Merck Manual

Please confirm that you are a health care professional

honeypot link

Bipolar Disorder in Children and Adolescents

By

Josephine Elia

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Apr 2021| Content last modified Apr 2021
Click here for Patient Education
Topic Resources

Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment is a combination of mood stabilizers (eg, lithium, certain anticonvulsants, antipsychotic drugs), psychotherapy, and antidepressants.

Bipolar disorder is rare in children. In the past, bipolar disorder was diagnosed in prepubertal children who were disabled by intense, unstable moods. However, because such children typically progress to a depressive rather than bipolar disorder, they are now classified as having disruptive mood dysregulation disorder Disruptive mood dysregulation disorder Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and... read more .

Etiology of Bipolar Disorder

Heredity is involved and several genetic variants have been associated with bipolar disorder (1 General references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ), although there are currently no markers useful for diagnosing bipolar disorder. However neuroimaging studies in youths report smaller volumes in the amygdala (2–4 General references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ) and prefrontal cortex (5 General references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ) as well as lack of the normal increase in volume of the amygdala (6 General references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ) and anterior white matter (5 General references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ) that occurs in normal controls during adolescence.

General references

  • 1. Craddock N, Sklar P: Genetics of bipolar disorder. Lancet 381(9878):1654-1662, 2013. doi: 10.1016/S0140-6736(13)60855-7

  • 2. Phillips ML, Swartz HA: A critical appraisal of neuroimaging studies of bipolar disorder: Toward a new conceptualization of underlying neural circuitry and a road map for future research. Am J Psychiatry 171(8):829-843, 2014. doi: 10.1176/appi.ajp.2014.13081008

  • 3. Hafeman D, Bebko G, Bertocci MA, et al: Amygdala-prefrontal cortical functional connectivity during implicit emotion processing differentiates youth with bipolar spectrum from youth with externalizing disorders. J Affect Disord 208:94-100, 2017. doi: 10.1016/j.jad.2016.09.064

  • 4. Mwangi B, Spiker D, Zunta-Soares JC, et al: Prediction of pediatric bipolar disorder using neuroanatomical signatures of the amygdala. Bipolar Disord16(7):713-721, 2104.

  • 5. Najt P, Wang F, Spencer L, et al: Anterior cortical development during adolescence in bipolar disorder. Biol Psychiatry 79(4):303-310, 2016.

  • 6. Bitter SM, Mills NP, Adler CM, et al: Progression of amygdala volumetric abnormalities in adolescents following their first manic episode. J Am Acad Child Adolesc Psychiatry 50(10):1017-1026, 2011.

Symptoms and Signs of Bipolar Disorder

Bipolar disorder is characterized by recurrent episodes of elevated mood (mania or hypomania). Manic episodes alternate with depressive episodes, which can be more frequent. During a manic episode in adolescents, mood may be very positive or hyperirritable; the 2 moods often alternate 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 of Bipolar Disorder

  • Clinical evaluation

  • Testing for toxicologic causes

Diagnosis of bipolar disorder is based on identification of symptoms of mania as described above, plus a history of remission and relapse.

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 Bipolar Disorder

Prognosis for adolescents with bipolar disorder varies but worsens with each recurrence. Factors that increase risk of recurrence include early age of onset, severity, family psychopathology, and lack of, and/or poor adherence to, treatment (1 Prognosis reference Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ). 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.

Prognosis reference

  • 1. Birmaher B, Merranko JA, Gill MK: Predicting personalized risk of mood recurrences in youths and young adults with bipolar spectrum disorder. J Am Acad Child Adolesc Psychiatry 59(10):1156-1164, 2020. doi:https://doi.org/10.1016/j.jaac.2019.12.005

Treatment of Bipolar Disorder

  • Mania: 2nd-generation antipsychotics, sometimes mood stabilizers

  • Depression: 2nd-generation antipsychotics plus an SSRI, sometimes lithium

For mania, 2nd-generation antipsychotics are the first line of treatment (1–3 Treatment references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ). Agents include aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone. Lithium or other mood stabilizers (divalproex, lamotrigine, carbamazepine) may be used for patients who fail 2 or 3 trials of antipsychotics (4 Treatment references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ).

