Bipolar Disorder

In-Depth

If your child experiences phases of extreme moods—from bursting with so much energy that he may not be able to sleep or sit still, to crippling depression that leaves him sad and withdrawn—he may have bipolar disorder.

What is bipolar disorder?
Bipolar disorder, which is also known as manic-depressive illness or bipolar affective disorder, is a chronic mental health condition that:

• gets its name from the extreme mood patterns it causes (going from “high highs” to “low lows”)
• is highly disruptive, causing serious emotional, behavioral and, at times, physical problems
• occurs in cycles that last for days or weeks
• has no clearly defined, single cause, but is believed to be linked to both biological and life experience factors
• can wax and wane over time
• has no permanent cure, but is treatable with evidence-based interventions 

Can kids really be bipolar, too?
Yes. While not nearly as common in children as it is in adults, research studies have revealed that bipolar disorder affects as many as 3 percent of all children, and up to 7 percent of children receiving outpatient psychiatric care. (The numbers are even higher in children hospitalized for inpatient psychiatric treatment.)

Bipolar disorder has been diagnosed in children as young as 5. When young children experience symptoms, this is called early-onset bipolar disorder.

What are mood episodes?
A child or adolescent who has bipolar disorder experiences both manic phases (periods of abnormally high energy and activity) and depressive phases (periods of intense sadness, tiredness, irritability or hopelessness) that last days or even weeks before dying down. These periods are known as mood episodes. 

Sometimes, a child will experience manic and depressive symptoms at the same time. This is called a mixed mood episode.

While all children, and especially adolescents, experience peaks and valleys in their moods and energy levels, the mood episodes of someone with bipolar disorder are very different:

• Their symptoms last most of the day, every day/
• They last for long periods of time (for the better part of a week, to several weeks, to even years).
• They cause serious disruptions to eating, sleeping, schoolwork, home life and social life.
• They might go away for a while, but almost always come back without proper treatment. 

What are the different types of bipolar disorder?
There are three described varieties of bipolar disorder:  

• Bipolar I, also referred to as “manic-depressive illness” or “classic” bipolar disorder, is the most serious form. Kids with this form experience manic episodes or mixed episodes that:
  • go on for at least a week
  • are so severe that the child cannot sleep or function properly
  • happen either right before, or right after, a depressive episode that has lasted for two weeks or more—or is serious enough to require hospitalization
     
• Bipolar II is very similar to Bipolar I, only slightly milder.  It causes manic episodes that seem almost identical to the mania of Bipolar I, but which only last for up to four days and cause slightly less serious symptoms. These milder manic episodes are called hypomania.
  
  In order to be diagnosed with Bipolar II, a child must experience depressive episodes that last for at least two weeks before or after a distinct period of mania as described above. Bipolar II is a serious condition in its own right, and requires intensive treatment just as Bipolar I does.
   
• Bipolar Not Otherwise Specified (NOS) is an even milder form of bipolar disorder whose mood episodes don’t last as long, or cause the same severity of symptoms, as Bipolar I or II.
  
  Although there is specific criteria for a Bipolar NOS diagnosis in adults, the criteria for children and adolescents is less clear. This means that the process of making the diagnosis is more challenging.

Is pediatric bipolar disorder treatable?
Yes. Unfortunately, there is no complete cure for bipolar disorder—but with early diagnosis and careful, multidimensional treatment, the illness can generally be controlled, allowing children and adolescents to return to more normal functioning. 

In the pages that follow, we hope you will find answers to your most pressing questions about bipolar disorder. When you meet with our experts here at Children’s Hospital Boston, we will carefully assess and then fully explain your child’s condition and treatment options. 

Causes

What causes bipolar disorder?
No one knows exactly why bipolar disorder develops. Current research has revealed that there are multiple biological and life experience factors that increase the risk of a child developing the disorder: 

• Genetic factors: Studies have shown that genetic factors contribute to the risk for bipolar disorder by up to 50 percent.
  
  However, it’s important to note that only 6 percent of children with a parent who has bipolar disorder also develop the condition. The vast majority of parents who have been diagnosed as bipolar do not have a child with the disorder.
   
• Environmental factors: We know of certain factors that make some children more likely to become depressed, which then puts them at increased risk for developing bipolar disorder. These risk factors may include:
  • poverty
  • ongoing environmental stresses, such as:
    • a parent who is mentally ill or abusing substances
    • harsh or abusive parenting
    • violence or other trauma
  • abusing drugs or alcohol
  • family history of depression
     
• Brain chemistry/development factors: While we don’t understand the exact mechanisms, we do know that both genetic and environmental risk factors can alter brain chemistry and development.
  
  The brain has special chemicals, called neurotransmitters, that carry messages back and forth and control all of the brain’s activities, including emotions. We believe that the neurotransmitters serotonin, norepinephrine and dopamine are the most likely to be involved in the onset of bipolar disorder; consequently, the medications we use to treat the disorder target these chemical imbalances. 

It’s suspected that the brains of children with bipolar disorder grow and develop differently than those of other children. We are hopeful that current treatment methods—including both medication and talk therapy—can restore some degree of normality to the brain’s chemical balance and development over time.

