Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. The label “bipolar” has also been applied to prepubertal children disabled by intense, unstable moods. However, in these young children, the mood states last from moments to days. In both cases, diagnosis is by history and mental status examination. Treatment is a combination of mood stabilizers (eg, lithium, certain anticonvulsants and antipsychotic drugs), psychotherapy, and antidepressants.
Bipolar disorder typically begins during mid-adolescence through the mid-20s. In many children, the initial manifestation is one or more episodes of depression; about 1/3 of children who have an episode of severe depression before puberty convert to bipolar disorder during their adolescent or early adult years. The term “bipolar” has been applied to prepubertal children with unstable, intense moods, but typically, the moods last only a short time. Thus, whether this condition constitutes bipolar disorder is unclear; research in this area is ongoing.
Etiology is unknown, but heredity is involved. Dysregulation of serotonin and norepinephrine may be involved, as may a stressful life event. Certain drugs (eg, cocaine, amphetamines, phencyclidines, certain antidepressants) and environmental toxins (eg, lead) can exacerbate or mimic the disorder. Certain disorders (eg, thyroid disorders) can cause similar symptoms.
Symptoms and Signs
The hallmark of bipolar disorder is the manic episode. Manic episodes alternate with depressive episodes, which can be more frequent.
During a manic episode in adolescents, mood may be very positive or hyperirritable and often alternates between the 2 moods depending on social circumstances. Speech is rapid and pressured, sleep is decreased, and self-esteem is inflated. Mania may reach psychotic proportions (eg, “I have become one with God”). Judgment may be severely impaired, and adolescents may engage in risky behaviors (eg, promiscuous sex, reckless driving). Prepubertal children may experience dramatic moods, but the duration of these moods is much shorter (often lasting only a few moments) than that in adolescents. Onset is characteristically insidious, and children typically have a history of always being very temperamental and difficult to manage.
Diagnosis is based on history and mental status examination. A number of medical disorders (eg, thyroid disorders, brain infections or tumors) and drug intoxication must be ruled out with appropriate medical assessment, including a toxicology screen for drugs of abuse and environmental toxins. The interviewer should also search for precipitating events, such as severe psychologic stress, including sexual abuse or incest.
Prognosis for adolescents with bipolar disorder varies. Those who have mild to moderate symptoms, who have a good response to treatment, and who remain adherent and cooperative with treatment have an excellent prognosis. However, treatment response is often incomplete, and adolescents are notoriously nonadherent to drug regimens. For such adolescents, the long-term prognosis is not as good.
Little is known about the long-term prognosis of prepubertal children diagnosed with bipolar disorder based on highly unstable and intense moods.
For adolescents and prepubertal children, mood stabilizers are used to treat manic or agitated episodes, and psychotherapy and antidepressants treat the depressive episodes.
Mood stabilizers (see Table 2: Mental Disorders in Children and Adolescents: Selected Drugs for Bipolar Disorder*) roughly fall into 3 categories:
All mood stabilizers have a potential for troubling and even dangerous adverse effects. Thus, treatment must be individualized. Furthermore, drugs that are highly successful during initial stabilization may be unacceptable for maintenance because of adverse effects, most notably weight gain.
Antidepressants may trigger a switch from depression to mania; therefore, they are usually used with a mood stabilizer.
Last full review/revision April 2009 by Hugh F. Johnston, MD