Sometimes Bipolar Surfaces in Childhood or Adolescense
Tuesday, July 07, 2009
Research findings, clinical experience, and family accounts provide substantial evidence that bipolar disorder, also called manic depression, can occur in children and adolescents. Bipolar disorder is difficult to recognize and diagnose in youth, however, because it does not precisely fit the symptom criteria established for adults, and because its symptoms can resemble or co-occur with those of other common childhood-onset mental disorders.

In addition, symptoms of bipolar disorder may be initially mistaken for developmentally normal emotions and behaviors of children and adolescents. But unlike normal mood changes, bipolar disorder significantly impairs functioning in school, with peers, and at home with family.

Symptoms and Diagnosis

Bipolar disorder is a serious condition characterized by recurrent episodes of depression, mania, and/or mixed states. These episodes cause unusual and extreme shifts in mood, energy, and behavior that significantly interfere with healthy functioning.

Manic symptoms include:

* Severe changes in mood--either extremely irritable or overly silly and elated

* Overly-inflated self-esteem; grandiosity

* Increased energy

* Decreased need for sleep--ability to go with very little or no sleep for days without tiring

* Increased talking—talks too much, too fast,; changes topics too quickly; cannot be interrupted

* Distractibility—attention moves constantly from one thing to the next

* Hypersexuality—increased sexual thoughts, feelings or behaviors; use of explicit sexual language

* Increased goal-directed activity or physical agitation

* Disregard of risk—excessive involvement in risky behaviors or activities

Depressive symptoms include:

* Persistent sad or irritable mood

* Loss of interest in activities once enjoyed

* Significant change in appetite or body weight

* Difficulty sleeping—or oversleeping

* Physical agitation or slowing

* Loss of energy

* Feelings of worthlessness or inappropriate guilt

* Difficulty concentrating

* Recurrent thoughts of death or suicide

What Do These Symptoms Look Like in Children and Adolescents?

Symptoms of mania and depression may manifest themselves through a variety of different behaviors. When manic, children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric.

When depressed, there may be many physical complaints such as headaches, muscle aches, stomachaches, or tiredness; frequent absences from school or poor performance in school; talk of or frequent attempts to run away from home; irritability, complaining, unexplained crying, social isolation, poor communication, and extreme sensitivity to rejection. Other manifestations of manic and depressive states may include alcohol or substance abuse and difficulty with relationships.

Differences Between Early and Later Onset

Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the condition than older adolescent- and adult-onset bipolar disorder. When bipolar disorder begins in puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms.

In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and to have a more episodic pattern with relatively stable periods between episodes. There is also less co-occurring ADHD or CD among those with later onset bipolar disorder.

How Do You Know When To Get Professional Help?

A child or adolescent who appears to be depressed and exhibits ADHD-like symptoms that are severe--excessive temper outbursts and mood changes--should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder. This evaluation is especially important since psychostimulant medication, often prescribed for ADHD, may worsen manic symptoms. There is also limited evidence suggesting that some of the symptoms of ADHD may be a forerunner of full-blown mania.

How Common is Bipolar Disorder in Children and Adolescents?

Findings from a National Institute of Mental Health-supported study suggest that bipolar disorder may be at least as common among youth as among adults. In this study, 1% of adolescents ages 14 to 18 were found to have met criteria for bipolar disorder or cyclothymia (a similar but milder condition) in their lifetime. In addition, close to 6% of adolescents in the study had experienced a distinct period of abnormally and persistently elevated, expansive, or irritable mood even though they never met full criteria for bipolar disorder or cyclothymia.

Compared to adolescents with a history of major depressive disorder and to a never-mentally-ill group, both the teens with bipolar disorder and those with subclinical symptoms had greater functional impairment and higher rates of c-occurring mental disorders (especially anxiety and disruptive behavior disorders), suicide attempts, and mental health services utilization. This study highlights the need for improved recognition, treatment, and prevention of even the milder and subclinical cases of bipolar disorder in adolescence.


Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. The essential treatment for this disorder in adults involves the use of appropriate doses of mood stabilizers, most typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Research on the effectiveness of these and other medications in children and adolescents with bipolar disorder is ongoing. In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy, to complement medication treatment for this illness in young people.

Ongoing Research

The National Institute of Mental Health (NIMH) is attempting to fill in the current gaps in treatment knowledge with carefully designed studies involving children and adolescents with bipolar disorder. Data from adults do not necessarily apply to younger patients because the differences in development may have implications for treatment efficacy and safety.

Current multi-site studies funded by NIMH are investigating the value of long-term treatment with lithium and other mood stabilizers in preventing recurrence of bipolar disorder in adolescents. Specifically, these studies aim to determine how well lithium and other mood stabilizers prevent recurrences of mania or depression and control subclinical symptoms in adolescents; to identify factors that predict outcome; and to assess side-effects and overall adherence to treatment.

Another NIMH-funded study is evaluating the safety and efficacy of the medication valproate for treatment of acute mania in children and adolescents, and also is investigating the biological correlates of treatment response. Other NIMH-supported investigators are studying the effects of antidepressant medications added to mood stabilizers in the treatment of the depressive phase of bipolar disorder in adolescents.

Source: National Institute of Mental Health