Bipolar disorder (also known as manic-depression) is a serious buttreatable medical illness. It is a disorder of the brain marked byextreme changes in mood, energy, thinking and behavior. Symptoms may bepresent since infancy or early childhood, or may suddenly emerge inadolescence or adulthood. Until recently, a diagnosis of the disorderwas rarely made in childhood. Doctors can now recognize and treatbipolar disorder in young children.
Early intervention and treatment offer the best chance forchildren with emerging bipolar disorder to achieve stability, gain thebest possible level of wellness, and grow up to enjoy their gifts andbuild upon their strengths. Proper treatment can minimize the adverseeffects of the illness on their lives and the lives of those who lovethem.
Families of affected children and adolescents are almostalways baffled by early-onset bipolar disorder and are desperate forinformation and support. In this section of the CABF web site, you willfind answers to some of the most common questions asked about thedisorder.
How common is bipolar disorder in children?
It is not known, because epidemiological studies are lacking.However, bipolar disorder affects an estimated 1-2 percent of adultsworldwide. The more we learn about this disorder, the more prevalent itappears to be among children. It is suspected that a significant number of childrendiagnosed in the United States with attention-deficit disorder withhyperactivity (ADHD) have early-onset bipolar disorder instead of, oralong with, ADHD. Depression in children and teens is usuallychronic and relapsing. According to several studies, a significantproportion of the 3.4 million children and adolescents with depressionin the United States may actually be experiencing the early onset ofbipolar disorder, but have not yet experienced the manic phase of theillness
What are the symptoms of bipolar disorder in children?
Bipolar disorder involves marked changes in mood and energy.Persistent states of extreme elation or agitation accompanied by highenergy are called mania. Persistent states of extreme sadness orirritability accompanied by low energy are called depression.
However, the illness may look different in children than itdoes in adults. Children usually have an ongoing, continuous mooddisturbance that is a mix of mania and depression. This rapid andsevere cycling between moods produces chronic irritability and fewclear periods of wellness between episodes.
Diagnosis is made using the DSM-IV criteria, for which thereis no lower age limit. See section below for DSM-IV criteria. However,it becomes more difficult to apply the DSM-IV criteria to very youngchildren.
Behaviors reported by parents in children diagnosed with bipolar disorder may include: an expansive or irritable moodextreme sadness or lack of interest in playrapidly changing moods lasting a few hours to a few daysexplosive, lengthy, and often destructive ragesseparation anxietydefiance of authorityhyperactivity, agitation, and distractibilitysleeping little or, alternatively, sleeping too muchbed wetting and night terrorsstrong and frequent cravings, often for carbohydrates and sweetsexcessive involvement in multiple projects and activitiesimpaired judgment, impulsivity, racing thoughts, and pressure to keep talkingdare-devil behaviors (such as jumping out of moving cars or off roofs)inappropriate or precocious sexual behaviordelusions and hallucinationsgrandiose 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. Mothersoften report that children later diagnosed with the disorder wereextremely difficult to settle and slept erratically. They seemedextraordinarily clingy, and from a very young age often haduncontrollable, seizure-like tantrums or rages out of proportion to anyevent. The word "no" often triggered these rages. Several ongoing studies are further exploring characteristics ofaffected children. Researchers are studying, with promising results,the effectiveness and safety of adult treatments in children.
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, theadolescent experiences alternating episodes of intense and sometimespsychotic mania and depression.
