Bipolar Disorder in Children and Teens

Bipolar Disorder in Children and Teens

Topic Overview

What is bipolar disorder?

Bipolar disorder causes mood swings with extreme ups (mania) and downs (depression). When people with this problem are up, they have brief, intense outbursts or feel irritable or extremely happy (mania) several times almost every day. They have a lot of energy and a high activity level. When they are down, they feel depressed and sad.

What causes bipolar disorder?

Experts don't fully understand what causes bipolar disorder. But they believe many factors may be involved.

It seems to run in families. Your child has a greater risk of having it if a close family member such as a parent, grandparent, brother, or sister has it.

What are the symptoms?

In children and teens, moods quickly change from one extreme to another without a clear reason. But for a child to have bipolar disorder, these mood changes must be different from the child's usual moods and must happen with other symptoms or changes in behaviour. These distinct periods of time with changes in mood and behaviour are called mood episodes. People with bipolar disorder have manic and depressive mood episodes.

Times of mania (ups) or depression (downs) may be less obvious in children and teens than in adults.

  • A manic episode lasts at least a week. It is a period of extremely happy, aggressive, and/or angry mood that occurs with some of the following symptoms. The child or teen may:
    • Have little need for sleep.
    • Have high energy levels.
    • Have extreme confidence in themselves.
    • Talk very fast.
    • Have many thoughts at once.
    • Seem very distracted and unable to focus.
    • Touch his or her genitals, use sexual language, and approach others in a sexual way.
    • Act inappropriate or be intrusive in social settings.
  • A depressive episode is a period of sad, low, or cranky mood that occurs with some of the following symptoms. The child or teen may:
    • Not find pleasure in things they normally enjoy.
    • Have low energy or feel "slowed down."
    • Have sleep and appetite changes.
    • Have low self-esteem.
    • Feel guilty or worthless.
    • Withdraw from friends or family.
    • Have difficulty focusing.
    • Have thoughts about death or suicide.

How is bipolar disorder diagnosed in children and teens?

This disorder can be hard to diagnose in children and teens. The symptoms can look a lot like the symptoms of other problems, such as:

Bipolar disorder can often occur along with these problems.

If your doctor thinks your child or teen may have bipolar disorder, he or she may ask questions about your child's feelings and behaviour. Your doctor may also give you and your child written tests to find out how severe the mania or depression is.

The doctor may do other tests (such as a blood test) to rule out other health problems. He or she may ask if your family has any history of mental illness or problems with drugs or alcohol. Any of these problems can be linked to bipolar disorder.

Why is early diagnosis of bipolar disorder important?

Children with this disorder are more likely to have other problems. These include alcohol and drug use, trouble in school, running away from home, fighting, and even suicide. Treating the disorder as early as possible may keep your child from having these problems.

Watch for the warning signs of suicide, which change with age. Warning signs of suicide in children and teens may include thinking too much about death or suicide. Watch also for things that can trigger a suicide attempt such as a recent breakup of a relationship or the loss of a parent or close family member through death or divorce.

How is it treated?

The mood changes that come with bipolar disorder can be a challenge. But with the right treatment, they can be managed well. Treatment usually includes both medicine (such as mood stabilizers) and counselling.

An important part of treatment is making sure your child takes his or her medicine. Children and teens with this disorder sometimes stop taking their medicines when they feel better. But without medicine, their symptoms usually come back.

Medicines for bipolar disorder in adults have been well studied. But more research is being done on how the medicines work and if they are safe for children and teens.

Keeping a consistent sleep-wake schedule is an important first step in managing bipolar disorder. Set a regular sleep-wake schedule for your child, to make sure they go to bed and wake up the same time every day, even on weekends.

Accepting that your child has bipolar disorder can be hard. The disorder can be a serious, lifelong problem. Your child will need long-term treatment and will need to be watched carefully. By working with your child's doctor, you can find a treatment that works for your child.

Cause

The cause of bipolar disorder is not well understood.

It seems to run in families. Your child is at greater risk of having bipolar disorder if a close family member such as a parent, grandparent, brother, or sister has it.

Stressful or traumatic events may trigger episodes of mania or depression in a child who has bipolar disorder. While it is normal for such events to cause mood changes, these reactions are much more extreme for children with bipolar disorder.

