Bipolar Disorder in Children

What is bipolar disorder?

Bipolar disorder (formerly known as manic-depressive illness or manic depression) is a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns and behavior. These shifts can last for hours, days, weeks or months and interrupt your ability to carry out day-to-day tasks.

Most people are diagnosed with bipolar disorder in adolescence or adulthood, but the symptoms can appear earlier in childhood.

There are a few types of bipolar disorder, most of which involve experiencing manic and depressive episodes. However, people with bipolar disorder don’t always experience either manic episodes or depressive episodes. They also experience euthymia, which is a relatively stable mood state in which they are their usual self.

Mania is a condition in which you have a period of abnormally elevated, extreme changes in your mood, emotions, energy level and activity level. People with certain types of bipolar disorder can experience hypomania, which is a less severe form of mania.

During a depressive episode, you experience a low or depressed mood and/or loss of interest in most activities, as well as many other symptoms of depression.

How does bipolar disorder affect children?

Bipolar disorder is different in children and teenagers than in adults. Adults with bipolar disorder often have clear episodes of mania or depression that last a week or longer. In children and teens, the phases may be less clear, and changes from one episode to the other may happen faster. For example, a child may exhibit periods of giddiness and silliness, anger outbursts, and unprovoked crying all in one day.

Bipolar disorder is different from the typical mood swings and ups and downs every child and teenager goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and also involve:

• Changes in sleep patterns.
• Changes in energy level.
• Issues with focus and the ability to think clearly.
• Bipolar disorder symptoms can make it hard for your child to perform well in school or to get along with friends and family members. Some children and teens with bipolar disorder may try to hurt themselves or attempt suicide.

How common is bipolar disorder in children?

Studies show that about 4% of people under the age of 18, including children as young as 5, have bipolar disorder.

To put this in perspective, here are the rates of the most common mental health conditions that affect children:

• 9.8% of children have attention-deficit/hyperactivity disorder (ADHD).
• 9.4% of children have an anxiety disorder.
• 4.4% of children have depression.

What are the symptoms of bipolar disorder in children?

To understand bipolar disorder, it's helpful to know how mental health providers talk about severe mood swings. Mood swings are often termed "mood episodes." Manic episodes describe periods when a child feels overly excited and confident, and they have a lot of energy. These feelings can quickly give way to confusion, irritability and possibly rage.

Depressive episodes describe periods when a child feels very sad (depressed) and has low energy.

Children may not have clear-cut episodes. Instead, they may have "mixed" episodes and exhibit both manic and depressive symptoms. Some children may show "rapid cycling" where they shift quickly between mania or hypomania and depression — sometimes even within the same day.

Depressive, manic or mixed episodes, by definition, are a change in behavior that differs from your child’s baseline state (euthymia).

Signs and symptoms of manic episodes in children

Children with bipolar disorder are more likely to be irritable and prone to destructive outbursts during manic episodes than to be happy or euphoric like adults with bipolar disorder typically are.

During a manic episode, your child may:

• Be overly happy, hopeful and excited, which is often inconsistent with external events.
• Have bursts of energy and be very active.
• Have frequent tantrums or seem more irritable than usual.
• Be unusually silly compared to others their age.
• Be defiant and destructive and not follow rules as they usually do.
• Go for days with little or no sleep without feeling or acting tired.
• Be more impatient and restless than usual.
• Talk very fast, not allowing others to talk.
• Be distracted, have trouble concentrating and jump between different ideas.
• Believe they have many unrealistic or grandiose skills and powers and can do things other people can't do (such as believe that they’re in charge instead of adults).
• Seem overly interested or involved in pleasurable but risky activities, such as unprotected sex and drinking alcohol.
• Do risky or reckless things that show poor judgment.

Signs and symptoms of depressive episodes in children

During a depressive episode, your child may:

• Feel frequent and unprovoked sadness.
• Be uninterested in things they used to enjoy.
• Cry often.
• Be irritable.
• Have trouble falling asleep, wake up very early or sleep too much.
• Have low energy.
• Lose interest in friends or classmates and isolate themselves from social interaction.
• Be extremely sensitive to rejection or failure.
• Have trouble concentrating or remembering things.
• Have poor performance in school.
• Eat too little or too much.
• Say negative things about themselves.
• Talk or think about death and suicide.
• They may also mention or complain of physical symptoms, including:
• Headaches.
• Stomachaches.
• Muscle aches.
• Tiredness.

Teens may be less likely than adults to admit that they’re sad and depressed. If your child shows signs of suicidal thinking, call your child’s healthcare provider.

If you think your child is in crisis and needs immediate help, call 911 or the Suicide and Crisis Lifeline at 988. It’s confidential, free and available 24/7.

What causes bipolar disorder in children?

Scientists don’t yet know the exact cause of bipolar disorder.

But they believe there’s a strong genetic (inherited) component. More than two-thirds of people with bipolar disorder have at least one close biological relative with the condition. However, just because you have a biological relative with bipolar disorder, it doesn’t necessarily mean that you’ll also develop it.

