Bipolar Disorder in Children and Teens: A Parent’s Guide From the National Institute of Mental Health
All parents can relate to the many changes their kids go through as they grow up. But sometimes it's hard to tell if a child is just going through a "phase," or perhaps showing signs of something more serious.
In the last decade, the number of children receiving the diagnosis of bipolar disorder, sometimes, called manic-depressive illness, has grown substantially. But what does this illness really mean for a child?
What is bipolar disorder?
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood and energy. It can also make it hard for someone to carry out day-to-day tasks, such as going to school or hanging out with friends. Symptoms of bipolar disorder can be severe. They are different from the normal ups and downs that everyone goes through from time to time. They can result in damaged relationships, poor school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.
Bipolar disorder often develops in a person's late teens or early adult years, but some people have their first symptoms during childhood. At least half of all cases start before age 25.
Bipolar disorder tends to run in families. Children with a parent or sibling who has bipolar disorder are up to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.3 However, most children with a family history of bipolar disorder will not develop the illness.
What are common symptoms of bipolar disorder in children and teens?
Youth with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." The extreme highs and lows of mood are accompanied by extreme changes in energy, activity, sleep, and behavior. Each mood episode represents a drastic change from a person's usual mood and behavior.
An overly joyful or overexcited state is called a manic episode. An extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.
Symptoms of bipolar disorder are described below.
Symptoms of mania include:
- Being in an overly silly or joyful mood that's unusual for your child. It is different from times when he or she might usually get silly and have fun.
- Having an extremely short temper. This is an irritable mood that is unusual.
- Sleeping little but not feeling tired
- Talking a lot and having racing thoughts
- Having trouble concentrating, attention jumping from one thing to the next in an unusual way
- Talking and thinking about sex more often than usual
- Behaving in risky ways more often, seeking pleasure a lot, and doing more activities than usual
Symptoms of depression include:
- Being in a sad mood that lasts a long time
- Losing interest in activities they once enjoyed
- Feeling worthless or guilty
- Complaining about pain more often, such as headaches, stomach aches, and muscle pains
- Eating a lot more or less and gaining or losing a lot of weight
- Sleeping or oversleeping when these were not problems before
- Losing energy
- Recurring thoughts of death or suicide death or suicide
It's normal for almost every child or teen to show some of these behaviors sometimes. These passing changes should not be confused with bipolar disorder.
Symptoms of bipolar disorder are not like the normal changes in mood and energy that everyone has. Bipolar symptoms are more extreme and tend to last for most of the day, nearly every day, for at least 1 week. Also, depressive or manic episodes include moods very different from a child's normal mood, and the behaviors described in the chart generally all come on at the same time. Sometimes the symptoms of bipolar disorder are so severe that the child needs to be treated in a hospital.
Bipolar disorder can be present even when mood swings are less extreme. For example, sometimes a child may have more energy and be more active than normal, but not show the severe signs of a full-blown manic episode. This is called hypomania. It generally lasts for at least 4 days in a row. Hypomania causes noticeable changes in behavior, but does not harm a child's ability to function in the same way that mania does.
How does bipolar disorder affect children and teens differently than adults?
Bipolar disorder that starts during childhood or during the teen years is called early-onset bipolar disorder. Early-onset bipolar disorder seems to be more severe than the forms that first appear in older teens and adults. Youth with bipolar disorder are different from adults with bipolar disorder. Young people with the illness appear to have more frequent mood switches, are sick more often, and have more mixed episodes.
Watch out for any sign of suicidal thinking or behaviors. Take these signs seriously. On average, people with early-onset bipolar disorder have greater risk for attempting suicide than those whose symptoms start in adulthood. One large study on bipolar disorder in children and teens found that more than one-third of study participants made at least one serious suicide attempt.Some suicide attempts are carefully planned and others are not. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that must be treated.
What treatments are available for children and teens with bipolar disorder?
