Bipolar disorder (also known as manic-depression) is a serious but treatable medical illness. It is a disorder of the brain marked by extreme changes in mood, energy, thinking and behavior. Symptoms may be present since infancy or early childhood, or may suddenly emerge in adolescence or adulthood. Until recently, a diagnosis of the disorder was rarely made in childhood. Doctors can now recognize and treat bipolar disorder in young children.
Early intervention and treatment offer the best chance for children with emerging bipolar disorder to achieve stability, gain the best possible level of wellness, and grow up to enjoy their gifts and build upon their strengths. Proper treatment can minimize the adverse effects of the illness on their lives and the lives of those who love them.
Families of affected children and adolescents are almost always baffled by early-onset bipolar disorder and are desperate for information and support. In this section of the CABF web site, you will find answers to some of the most common questions asked about the disorder.
How common is bipolar disorder in children?
It is not known, because studies are lacking. However, bipolar disorder affects an estimated 1-2 percent of adults worldwide. The more we learn about this disorder, the more prevalent it appears to be among children.
* It is suspected that a significant number of children diagnosed in the United States with attention-deficit disorder with hyperactivity (ADHD) have early-onset bipolar disorder instead of, or along with, ADHD.
* According to the American Academy of Child and Adolescent Psychiatry, up to one-third of the 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder.
What are the symptoms of bipolar disorder in children?
Bipolar disorder involves marked changes in mood and energy. In most adults with the illness, persistent states of extreme elation or agitation accompanied by high energy are called mania. Persistent states of extreme sadness or irritability accompanied by low energy are called depression.
However, the illness looks different in children than it does in adults. Children usually have an ongoing, continuous mood disturbance that is a mix of mania and depression. This rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes.
Symptoms may include:
* an expansive or irritable mood
* depression
* rapidly changing moods lasting a few hours to a few days
* explosive, lengthy, and often destructive rages
* separation anxiety
* defiance of authority
* hyperactivity, agitation, and distractibility
* sleeping little or, alternatively, sleeping too much
* bed wetting and night terrors
* strong and frequent cravings, often for carbohydrates and sweets
* excessive involvement in multiple projects and activities
* impaired judgment, impulsivity, racing thoughts, and pressure to keep talking
* dare-devil behaviors
* inappropriate or precocious sexual behavior
* delusions and hallucinations
* grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)
Symptoms of bipolar disorder can emerge as early as infancy. Mothers often report that children later diagnosed with the disorder were extremely difficult to settle and slept erratically. They seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event. The word "no" often triggered these rages.
Several ongoing studies are further exploring characteristics of affected children. Researchers are studying, with promising results, the effectiveness and safety of adult treatments in children. CABF will report all new findings on early-onset bipolar disorder and will include the more important articles in our Learning Center whenever possible.
What are the symptoms of bipolar disorder in adolescents?
In adolescents, bipolar disorder may resemble any of the following classical adult presentations of the illness.
Bipolar I. In this form of the disorder, the adolescent experiences alternating episodes of intense and sometimes psychotic mania and depression.
Symptoms of mania include:
* elevated, expansive or irritable mood
* decreased need for sleep
* racing speech and pressure to keep talking
* grandiose delusions
* excessive involvement in pleasurable but risky activities
* increased physical and mental activity
* poor judgment
* in severe cases, hallucinations
Symptoms of depression include:
* pervasive sadness and crying spells
* sleeping too much or inability to sleep
* agitation and irritability
* withdrawal from activities formerly enjoyed
* drop in grades and inability to concentrate
* thoughts of death and suicide
* low energy
* significant change in appetite
Periods of relative or complete wellness occur between the episodes.
* Bipolar II. In this form of the disorder, the adolescent experiences episodes of hypomania between recurrent periods of depression. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy. Hypomania can be a time of great creativity.
* Cyclothymia. Adolescents with this form of the disorder experience periods of less severe, but definite, mood swings.
* Bipolar Disorder NOS (Not Otherwise Specified). Doctors make this diagnosis when it is not clear which type of bipolar disorder is emerging.
For some adolescents, a loss or other traumatic event may trigger a first episode of depression or mania. Later episodes may occur independently of any obvious stresses, or may worsen with stress. Puberty is a time of risk. In girls, the onset of menses may trigger the illness, and symptoms often vary in severity with the monthly cycle.
Once the illness starts, episodes tend to recur and worsen without treatment. Studies show that after symptoms first appear, typically there is a 10-year lag until treatment begins. CABF encourages parents to take their adolescent for an evaluation if four or more of the above symptoms persist for more than two weeks. Early intervention and treatment can make all the difference in the world during this critical time of development.
Is substance abuse and addiction related to bipolar disorder?
A majority of teens with untreated bipolar disorder abuse alcohol and drugs. Any child or adolescent who abuses substances should be evaluated for a mood disorder.
