Bipolar Disorder in Childhood and Adolescence

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

What is childhood bipolar disorder?

Children or teens with bipolar disorder, also called manic-depressive disorder, have moods with extreme ups and downs. Sometimes they have bouts of mania and may have lots of energy or feel irritated. At other times their mood swings to depression, and they feel sad. Experts used to think only adults developed bipolar disorder. They now believe even a young child can develop bipolar disorder, although with different symptoms than adults.

What causes bipolar disorder?

We don't fully understand what causes bipolar disorder. It seems to be linked to an imbalance in brain chemicals or problems with the endocrine system, which controls hormones.¹ Some research shows there may be a problem with the structure or size of certain parts of the brain, which might also interfere with mood regulation.²

Bipolar disorder seems to run in families. Your child is at greater risk of developing bipolar disorder if a close family member such as a parent, grandparent, or sibling has the condition.

It is common for parents to wonder whether they did something to cause bipolar disorder in their child. While stress, certain medications, and some conditions can trigger an episode of mania or depression in a child with bipolar disorder, there is nothing a parent can do to cause—or prevent—the development of the condition.

What are the symptoms?

Children with bipolar disorder have intense moods that quickly change from one extreme to another without a clear cause. These moods alternate between having high energy or irritability (mania) and having low energy or feeling sad (depression). Some children may briefly return to a normal mood between extremes. Many children cycle continuously between mania and depression, sometimes several times in the same day. Sometimes children with bipolar disorder have symptoms of both mania and depression at the same time.

Episodes of mania or depression may be less clearly defined than those in adults. Children may be irritable and throw violent temper tantrums, be obsessed with sexuality, or have an extremely high level of energy. At other times they may say they feel empty, sad, bored, or "down." They may complain of headaches, muscle aches, stomachaches, or fatigue. Children with bipolar disorder frequently miss school or talk about running away from home and often become isolated and overly sensitive to rejection or criticism.

Like adults with the condition, older children and teens with bipolar disorder may be extremely motivated or intense during the manic phase and depressed during the opposite cycle. Teens and older children who are not being treated for their bipolar disorder are more likely to have difficulty in school or at work, may use alcohol or drugs, may have trouble making and keeping friends, and are more likely to engage in risky behaviors.³

Untreated bipolar disorder can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Because a child or teen with bipolar disorder can have such a difficult time, it is important to identify the problem as early as possible and provide support, understanding, and treatment.

How is bipolar disorder in children and adolescents diagnosed?

If your child's doctor suspects bipolar disorder, he or she may ask you and your child to answer a few questions or complete written tests that identify the child's current mental state and the severity of depression or mania. The doctor may do physical tests (such as a blood test) to rule out other possible health problems that could be causing symptoms. He or she may ask whether your family has any history of mental illness and drug or alcohol problems. Both conditions can be linked to bipolar disorder.

Bipolar disorder in children is difficult to diagnose, and the symptoms often resemble those of other conditions, such as attention deficit hyperactivity disorder (ADHD), substance abuse problems, or conduct disorder. Bipolar disorder also frequently occurs along with other such conditions.

How is it treated?

Although the mood changes associated with bipolar disorder are challenging, they can be managed effectively. Treatment usually includes medicines (such as mood stabilizers) and professional counseling; often a combination of both medications and counseling is needed.

Medicines to treat bipolar disorder in adults have been well studied, but research on the safety and effectiveness of these medicines for children and adolescents is limited. However, new studies are currently under way.

Why is early diagnosis of bipolar disorder important?

Children with bipolar disorder are at increased risk for substance abuse problems, difficulty in school, fighting, reckless or violent behavior, and legal problems. Early diagnosis and appropriate treatment will help your child continue with normal development and avoid social problems caused by bipolar disorder.

Untreated bipolar disorder can lead to suicide. An estimated 10% to 20% of people with bipolar disorder commit suicide, and nearly a third say that they have made at least one suicide attempt. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship. Treatment for bipolar disorder, especially lithium, has been shown to reduce suicidal behavior. Early diagnosis and treatment may be important in lowering this risk.

