Bipolar Disorder in Children and Adolescents

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.

Certain drugs (eg, cocaine Cocaine Cocaine is a sympathomimetic drug with central nervous system stimulant and euphoriant properties. High doses can cause panic, schizophrenic-like symptoms, seizures, hyperthermia, hypertension... read more , amphetamines Amphetamines Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more , phencyclidine Ketamine and Phencyclidine (PCP) Ketamine and phencyclidine are N-methyl-D-aspartate receptor antagonists and dissociative anesthetics that can cause intoxication, sometimes with confusion or a catatonic state. Overdose can... read more , certain antidepressants) and environmental toxins (eg, lead) can exacerbate or mimic the disorder. Certain disorders (eg, thyroid disorders) can cause similar symptoms. There are also a few case reports of mania associated with asymptomatic (7 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 symptomatic (8 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 ) COVID-19 infections in youths.

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 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.

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.

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.