Symptoms of mania include: elevated, expansive or irritable mooddecreased need for sleepracing speech and pressure to keep talkinggrandiose delusionsexcessive involvement in pleasurable but risky activitiesincreased physical and mental activitypoor judgmentin severe cases, hallucinationsSymptoms of depression include: pervasive sadness and crying spellssleeping too much or inability to sleepagitation and irritabilitywithdrawal from activities formerly enjoyeddrop in grades and inability to concentratethoughts of death and suicidelow energysignificant change in appetitePeriods of relative or complete wellness occur between the episodes. Bipolar II. In this form of the disorder,the adolescent experiences episodes of hypomania between recurrentperiods of depression. Hypomania is a markedly elevated or irritablemood accompanied by increased physical and mental energy. Hypomania canbe 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.Forsome adolescents, a loss or other traumatic event may trigger a firstepisode of depression or mania. Later episodes may occur independentlyof any obvious stresses, or may worsen with stress. Puberty is a timeof risk. In girls, the onset of menses may trigger the illness, andsymptoms often vary in severity with the monthly cycle.
Once the illness starts, episodes tend to recur and worsenwithout treatment. Studies show that after symptoms first appear,typically there is a 10-year lag until treatment begins. CABFencourages parents to take their adolescent for an evaluation if fouror more of the above symptoms persist for more than two weeks. Earlyintervention and treatment can make all the difference in the worldduring this critical time of development.
Is substance abuse and addiction related to bipolar disorder?
A majority of teens with untreated bipolar disorder abusealcohol and drugs. Any child or adolescent who abuses substances shouldbe evaluated for a mood disorder.
Adolescents who seemed normal until puberty and experience acomparatively sudden onset of symptoms are thought to be especiallyvulnerable to developing addiction to drugs or alcohol. Substances maybe readily available among their peers and teens may use them toattempt to control their mood swings and insomnia. If addictiondevelops, it is essential to treat both the bipolar disorder and thesubstance 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 clearlyenvironmental factors that influence whether the illness will occur ina particular child. Bipolar disorder can skip generations and takedifferent 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 anindividual'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 incidenceand an earlier age of onset of bipolar disorder and depression. Onaverage, children with bipolar disorder experience their first episodeof illness 10 years earlier than their parents' generation did. Thereason for this is unknown.
The family trees of many children who develop early-onsetbipolar disorder include individuals who suffered from substance abuseand/or mood disorders (often undiagnosed). Also among their relativesare found highly-accomplished, creative, and extremely successfulindividuals 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 LincolnWinston ChurchillTheodore RooseveltGoetheBalzacHandelSchumannBerliozTolstoyVirginia WoolfHemingwayRobert LowellAnne SextonThe biographies of Beethoven, Newton, and Dickens, in particular,reveal severe and debilitating recurrent mood swings beginning inchildhood.
Healthychildren often have moments when they have difficulty staying still,controlling their impulses, or dealing with frustration. The Diagnosticand Statistical Manual IV (DSM-IV) still requires that, for a diagnosisof bipolar disorder, adult criteria must be met. There are as yet noseparate criteria for diagnosing children.
Some behaviors by a child, however, should raise a red flag: destructive rages that continue past the age of fourtalk of wanting to die or kill themselvestrying to jump out of a moving carTo illustrate how difficult it is to use the DSM-IV to diagnosechildren, the manual says that a hypomanic episode requires a "distinctperiod of persistently elevated, expansive, or irritable mood lastingthroughout at least four days." Yet upwards of 70 percent of childrenwith the illness have mood and energy shifts several times a day.
Since the DSM-IV is not scheduled for revision in theimmediate future, experts often use some DSM-IV criteria as well asother measures. For example, a Washington University team ofresearchers uses a structured diagnostic interview called Wash UKIDDE-SADS, which is more sensitive to the rapid-cycling periodscommonly 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 oftenaccompanied by symptoms of other psychiatric disorders. In somechildren, proper treatment for the bipolar disorder clears up thetroublesome symptoms thought to indicate another diagnosis. In otherchildren, bipolar disorder may explain only part of a more complicatedcase that includes neurological, developmental, and other components.