Research also shows that trauma and stressful life events— such as the death of a family member or abuse — may increase the chances of developing bipolar disorder in people with a genetic risk of having the condition.

Some children with bipolar disorder may have physical changes in their brain, which may mean that some parts of their brain are more active or less active than in other children.

Scientists are currently performing research to determine the relationship that these factors have in bipolar disorder, how they may help prevent its onset and what role they may play in its treatment.

How is bipolar disorder diagnosed in children?

To be diagnosed with bipolar disorder, your child must have experienced at least one episode of mania or hypomania (with or without a depressive episode).

To diagnose bipolar disorder, your child’s healthcare provider may use many tools, including:

• A physical examination.
• A thorough medical history, which will include asking about your child’s symptoms, lifetime history, experiences and family history.
• Medical tests, such as blood tests, to rule out other conditions that could be causing your child’s symptoms.
• A mental health evaluation. Your child’s provider may perform the evaluation, or they may refer your child to a mental health specialist, such as a psychologist or psychiatrist, to get one.

Providers can often diagnose bipolar disorder in children more accurately when they ask the children, their teachers and their caregivers to fill out questionnaires that ask about mood, energy levels and other factors.

Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in children and teens, including:

• Attention-deficit/hyperactivity disorder (ADHD).
• Disruptive mood regulation disorder.
• Oppositional defiant disorder.
• Conduct disorder.
• Major depression.
• Anxiety disorders.
• Because of this, diagnosing bipolar disorder in children can be complicated and requires a careful and thorough evaluation by a trained, experienced mental health professional.

How is bipolar disorder treated in children?

Over the past decade, mental health experts across psychology and psychiatry have helped refine the assessment and treatment of bipolar disorder among children and teens.

An effective treatment plan usually includes a combination of the following therapies:

• Psychotherapy (talk therapy).
• Medications.
• Helpful lifestyle habits, such as exercise, meditation and consistent routines.
• Other therapies.

Bipolar disorder is a lifelong condition, so treatment is a lifelong commitment. It can sometimes take several months to years before you, your child and their provider find a comprehensive treatment plan that works best for your child. Although this can be discouraging, it’s important for your child to continue treatment.

Psychotherapy for children with bipolar disorder

Psychotherapy, also called “talk therapy,” can be an effective part of the treatment plan for children with bipolar disorder.

Psychotherapy is a term for a variety of treatment techniques that aim to help your child identify and change troubling emotions, thoughts and behaviors. Working with a mental health professional, such as a psychologist or psychiatrist, can provide support, education and guidance to your child and your family.

Some types of therapy for bipolar disorder include:

• Psychoeducation: Psychoeducation is the way that mental health professionals teach people and their families about their mental health conditions.
• Family-focused therapy (FFT): This therapy is for people with bipolar disorder and their caregivers and family. During this treatment, together, your child and your family learn about bipolar disorder, communication improvement training and problem-solving skills training. It greatly helps family members to recognize symptoms of the condition and develop a plan for managing manic and depressive episodes.
• Chronotherapy: This therapy helps your child establish a steady and predictable sleep routine. Your child learns to go to bed at the same time and wake up at the same time every day.
• Interpersonal and social rhythm therapy (IPSRT): This therapy is designed to help your child improve their moods by understanding and working with their biological and social rhythms. IPSRT emphasizes techniques to improve medication adherence, manage stressful life events and reduce disruptions in social rhythms (day-to-day variability of habitual behaviors).

Medications for children with bipolar disorder

Mood stabilizers and antipsychotic (neuroleptic) drugs, which healthcare providers have used for decades to treat bipolar disorder in adults, are also effective in children with bipolar disorder.

Your child’s provider will work with you and them to select the best medicine. If your child also has attention-deficit/hyperactivity disorder (ADHD), their provider may prescribe medicines for it. But, in some cases, the medicines for ADHD can trigger manic symptoms or mood swings in children with bipolar disorder. Depression medications can also bring on bipolar symptoms in children.

Mood-stabilizing medications can help manage manic or hypomanic episodes. Types of mood stabilizers and their brand names include:

• Lithium (Eskalith®, Lithobid®, Lithonate®).
• Valproic acid (Depakene®).
• Divalproex sodium (Depakote®).
• Carbamazepine (Tegretol®, Equetro®).
• Lamotrigine (Lamictal®).

Providers often prescribe second-generation or “atypical” antipsychotics (neuroleptics) in combination with a mood stabilizer for people with bipolar disorder. These medications help with both manic and depressive episodes.

Only four of these drugs are FDA-approved to help treat bipolar depression, including:

• Cariprazine (Vraylar®).
• Lurasidone (Latuda®).
• Olanzapine-fluoxetine combination (Symbyax®).
• Quetiapine (Seroquel®).

What are the possible side effects of medications used to treat bipolar disorder in children?

Side effects of bipolar disorder medications are common and vary by medication.