Frequently Asked Questions

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	Managing a manic episode in a child or adolescent

The cause of bipolar disorder is not well understood. It runs in families and seems to be linked to an imbalance of brain chemicals (neurotransmitters) that help regulate mood. It may also be linked to the endocrine system, which controls hormones, or to problems with the structure or size of certain parts of the brain that control mood.^{1, 2}

Stressful or traumatic events may trigger episodes of mania or depression in a child with bipolar disorder. While it is normal for such events to cause mood changes, these reactions are much more extreme for children with bipolar disorder.

Sometimes symptoms of mania occur as a result of another medical condition, such as an overactive thyroid gland (hyperthyroidism) or multiple sclerosis. Symptoms can also develop as a side effect of some medications, such as corticosteroids or antidepressants. Using drugs or alcohol, consuming too much caffeine, or not getting enough sleep can also trigger a manic episode.

All types of bipolar disorder consist of cycles of mania (or hypomania, a less severe form of mania) and depression. The different types of bipolar disorder are based on whether a person has more severe symptoms of mania or depression and how quickly mood cycles occur.

• With bipolar I disorder, moods swing between mania and depression, sometimes with periods of normal mood between extremes. Some children with type I bipolar disorder have episodes of mania and are hardly ever depressed.
• With bipolar II disorder, depression is more prominent than mania, and manic episodes may be less common and less severe.

Children and young adolescents with bipolar disorder tend to have rapid-cycling or mixed-cycling types of bipolar disorder—meaning that the cycles between depression and mania occur quickly (rapid cycling), sometimes within the same day, or that symptoms of both mania and depression occur at the same time (mixed cycling).

Following are some common symptoms of bipolar disorder in children and adolescents. A combination of depressive and manic mood swings must occur for at least 1 week before bipolar disorder is diagnosed.^{4, 5}

Symptoms of depression

• Continuous sad or irritable mood
• Loss of interest in activities the child once enjoyed, such as hobbies, sports, games, or friends
• Significant changes in appetite or body weight (weight loss or gain)
• Sleeping too much or too little or having trouble falling asleep
• Slowed or agitated body movements or restlessness
• No energy or loss of energy
• Inappropriate feelings of guilt or worthlessness
• Difficulty concentrating
• Recurrent thoughts or talk of death or suicide

Manic symptoms

• Severe changes in mood from being extremely irritable or sad to overly silly and elated
• Too much energy, such as the ability to keep going without tiring while the child's peers are tiring
• Decreased need for sleep, such as going for days with very little or no sleep and not being tired
• Talking too much or too fast, changing topics too quickly, and not allowing interruptions
• Increased distraction and constantly moving from one thing to another
• Grandiosity, such as inflated self-esteem or a belief in unrealistic abilities or powers
• Increased sexual thoughts, feelings, activity, and use of sexual language (hypersexuality)
• Increased obsession with reaching goals or becoming involved in too many activities

During severe episodes of mania, your child may suffer from symptoms of psychosis, such as having hallucinations or delusions of grandeur (for example, telling people that a rock band is coming to his or her birthday party).

Bipolar disorder frequently occurs along with other conditions (such as conduct disorder), and each condition needs appropriate evaluation and treatment.

Untreated bipolar disorder can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Often the first signs of bipolar disorder are severe moodiness, unhappiness, or other symptoms of depression. It is common for children with bipolar disorder to be diagnosed first with only depression and then later to be diagnosed with bipolar disorder after a cycle of mania or hypomania (a less severe form of mania). For more information on depression, see the topic Depression in Childhood and Adolescence.

A first manic or hypomanic episode can be triggered by a stressful situation or may occur without an obvious cause. It can also be started by certain medications used to treat other conditions. Drugs (such as antidepressants or stimulants) that are used to treat depression, attention deficit hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD) are sometimes prescribed to children with bipolar disorder who have not yet been correctly diagnosed. These drugs can trigger sudden bouts of mania, sometimes with bizarre, aggressive, or psychotic behavior. (However, these medications are sometimes effective for children with bipolar disorder when they are combined with a mood-stabilizing drug.)³

In adults with bipolar disorder, mood swings usually occur over weeks or even months. In children, cycles usually occur more rapidly, sometimes within the same day (rapid, ultra rapid, or ultradian cycling). Frequently, children with bipolar disorder have difficulty getting going in the morning but then have intense energy later in the day. Often the mood shifts are continuous, rarely returning to a normal mood between extremes. Sometimes elements of depression and mania or hypomania may be present at the same time (a mixed state). These rapid and severe mood changes may make your child appear constantly irritable, and they can significantly interfere with your child's ability to function at school, at home, and with peers.