Sometimes symptoms of mania occur as a result of another medical condition, such as an overactive thyroid gland (hyperthyroidism) or multiple sclerosis. Symptoms can also develop as a side effect of some medicines, such as corticosteroids or antidepressants. Using drugs or alcohol, consuming too much caffeine, or not getting enough sleep can also trigger a manic episode.

Symptoms

Bipolar disorder causes cycles of mania (or hypomania, a less severe form of mania) and depression. The different types of bipolar disorder are based on whether a person has more severe symptoms of mania or depression.

  • With bipolar I disorder, moods swing between mania and depression, sometimes with periods of normal mood between extremes. All children with this disorder have episodes of mania, but episodes of depression vary. For example, some children do experience depression, and others rarely are depressed.
  • With bipolar II disorder, depression is more severe than mania. And manic episodes may last for fewer days and be less intense.
  • With cyclothymia, the high and low mood swings are not as severe as the mania and depression seen in bipolar I or bipolar II disorders.
  • Bipolar, NOS (not otherwise specified), is diagnosed when symptoms of mania and depression are not frequent or severe enough for the above diagnoses.

In children and younger teens, bipolar disorder tends to be rapid-cycling or mixed cycling:

  • Rapid-cycling means that there have been at least four shifts between depression and mania over the past 12 months. These shifts occur quickly, sometimes within the same day. Often the shifts happen without a return to a normal mood in between the extremes.
  • Mixed-cycling (also known as mixed-features) means that symptoms of both mania and depression occur at the same time.

Following are some common symptoms of bipolar disorder in children and teens.footnote 1

Depression symptoms

  • Continuous sad or irritable mood
  • Loss of interest in activities that the child enjoyed in the past, such as hobbies, sports, games, or friends
  • Significant changes in appetite or body weight (weight loss or gain)
  • Sleeping too much or too little or having trouble falling asleep
  • Slowed body movements or restlessness
  • No energy, or loss of energy
  • Inappropriate feelings of guilt or worthlessness
  • Problems concentrating
  • Recurrent thoughts or talk of death or suicide
  • Headaches, muscle aches, or stomach aches

Manic symptoms

  • Severe changes in mood from being extremely irritable to overly silly and elated
  • Too much energy, such as the ability to keep going without tiring while the child's peers are tiring
  • Decreased need for sleep, such as going for days with very little sleep and not being tired
  • Talking too much or too fast, changing topics too quickly, and not allowing interruptions
  • Increased distraction and constantly moving from one thing to another
  • Grandiosity, such as inflated self-esteem or a belief in unrealistic abilities or powers
  • Increased sexual thoughts, feelings, activity, and use of sexual language (hypersexuality)
  • Increased obsession with reaching goals or becoming involved in too many activities
  • Risky, wild, thrill-seeking behaviour

During severe episodes of mania, your child may suffer from symptoms of psychosis, such as having hallucinations or delusions of grandeur (for example, telling people that a rock band is coming to his or her birthday party).

Bipolar disorder frequently occurs along with other conditions, such as conduct disorder. And each condition needs treatment.

Untreated bipolar disorder can lead to suicide. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

People sometimes confuse bipolar disorder in children with other conditions with similar symptoms, such as attention deficit hyperactivity disorder (ADHD). Although there is some evidence of a link between ADHD and bipolar disorder, the conditions have distinct features that you can usually identify.

In young children, the symptoms of mania are more than just being a bother to adults and other children now and then. For example, many children can be silly and giggly to a point that it bothers their parents sometimes. This is not considered to be a sign of mania. But if a child is silly and giggly for several hours, several times almost every day, and this is interrupting the family's usual routine, then it may be a symptom of mania.

What Happens

Often the first signs of bipolar disorder are severe moodiness, unhappiness, or other symptoms of depression. It is common for children with bipolar disorder to be diagnosed first with only depression and then later to be diagnosed with bipolar disorder.

A first manic or hypomanic episode can be triggered by a stressful situation or by certain medicines. Or it may occur without an obvious cause.

Children with bipolar disorder may:

  • Have trouble getting going in the morning but then have intense energy later in the day.
  • Miss school often or talk about running away from home.
  • Become socially isolated and overly sensitive to any kind of rejection or criticism.
  • Behave irresponsibly, take risks and not think about the consequences, or have trouble making and keeping friends.