Diagnoses that mask or sometimes occur along with bipolar disorder include: depressionconduct disorder (CD)oppositional-defiant disorder (ODD)attention-deficit disorder with hyperactivity (ADHD)panic disordergeneralized anxiety disorder (GAD)obsessive-compulsive disorder (OCD)Tourette's syndrome (TS)intermittent explosive disorderreactive attachment disorder (RAD)In adolescents, bipolar disorder is often misdiagnosed as: borderline personality disorderpost-traumatic stress disorder (PTSD)schizophrenia
The need for prompt and proper diagnosis
After symptoms first appear in children, years oftenpass before treatment begins, if ever. Meanwhile, the disorder worsensand the child's functioning at home, school, and in the community isprogressively more impaired.
The importance of proper diagnosis cannot be overstated. Theresults of untreated or improperly treated bipolar disorder caninclude: an unnecessary increase in symptomatic behaviors leading toremoval from school, placement in a residential treatment center,hospitalization in a psychiatric hospital, or incarceration in thejuvenile 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 scientificfact. It is a considered opinion based upon the behavior of the childover time, what is known of the child's family history, the child'sresponse to medications, his or her developmental stage, the currentstate of scientific knowledge and the training and experience of thedoctor making the diagnosis. These factors (and the diagnosis) canchange as more information becomes available. Competent professionalscan disagree on which diagnosis fits an individual best. Diagnosis isimportant, however, because it guides treatment decisions and allowsthe family to put a name to the condition that affects their child.Diagnosis can provide answers to some questions but raises others thatare unanswerable given the current state of scientific knowledge.
How can I help my child?
Parents concerned about their child's behavior, especiallysuicidal talk and gestures, should have the child immediately evaluatedby a professional familiar with the symptoms and treatment ofearly-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 (orany psychiatric illness) should take daily notes of their child's mood,behavior, sleep patterns, unusual events, and statements by the childof concern to the parents. Share these notes with the doctor making theevaluation and with the doctor who eventually treats your child. Someparents fax or e-mail a copy of their notes to the doctor before eachappointment.
Because children with bipolar disorder can be charming andcharismatic during an appointment, they initially may appear to aprofessional to be functioning well. Therefore, a good evaluation takesat least two appointments and includes a detailed family history.
Finding the right doctor
If possible, have a board-certified child psychiatrist diagnoseand treat your child. A child psychiatrist is a medical doctor who hascompleted two to three years of an adult psychiatric residency and twoadditional years of a child psychiatry fellowship program.Unfortunately, there is a severe shortage of child psychiatrists, andfew have extensive experience treating early-onset bipolar disorder.
Teaching hospitals affiliated with reputable medical schoolsare often a good place to start looking for an experienced childpsychiatrist. You can also ask your child's pediatrician for areferral. Check the CABF Directory of Professional Members to see the names of doctors who practice in your area.
If your community does not have a child psychiatrist withexpertise in mood disorders, then look for an adult psychiatrist whohas 1) a broad background in mood disorders, and 2) experience intreating children and adolescents.
Other specialists who may be able to help, at least with aninitial evaluation, include pediatric neurologists. Neurologists haveexperience with the anti-convulsant medications often used for treatingjuvenile bipolar disorders. Pediatricians who consult with apsychopharmacologist can also provide competent care if a childpsychiatrist is not available.
Some families take their child to nationally-known doctors atteaching hospitals for diagnosis and stabilization. They then turn tolocal professionals for medical management of their child's treatmentand psychotherapy. The local professionals consult with the expert asneeded.
Experienced parents recommend that you look for a doctor who: is knowledgeable about mood disorders, has a strongbackground in psychopharmacology, and stays up-to-date on the latestresearch 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 understandshow traumatic a hospitalization is for both child and parents, andkeeps 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 casestreatment can stabilize mood and allow for management and control ofsymptoms.