Children with mania can be more irritable and prone to temper tantrums or destructive outbursts than adults with mania. In a depressive episode, children may complain of headaches, muscle aches, stomachaches, or fatigue. They frequently miss school or talk about running away from home. They become socially isolated and overly sensitive to any kind of rejection or criticism.

While all teens may be rebellious or make bad choices from time to time, teenagers with bipolar disorder are more likely to show poor judgment, take risks such as breaking the law or having unprotected sex, and believe they are more powerful or important than they really are (delusions of grandeur) during manic episodes. A teen in a depressive episode may withdraw from social activities, do poorly in school, and have problems concentrating and sleeping.

Obsession with sex (hypersexuality) is common in children and teens who have bipolar disorder. Even young children may touch themselves, use sexual language, and approach others in a sexual way. Adolescents with bipolar disorder may be obsessed with sexuality and engage in risky sexual behavior. Hypersexual behavior is common in children who have been sexually abused; however, many children with bipolar disorder experience hypersexuality without having been molested.

People sometimes confuse bipolar disorder in children with other conditions with similar symptoms, such as oppositional defiant disorder, anxiety disorders, or attention-deficit hyperactivity disorder (ADHD). Frequently children with bipolar disorder are misdiagnosed with another such disorder or are diagnosed with one of those conditions and bipolar disorder.⁶ Although there is some evidence of a link between ADHD and bipolar disorder,⁷ the conditions have distinct features that you can usually identify.

A child or teen with bipolar disorder may behave irresponsibly, take risks and not think about the consequences, or have difficulty making and keeping friends. Older children and adolescents with undiagnosed bipolar disorder frequently use alcohol and drugs. If your child is using drugs or alcohol and having behavioral problems, you may want to schedule an evaluation to determine whether your child is suffering from a condition such as bipolar disorder.

In young children

In children younger than age 9, bipolar disorder frequently appears as depression or irritability.² During a depressive episode, a young child may become withdrawn, have a short attention span, feel guilty for no reason, and have low energy that can last for hours, days, or weeks. Your child may throw temper tantrums, become easily frustrated, and become explosively angry. Irritability and temper tantrums can also be part of manic episodes.

In children, it can be difficult to tell the difference between a depressive and a manic episode, especially if cycles are rapid or symptoms of depression and mania occur together. Irritability may progress into severe, seizure-like temper tantrums when the child is told "no." A bipolar child may kick, bite, hit, and make hateful comments, including threats and curses.⁶ During tantrums, which may last for hours, a child may destroy property or become increasingly violent.

In older children and adolescents

During a manic episode, an older child or adolescent may have high energy levels and feelings of extreme happiness (euphoria). He or she may need less sleep and may talk rapidly and continuously. He or she may be aggressive and get into fights and may use sexual language when it is not appropriate or engage in risky sexual behavior.² An adolescent with bipolar disorder may suffer consequences from manic behavior such as suspension from school, arrest as a result of fighting or drug use, or an unwanted pregnancy or sexually transmitted disease (STD) resulting from unsafe sexual behavior.

During depressive episodes, an adolescent may become withdrawn or quiet, do poorly in school, and stop participating in activities he or she once enjoyed (such as quitting a sports team). Your adolescent may cry often, sleep too much, and feel that he or she doesn't "belong." He or she may speak of death or suicide. You should take any threats of suicide seriously, because children with bipolar disorder have an increased risk of suicide.²

Substance abuse in adolescents with bipolar disorder is common, and your child's health professional may recommend an evaluation for both substance abuse problems and bipolar disorder if your child appears to suffer from either condition.

