Manic Depression / Bipolar Disorder Treatment

Parents concerned about the behavior of a child with bipolar disorder, especially suicidal talk and gestures, should have the child immediately evaluated by a board-certified child and adolescent psychiatrist familiar with the symptoms and treatment of pediatric bipolar disorders.

There is no a blood test, genetic test or brain scan 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 email 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.

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. There are "many specialists, few experts."

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

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

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.

Few controlled studies have been done on the use of psychiatric medications in children. Psychiatrists must adapt what they know about treating adults to children and adolescents as 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.

Treatment of Guidelines for Children and Adolescents with Bipolar Disorder (March 2005).

  • From the Journal of the Academy of Child & Adolescent Psychiatry. Guidelines based on medical literature, ranking evidence for the treatment of the classic form of the illness (called Bipolar-1) in children ages 6 to 17, and include step-by-step strategies (called algorithms) for treatment of mania and depression, with or without psychosis, in young patients.

Mood Stabilizers and Atypical Antipsychotics Agents

Lithium (Eskalith, Lithobid, lithium carbonate)

A salt that occurs naturally, lithium has been used successfully for several decades to treat mania and prevent mood cycling. Lithium has a proven antisuicidal effect. An estimated 50-60 percent of adult bipolar patients respond positively to lithium treatment. Some children do well on lithium, but others do better on other mood stabilizers or combinations of mood stabilizers. Lithium is often used in combination with another mood stabilizer.

Divalproex sodium or valproic acid (Depakote)

Doctors frequently prescribe this anticonvulsant for children with bipolar disorders.

Carbamazepine (Tegretol)

Doctors prescribe this anticonvulsant because of its antimanic and antiaggressive properties. It is useful in treating frequent rage attacks.

Oxcarbazepine (Trileptal)

Is an anticonvulsant agent very similar to Tegretol but with lower side effects.

Lamotrigine (Lamictal)

This newer anticonvulsant medicine can be effective in treating the depressive episodes of bipolar disorders. Lamictal may not prevent manic episodes and is best used in combination with other mood stabilizers. Lamictal has been associated with serious rashes, and any appearance of rash must be immediately reported to the doctor.

Topiramate (Topamax)

This newer anticonvulsant drug may control rapid-cycling and mixed bipolar states in patients who have not responded well to divalproex sodium or carbamazepine. Unlike some other mood stabilizers, it does not cause weight gain as a side effect, but its efficacy in children has not been established and it has been associated with memory problems in some patients.

Tiagabine (Gabitril)

This newer anticonvulsant drug has FDA approval for use in adolescents and is now being used in children as well but its efficacy is unknown.

The Atypical Antipsychotics

Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, Aripiprazole (Abilitat) – These newer agents are often used to treat bipolar disorders in adults, children and adolescents and appear to be effective mood stabilizers.

Combination Medication Treatment

Many times, it is necessary to use 3-4 medications to effectively treat a child or adolescent with a bipolar disorder. Typically, there is a partial response to one medication and another psychotropic agent is added in the hopes of achieving a full response. It is not unusual for pediatric patients with a bipolar disorder to be treated with 1 or 2 mood stabilizers, an atypical antipsychotic agent, a stimulant for ADHD, and clonidine or gabapentin for sleep. The critical thing is that each agent is added with a clear idea as to what the target symptoms are and how long it will be continued for.

In addition to seeing a child psychiatrist, the treatment plan for a child with bipolar disorder usually includes regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist who provides psychotherapy. Cognitive behavioral therapy, interpersonal therapy, and multifamily support groups are an essential part of treatment for children and adolescents with bipolar disorder. A support group for the child or adolescent with the disorder can also be beneficial.

A diagnosis of bipolar disorder means the child has a significant health impairment (the same as diabetes, epilepsy or leukemia) that requires ongoing medical management. The child needs and is entitled to accommodations in school to benefit from his or her education. Bipolar disorder and the medications used to treat it can affect a child's school attendance, alertness and concentration, sensitivity to light, noise and stress, motivation, and energy available for learning. The child's functioning can vary greatly at different times throughout the day, season and school year.

The special education staff, parents and professionals should meet as a team to determine the child's educational needs. An evaluation including psychoeducational testing will be done by the school (some families arrange for more extensive private testing). The educational needs of a particular child with bipolar disorder vary depending on the frequency, severity and duration of episodes of illness. These factors are difficult to predict in an individual case. Transitions to new teachers and new schools, return to school from vacations and absences, and changing to new medications are common times of increased symptoms for children with bipolar disorder.

Medication side effects that can be troublesome at school include increased thirst and urination, excessive sleepiness or agitation, and interference with concentration. Weight gain, fatigue, and a tendency to become easily overheated and dehydrated impact a child's participation in gym and regular classes.