To date, there is no cure for bipolar disorder. However, treatment with medications, psychotherapy (talk therapy), or both may help people get better.
It's important for you to know that children sometimes respond differently to psychiatric medications than adults do.
To treat children and teens with bipolar disorder, doctors often rely on information about treating adults. This is because there haven't been many studies on treating young people with the illness, although several have been started recently.
One large study with adults funded by NIMH is the Systematic Treatment Enhancement Program for Bipolar Disorder. This study found that treating adults with medications and intensive psychotherapy for about nine months helped them get better. These adults got better faster and stayed well longer than adults treated with less intensive psychotherapy for six weeks. Combining medication treatment and psychotherapies may help young people with early-onset bipolar disorder as well. However, it's important for you to know that children sometimes respond differently to psychiatric medications than adults do.
Once the diagnosis of bipolar disorder is made, the treatment of children and adolescents is based mainly on experience with adults, since as yet there is very limited data on the efficacy and safety of mood stabilizing medications in youth.
The essential treatment for this disorder in adults involves the use of appropriate doses of mood stabilizers, most typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Research on the effectiveness of these and other medications in children and adolescents with bipolar disorder is ongoing. In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy, to complement medication treatment for this illness in young people.
Before starting medication, the doctor will want to determine your child's physical and mental health. This is called a "baseline" assessment. Your child will need regular follow-up visits to monitor treatment progress and side effects. Most children with bipolar disorder will also need long-term or even lifelong medication treatment. This is often the best way to manage symptoms and prevent relapse, or a return of symptoms.
It's better to limit the number and dose of medications. A good way to remember this is "start low, go slow." Talk to the psychiatrist about using the smallest amount of medication that helps relieve your child's symptoms. To judge a medication's effectiveness, your child may need to take a medication for several weeks or months. The doctor needs this time to decide whether to switch to a different medication. Because children's symptoms are complex, it's not unusual for them to need more than one type of medication.
Keep a daily log of your child's most troublesome symptoms. Doing so can make it easier for you, your child, and your doctor to decide whether a medication is helpful. Also, be sure to tell your doctor about all other prescription drugs, over-the-counter medications, or natural supplements your child is taking. Combining certain medications and supplements may cause unwanted or dangerous side effects.
Some of the types of medications generally used to treat bipolar disorder are listed below. Information on medications can change. For the most up-to-date information on use and side effects of medications, see the U.S. Food and Drug Administration (FDA) website. You can also find more information about medications in the NIMH Mental Health Medications booklet.
Mood stabilizers, such as lithium are usually the first choice to treat bipolar disorder. Lithium is approved for the treatment and prevention of manic symptoms in children ages 12 and older. In addition, lithium might act as an antidepressant and help prevent suicidal behavior. However, FDA's approval of lithium was based on treatment studies in adults, not children.
Anticonvulsant medications, originally developed to treat seizures, are also sometimes used as mood stabilizers. They are not approved by the FDA for treating bipolar disorder in children, but your doctor may prescribe one on an "off label" basis. They may be very helpful for difficult-to-treat bipolar episodes. For some children, anticonvulsants may work better than lithium. Examples of anticonvulsant medications include valproic acid or divalproex sodium (Depakote) and lamotrigine (Lamictal).
These medications may also be linked with rare but serious side effects. Talk with the doctor or a pharmacist to make sure you understand signs of serious side effects for the specific medications your child is taking.
In addition, valproic acid, lamotrigine, and other anticonvulsant medications carry an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.
Atypical antipsychotics are sometimes used to treat symptoms of bipolar disorder. Those approved by the FDA to treat youth with bipolar disorder are risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), and olanzapine (Zyprexa). Short-term treatment with risperidone can help reduce symptoms of mania or mixed mania in children ages 10 and up. Some research has indicated that risperidone is more effective in treating mania in young children than other medications. Aripiprazole and quetiapine are approved to treat mania symptoms in children 10–17 years old who have bipolar I, while olanzapine is approved for use in children ages 13–17.