Adolescents who seemed normal until puberty and experience a comparatively sudden onset of symptoms are thought to be especially vulnerable to developing addiction to drugs or alcohol. Substances may be readily available among their peers and teens may use them to attempt to control their mood swings and insomnia. If addiction develops, it is essential to treat both the bipolar disorder and the substance abuse at the same time.
What role does genetics or family history play in bipolar disorder?
The illness tends to be highly genetic, but there are clearly environmental factors that influence whether the illness will occur in a particular child. Bipolar disorder can skip generations and take different forms in different individuals.
The small group of studies that have been done vary in the estimate of risk to a given individual:
* For the general population, a conservative estimate of an individual's risk of having full-blown bipolar disorder is 1 percent. Disorders in the bipolar spectrum may affect 4-6%.
* When one parent has bipolar disorder, the risk to each child is l5-30%.
* When both parents have bipolar disorder, the risk increases to 50-75%.
* The risk in siblings and fraternal twins is 15-25%.
* The risk in identical twins is approximately 70%.
In every generation since World War II, there is a higher incidence and an earlier age of onset of bipolar disorder and depression. On average, children with bipolar disorder experience their first episode of illness 10 years earlier than their parents' generation did. The reason for this is unknown.
The family trees of many children who develop early-onset bipolar disorder include individuals who suffered from substance abuse and/or mood disorders (often undiagnosed). Also among their relatives are found highly-accomplished, creative, and extremely successful individuals in business, politics, and the arts.
Historical Perspective
Bipolar disorder has left its mark on history. Many famous and accomplished people had symptoms of the illness, including:
* Abraham Lincoln
* Winston Churchill
* Theodore Roosevelt
* Goethe
* Balzac
* Handel
* Schumann
* Berlioz
* Tolstoy
* Virginia Woolf
* Hemingway
* Robert Lowell
* Anne Sexton
The biographies of Beethoven, Newton, and Dickens, in particular, reveal severe and debilitating recurrent mood swings beginning in childhood.
* Timeline
Diagnosing Bipolar Disorder in Children
Healthy children often have moments when they have difficulty staying still, controlling their impulses, or dealing with frustration. The Diagnostic and Statistical Manual IV (DSM-IV) still requires that, for a diagnosis of bipolar disorder, adult criteria must be met. There are as yet no separate criteria for diagnosing children.
Some behaviors by a child, however, should raise a red flag:
* destructive rages that continue past the age of four
* talk of wanting to die or kill themselves
* trying to jump out of a moving car
To illustrate how difficult it is to use the DSM-IV to diagnose children, the manual says that a hypomanic episode requires a "distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." Yet upwards of 70 percent of children with the illness have mood and energy shifts several times a day.
Since the DSM-IV is not scheduled for revision in the immediate future, experts often use some DSM-IV criteria as well as other measures. For example, a Washington University team of researchers uses a structured diagnostic interview called Wash U KIDDE-SADS, which is more sensitive to the rapid-cycling periods commonly observed in children with bipolar disorder.
How does bipolar disorder differ from other conditions?
Even when a child's behavior is unquestionably not normal, correct diagnosis remains challenging. Bipolar disorder is often accompanied by symptoms of other psychiatric disorders. In some children, proper treatment for the bipolar disorder clears up the troublesome symptoms thought to indicate another diagnosis. In other children, bipolar disorder may explain only part of a more complicated case that includes neurological, developmental, and other components.
Diagnoses that mask or sometimes occur along with bipolar disorder include:
* depression
* conduct disorder (CD)
* oppositional-defiant disorder (ODD)
* attention-deficit disorder with hyperactivity (ADHD)
* panic disorder
* generalized anxiety disorder (GAD)
* obsessive-compulsive disorder (OCD)
* Tourette's syndrome (TS)
* intermittent explosive disorder
* reactive attachment disorder (RAD)
In adolescents, bipolar disorder is often misdiagnosed as:
* borderline personality disorder
* post-traumatic stress disorder (PTSD)
* schizophrenia
The need for prompt and proper diagnosis
Tragically, after symptoms first appear in children, years often pass before treatment begins, if ever. Meanwhile, the disorder worsens and the child's functioning at home, school, and in the community is progressively more impaired.
The importance of proper diagnosis cannot be overstated. The results of untreated or improperly treated bipolar disorder can include:
* an unnecessary increase in symptomatic behaviors leading to removal from school, placement in a residential treatment center, hospitalization in a psychiatric hospital, or incarceration in the juvenile justice system
* the development of personality disorders such as narcissistic, antisocial, and borderline personality
* a worsening of the disorder due to incorrect medications
* drug abuse, accidents, and suicide.
