Information on child and adolescent bipolar disorder including diagnosis and treatment along with links to support groups and recommendations on useful books and materials for parents, children and teens.
Research findings, clinical experience, and family accounts provide substantial evidence that bipolar disorder, also called manic-depressive illness, can occur in children and adolescents. Bipolar disorder is difficult to recognize and diagnose in youth, however, because it does not fit precisely 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 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. Better understanding of the diagnosis and treatment of bipolar disorder in youth is urgently needed. In pursuit of this goal, the National Institute of Mental Health (NIMH) is conducting and supporting research on child and adolescent bipolar disorder.
Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.
Symptoms and Diagnosis
Bipolar disorder is a serious mental illness
characterized by recurrent episodes of depression,
mania, and/or mixed symptom states. These episodes cause
unusual and extreme shifts in mood, energy, and behavior
that interfere significantly with normal, healthy
functioning.
Manic symptoms include:
Depressive symptoms include:
Symptoms of mania and depression in children and
adolescents may manifest themselves through a variety of
different behaviors 1,2. 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 efforts to run
away from home, irritability, complaining, unexplained
crying, social isolation, poor communication, and
extreme sensitivity to rejection or failure. Other
manifestations of manic and depressive states may
include alcohol or substance abuse and difficulty with
relationships.
Existing evidence indicates that bipolar disorder
beginning in childhood or early adolescence may be a
different, possibly more severe form of the illness than
older adolescent- and adult-onset bipolar disorder 1,2.
When the illness begins before or soon after 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
illness.
A child or adolescent who appears to be depressed and
exhibits ADHD-like symptoms that are very severe, with
excessive temper outbursts and mood changes, should be
evaluated by a psychiatrist or psychologist with
experience in bipolar disorder, particularly if there is
a family history of the illness. This evaluation is
especially important since psychostimulant medications,
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.
Findings from an NIMH-supported study suggest that the
illness may be at least as common among youth as among
adults. In this study, one percent of adolescents ages
14 to 18 were found to have met criteria for bipolar
disorder or cyclothymia, a similar but milder illness,
in their lifetime 3. In addition, close to six percent
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 co-occurring illnesses (especially
anxiety and disruptive behavior disorders), suicide
attempts, and mental health services utilization. The
study highlights the need for improved recognition,
treatment, and prevention of even the milder and
subclinical cases of bipolar disorder in adolescence.
Treatment
Once the diagnosis of bipolar disorder is made, the
treatment of children and adolescents is based mainly on
experience with adults, since as yet there is very
limited data on the efficacy and safety of mood
stabilizing medications in youth 4. 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.
Valproate Use
According to studies conducted in Finland in patients
with epilepsy, valproate may increase testosterone
levels in teenage girls and produce polycystic ovary
syndrome in women who began taking the medication before
age 20 5. Increased testosterone can lead to polycystic
ovary syndrome with irregular or absent menses, obesity,
and abnormal growth of hair. Therefore, young female
patients taking valproate should be monitored carefully
by a physician.
NIMH is attempting to fill 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 4.
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 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.