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Child and Adolescent Bipolar Disorder

Can children and adolescents get bipolar disorder?

Bipolar disorder can occur in children and adolescents and has been investigated by federally funded teams in children as young as age six.

How common is it in children and adolescents?

Although once thought rare, caseloads of patients examined for federally funded studies have shown that approximately 7 percent of children seen at psychiatric facilities fit the research standards for bipolar disorder.

What are the symptoms of bipolar disorder in children and adolescents?

One of the biggest challenges has been to differentiate children with mania from those with attention deficit hyperactivity disorder. Since both groups of children present with irritability, hyperactivity and distractibility, these symptoms are not useful for the diagnosis of mania. By contrast, elated mood, grandiose behaviors, flight of ideas, decreased need for sleep and hypersexuality occur primarily in mania and are uncommon in ADHD. Below is a brief description of how to recognize these mania-specific symptoms in children.

• Elation. Elated children may laugh hysterically and act infectiously happy without any reason at home, school or in church. If someone who did not know them saw their behaviors, they would think the child was on his/her way to Disneyland. Parents and teachers often see this as "Jim Carey-like" behaviors.
  
  
• Grandiose behaviors. Grandiose behaviors are when children act as if the rules do not pertain to them. For example, they believe they are so smart that they can tell the teacher what to teach, tell other students what to learn and call the school principal to complain about teachers they do not like. Some children are convinced that they can do superhuman deeds (e.g., that they are Superman) without getting seriously hurt, e.g. "flying" out of windows.
  
  
• Flight of ideas. Children display flight of ideas when they jump from topic to topic in rapid succession during a normal conversation—not just when a special event has happened.
  
  
• Decreased need for sleep. Children who sleep only 4-6 hours and are not tired the next day display a decreased need for sleep. These children may stay up playing on the computer and ordering things or rearranging furniture.
  
  
• Hypersexuality. Hypersexual behavior can occur in children without any evidence of physical or sexual abuse in children who are manic. These children act flirtatious beyond their years, may try to touch the private areas of adults (including teachers) and use explicit sexual language.

In addition, it is most common for children with mania to have multiple cycles during the day from giddy, silly highs to morose, gloomy suicidal depressions. It is very important to recognize these depressed cycles because of the danger of suicide.

What treatments—medications and psychosocial—have been shown to be effective and what are their side effects?

First, it is important to recognize that bipolar disorder in children and adolescents is an emerging field and there is much more to learn. A comprehensive evaluation including family history is essential to understanding the diagnosis and the consideration of other possible diagnoses.  

Bipolar disorder raises many risks in youth including substance use, suicide and poor school performance.

Be sure to ask your clinician about a comprehensive treatment approach. For an example of how expert clinicians conceptualize approaches to treatment for this condition, please review the Treatment Guidelines by the American Academy of Child and Adolescent Psychiatry from March 2005.

There are medications that have been FDA approved for use in teens with bipolar disorder. All other medication use is “off label” which means that it has not been approved by the FDA for this purpose. Those drugs that are FDA approved were studied for effectiveness in short-term studies—which means we do not understand the positive impact and side effects of longer term use.

Antipsychotics

Several of the atypical antispychotics—aripipazole (Abilify), quetiapine (Seroquel) and risperidone (Resperidol)—have FDA approval for bipolar disorder in youth ages 10 to 17. Olanzapine (Zyprexa) has FDA approval for youths ages 13 to 17 with bipolar 1 disorder.

Lithium

Lithium, which is a mood stabilizer that is not an antipsychotic, also has FDA approval for youths aged 12 to17. All of these compounds have important side effects that can include weight gain, increased cholesterol and diabetes risk for the antipsychotics. Lithium has risks in thyroid and kidney side effects. More needs to be learned about the safe and effective use of these medications over time in youth with bipolar disorder.

Anticonvulsants

The use of anticonvulsants such as valproic acid (Depakote) and topiramate (Topamax) are not FDA approved for use in youth with bipolar disorder.

Antidepressants

The FDA warning on antidepressants and the increased risk of suicidal ideation is also worth noting as some youth present first with depressive symptoms.

The medication management of youth bipolar disorder requires a clear understanding of the limited scientific data for longer term use. It is also important to know what side effects need to be monitored in youth.

There are no FDA approved medications for youth under age 10.

Are there any side effects associated with these treatments, including those that may only occur in young people?

Side effects that are particularly troublesome and that are worse in children include the following.  Atypical neuroleptics (except aripiprazloe) are associated with marked weight gain in many children. One day we hope to have specific genetic tests that will tell us beforehand which people will gain weight on these medications, but right now it is trial and error. The dangers of this weight gain include glucose problems that may include the onset of diabetes and increased blood lipids that may worsen heart and stroke problems later in life. In addition, these drugs can cause an illness called tardive dyskinesia—irreversible, unsightly, repeated movements of the tongue in and out of the mouth or cheek—and some other movement abnormalities. Depakote may also be associated with increased weight and possibly with a disease called polycystic ovarian syndrome (PCOS), whic in some cases may be associated with infertility later in life. Lithium has been the market the longest and is the only medication that has been shown to be effective against future episodes of mania and of depression and of completed suicides. Some people who take lithium over a long time will need a thyroid supplement and in rare cases may develop serious kidney disease.

It is very important that children on these medications be monitored for the development of serious side effects. These side effects need to be weighed against the dangers of bipolar disorder itself, which can rob children of their childhood.

How do children and adolescents with this disease fare over time and as adults?

At this time, regrettably, bipolar disorder in childrena and youth appears to be more severe and have a much longer road to recovery than is seen with adults. While some adults may have episodes of mania or depression with better functioning between episodes, children seem to have continuous illness over months and years.

Does bipolar disorder in children have an impact on educational achievement?

It is challenging to educate a child whose mood is much too "high" or too "low." Therefore educators need to be aware of the diagnosis and make special arrangements.

Is suicide a risk?

Talking about wanting to die, asking why they were born or wishing they were never born must be taken very seriously. Even quite young children can hang themselves in the shower, shoot themselves or complete suicide by other means.

Reviewed by Ken Duckworth, M.D., July 2010

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