It is important to remember that a diagnosis is not a scientific fact. It is a considered opinion based upon the behavior of the child over time, what is known of the child's family history, the child's response to medications, his or her developmental stage, the current state of scientific knowledge and the training and experience of the doctor making the diagnosis. These factors (and the diagnosis) can change as more information becomes available. Competent professionals can disagree on which diagnosis fits an individual best. Diagnosis is important, however, because it guides treatment decisions and allows the family to put a name to the condition that affects their child. Diagnosis can provide answers to some questions but raises others that are unanswerable given the current state of scientific knowledge.
How can I help my child?
Parents concerned about their child's behavior, especially suicidal talk and gestures, should have the child immediately evaluated by a professional familiar with the symptoms and treatment of early-onset bipolar disorder.
There is no a blood test or brain scan, as yet, that can establish a diagnosis of bipolar disorder.
Parents who suspect that their child has bipolar disorder (or any psychiatric illness) should take daily notes of their child's mood, behavior, sleep patterns, unusual events, and statements by the child of concern to the parents. Share these notes with the doctor making the evaluation and with the doctor who eventually treats your child. Some parents fax or e-mail a copy of their notes to the doctor before each appointment.
Because children with bipolar disorder can be charming and charismatic during an appointment, they initially may appear to a professional to be functioning well. Therefore, a good evaluation takes at least two appointments and includes a detailed family history.
Finding the right doctor
If possible, have a board-certified child psychiatrist diagnose and treat your child. A child psychiatrist is a medical doctor who has completed two to three years of an adult psychiatric residency and two additional years of a child psychiatry fellowship program. Unfortunately, there is a severe shortage of child psychiatrists, and few have extensive experience treating early-onset bipolar disorder.
Teaching hospitals affiliated with reputable medical schools are often a good place to start looking for an experienced child psychiatrist. You can also ask your child's pediatrician for a referral. Check the CABF Directory of Professional Members to see the names of doctors who practice in your area. You may also send a note to profrelations@bpkids.org to ask whether CABF is aware of other doctors where you live.
If your community does not have a child psychiatrist with expertise in mood disorders, then look for an adult psychiatrist who has 1) a broad background in mood disorders, and 2) experience in treating children and adolescents.
Other specialists who may be able to help, at least with an initial evaluation, include pediatric neurologists. Neurologists have experience with the anti-convulsant medications often used for treating juvenile bipolar disorders. Pediatricians who consult with a psychopharmacologist can also provide competent care if a child psychiatrist is not available.
Some families take their child to nationally-known doctors at teaching hospitals for diagnosis and stabilization. They then turn to local professionals for medical management of their child's treatment and psychotherapy. The local professionals consult with the expert as needed.
Experienced parents recommend that you look for a doctor who:
* is knowledgeable about mood disorders, has a strong background in psychopharmacology, and stays up-to-date on the latest research in the field
* knows he or she does not have all the answers and welcomes information discovered by the parents
* explains medical matters clearly, listens well, and returns phone calls promptly
* offers to work closely with parents and values their input
* has a good rapport with the child
* understands how traumatic a hospitalization is for both child and parents, and keeps in touch with the family during this period
* advocates for the child with managed care companies when necessary
* advocates for the child with the school to make sure the child receives services appropriate to the child's educational needs.
Treatment
Although there is no cure for bipolar disorder, in most cases treatment can stabilize mood and allow for management and control of symptoms.
A good treatment plan includes medication, close monitoring of symptoms, education about the illness, counseling or psychotherapy for the individual and family, stress reduction, good nutrition, regular sleep and exercise, and participation in a network of support.
The response to medications and treatment varies. Factors that contribute to a better outcome are:
* access to competent medical care
* early diagnosis and treatment
* adherence to medication and treatment plan
* a flexible, low-stress home and school environment
* a supportive network of family and friends
Factors that complicate treatment are:
* lack of access to competent medical care
* time lag between onset of illness and treatment
* not taking prescribed medications
* stressful and inflexible home and school environment
* the co-occurrence of other diagnoses
* use of substances such as illegal drugs and alcohol
The good news is that with appropriate treatment and support at home and at school, many children with bipolar disorder achieve a marked reduction in the severity, frequency and duration of episodes of illness. With education about their illness (as is provided to children with epilepsy, diabetes, and other chronic conditions) they learn how to manage and monitor their symptoms as they grow older.
The parent's role in treatment
As with other chronic medical conditions such as diabetes, epilepsy, and asthma, children and adolescents with bipolar disorder and their families need to work closely with their doctor and other treatment professionals. Having the entire family involved in the child's treatment plan can usually reduce the frequency, duration, and severity of episodes. It can also help improve the child's ability to function successfully at home, in school, and in the community.