These factors and any others that affect the child's education must be identified. A plan (called an IEP) will be written to accommodate the child's needs. The IEP should include accommodations for periods when the child is relatively well (when a less intense level of services may suffice), and accommodations available to the child in the event of relapse. Specific accommodations should be backed up by a letter or phone call from the child's doctor to the director of special education in the school district. Some parents find it necessary to hire a lawyer to obtain the accommodations and services that federal law requires public schools to provide for children with similar health impairments.

Examples of accommodations helpful to children and adolescents with bipolar disorder include:

  • Preschool special education testing and services
  • Small class size (with children of similar intelligence) or self-contained classroom with other emotionally fragile (not "behavior disorder") children for part or all of the day
  • One-on-one or shared special education aide to assist child in class
  • Back-and-forth notebook between home and school to assist communication
  • Homework reduced or excused and deadlines extended when energy is low
  • Late start to school day if fatigued in morning
  • Recorded books as alternative to self-reading when concentration is low
  • Designation of a "safe place" at school where child can retreat when overwhelmed
  • Designation of a staff member to whom the child can go as needed
  • Unlimited access to bathroom
  • Unlimited access to drinking water
  • Art therapy and music therapy
  • Extended time on tests
  • Use of calculator for math
  • Extra set of books at home
  • Use of keyboard or dictation for writing assignments
  • Regular sessions with a social worker or school psychologist
  • Social skills groups and peer support groups
  • Annual in-service training for teachers by child's treatment professionals (sponsored by school)
  • Enriched art, music, or other areas of particular strength
  • Curriculum that engages creativity and reduces boredom (for highly creative children)
  • Tutoring during extended absences
  • Goals set each week with rewards for achievement
  • Summer services such as day camps and special education summer school
  • Placement in a day hospital treatment program for periods of acute illness that can be managed without inpatient hospitalization
  • Placement in a therapeutic day school during extended relapses or to provide a period of extra support after hospitalization and before returning to regular school
  • Placement in a residential treatment center during extended periods of illness if a therapeutic day school near the family's home is not available or is unable to meet the child's needs
  • Resources for parents about bipolar disorders

Print Resources

New Hope for Children and Teens with Bipolar Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions. By Boris Birmaher, MD. Current information, and packed with useful tips on parenting strategies, treatment strategies, and hope. It contains great advice for dealing with the schools and other steps parents can take to reduce stress and enhance flexibility.

Raising a Moody Child: How to Cope with Depression and Bipolar Disorder, by Jill S. Goldberg Arnold, MD, and Mary A. Fristad, MD. Why symptoms look different in children and teens, how to find the right doctor or therapist, and how to help kids develop their own "coping toolkits." A practical guide to everything from dealing with medical crises to resolving school problems, sibling conflicts, and marital stress.

The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder (Revised and Expanded Edition) by Demitri Papolos, MD, and Janice Papolos (Broadway Books, 2002). A compelling account of the illness in children. Stresses the benefits of early intervention and the urgent need for further research. The authors spent over a year in BPParents and let real family voices speak eloquently about their struggles and triumphs. Revised edition details some of the newest developments in the fields of research and treatment, and addresses neuropsychological testing in greater depth.

Understanding and Educating Children and Adolescents with Bipolar Disorder: A Guide for Educators, by Margot Andersen, MSW; Jane Boyd Kubisak, MS; Ruth Field, MSW, LSW; and Steven Vogelstein, MA, LCSW. (The Josselyn Center, 2003). A manual providing educators with guiding principles that inform assessment, programming, and intervention decisions for students with bipolar disorder. Included are case examples, IEP tips, and sample functional behavioral analyses and behavior intervention plans.

Online Resources

  • The Balanced Mind Foundation. Offers resources and education materials to families with children with mood disorders and guides you to find ways to connect with other families. Includes Flipswitch, dedicated to helping teens and young adults understand their depression and mood disorder.

  • The Depression and Bipolar Support Alliance (DBSA). The nation's leading patient-directed organization focusing on the most prevalent mental illnesses – depression and bipolar disorder. The organization fosters an understanding about the impact and management of these life-threatening illnesses by providing up-to-date, scientifically based tools and information written in language the general public can understand. DBSA supports research to promote more timely diagnosis, develop more effective and tolerable treatments and discover a cure. The organization works to ensure that people living with mood disorders are treated equitably.

  • National Alliance on Mental Illness (NAMI). A nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, autism and pervasive developmental disorders, attention deficit / hyperactivity disorder, and other severe and persistent mental illnesses that affect the brain. 

Last Updated 07/2012