Young children

In addition to having manic symptoms, children may have severe, seizure-like temper tantrums when they are told "no." A child with bipolar disorder may kick, bite, hit, and make hateful comments, including threats and curses. During tantrums, which may last for hours, a child may destroy property or become increasingly violent.

Young children with bipolar disorder may have more extreme happy or silly moods than most children have.

Teens

Manic behaviour by a teen with bipolar disorder may result in such problems as:

  • Suspension from school.
  • Arrest as a result of fighting or drug misuse.
  • An unwanted pregnancy.
  • A sexually transmitted infection (STI) from unsafe sexual behaviour.

During depressive episodes, a teen may do poorly in school and may stop taking part in activities he or she enjoyed in the past, such as a sports team.

Watch for warning signs of suicide, which can include preoccupation with death or suicide or a recent breakup of a relationship.

Substance use disorder is common. Your child's doctor may recommend an evaluation for both substance use disorder and bipolar disorder if your child appears to suffer from either condition.

Treating other conditions

Sometimes treatment for other conditions can make your child's bipolar disorder worse. For example:

  • Treating depression with antidepressants can trigger a manic episode or make one worse.
  • Treating attention deficit hyperactivity disorder (ADHD) with stimulants may also trigger severe mania, depression, and even psychosis (loss of touch with reality).
  • Treatment with corticosteroids for conditions such as asthma may also trigger a manic or depressive episode.

Medicines that intensify bipolar symptoms may need to be stopped or changed to a different dose or medicine. Sometimes an additional medicine (such as a mood stabilizer) can solve the problem. But each child responds to medicines differently. And it may take several tries before your doctor can identify an effective medicine, dose, or combination of medicines for your child's conditions.

What Increases Your Risk

Your child's risk for bipolar disorder or other mood disorders is higher if the child:

  • Has a close relative such as a parent, sibling, or grandparent with bipolar disorder or another mood disorder.
  • Has a family history of problems with alcohol or drugs. Such family members may be using alcohol or drugs as a way to deal with a psychological disorder.

When should you call your doctor?

Call 9-1-1 or other emergency services immediately if:

  • Your child is thinking seriously of suicide or has recently tried suicide. Serious signs include these thoughts:
    • Deciding how to kill themself, such as with a weapon or medicines.
    • Setting a time and having a plan.
    • Thinking there is no other way to solve the problem or end the pain.
  • Your child feels that they can't stop from hurting themself or someone else.

Keep the number for a suicide crisis centre on or near your phone. Go to the Canadian Association for Suicide Prevention web page at http://suicideprevention.ca/need-help to find a suicide crisis prevention centre in your area.

Call a doctor now if:

  • Your child hears voices.
  • Your child has been thinking about death or suicide a lot but doesn't have a suicide plan.
  • Your child is worried a lot that the feelings of depression or thoughts of suicide aren't going away.

Seek care soon if:

  • Your child has symptoms of depression or mania, such as:
    • Feeling sad or hopeless.
    • Not enjoying anything.
    • Having trouble with sleep.
    • Feeling guilty.
    • Feeling anxious or worried.
    • Feeling extremely happy or very grouchy.
    • Talking too fast or more than usual.
    • Being more active than usual.
    • Having trouble concentrating because of having too many thoughts at the same time (racing thoughts).
    • Acting inappropriately or intruding in social settings.
    • Touching their genitals, using sexual language, and approaching others in a sexual way.
    • Showing risky, wild, thrill-seeking behaviour.
  • Your child has been treated for depression for more than 3 weeks but is not getting better.

Family support

It's best to build a long-term relationship with your child's care providers. Then when a depressive or manic episode occurs, the care providers can recognize the changes in the child's behaviour and provide quick treatment advice.

If you are a family member of a child with bipolar disorder, it's very important to get the support and help you need. Living with or caring for someone who has bipolar disorder can really disrupt your own life. Manic episodes can be extra tough. It may help to seek your own counsellor or therapist to support you.

Also, some national support organizations may have a local chapter in your area or provide information online. Examples of such groups include the Canadian Mental Health Association and the Mood Disorders Society of Canada.