Signs and symptoms

What are the symptoms of bipolar disorder?
A child or adolescent may have bipolar disorder if he:

• experiences manic, hypomanic or mixed episodes, accompanied by depressive episode(s)
• experiences manic symptoms that last for the majority of the day, every day, for at least a week at a time in the case of bipolar I (or for at least four days in the case of bipolar II)
• experiences depressive episodes that last for at least two weeks at a time (and often last much longer)
• experiences symptoms that are cyclical, waxing and waning over time 

What are the symptoms of a manic episode?
Manic symptoms can include one or more of the following:

• feeling and acting as though on a “high”
• overly animated and active behavior
• talking very quickly
• changing topics suddenly/multiple times during a conversation
• intense aggravation or “jumpiness”
• becoming completely immersed in one or more new, time-consuming, driven projects
• not wanting to sleep
• inability to sleep
• expressing an unusual/unrealistic degree self-confidence (for example, stating “I’m like a god” or “I’m untouchable—nothing can hurt me”)
• disregarding or failing to recognize risky situations and behaviors
• making highly impulsive choices and actions, especially involving sexual activity, spending money and use of drugs or alcohol 

What are the symptoms of a depressive episode?
Depressive symptoms can include:

• feeling and acting sad, tired and “empty”
• failing to take pleasure in anything, even favorite activities and interests
• difficulty with memory and concentration
• restlessness and irritability
• sleeping too much or not enough
• loss of appetite, or overeating in an attempt to feel better
• thinking of, talking about or threatening suicide

What are the symptoms of a mixed episode?
If a child is going through a mixed episode, he may:

• be agitated
• get upset easily or for no apparent reason
• have trouble falling or staying asleep
• lose his appetite, or start overeating
• think of, mention or threaten suicide
• experience any combination of the above noted symptoms of both mania and depression 

If you suspect your child is considering suicide, always seek help immediately—do not wait. Call 911 or bring your child to the closest emergency room.
 

FAQ 

Q: How common is bipolar disorder in children?
A: It is estimated that more than 3 percent of all children and adolescents have some form of bipolar disorder, which is about half the incidence in adults. 

The most severe form of bipolar disorder, bipolar I, affects 0.5 percent of all children. It is found much more often in children who are either receiving outpatient psychiatric treatment, or who have been hospitalized for mental health care. 

Q: How serious is bipolar disorder?
A: If left untreated, or if treated inadequately, bipolar disorder can be highly disruptive and lead to:

• failure at school and/or work
• damaged interpersonal relationships
• involvement in violence (either as the victim or the perpetrator)
• financial and legal troubles
• criminal activity
• substance abuse
• attempted or completed suicide

For all of these reasons, prompt and ongoing care from a qualified clinician is a must.

Q: How can I tell if my child or adolescent has symptoms of bipolar disorder or is just going through a “typical mood swing”?
A: Just about every child, and especially adolescents, goes through “mood swings.”  However, a child or teen with bipolar disorder experiences periods of extraordinary high moods and activity levels, called mania, accompanied by (either before, after or during the mania) unusually low moods and activity levels.

These periods occur in cycles and must last for at least several days or a week at a time during the manic phase, and for at least two weeks during the depressive phase. 

Q: Does bipolar disorder cause multiple personalities?
A: No. People sometimes confuse bipolar disorder with dissociative identity disorder (also referred to as “multiple personality disorder”). However, these are two separate conditions with very different symptoms. 

Q: If my child has bipolar disorder, does that mean her siblings are also at risk?
A: Yes, they are at some risk—but keep in mind that the majority of siblings will not develop bipolar disorder.

There is clear evidence that bipolar disorder does have a genetic link, and the incidence is especially high (50 percent) among identical twins. If your child has a sibling who is showing possible signs of bipolar disorder, you should seek an evaluation from a qualified mental health professional. 

Q: Can I do anything to keep my child from developing bipolar disorder?
A: Because we still don’t understand exactly how or why bipolar disorder occurs—and because many researchers believe a defect in the genes plays a role—there is no way to prevent the disease altogether.

However, parents who have been diagnosed with bipolar disorder themselves (and/or who are dealing with another mental illness, or with substance abuse) can take steps to lessen the likelihood of their children developing the disease by getting prompt treatment from a licensed mental health professional.

Q: Could my child have another mental health condition along with bipolar disorder?
A: It’s possible, since bipolar disorder, like many mental health disorders, often occurs alongside a second condition.  Bipolar disorder can accompany:

• attention-deficit hyperactivity disorder (ADHD)
• anxiety disorders like obsessive-compulsive disorder and social anxiety disorder
• post-traumatic stress disorder (PTSD)
• a substance abuse problem 

If your child is diagnosed with another condition, it’s essential that both disorders be treated at the same time. Your treating clinician will develop a plan for managing both conditions and meeting all of your child’s individual needs. 

Q: What is the long-term outlook for my child?
A: Bipolar disorder is most often a chronic (long-lasting) mental health condition that requires careful monitoring and ongoing care, often including a long-term medication regimen.