For depression, 2nd-generation antipsychotics combined with a selective serotonin reuptake inhibitor (SSRI) are the first line of treatment. Lithium is an alternative and may also be combined with an SSRI. Compared to other mood stabilizers and antipsychotics, lithium results in decreased suicidality, less depression and better psychosocial function. These findings mimic those found in adults (5 Treatment references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ). Antidepressants should not be used alone but in combination with the antipsychotics or lithium. Antidepressants do not increase the risk of treatment-emergent mania (as was thought in the past) but may destabilize children and adolescents with a bipolar disorder (6–8 Treatment references Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment... read more ). Psychotherapy is also important.

Pearls & Pitfalls

  • 2nd-generation antipsychotics are the first-line treatment for pediatric bipolar disorder.

  • Lithium can decrease suicidal ideation.

Table
icon

Treatment references

  • 1. Kendall T, Morriss R, Mayo-Wilson E, et al: Assessment and management of bipolar disorder: Summary of updated NICE guidance. BMJ 349:g5673, 2014. doi: https://doi.org/10.1136/bmj.g5673

  • 2. Yatham LN, Kennedy SH, Parikh SV, et al: Canadian Network for mood and anxiety treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: Update 2013. Bipolar Disord 15(1):1-44, 2013. doi: 10.1111/bdi.12025

  • 3. Walkup JT, Wagner KD, Miller L: Treatment of early-age mania: Outcomes for partial and nonresponders to initial treatment. J Am Acad Child Adolesc Psychiatry 54(12):10081019, 2015.

  • 4. Kowatch RA, Suppes T, Carmody TJ, et al: Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry39(6):713-720, 2000. doi: 10.1097/00004583-200006000-00009

  • 5. Hafeman DM, Rooks B, Merranko J, et al: Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. J Am Acad Child Adolesc Psychiatry 59(10):1146-1155, 2020. doi: 10.1016/j.jaac.2019.06.013

  • 6. Biederman J, Mick E, Spencer TJ, et al: Therapeutic dilemmas in the pharmacotherapy of bipolar depression in the young. J Child Adolesc Psychopharmacol 10(3):185-192, 2000. doi: 10.1089/10445460050167296

  • 7. Scheffer RE, Tripathi A, Kirkpatrick FG, et al: Guidelines for treatment-resistant mania in children with bipolar disorder. J Psychiatr Pract 17(3):186-193, 2011. doi: 10.1097/01.pra.0000398411.59491.8c

  • 8. Baumer FM, Howe M, Gallelli K, et al: A pilot study of antidepressant-induced mania in pediatric bipolar disorder: Characteristics, risk factors, and the serotonin transporter gene. Biol Psychiatry60(9):1005-1012, 2006. doi: 10.1016/j.biopsych.2006.06.010

Key Points

  • Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time.

  • Bipolar disorder typically begins during mid-adolescence through the mid-20s; it is rare in children.

  • Typically, onset is insidious; children have a history of being very temperamental and difficult to manage.

  • In adolescents and prepubertal children, treat manic or agitated episodes with antipsychotics first since these medications work quickly, followed by mood stabilizers to prevent relapses, and SSRIs and psychotherapy to treat depressive episodes.

Drugs Mentioned In This Article

Drug Name Select Trade
No US brand name
TEGRETOL
INVEGA
ABILIFY
GEODON
RISPERDAL
LAMICTAL
LATUDA
PROZAC, SARAFEM
ZYPREXA
SEROQUEL
LITHOBID
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Test your knowledge

Neonatal Herpes Simplex Virus (HSV) Infection
Neonatal herpes simplex virus (HSV) infection has a high morbidity and mortality rate. The usual presenting symptom in neonates is a vesicular eruption that appears between the 1st and 3rd week of life. There are several ways in which this disease is transmitted to the neonate. Of these modes of transmission, which of the following is the most common? 
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
 

Also of Interest

 
TOP