Research findings, clinical experience, and family accounts provide substantial evidence that bipolar disorder, also called manic-depressive illness, can occur in children and adolescents. Bipolar disorder is difficult to recognize and diagnose in youth because it doesn’t precisely fit the symptom criteria established for adults. Adolescent bipolar disorder is also hard to recognize because its symptoms can resemble or co-occur with those of other common childhood-onset mental disorders.
Some symptoms of bipolar disorder may also be initially mistaken for normal emotions or behaviors of children and adolescents. But unlike normal mood changes, bipolar disorder significantly impairs a teen’s ability to function in school, with peers, and at home with family. There is an urgent need for us to better understand the diagnosis and treatment of bipolar disorder in youth. Fortunately, the National Institute of Mental Health (NIMH) is conducting and supporting research on child and adolescent bipolar disorder so we can do just that.
A CAUTIONARY NOTE
Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressants to treat bipolar disorder may induce manic symptoms if they are taken without a mood stabilizer. Similarly, using stimulant medications to treat ADHD or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. If the teenager in question has a family history of bipolar disorder, this worsening of manic symptoms becomes more likely. If your child is using antidepressants or stimulants and exhibiting manic symptoms, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.
SYMPTOMS OF BIPOLAR DISORDER
Bipolar disorder is a serious mental illness characterized by recurrent episodes of depression, mania, and/or mixed symptom states. These episodes cause unusual and extreme shifts in mood, energy, and behavior that interfere significantly with one’s ability to function.
Manic symptoms include:
- Severe changes in mood: either extremely irritable or overly silly and elated
- Overly-inflated self-esteem; grandiosity
- Increased energy
- Decreased need for sleep: ability to go with very little or no sleep for days without tiring
- Increased talking: talks too much, too fast; changes topics too quickly; cannot be interrupted
- Distractibility: attention moves constantly from one thing to the next
- Hypersexuality: increased sexual thoughts, feelings, or behaviors; use of explicit sexual language
- Increased goal-directed activity
- Physical agitation
- Disregard for risk: excessive involvement in risky behaviors or activities
Depressive symptoms include:
- Persistent sad or irritable mood
- Loss of interest in activities once enjoyed
- Significant change in appetite or body weight
- Difficulty sleeping or oversleeping
- Physical agitation or slowing
- Loss of energy
- Feelings of worthlessness or inappropriate guilt
- Difficulty concentrating
- Recurrent thoughts of death or suicide
Symptoms of mania and depression in children and adolescents may manifest themselves through a variety of different behaviors. 1,2 Unlike manic adults, manic children and teens are more likely to be irritable and prone to destructive outbursts than they are to be elated or euphoric. When depressed, there may be many physical complaints such as headaches, muscle aches, stomachaches, or tiredness. A bipolar adolescent may frequently miss or perform poorly in school, talk about or make efforts to run away from home, cry without tangible reason, isolate themselves socially, and become extremely sensitive to rejection or failure. Other manifestations of manic and depressive states may include alcohol or substance abuse and difficulty with communication or relationships.
Current evidence indicates that bipolar disorder in childhood or early adolescence may be a different and possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. 1,2 When the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed-symptom state. This may all co-occur with disruptive behavior disorders, particularly ADHD or conduct disorder (CD), or exhibit features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode. Adult bipolar disorder also tends to have a more episodic pattern with relatively stable periods in between. There is also less co-occurring ADHD or CD among those with later onset bipolar disorder.
A child or adolescent who appears to be depressed and exhibits severe ADHD-like symptoms like excessive temper outbursts or mood changes should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder. Professional evaluation is particularly important if there is a family history of the illness. Misdiagonses by those less familiar with bipolar disorder are dangerous because psychostimulant medications, often prescribed for ADHD, may worsen manic symptoms. There is also limited evidence suggesting that some of the symptoms of ADHD may be a forerunner of full-blown mania.
Findings from an NIMH-supported study suggest that bipolar disorder may be at least as common among youth as it is among adults. In this study, one percent of adolescents ages 14 to 18 were found to have met criteria for bipolar disorder or cyclothymia, a similar but milder illness. 3 In addition, close to 6% of adolescents in the study had experienced a distinct period of abnormally elevated or irritable mood, even though they never met full criteria for bipolar disorder or cyclothymia.
Compared to adolescents with a history of major depressive disorder, as well as a never-mentally-ill control group, both the teens with bipolar disorder and those with subclinical symptoms were found to have:
- greater functional impairment
- higher rates of co-occurring illnesses (especially anxiety and disruptive behavior disorders)
- suicide attempts
- mental health services utilization.
The study highlights the need for improved recognition, treatment, and prevention of even the milder and subclinical cases of bipolar disorder in adolescents.
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. 4 The essential treatment for bipolar disorder in adults involves the use of mood stabilizers, most typically lithium and/or valproate. Mood stabilizers like these are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Research on the effectiveness of these medications in children and adolescents is ongoing. Studies are also investigating various forms of psychotherapy, including cognitive-behavioral therapy, to complement medication treatment for adolescent bipolar disorder.
According to studies conducted in Finland, valproate may increase testosterone levels in teenage girls with epilepsy, and produce polycystic ovary syndrome in women who began taking the medication before age 20. 5 Increased testosterone can also lead to irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician.
NIMH is attempting to fill the gaps in treatment knowledge with carefully designed studies involving children and adolescents with bipolar disorder. Data from adults does not necessarily apply to younger patients because the differences in development may have implications for treatment efficacy and safety. 4 Current multi-site studies funded by NIMH are investigating the value of long-term treatment with lithium and other mood stabilizers, specifically how well they prevent recurrences of mania or depression and control subclinical symptoms in adolescents.
These studies also aim to identify factors that predict the outcome of certain medication use, and to assess side effects and overall adherence to treatment. Another NIMH-funded study is evaluating the safety and efficacy of valproate for treatment of acute mania in children and adolescents, as well as the biological correlates of treatment response. Other NIMH-supported investigators are studying the effects of antidepressant medications added to mood stabilizers in the treatment of the depressive phase of adolescent bipolar disorder
- Carlson GA, Jensen PS, Nottelmann ED, eds. Special issue: current issues in childhood bipolarity. Journal of Affective Disorders, 1998; 51: entire issue.
- Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry , 1997; 36(9): 1168-76.
- Lewinsohn PM, Klein DN, Seely JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry , 1995; 34(4): 454-63.
- McClellan J, Werry J. Practice parameters for the assessment and treatment of adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry , 1997; 36(Suppl 10): 157S-76S.
- Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.
NIH Publication No. 00-4778
Updated: June 28, 2002