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Bipolar Disorder in Children and Adolescents (Manic-Depressive Illness)

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

In bipolar disorder (formerly called manic-depressive illness), periods of intense elation and excitation (mania) alternate with periods of depression and despair. Mood may be normal in between these periods.

  • Children may rapidly go from being excited, happy, and active to being depressed, withdrawn, and sluggish or full of rage and violent.

  • Doctors base the diagnosis on symptoms and results of psychiatric tests.

  • The diagnosis of bipolar disorder in young children is very controversial.

  • Treatment may include mood-stabilizing drugs to treat mania, antidepressants to treat depression, and psychotherapy.

Children normally have fairly rapid mood swings, going from happy and active to glum and withdrawn. These swings rarely indicate a mental health disorder. Bipolar disorder is far more severe than these normal mood changes, and the moods last much longer, often for weeks or months.

Bipolar disorder is rare in children. In the past, bipolar disorder was often diagnosed when young children (aged 4 to 11 years) became intensely irritable many times a day. Such children are now thought to have a disruptive mood dysregulation disorder instead.

Bipolar disorder typically begins during mid-adolescence or early adulthood. Bipolar disorder in adolescents is similar to bipolar disorder in adults.

The cause is unknown, but a tendency to develop bipolar disorder can be inherited. Chemical abnormalities in the brain may be involved. In children with the disorder, stress may trigger an episode. Also, certain other disorders, such as overactive thyroid gland or attention-deficit/hyperactivity disorder (ADHD), can cause some similar symptoms. Certain drugs and toxins in the environment (such as lead) can cause similar symptoms.

Symptoms

In many children, the first symptom of bipolar disorder is one or more episodes of depression.

The main symptoms are episodes of feeling intense elation and excitement (mania) that alternate with episodes of depression, which may occur more often. Children may go through intense changes in mood.

During a manic episode, sleep is disturbed, and children may become aggressive. They may have a very positive mood or be very irritable. They may talk rapidly. Their thoughts may race. They may have grandiose thoughts. For example, children may feel they have some great talent or have made an important discovery. Their judgment may be impaired, and adolescents may behave irresponsibly—for example, by becoming sexually promiscuous or driving recklessly. Younger children may have dramatic moods, but these moods often last only a few moments. School performance often deteriorates.

During an episode of depression, children with bipolar disorder, like those with depression alone, feel excessively sad and lose interest in their usual activities. They may think and move slowly and sleep more than usual. Feelings of hopelessness and guilt may overwhelm them.

Children with bipolar disorder appear normal between episodes, in contrast to children with ADHD, who are in a constant state of increased activity.

Symptoms often begin gradually. However, before the disorder develops, children typically have been very temperamental and difficult to manage.

Diagnosis

  • Symptoms

  • Tests to check for other causes

Doctors base the diagnosis of bipolar disorder on a description of typical episodes by children and their parents. Doctors try to determine whether something, such as severe stress, triggered the episode.

Distinguishing bipolar disorder from other disorders is important. For example, both bipolar disorder (in a manic episode) and ADHD can cause children to be very active, but doctors can usually distinguish the disorders because most children with ADHD, unlike those with bipolar disorder, do not have intense mood changes.

Doctors determine whether children are taking any drugs that could contribute to the symptoms. Doctors may also check for signs of other disorders that may contribute to or cause the symptoms. For example, they may do blood tests to check for an overactive thyroid gland.

Treatment

  • Mood-stabilizing drugs and antidepressants

  • Psychotherapy

In bipolar disorder, episodes of mania and agitation are treated with mood-stabilizing drugs. Mood-stabilizing drugs include

  • Lithium

  • Antipsychotic drugs that stabilize mood (such as aripiprazole, quetiapine, and risperidone)

  • Anticonvulsants that stabilize mood (such as carbamazepine and valproate).

Episodes of depression are treated with psychotherapy and antidepressants. Antidepressants may trigger a switch from depression to mania and are thus usually used with a mood-stabilizing drug.

Individual and family psychotherapy helps children and their families cope with the consequences of the disorder. Psychotherapy can help adolescents, who are prone to not follow their drug regimen, continue to follow it. If adolescents have mild to moderate symptoms and follow their drug regimen, they usually do well.

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • SEROQUEL
  • LITHOBID
  • TEGRETOL
  • RISPERDAL
  • ABILIFY