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Mental Health

What is pediatric bipolar disorder?

Bipolar disorder can be considered a spectrum disorder, which means that different profiles of symptom severity and duration comprise variations of this disorder. Bipolar spectrum disorders can occur in children or adults; childhood onset is referred to as pediatric bipolar disorder. It is estimated that 1% to 3% of adolescents in the United States (three to nine million) suffer from symptoms of pediatric bipolar spectrum disorder.

Symptoms

Bipolar disorder is comprised of manic and depressive episodes:

An episode of depression is characterized by a two-week or longer period of sad or irritable mood or markedly diminished interest/pleasure in most activities. This low is accompanied by four or more of the following symptoms:

A manic episode is defined as a four- to seven-day period of excessively elevated (i.e., inappropriately happy) or irritable (i.e., tantrums and rages out of proportion to events) mood. This change in mood is accompanied by three or more (four, if the mood is irritable) of the following symptoms, all of which must reflect a clear change from the child's baseline behavior and cause disruption at home, school or with peers:

Manic moods in children are often expressed as intense irritability, rather than euphoria. In addition, children and adolescents often experience both manic and depressive symptoms at the same time, continuously, or at multiple times within the same day (i.e., mixed or rapid cycling presentation). When talking about bipolar symptoms, you might also hear the word hypomania. Hypomania is similar to mania, but not as severe and does not last as long.

More information about symptoms of bipolar spectrum disorder can be found at What are common symptoms of bipolar disorder in children and teens?

Types of Bipolar

In the past, bipolar has been called manic-depressive disorder. Today, it is divided into four basic types based on the symptoms that the child has:

More information about the types of bipolar can be found at How is bipolar disorder detected in children and teens?

Causes

Doctors are not sure what causes bipolar spectrum disorder. They know that the illness is in large part hereditary. This means that if a parent has bipolar disorder, his or her child is more likely to also have bipolar than the child of a parent who does not have bipolar disorder.

It is important to note that bipolar spectrum disorder is not caused by poor parenting. However, its onset may be delayed and/or course of illness lessened by addressing environmental stressors and providing stable sleep routines.

What affects a child's risk of getting bipolar disorder? has additional information.

Diagnosis

Early diagnosis and treatment is important for the long-term success of the child. This is best done by a mental health professional highly familiar with bipolar spectrum disorder in children. Mental health professionals use different strategies to evaluate children, including interviewing the parent and child and questionnaires for the child, parent, and possibly teacher to complete.

Your insurance company can provide you a list of mental health professionals. Other resources for information and referrals include:

Treatment

Medication

Child and adolescent psychiatrists are an important component of your child's treatment team. In some communities, nurse practitioners initiate or provide follow-up medication management.

Mood stabilizers help the child avoid the deep lows of depression and the highs of mania. Many mood stabilizers are available, but Lithium and Depakote (Valproic Acid) are two examples.

Antipsychotics may be used if the child has psychosis as a result of bipolar 1. Risperdal (Risperidone) and Seroquel (Quetiapine) are two kinds of antipsychotics.

Antidepressants, such as Prozac (Fluoxetine) are sometimes used with caution, after the child's manic symptoms are stabilized, to address depressive symptoms. Your child's doctor will talk with you about which medications are right for your child. Even with medicine, continued therapy is important.

More information about these medications and treatments can be found at What treatments are available for children and teens with bipolar disorder?

Psychotherapy

Treatment can vary depending on the child and his or her situation. Medication, individual therapy, family therapy, group therapy and school-based interventions all can be helpful. Treatment should include teaching the family about bipolar disorder and working with the child to develop coping skills to manage his or her behavior. Some skills for parents and children include:

School-based Treatments

A number of clinical and educational recommendations for school difficulties are available. These might include arranging for a Multi-Factored Evaluation (MFE) and/or Functional Behavior Assessment (FBA) to identify special education needs, behavioral-emotional difficulties, and associated triggers and events that trigger symptoms. After an MFE or FBA, an Individualized Educational Program (IEP), a 504 plan, and/or behavior plan can be developed to provide educational accommodations and modifications to help your child manage problems at school.

Other Disorders

Children with bipolar disorder often have other diagnoses as well. Common illnesses include ADD/ADHD, oppositional defiant disorder, conduct disorder, anxiety disorders, and substance abuse. Because some of these disorders have symptoms that appear similar cross-sectionally to those of bipolar disorder, it is important to complete a very careful and thorough diagnostic process.

Where to Get Help

If you suspect that your child may be experiencing symptoms of bipolar disorder, your family doctor is a good place to start. Other helpful resources can be found at Where can I go for help?

References and Resources:
Bipolar Disorder in Children and Teens: A Parent's Guide

Case Studies

The following case studies illustrate some of the typical behaviors children with bipolar disorders experience. Notice the examples of depression and mania.

Case Study #1

Maria is 10 years old. She feels very sad for weeks at a time. She goes to sleep early and has a hard time waking up for school. Her teachers say she sometimes falls asleep in class. Maria has lost 15 pounds over the last two months. Usually bubbly, during these sad times, Maria does not want to talk with her friends. In fact, she does not want to talk to anyone or do any of the activities she usually enjoys. However, Maria also has other time periods when she is full of energy, though these do not happen as often. This energy is much more extreme than her usual happy self. During these times, Maria talks non-stop. She talks so fast that her parents and teachers have a hard time understanding what she is saying. She will go a few nights in a row without sleeping at all. Maria is her normal self in between these depressed and full of energy periods.

Maria is clearly exhibiting symptoms of depression and mania. As her depressive symptoms are reported to last weeks at a time, determining the length and extent of her manic symptoms will allow for a specific diagnosis of BP1, BP2 or BP-NOS.


Case Study #2

Jaden is 16 years old. He has episodes of depression that last a few days. During these times, he talks about killing himself. He has tried to kill himself several times. Jaden also feels a lot of guilt for things outside of his control, sleeps too much, and cries frequently. However, as suddenly as these days of depression come on, they are replaced by times of extreme energy and feelings of greatness. Jaden, who used to be an honor roll student, begins to skip class. He says he is too smart for school, and details grand plans about how he will become rich and famous. He suddenly thinks he has the answers to everyone's problems. Jaden becomes reckless during these energetic periods too, spending tons of money and using drugs. His family is worried about him.

It will also be important to rule out other reasons for Jaden's behavior, such as use of alcohol or illicit (or prescription) drugs. Assuming no other explanation becomes apparent, Jaden will meet criteria for BP1-Mixed Episode.

This article was written by Maya Brown-Zimmerman, Graduate Student, MPH Program, OSU College of Public Health.

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Last Reviewed: May 11, 2009

Mary A Fristad, PhD, ABPP Mary A Fristad, PhD, ABPP
Professor of Psychiatry and Psychology
College of Medicine
The Ohio State University

Nicholas   Lofthouse, PhD Nicholas Lofthouse, PhD
Clinical Assistant Professor of Psychiatry
College of Medicine
The Ohio State University