Untreated bipolar disorder can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Your child's risk of developing bipolar disorder or other mood disorders increases if the child:

• Has a close relative such as a parent, sibling, or grandparent with bipolar disorder or another mood disorder.
• Has a family history of problems with alcohol or drugs. This may be an indication of "self-medication" for an underlying psychological disorder, such as bipolar disorder.
• Has had several episodes of major depression. At least 15% of adolescents with recurring depression are later diagnosed with bipolar disorder.⁴

Certain factors can trigger depressive or manic episodes in your child, such as:

• Erratic sleep or changes in daily routines.
• Treatment with antidepressants, which can increase the risk for a manic episode.
• Stressful life events.
• Not taking medications as prescribed.
• Using alcohol or drugs (substance abuse).
• Entering puberty.

Call 911 or other emergency services immediately if:

• Your child makes threats or attempts to harm himself or herself or another person, or shows warning signs of suicide.
• Your child hears voices (has auditory hallucinations).
• You are a young person and you feel you cannot stop from harming yourself or someone else.

Watchful Waiting

Watchful waiting is a wait-and-see approach. If you think your child may have bipolar disorder, watchful waiting is not appropriate. Schedule an appointment with your child's doctor for evaluation.

If your child is currently receiving treatment for bipolar disorder, watchful waiting may be enough if a mood episode has just started and your child is taking proper medications. If your child's depressive or manic mood episodes have not improved within 2 weeks, call your doctor.

Untreated bipolar disorder can lead to suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

Who To See

It is best to establish a long-term relationship with your child's care providers so that when a depressive or manic episode occurs, the care providers can recognize the changes in the child's behavior and provide quick treatment advice.

Since bipolar disorder in childhood and adolescence is just beginning to be recognized and treated, you may wish to find a health professional who has special training in children's mental health conditions or experience treating bipolar disorder in young people. Bipolar disorder can be diagnosed and treated by a health professional such as a:

• Psychiatrist, preferably a child psychiatrist.
• Pediatrician.
• Family medicine physician.
• Nurse practitioner.
• Physician assistant.

Your child may also benefit from professional counseling to help deal with mood changes and the effects bipolar disorder has on your child's life. A counselor with special training in childhood mood disorders or experience treating childhood bipolar disorder may be most helpful. Counseling for bipolar disorder can be provided by a:

• Psychiatrist.
• Psychologist.
• Social worker.
• Licensed mental health counselor.
• Psychiatric nurse.

Who to see for family member support

If you are a family member of a child with bipolar disorder, it is very important to get the support and help you need. Living with or caring for someone who has bipolar disorder can be very disruptive to your own life. Manic episodes can be particularly difficult. It may be helpful to seek your own counselor or therapist to help you.

There are also national support organizations that may have a local chapter in your area or provide information on the Internet. Examples of such organizations include the National Alliance for the Mentally Ill (NAMI) and the Child and Adolescent Bipolar Foundation.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

There is no laboratory test to diagnose bipolar disorder. Doctors make the diagnosis through a combination of:

• A medical history, asking questions to help identify other past and present health conditions that could cause the symptoms.
• A family history to identify bipolar disorder, other mood disorders, or substance abuse problems in close relatives. (All of these conditions are linked to bipolar disorder.)
• A physical exam, which can rule out other conditions with similar symptoms (such as hyperthyroidism).
• A mental health assessment, which can help identify your child's current mental state and the severity of depression or mania.
• Other written or verbal mental health tests.

Although mood changes and other symptoms associated with bipolar disorder are challenging, they can be managed effectively. Treatment usually includes medications (such as mood stabilizers) and professional counseling, and often a combination of both is needed.

Bipolar illness is a serious disorder that has a big impact on both the child and his or her family. Successful treatment requires that the child and family members understand what happens in bipolar disorder and that the family members help make sure that the child follows the treatment.

It can take time for you and your child to accept that the child has a serious, long-term condition that requires ongoing treatment and constant monitoring. However, keep in mind that by working with your child's doctor, you and your child can find effective treatment for the condition.

You and your child's doctor can discuss which treatment is right for your child. Older children and teenagers may want to participate in their own treatment decisions.

Initial treatment

The first step in determining appropriate treatment for your child with bipolar disorder is evaluating the severity of his or her symptoms. If your child's behavior is suicidal, aggressive, reckless, or dangerous, or if he or she is out of touch with reality (psychotic) or unable to function, the child may need a period of hospitalization. Also, many medications can make the symptoms of bipolar disorder worse, and if your child is taking one of these, he or she may need to taper off and stop the medication. This should only be done under the supervision of a doctor.