Examinations and Tests

There is no lab test that can diagnose bipolar disorder. Doctors make the diagnosis through a combination of:

  • A medical history, asking questions to help identify other past and present health conditions that could cause the symptoms.
  • A family history to identify bipolar disorder, other mood disorders, or drug or alcohol problems in close relatives. (All of these conditions are linked to bipolar disorder.)
  • A physical examination, which can rule out other conditions with similar symptoms.
  • A mental health assessment, which can help identify your child's current mental state and the severity of depression or mania.
  • Other written or verbal mental health tests.

Before prescribing medicine to treat bipolar disorder, your doctor will ask questions about possible suicidal behaviour.

Treatment Overview

Mood changes and other symptoms of bipolar disorder are challenging, but they can be managed effectively. Treatment usually includes medicines (such as mood stabilizers) and counselling. Often a combination of both is needed.

Medicine

An important part of treatment is making sure your child takes his or her bipolar medicine. Often people who feel better after taking their medicine for a while think they are cured and no longer need treatment. But when a person stops taking medicine, symptoms usually return. So it is important that your child follow the treatment plan.

Counselling

Counselling works best when symptoms of bipolar disorder are controlled with medicines. For more information on the types of counselling used to treat bipolar disorder, see Other Treatment.

Home treatment

Home treatment includes helping your child get regular exercise, eat a balanced diet, and have a regular sleep schedule. For more information, see Home Treatment.

Hospital treatment

If your child's behaviour is suicidal, aggressive, reckless, or dangerous, or if he or she is out of touch with reality (psychotic) or unable to function, the child may need to go into the hospital for a while. Also, many medicines can make the symptoms of bipolar disorder worse. If your child is taking one of these, he or she may need to taper off and stop the medicine. This should only be done under the supervision of a doctor.

Impact on the family

Bipolar disorder has a big impact on both the child and his or her family. Successful treatment requires that the child and family members know what happens in bipolar disorder and that the family members help make sure that the child follows the treatment.

It can take time for you and your child to accept that the child has a serious, long-term condition that requires ongoing treatment and constant monitoring. But keep in mind that by working with your child's doctor, you and your child can find treatment that works.

Prevention

Bipolar disorder can't be prevented. But there are ways to help manage or prevent mood changes.

The first and most important preventive measure is to make sure that your child takes his or her medicines as directed. Bipolar disorder is a long-term condition and often requires lifelong treatment with medicines.

Reducing stress, getting regular sleep and exercise, and staying on a daily routine may help prevent mood swings and can help with the symptoms of depression and mania.

Home Treatment

Learning as much as you can about bipolar disorder may help you recognize mood changes in your child as they begin to occur. Catching and treating these mood changes early may help reduce the length of the manic or depressive episode and improve the quality of your child's life.

There are steps you can take at home to reduce your child's symptoms.

  • Keep your child's room quiet, and have your child go to bed at the same time every night.
  • Control the amount of stress in your child's life. You may need to seek ways to help your child reduce academic requirements during times of severe mania or depression.
  • Learn to recognize the early warning signs of your child's manic and depressive mood episodes.

Steps your child can take to help control moods include:

  • Getting enough exercise. During a depressive episode, your child may feel like doing only gentle exercises, such as taking a walk or swimming.
  • Getting enough sleep and keeping a consistent sleep schedule.
  • Eating a balanced diet.
  • Avoiding the use of alcohol or drugs. Substance use disorder makes bipolar disorder worse.
  • Avoiding beverages that contain caffeine, including coffee, tea, colas, and energy drinks. Health Canada recommends that children and teens not drink caffeinated energy drinks.footnote 2
  • Learning to recognize the early warning signs of manic and depressive mood episodes.
  • Asking for help from friends and family when needed.

For some children with bipolar disorder, depression can cause debilitating symptoms. For information about managing childhood depression, see the topic Depression in Children and Teens.

Medications

Medicines for bipolar disorder in adults have been well studied. But more research is being done on how well the medicines work and if they are safe for children and teens.

When you and your child's doctor are deciding which types of medicines to use, think about:

  • The side effects of each medicine and how well your child can tolerate them.
  • How often your child will need to take the medicines.
  • Whether your child is being treated for other illnesses or disorders and how those medicines will interact with medicines for bipolar disorder.
  • Whether your child has used any of the medicines before and whether they worked.

Before prescribing medicine to treat bipolar disorder, your doctor will ask questions about possible suicidal behaviour.

Be sure to use all medicines exactly as your child's doctor has prescribed them. If your child has intolerable side effects from any medicine, call your doctor immediately.

