Bipolar disorder (manic-depressive illness) is a serious but treatable medical illness that occurs in all age groups but is most often diagnosed in the late teens to the early adult years. It is a disorder of the brain marked by changes in mood, energy and behavior that are much more extreme than the normal ups and downs that most people experience. 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. Child psychiatrists can now recognize and treat bipolar disorder in very young children.
Early intervention and treatment offer the best chance for children with pediatric bipolar disorder to achieve mood stability, gain the best possible level of wellness and develop normally. Proper treatment can minimize the adverse effects of this illness on the lives of these children and their families.
Helping a Child with Bipolar Disorder
Parents concerned about their child's behavior, especially frequent, severe mood swings, depression, periods of "hyperactivity" accompanied by decreased need for sleep and hypersexuality, should have the child evaluated by a board-certified child and adolescent psychiatrist familiar with the symptoms and treatment of pediatric bipolar disorders. There is no blood test, genetic test or brain scan that can establish a diagnosis of bipolar disorder.
Incidence of Bipolar Disorder in Children and Adolescents
According to the National Institute of Mental Health, community studies estimate the lifetime prevalence of bipolar disorder for adolescents ranges from 0 to 3% of the population. Prevalence of bipolar disorder during childhood is not well established. It is thought 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.
Signs and Symptoms in Children
Bipolar disorder involves marked changes in mood and energy. In most adults with the illness, ongoing states of extreme elation or agitation accompanied by high energy are called mania. Ongoing states of extreme sadness or irritability and low energy are called depression.
However, the illness can look different in children than it does in adults. Children often 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. Children with bipolar disorder typically have 4-5 severe mood swings a day and are more irritable than euphoric.
Symptoms may include:
- An expansive or irritable mood
- Rapidly changing moods lasting minutes to hours
- Explosive, lengthy and often destructive rages
- Sleeping little or sleeping too much
- Excessive involvement in multiple projects and activities
- Impaired judgment, impulsivity, racing thoughts and pressured speech
- Inappropriate or precocious sexual behavior
- Grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)
Signs and Symptoms in Adolescents
In adolescents, bipolar disorder may resemble any of the following classical adult presentations of the illness.
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.
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 that last three to four days. Bipolar II disorder is five to 10 times more common than Bipolar I disorder.
- Adolescents with this form of the disorder experience periods of less severe, but definite, mood swings between mild euphoria and depression that last a year or more.
Bipolar Disorder NOS (Not Otherwise Specified)
- Significant mood symptoms suggestive of bipolar I, II or cyclothymia but not sufficient duration or severity to meet criteria for these disorders.
For some adolescents, a loss or other traumatic event may trigger a first episode of depression or mania. Later episodes may occur without 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.
Substance Abuse and Addiction
Many 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 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.
Genetics and Family History
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 one percent. Disorders in the bipolar spectrum may affect four to six percent.
- When one parent has bipolar disorder, the risk to each child is 15-30 percent.
- When both parents have bipolar disorder, the risk increases to 50-75 percent.
Many children who develop early-onset bipolar disorder have a family history of individuals who suffered from substance abuse and/or mood disorders (often undiagnosed).
Diagnosis in Children and Adolescents
The importance of proper diagnosis and treatment 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
- Hospitalization in a psychiatric hospital
- 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 based on the behavior of the child over time, what is known of the child's family history, the child's response to medications, and the child’s developmental stage. 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.
It is important that if you are concerned about your child’s behaviors, do not hesitate to obtain a full psychiatric evaluation. Mental health professionals are available to provide information about diagnosis and treatment options and to support you as you care for your child.
While it is difficult to diagnose bipolar disorder in children, some behaviors by a child should raise a red flag:
- Frequent, severe and prolonged mood swings that continue past the age of 4 years
- Frequent talk of wanting to die or kill themselves
- Trying to jump out of a moving car
- Rages lasting for hours
- Sexual behavior in the absence of abuse
Bipolar Disorder Compared to Other Conditions
Correct diagnosis of bipolar disorder 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 (comorbid) with bipolar disorder include:
- 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)