Initial treatment usually includes medications and counseling.

Medications. Medications most often used include:

• Mood stabilizers, such as lithium (for example, Eskalith, Lithane, or Lithobid), divalproex (Depakote), carbamazepine (for example, Tegretol), or lamotrigine (Lamictal).
• Antipsychotics, such as olanzapine (Zyprexa) or risperidone (Risperdal), which your doctor may combine with a mood stabilizer for more effective control of manic episodes.
• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (for example, Prozac), or other types of antidepressants to control episodes of depression. While antidepressants can be helpful for some children, they might also trigger mania. A doctor will usually prescribe antidepressants with other medications that help regulate mood, and he or she must carefully monitor the child.

Professional counseling. Counseling works best when symptoms of bipolar disorder are controlled with medications. Several types of therapy may be helpful, depending on the age of the child. These include:

• Cognitive-behavioral therapy, which focuses on modifying certain thinking and behavior patterns.
• Interpersonal therapy, which focuses on social and personal relationships and related problems.
• Problem-solving therapy, a brief type of cognitive therapy that helps you find immediate solutions to problems.
• Family therapy, which can help educate and comfort the entire family.
• Play therapy for very young children.
• Psychological education and support groups.

Ongoing treatment

Ongoing treatment of bipolar disorder includes long-term treatment with medications and may include professional counseling.

Some children and adolescents do not respond to the first medication they try, and they may need to try several different medications to find relief from the symptoms. A combination of medication and professional counseling may be the most effective treatment.

An important part of ongoing treatment is making sure your child takes the medication as prescribed. Often people who feel better after taking bipolar medication for a period of time may feel that they are "cured" and no longer need treatment. However, when a person stops taking medication, symptoms usually return, so it is important that your child follows the treatment plan.

Medications for bipolar disorder have side effects that need to be managed. Some things you cannot change, such as increased urination (common with lithium). But you can deal with some side effects like weight gain (common with several medications used to treat bipolar disorder) by increasing exercise and reducing calorie intake. You can work with your child and his or her doctor to find ways of coping with side effects. If side effects from a medication are intolerable, the doctor may have to change the dose or the medication.

Some medications, such as lithium carbonate (Eskalith, Lithane, or Lithobid, for example) and divalproex (Depakote), require ongoing blood monitoring every few months. Your doctor may have to adjust the amount of medication your child is taking so your child has the right amount of medication for treatment.

During initial treatment, your doctor may prescribe a medication such as an antipsychotic for a short time to help your child deal with immediate symptoms. Once your child's long-term medications kick in and symptoms improve, he or she will need to taper off and stop the short-term medication.

Other ongoing treatment includes:

• Academic adjustments. If your child is in school, he or she may need a reduced homework load or school schedule during severe depressive or manic episodes. You can work with the school to find ways to help your child maintain performance requirements until the symptoms are under control.
• Relaxation and exercise. Steps your child can take at home to improve symptoms include:
  • Getting regular physical exercise, such as swimming or walking, to help reduce stress.
  • Avoiding the use of drugs, alcohol, tobacco, caffeinated beverages, and energy drinks.
  • Eating a balanced diet.
  • Getting enough sleep and keeping a regular sleep-wake cycle. (Children and teenagers need more sleep than adults.)

Sometimes treatment for other conditions can make your child's bipolar disorder worse. For example, treating depression with antidepressants can trigger or worsen a manic episode. Treating attention deficit hyperactivity disorder (ADHD) with stimulants may also trigger severe mania, depression, and even psychosis (loss of touch with reality). Treatment with corticosteroids for conditions such as asthma may also trigger a manic episode. Medications that intensify bipolar symptoms may need to be stopped altogether or changed to a different dose or medication. Sometimes an additional medication (such as a mood stabilizer) can solve the problem. However, each child responds to medications differently, and it may take several tries before your doctor can identify an effective medication or combination of medications for your child's conditions.

Learning as much as you can about childhood and adolescent bipolar disorder may help you recognize mood changes in your child as they begin to occur. Catching and treating these mood changes early may help reduce the length of the manic or depressive episode and improve the quality of your child's life.