Medicine choices

Medicines most often used to treat bipolar disorder in children and teens include:

  • Mood stabilizers , such as:
    • Lithium (for example, Carbolith or Lithane).
    • Carbamazepine (for example, Tegretol).
    • Divalproex.
    • Lamotrigine (Lamictal).
    • Valproate (Depakene).
  • Antipsychotics , such as:
    • Aripiprazole (Abilify).
    • Quetiapine.
    • Risperidone (Risperdal).
  • Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac, for example).

While antidepressants can be helpful for some children with bipolar disorder, they can also trigger mania. Doctors usually prescribe antidepressants along with mood stabilizers or antipsychotics to help prevent a manic episode. And the doctor needs to carefully monitor the child for mood changes. Antipsychotics can be used alone, or they may be combined with mood stabilizers for more effective control of manic episodes.

Side effects

Medicines for bipolar disorder have side effects that need to be managed. Some things you cannot change, such as increased urination (common with lithium). But you can deal with some side effects like weight gain (common with several medicines used to treat bipolar disorder) by increasing exercise and reducing calorie intake.

You can work with your child and his or her doctor to find ways of coping with side effects. If side effects from a medicine are intolerable, the doctor may have to change the dose or the medicine.

Advisories

Advisories. Health Canada and the U.S. Food and Drug Administration (FDA) have issued advisories on antidepressant medicines and the risk of suicide. Talk to your doctor about possible side effects and the warning signs of suicide.

Other Treatment

Most children who have bipolar disorder need medicine. But other forms of treatment used along with medicine play an important role in balancing mood and improving quality of life. Counselling, education about the disorder, and stress reduction can help.

Psychological treatments

Counselling along with medicine has been used effectively to manage bipolar disorder. Types of therapy that counsellors use to treat bipolar disorder include:

  • Cognitive-behavioural therapy. This focuses on modifying certain thinking and behaviour patterns.
  • Interpersonal and social rhythm therapy. This focuses on social and family relationships and related problems. It teaches family members about the disorder. They learn how to recognize signs of relapse and how to manage what creates stress in each family member. This therapy also helps with setting and keeping a regular social and sleep schedule.
  • Problem-solving therapy. This is a type of cognitive therapy that helps you find immediate solutions to problems.
  • Family therapy. This helps educate and support the entire family.
  • Play therapy for very young children.
  • Psychological education and support groups.
  • Dialectical-behavioural therapy. This focuses on building skills to manage mood swings.

In some cases, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.

Complementary therapy

Complementary medicine is a term used for a wide variety of health care practices that may be used along with standard medical treatment. A few studies suggest that adding omega-3 fatty acids to medicine (such as lithium) can help reduce the depressive symptoms of bipolar disorder in some people. Omega-3 fatty acids don't seem to have an effect on the manic symptoms of bipolar disorder. And omega-3 fatty acids alone are not a good treatment for bipolar disorder. They are not a replacement for medicine or other therapy used to treat bipolar disorder.footnote 3, footnote 4

References

Citations

  1. American Psychiatric Association (2013). Bipolar and related disorders. In Diagnostic and Statistical Manual of Mental Disorders, 5th ed., pp. 123–154. Washington, DC: American Psychiatric Association.
  2. Health Canada (2012). Category-specific guidance for temporary marketing authorization: Caffeinated energy drinks. Available online: http://www.hc-sc.gc.ca/fn-an/legislation/guide-ld/guidance-caf-drink-boiss-tma-amt-eng.php.
  3. Sarris J, et al. (2012). Omega-3 for bipolar disorder: Meta-analyses of use in mania and bipolar depression. Journal of Clinical Psychiatry, 73(1): 81–86.
  4. Montgomery P, Richardson AJ (2009). Omega-3 fatty acids for bipolar disorder. Cochrane Database of Systematic Reviews (1).

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Credits

Current as of: June 16, 2021

Author: Healthwise Staff
Medical Review:
John Pope MD - Pediatrics
Brian D. O'Brien MD - Internal Medicine
Adam Husney MD - Family Medicine
Kathleen Romito MD - Family Medicine
Elizabeth T. Russo MD - Internal Medicine
David A. Axelson MD - Child and Adolescent Psychiatry
David A. Brent MD - Child and Adolescent Psychiatry