A good treatment plan includes medication, close monitoring ofsymptoms, education about the illness, counseling or psychotherapy forthe individual and family, stress reduction, good nutrition, regularsleep 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 careearly diagnosis and treatmentadherence to medication and treatment plana flexible, low-stress home and school environmenta supportive network of family and friendsFactors that complicate treatment are: lack of access to competent medical caretime lag between onset of illness and treatmentnot taking prescribed medicationsstressful and inflexible home and school environmentthe co-occurrence of other diagnosesuse of substances such as illegal drugs and alcoholThe good news is that with appropriate treatment and support at homeand at school, many children with bipolar disorder achieve a markedreduction in the severity, frequency and duration of episodes ofillness. With education about their illness (as is provided to childrenwith epilepsy, diabetes, and other chronic conditions) they learn howto 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 disorderand their families need to work closely with their doctor and othertreatment professionals. Having the entire family involved in thechild's treatment plan can usually reduce the frequency, duration, andseverity of episodes. It can also help improve the child's ability tofunction successfully at home, in school, and in the community.
Parents: Learn all you can about bipolar disorder. Read, joinsupport groups, and network with other parents. There are manyquestions still unanswered about early onset bipolar disorder, butearly intervention and treatment can often stabilize mood and restorewellness. You can best manage relapses by prompt intervention at thefirst re-occurrence of symptoms.
Medication
Few controlled studies have been done on the use of psychiatricmedications in children. The U.S. Food and Drug Administration (FDA)has approved only a handful for pediatric use. Psychiatrists must adaptwhat they know about treating adults to children and adolescents.
Medications used to treat adults are often helpful instabilizing mood in children. Most doctors start medication immediatelyupon diagnosis if both parents agree. If one parent disagrees, a shortperiod of watchful waiting and charting of symptoms can be helpful.Treatment should not be postponed for long, however, because of therisk of suicide and school failure.
A symptomatic child should never be left unsupervised. Ifparental disagreement makes treatment impossible, as may happen infamilies undergoing divorce, a court order regarding treatment may benecessary.
Other treatments, such as psychotherapy, may not be effectiveuntil mood stabilization occurs. In fact, stimulants andantidepressants given without a mood stabilizer (often the result ofmisdiagnosis) can cause havoc in bipolar children, potentially inducingmania, more frequent cycling, and increases in aggressive outbursts.
No one medication works in all children. The family shouldexpect a trial-and-error process lasting weeks, months, or longer asdoctors try several medications alone and in combination before theyfind the best treatment for your child. It is important not to becomediscouraged during the initial treatment phase. Two or more moodstabilizers, plus additional medications for symptoms that remain, areoften necessary to achieve and maintain stability.
Parents often find it hard to accept that their child has achronic condition that may require treatment with several medications.It is important to remember that bipolar disorder has a high rate ofsuicide. Estimates vary, but mortality rates of 5-10% from suicide arereported by various studies, rates equal to or greater than themortality rates for many serious physical illnesses. The untreateddisorder carries the risk of drug and alcohol addiction, damagedrelationships, school failure, and difficulty finding and holding jobs.The risks of not treating are substantial and must be measured againstthe unknown risks of using medications whose safety and efficacy havebeen established in adults, but not yet in children.
A Cautionary Note on Antidepressants and Stimulants from the National Institute of Mental Health
Effective treatment depends on appropriate diagnosis of bipolardisorder in children and adolescents. There is some evidence that usingantidepressant medication to treat depression in a person who hasbipolar disorder may induce manic symptoms if it is taken without amood stabilizer. In addition, using stimulant medications to treatattention deficit hyperactivity disorder (ADHD) or ADHD-like symptomsin a child with bipolar disorder may worsen manic symptoms. While itcan be hard to determine which young patients will become manic, thereis a greater likelihood among children and adolescents who have afamily history of bipolar disorder. If manic symptoms develop ormarkedly worsen during antidepressant or stimulant use, a physicianshould be consulted immediately, and diagnosis and treatment forbipolar disorder should be considered.From: Child and Adolescent Bipolar Disorder:[NL]An Update from the National Institute of Mental Health
Psychotherapy
In addition to seeing a child psychiatrist, the treatment planfor a child with bipolar disorder usually includes regular therapysessions with a licensed clinical social worker, a licensedpsychologist, or a psychiatrist who provides psychotherapy. Cognitivebehavioral therapy, interpersonal therapy, and multi-family supportgroups are an essential part of treatment for children and adolescentswith bipolar disorder. A support group for the child or adolescent withthe disorder can also be beneficial, although few exist.