Treatment if the condition gets worse

If your child's condition gets worse while he or she is undergoing treatment for bipolar disorder (including medications, counseling, and lifestyle changes), the doctor may give additional treatment. You and your doctor should:

• Make sure your child is taking medications as prescribed and following other treatment recommendations.
• Determine whether ongoing symptoms are caused by another disorder (such as attention deficit hyperactivity disorder or post-traumatic stress disorder), and treat the other condition if necessary.
• Identify and reduce stresses that may be making symptoms worse.
• Adjust the dose of medications if the current dose is not effective.
• Add or change medications if the current ones are not working.

A brief hospital stay may be necessary, especially if your child is showing any warning signs of suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.

For older children with severe bipolar symptoms who have not responded to medications, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.²

Bipolar disorder cannot be prevented. However, there are ways to help manage or prevent mood changes.

The first and most important preventive measure is to make sure your child takes his or her medications as directed. Bipolar disorder is a long-term condition and generally requires lifelong treatment with medications. However, about 1 in 3 adults remains completely free of symptoms of bipolar disorder just by taking mood-stabilizing medicines, such as carbamazepine, divalproex, or lithium.⁸ (There are no statistics available for children.)

Reducing stress, getting regular sleep and exercise, and maintaining a daily routine may help prevent mood swings and can help with the symptoms of depression and mania.

There are steps you can take at home to reduce your child's symptoms of bipolar disorder.

• Keep your child's room quiet, and have your child go to bed at the same time every night.
• Control the amount of stress in your child's life. You may need to seek ways to help your child reduce academic requirements during severe mood swings.
• Learn to recognize the early warning signs of your child's manic and depressive mood episodes.

Steps your child can take to help control moods include:

• Getting enough exercise. During a depressive episode, your child may feel like doing only gentle exercises, such as taking a walk or swimming.
• Getting enough sleep and keeping a consistent sleep schedule.
• Eating a balanced diet.
• Avoiding the use of alcohol or drugs. Substance abuse makes bipolar disorder worse.
• Avoiding beverages that contain caffeine, including coffee, tea, colas, and energy drinks.
• Learning to recognize the early warning signs of manic and depressive mood episodes.
• Asking for help from friends and family when needed.

Managing a manic episode in a child or adolescent

For some children with bipolar disorder, depression can cause debilitating symptoms. For information about managing childhood depression, see the topic Depression in Childhood and Adolescence.

While medications to treat bipolar disorder have been well studied for use in adults, there are few long-term studies that confirm the effectiveness and safety of mood stabilizers in children and adolescents with bipolar disorder. Be sure to use all medications exactly as your child's doctor has prescribed them. If your child develops intolerable side effects from any medication, call your health professional immediately.

Medication Choices

Medications most often used to treat bipolar disorder in children and adolescents include:

• Mood stabilizers, such as lithium carbonate (Eskalith, Lithane, Lithobid, Lithonate, or Lithotabs, for example), divalproex (Depakote), carbamazepine (Tegretol or Epitol, for example), or lamotrigine (Lamictal).
• Antipsychotics, such as olanzapine (Zyprexa), risperidone (Risperdal), or aripiprazole (Abilify). Antipsychotics may be combined with mood stabilizers for more effective control of manic episodes.
• Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac, for example), to control episodes of depression. (While antidepressants can be helpful for some children with bipolar disorder, they can also trigger mania. Doctors usually prescribe antidepressants along with mood stabilizers to help prevent a manic episode, and they need to carefully monitor the child for mood changes.)

What To Think About

Deciding which medications to use to treat bipolar disorder in children and adolescents can be a complicated issue. Be sure to discuss all the options and side effects with your child's doctor. Your child may have to try several medications or combinations of medications before finding what works best. Some medications that seem to work at first may not work in the long term. Carefully monitoring the effects of medications is an ongoing process that is essential in identifying what is working and what may need to be changed.

If the doctor prescribes the mood stabilizer lithium carbonate, your child will need regular blood tests to monitor the amount of lithium in the blood. Too much lithium may lead to serious side effects. Your child will also need regular blood tests to monitor the amount of carbamazepine and divalproex in the blood when using these medications.