Atypical antipsychotics can cause major weight gain and changes in metabolism, especially in children. This may increase the risk of developing diabetes and high cholesterol. While taking an atypical antipsychotic, your child's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.
In rare cases, long-term use of atypical antipsychotics may lead to a condition called tardive dyskinesia (TD). The condition causes uncontrollable muscle movements that commonly occur around the mouth. TD can range from mild to severe. Sometimes people with TD recover partially or fully after they stop taking the drug, but others do not.
Antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are sometimes used to treat symptoms of depression in bipolar disorder. Doctors who prescribe antidepressants for bipolar disorder usually prescribe a mood stabilizer or anticonvulsant medication at the same time. If your child takes only an antidepressant, he or she may be at risk of switching to mania or hypomania. He or she may also be at risk of developing rapid cycling symptoms.Rapid cycling occurs when someone has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.
However, results on effectiveness of antidepressants for treating bipolar depression are mixed. The STEP-BD study showed that, in adults, adding an antidepressant to a mood stabilizer is no more effective in treating depression than using a mood stabilizer alone.
Some antidepressants are more likely to cause certain side effects than other antidepressants. Your doctor or pharmacist can answer questions about these medications.
Antidepressants carry an FDA warning. Although they are generally safe and popular, some studies have suggested that they may have unintentional side-effects in some people, especially teens and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor.
Unusual or severe side effects of any medication should be reported to a health care provider right away. Your child may need a change in the dose or a different medication.
Children and teens being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms, or other uncomfortable or possibly dangerous withdrawal effects.
In addition to medication, psychotherapy ("talk" therapy) can be an effective treatment for bipolar disorder. When treating bipolar disorder, psychotherapy is usually prescribed in combination with medication. Studies in adults show that it can provide support, education, and guidance to people with bipolar disorder and their families. Psychotherapy may also help children keep taking their medications to stay healthy and prevent relapse.
Some psychotherapy treatments used for bipolar disorder include:
- Cognitive behavioral therapy, which helps young people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
- Family-focused therapy, which includes a child's family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their child. This therapy also improves communication and problem-solving.
- Interpersonal and social rhythm therapy, which helps children and teens with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
- Psychoeducation, which teaches young people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of an impending relapse, allowing them time to seek treatment early, before a full-blown episode occurs. Psychoeducation also may be helpful for family members and caregivers.
Other types of therapies may be tried as well, or used along with those mentioned above. The number, frequency, and type of psychotherapy sessions should be based on your child's treatment needs.
A licensed psychologist, social worker, or counselor typically provides these therapies. He or she should work with your child's doctor to monitor care. In addition to getting therapy to help reduce symptoms of bipolar disorder, children and teens may also benefit from therapies that address problems at school, work, or in the community. Such therapies may target communication skills, problem-solving skills, or skills for school or work. Other programs, such as those provided by social welfare programs or support and advocacy groups, can help as well.
Some children with bipolar disorder may also have learning disorders or language problems. Your child's school may need to make accommodations that reduce the stresses of a school day and provide proper support or interventions.
What can children and teens with bipolar disorder expect from treatment?
There is no cure for bipolar disorder, but it can be treated effectively over the long term. Doctors and families of children with bipolar disorder should keep track of symptoms and treatment effects to decide whether changes to the treatment plan are needed.
One way to do this is by creating a mood or daily life chart, where you and the doctor can track your child's moods, treatments, sleep patterns, and life events. The chart can help you track and treat the illness more effectively. Be sure to work closely with your child's treatment providers. Talk openly and frequently with them about treatment choices.
Working closely with your child's doctor and therapist and talking openly about treatment choices can make treatment more effective. You may need to talk about changing the treatment plan occasionally to help your child manage the illness most effectively.
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NIH Publication No. 12-6380
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