Therapeutic ParentingTM
Parents of children with bipolar disorder have discovered numerous techniques that the CABF refers to as therapeutic parenting.These techniques help calm their children when they are symptomatic andcan help prevent and contain relapses. Such techniques include: practicing and teaching their child relaxation techniquesusing firm restraint holds to contain ragesprioritizing battles and letting go of less important mattersreducing stress in the home, including learning and using good listening and communication skillsusing music and sound, lighting, water, and massage to assist the child with waking, falling asleep, and relaxationbecoming an advocate for stress reduction and other accommodations at schoolhelping the child anticipate and avoid, or prepare for stressful situations by developing coping strategies beforehandengaging the child's creativity through activities that express and channel their gifts and strengthsproviding routine structure and a great deal of freedom within limitsremovingobjects from the home (or locking them in a safe place) that could beused to harm self or others during a rage, especially guns; keepingmedications in a locked cabinet or box.
A diagnosis of bipolar disorder means the child has asignificant health impairment (such as diabetes, epilepsy, or leukemia)that requires ongoing medical management. The child needs and isentitled to accommodations in school to benefit from his or hereducation. Bipolar disorder and the medications used to treat it canaffect a child's school attendance, alertness and concentration,sensitivity to light, noise and stress, motivation, and energyavailable for learning. The child's functioning can vary greatly atdifferent times throughout the day, season, and school year.
The special education staff, parents and professionals shouldmeet as a team to determine the child's educational needs. Anevaluation including psychoeducational testing will be done by theschool (some families arrange for more extensive private testing). Theeducational needs of a particular child with bipolar disorder varydepending on the frequency, severity and duration of episodes ofillness. These factors are difficult to predict in an individual case.Transitions to new teachers and new schools, return to school fromvacations and absences, and changing to new medications are commontimes of increased symptoms for children with bipolar disorder.Medication side effects that can be troublesome at school includeincreased thirst and urination, excessive sleepiness or agitation, andinterference with concentration. Weight gain, fatigue, and a tendencyto become easily overheated and dehydrated impact a child'sparticipation in gym and regular classes.
These factors and any others that affect the child's educationmust be identified. A plan (called an IEP) will be written toaccommodate the child's needs. The IEP should include accommodationsfor periods when the child is relatively well (when a less intenselevel of services may suffice), and accommodations available to thechild in the event of relapse. Specific accommodations should be backedup by a letter or phone call from the child's doctor to the director ofspecial education in the school district. Some parents find itnecessary to hire a lawyer to obtain the accommodations and servicesthat federal law requires public schools to provide for children withsimilar health impairments.
Examples of accommodations helpful to children and adolescents with bipolar disorder include: preschool special education testing and services smallclass size (with children of similar intelligence) or self-containedclassroom 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 placementin a day hospital treatment program for periods of acute illness thatcan be managed without inpatient hospitalization placement ina therapeutic day school during extended relapses or to provide aperiod of extra support after hospitalization and before returning toregular school placement in a residential treatment centerduring extended periods of illness if a therapeutic day school near thefamily's home is not available or is unable to meet the child's needs
A Turning Point
Learning that one's child has bipolar disorder can be traumatic.Diagnosis usually follows months or years of the child's moodinstability, school difficulties, and damaged relationships with familyand friends. However, diagnosis can and should be a turning point foreveryone concerned. Once the illness is identified, energies can bedirected towards treatment, education, and developing copingstrategies.