Parents: Learn all you can about bipolar disorder. Read, join support groups, and network with other parents. There are many questions still unanswered about early onset bipolar disorder, but early intervention and treatment can often stabilize mood and restore wellness. You can best manage relapses by prompt intervention at the first re-occurrence of symptoms.
Medication
Few controlled studies have been done on the use of psychiatric medications in children. The U.S. Food and Drug Administration (FDA) has approved only a handful for pediatric use. Psychiatrists must adapt what they know about treating adults to children and adolescents.
Medications used to treat adults are often helpful in stabilizing mood in children. Most doctors start medication immediately upon diagnosis if both parents agree. If one parent disagrees, a short period of watchful waiting and charting of symptoms can be helpful. Treatment should not be postponed for long, however, because of the risk of suicide and school failure.
A symptomatic child should never be left unsupervised. If parental disagreement makes treatment impossible, as may happen in families undergoing divorce, a court order regarding treatment may be necessary.
Other treatments, such as psychotherapy, may not be effective until mood stabilization occurs. In fact, stimulants and antidepressants given without a mood stabilizer (often the result of misdiagnosis) can cause havoc in bipolar children, potentially inducing mania, more frequent cycling, and increases in aggressive outbursts.
No one medication works in all children. The family should expect a trial-and-error process lasting weeks, months, or longer as doctors try several medications alone and in combination before they find the best treatment for your child. It is important not to become discouraged during the initial treatment phase. Two or more mood stabilizers, plus additional medications for symptoms that remain, are often necessary to achieve and maintain stability.
Parents often find it hard to accept that their child has a chronic condition that may require treatment with several medications. It is important to remember that untreated bipolar disorder has a fatality rate of 18 percent or more (from suicide), equal to or greater than that for many serious physical illnesses. The untreated disorder carries the risk of drug and alcohol addiction, damaged relationships, school failure, and difficulty finding and holding jobs. The risks of not treating are substantial and must be measured against the unknown risks of using medications whose safety and efficacy have been established in adults, but not yet in children.
The following is a brief overview of medications used to treat bipolar disorder. More information about specific medications is available in the Drug Database.
This brief overview is not intended to replace the evaluation and treatment of any child by a physician. Be sure to consult with a doctor who knows your child before starting, stopping, or changing any medication.
Mood Stabilizers
* Lithium (Eskalith, Lithobid, lithium carbonate) - A salt that occurs naturally in the earth, lithium has been used successfully for decades to calm mania and prevent mood cycling. Lithium has a proven anti-suicidal effect. An estimated 70 to 80 percent of adult bipolar patients respond positively to lithium treatment. Some children do well on lithium, but others do better on other mood stabilizers. Lithium is often used in combination with another mood stabilizer.
* Divalproex sodium or valproic acid (Depakote) - Doctors frequently prescribe this anti-convulsant for children who have rapid cycling between mania and depression.
* Carbamazepine (Tegretol) - Doctors prescribe this anti-convulsant because of its anti-manic and anti-aggressive properties. It is useful in treating frequent rage attacks.
* Gabapentin (Neurontin)-This is a newer anti-convulsant drug that seems to have fewer side effects than other mood stabilizers. However, doctors do not know how effective this drug is, and some parents report activation of manic symptoms in young children.
* Lamotrigine (Lamictal)-This newer anti-convulsant medicine can be effective in controlling rapid cycling. It seems to work well in the depressive, as well as the manic, phase of bipolar disorder. Any appearance of rash must be immediately reported to the doctor, as a rare but severe side-effect may occur (for this reason Lamictal is not used in children under l6).
* Topiramate (Topamax)-This newer anti-convulsant drug may control rapid-cycling and mixed bipolar states in patients who have not responded well to divalproex sodium or carbamazepine. Unlike other mood stabilizers, it does not have weight gain as a side effect, but its efficacy in children has not been established.
* Tiagabine (Gabitril) -This newer anti-convulsant drug has FDA approval for use in adolescents and is now being used in children as well.
Other Medications
Doctors may prescribe antipsychotic medications (Risperdal, Zyprexa, Seroquel) for use during manic states, particularly when children experience delusions or hallucinations and when rapid control of mania is needed. Some of the newer antipsychotic medications are very effective in controlling rages and aggression. Weight gain is often a side effect of anti-psychotic medications.
Calcium channel blockers (verapamil, nimodipine, isradipine) have recently received attention as potential mood stabilizers for treating acute mania, ultra-ultra-rapid cycling, and recurrent depression.
Anti-anxiety medications (Klonopin, Xanax, Buspar, and Ativan) decrease anxiety by diminishing activity in brain arousal systems. They reduce agitation and over-activity, and help promote standard sleep. Doctors commonly use these medications as add-ons to mood stabilizers and antipsychotic drugs in acute mania.

A Cautionary Note on Antidepressants and Stimulants from the National Institute of Mental Health
Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.