It’s important to talk with your child’s healthcare provider about what you and your child can expect when taking certain medications. It’s also important to carefully assess your child for side effects and encourage them to tell you if they’re experiencing any. Report any negative side effects to their provider as soon as possible.

Your child should never stop taking their medication unless their provider tells them to do so. Abruptly stopping medication can cause severe side effects and trigger severe episodes.

The most common side effects of bipolar disorder medications include:

• Weight gain.
• Metabolic dysregulation, including abnormal lipid levels (dyslipidemia), high blood pressure (hypertension) and high blood sugar (hyperglycemia).
• Drowsiness.
• Akathisia — feelings of restlessness and agitation with a compelling need to move, rock or pace.

Lithium is one of the most common drugs used to treat bipolar disorder. Anything that lowers the level of sodium (salt) in your child’s body, such as switching to a low-sodium diet, heavy sweating, fever, vomiting or diarrhea may cause a toxic buildup of lithium in their body.

The following are signs of lithium toxicity (lithium overdose). Call your child’s provider immediately or go to the nearest emergency room if your child experiences:

• Blurred vision or double vision.
• Irregular pulse.
• Extremely fast or slow heartbeat.
• Difficulty breathing.
• Confusion and dizziness.
• Severe trembling or convulsions.
• Passing large amounts of pee.
• Uncontrolled eye movements.
• Unusual bruising or bleeding.

Can bipolar disorder be prevented?

Unfortunately, there’s no known way to prevent bipolar disorder because scientists don’t know its exact cause.

But it’s important to know the signs and symptoms of bipolar disorder in children and to seek early intervention if your child is experiencing symptoms.

What can I expect if my child has bipolar disorder?

Caring for a child or teenager with bipolar disorder can be stressful for parents, caregivers and families.

It’s important that you take care of yourself as well. Consider seeing a therapist or consult your healthcare provider about support groups. You may also want to consider family-focused therapy. During this type of therapy, together, your family learns about bipolar disorder, communication improvement training and problem-solving skills training.

Finding support and strategies for managing stress can help you, your child and your family.

What is the prognosis (outlook) for bipolar disorder in children?

The prognosis for bipolar disorder is often poor unless it’s properly treated.

If bipolar disorder goes untreated in children, it may make school, relationships and daily life very difficult. Children and teenagers with bipolar disorder are also at increased risk for:

• Delinquent behavior that results in incarceration.
• Misuse of alcohol and/or drugs.
• Suicide.

This is why it’s essential to seek medical care for your child if you think they may have bipolar disorder and to help them stay committed to treatment if they do have the condition.

Regular and continued use of medication can help reduce episodes of mania and depression. By knowing how to recognize the symptoms and triggers of these episodes, there’s a better chance for effective treatment and finding coping methods that may prevent long periods of illness, extended hospital stays and suicide.

How can I help my child with bipolar disorder?

If your child or teen has bipolar disorder, here are some things you can do to help them:

• Support your child: Encourage them to talk about their thoughts and feelings and be a good listener. This helps your child realize that feelings and thoughts really do matter and that you always have and always will care for them.
• Be patient: Finding the proper treatment that works best for your child and seeing improvement in their symptoms takes time. Although this can be daunting, it’s important to stay committed to the process.
• Pay attention to your child’s moods: Be alert to any major changes in your child. Stay in touch with teachers, babysitters and other people in your child’s life to share information about their symptoms.
• Keep a symptom diary to track your child’s moods: This can help you and your child’s healthcare team better understand their triggers and determine the best treatment strategy.
• Maintain a consistent routine at home: Maintaining regular daily routines, especially sleep routines, have been shown to help stabilize the moods of people with bipolar disorder.
• Help your child learn to manage stress: Stress and anxiety can worsen mood symptoms in many people with bipolar disorder. It’s important to help your child manage their stress in a healthy way, such as with deep breathing exercises or relaxing activities.
• Help your child understand that treatment can make life better: Explain the benefits of treatment for bipolar disorder and make sure your child takes their prescribed medicines every day and attends their therapy sessions.

When should my child see their healthcare provider about bipolar disorder?

If your child or teenager has been diagnosed with bipolar disorder, they’ll need to see their healthcare team regularly throughout their life to make sure their treatment is working well. This team may include a:

• Primary healthcare provider.
• Pediatric psychiatrist.
• Child psychologist or therapist.
• Pediatric neurologist.

When should I take my child to the ER?

If your child is experiencing any of the following situations, it’s essential to call 911 or get to the nearest emergency room:

• Thoughts of death or suicide.
• Thoughts or plans of hurting themselves or others.
• Experiencing hallucinations and delusions.
• Symptoms of lithium toxicity (overdose), such as severe nausea and vomiting, severe hand tremors, confusion and vision changes.

A note from Cleveland Clinic

It can be difficult and overwhelming to learn that your child has bipolar disorder. Know that the condition is treatable. Early identification, diagnosis and treatment can help your child reach their full potential. Be sure to reach out to family and friends for support. Your child’s healthcare provider is also available to answer any questions you may have.