substances, both legal and illegal, can affect the mood. Recreational or club drugs can be particularly dangerous, but legal drugs such as diet drugs may also need to be avoided. Parents should also observe any foods that may trigger an episode in their child. For instance, excessive consumption of sugar can result in a temporary surge in energy followed by fatigue and lethargy, which can accentuate the mood symptoms of individuals with bipolar disorder. It is also important to discuss any of the child’s over-the-counter or prescription medications with the physician or mental health professional who is treating the child’s bipolar disorder.
In addition, parents should ensure that their child eats a varied, well-balanced diet that is high in nutrients (e.g., vitamins A, B-12 and C, calcium, folate, iron), which is important for overall mental and physical well-being.
Questions for your doctor on bipolar disorder
Preparing questions in advance can help parents and patients have more meaningful discussions with their physicians regarding their conditions. Parents may wish to ask their doctor the following questions related to bipolar disorder in children:
- How will I know if my child’s mood swings are more serious than typical childhood angst?
- Do you have experience treating children with bipolar disorder?
- How will you distinguish between possible bipolar disorder and another condition my child may have?
- What form of bipolar disorder does my child have?
- How severe is my child’s bipolar disorder?
- How can you differentiate between bipolar disorder and attention deficit hyperactivity disorder in my child?
- What other mental health disorders do you suspect my child may have?
- Which medications are right for my child?
- What are the side effects of these medications?
- How can I help teach my child to take his or her medication regularly?
- Which psychotherapies might be beneficial to my child?
- How will my child’s condition impact academics, extracurricular activities, etc.?
- What does my child’s school need to know about his or her condition?
- What is my child’s long-term prognosis?
- Are my other children more likely to develop bipolar disorder?