In adults, where there has been more data collected, long-term care that combines medication and “talk therapy” has proven very effective in containing and controlling the illness. Unfortunately, we still don’t have all of the data we need to give a clear picture of the long-term outlook for bipolar disorder in children.

However, we do know that—although there is no cure for pediatric bipolar disorder—as long as your child follows his treatment plan, he can grow up to be healthy, happy and productive despite the challenges of his illness.

Questions to ask your doctor

You and your family play an essential role in your child’s treatment for bipolar disorder. It’s important that you share your observations and ideas with your child’s treating clinician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations. 

You’ve probably thought of many questions to ask about your child’s condition and prognosis. It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you will have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you. (If your child is old enough, you can encourage him or her to write down questions, too.)
 
Initial questions to ask your doctor might include:

• What criteria did you use in reaching this diagnosis?
• Is it possible that these symptoms could point to any other condition (for example, another mental health disorder)?
• What type of bipolar disorder does my child have (bipolar I, bipolar II or bipolar NOS)?
• What are your treatment goals for my child?
• How can I encourage my child to talk to me and ask questions about her bipolar disorder and treatment?
• What role should I play in my child’s treatment?
• What are the warning signs that my child may be entering a manic or depressive episode?
• How should I respond if my child is in the midst of a manic episode?
• What about a depressive episode?
• How long do you expect my child to need therapy?
• How can I tell if my child is making progress?
• How should I involve my child's school in treatment?
• How should I explain my child's condition to other members of the family?
• What medication(s) will you prescribe for my child?
• What are the possible side effects of this medication?
• How can my family and I best support my child through treatment?
• Does anything in my child’s day-to-day routine need to change?
• How long will it take for my child to start feeling “back to normal”?
• What other resources can you point me to for more information?

How is bipolar disorder diagnosed?

A mental health clinician (typically a child and adolescent psychiatrist, child psychologist or psychiatric social worker) will determine whether your child has bipolar disorder after a comprehensive psychiatric assessment.

During the assessment, you and your child will both be asked to talk about his symptoms, how they make him feel and how they are affecting him and the family. You will also be asked to provide an overview of your child’s family history, medical history, academic life and social interactions.

At this time, there are no laboratory tests or imaging studies that can confirm a diagnosis of bipolar disorder (although tests are sometimes used to rule out other disorders). After completing the evaluation, your child’s doctor will compare his symptoms to the established criteria for bipolar disorder in order to make a definitive diagnosis.

If my child is diagnosed with bipolar disorder, what happens next?

Your mental health clinician will explain the diagnosis, provide the information you need to be well-informed about the condition and answer any questions you or your child may have.

The next step is developing a mutually agreed-upon, evidence-based treatment plan that works for you, your child and your family.

How do we treat bipolar disorder?

We typically treat bipolar disorder through a combination of:

• psychotherapy, or “talk therapy”
• medication
• family support
• systems interventions (at school and in the community) as needed

Our approach to mental health care is evidence-based — our treatments have been tested and proven effective through scientific studies, both here at our hospital and by other leading institutions worldwide.

Psychotherapy

Psychotherapy, or “talk therapy,” is designed to help your child learn the best ways to identify and respond to his manic and depressive symptoms when they occur.

Here at Boston Children's, a mental health clinician will teach your child to:

• anticipate and manage the onset of his mood episodes
• recognize that the “high high” and “low low” feelings he's experiencing are caused by his bipolar disorder
• change his negative and potentially harmful thoughts, feelings, and behaviors (this process is called cognitive behavioral therapy or CBT)
• learn new and healthy ways of relating to his family members, teachers, and peers
• build his self-esteem and define himself as much more than his illness
• become an active member in their own care “team”

In addition, family counseling can help you and your child's other loved ones learn how to live with and manage the ups and downs arising from his bipolar disorder.

Medication

Unfortunately, no matter how hard you or your child try, most often it's not possible to stop mood episodes with talk therapy or willpower alone.

Just like a congenital heart defect or asthma, bipolar disorder is a medical condition, and a biological process or imbalance is responsible for it. In almost every case, the best way to correct this faulty biological process is through medication. Our Psychopharmacology Clinic is devoted to helping children, families, and clinicians incorporate medication into a treatment plan.

Many people with bipolar disorder need to take medication for long periods (over several years) to best combat the illness. Though this isn't always easy, the benefits of the medication far outweigh the inconvenience and possible side effects.

There are several different medications that can be prescribed for bipolar disorder. Your child's treating clinician will advise you on the best choice for her and her symptoms. We will carefully go over the specifics of the drug and explain any and all of the potential benefits, alternatives and side effects that you should watch for.

Here are some of the basic facts about the various medications used to manage bipolar disorder: (Please note that the bolded medications have the best evidence of effectiveness and are supported by the U.S. Food and Drug Administration.)

Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to her medication, and are always here to address any concerns you may have.

Learn more about psychiatric medications.

Is bipolar disorder ever considered 'cured'?

This is not clear at this time. Although the condition responds to treatment in most cases, bipolar disorder is generally seen as a chronic (long-lasting) disease that may come and go for many years.

Your child will need to follow the treatment plan outlined by her care team, and any changes should be carefully discussed among all members of her treatment team.