When you and your child's doctor are deciding which types of medications to use in the treatment of bipolar disorder, consider:

• The side effects of each medication and how well your child can tolerate them.
• How often your child will need to take the medications.
• Whether your child is being treated for other illnesses or disorders and how those medications will interact with medications for bipolar disorder.
• Whether your child has used any of the medications before and whether they worked.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued advisories to patients, families, and health care providers to closely monitor children and adults taking antidepressants for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.

The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviors in children, who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses.

While medications can be an effective treatment for children with depression, the FDA has issued a warning asking drug companies to include extensive packaging information warning about the danger of suicidal thoughts or actions during antidepressant use. The FDA encourages anyone considering the use of an antidepressant in a child or adolescent to balance the increased risk with the need to use the medication. If your child is taking an antidepressant, do not stop its use suddenly. Talk to your health professional about any concerns you may have, and watch your child closely for any warning signs of suicide.

There is no surgery to treat bipolar disorder.

Most children who have bipolar disorder need medication. However, other forms of treatment used along with medications play an important role in balancing mood and improving quality of life. Counseling, education about the disorder, and stress reduction can help children with bipolar disorder.

Other Treatment Choices

Counseling along with medications has been used effectively to manage bipolar disorder. Types of therapy that counselors use to treat bipolar disorder include:

• Cognitive-behavioral therapy, which focuses on modifying certain thinking and behavior patterns.
• Interpersonal therapy, which focuses on social and personal relationships and related problems.
• Problem-solving therapy, a type of cognitive therapy that helps you find immediate solutions to problems.
• Family therapy, which can help educate and comfort the entire family.
• Play therapy for very young children.
• Psychological education and support groups.

In some cases, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.

Complementary therapy

Complementary medicine is a term used for a wide variety of health care practices that may be used along with standard medical treatment. Omega-3 fatty acids found in fish oils have been getting some attention as a possible complementary treatment of bipolar disorder. However, more research is needed to prove the effectiveness of omega-3 fatty acids in treating this condition in children, adolescents, and adults. ⁹

What To Think About

Deciding which medications to use to treat childhood and adolescent bipolar disorder is an important decision for you, your child, and your child's doctor. Both you and your child need to understand how taking the medications and not taking the medications will affect the child's life. It is important that your child continue to take any medications prescribed to avoid a return of depressive or manic episodes.

Your child should establish a long-term relationship with a health professional both of you like. The health professional will then be able to help recognize personality changes that indicate when your child is moving into a mood episode. Getting early treatment can reduce the length of the mood episode.

Encourage your family to seek support as well. Bipolar disorder greatly affects family members. They will need to understand the disorder and what they can do to help the child, as well as themselves, in dealing with the disorder.

Adolescents (and adults) with bipolar disorder are at a high risk for suicide. You should talk to your teen about his or her feelings and watch for any self-destructive thinking or warning signs of suicide, such as making suicidal statements or having a preoccupation with death. If your child is suicidal, immediately call 911 or contact other emergency services.

Overdosing on medication is the most common way adolescents attempt suicide. However, your child is at increased risk for a completed suicide if you have a gun in your home. If your child is depressed, remove all guns (even if they are locked up) and potentially fatal medications from your home, especially if your child has shown any warning signs of suicide.

Online Resource

Organizations

• Attention Deficit Hyperactivity Disorder (ADHD)
• Bipolar Disorder
• Borderline Personality Disorder
• Depression in Childhood and Adolescence
• Hyperthyroidism
• Panic Attacks and Panic Disorder
• Post-Traumatic Stress Disorder
• Schizophrenia
• Teen Alcohol and Drug Abuse

Citations

1. Müller-Oerlinghausen B, et al. (2002). Bipolar disorder. Lancet, 359(9302): 241–247.

2. Weller EB, et al. (2002). Bipolar disorders in children and adolescents. In M Lewis, ed., Child and Adolescent Psychiatry, 3rd ed., pp. 782–791. Philadelphia: Lippincott Williams and Wilkins.

3. Dubovsky SL, et al. (2003). Mood disorders. In RE Hales, SC Yudofsky, eds., American Psychiatric Publishing Textbook of Clinical Psychiatry, 4th ed., pp. 439–512. Washington, DC: American Psychiatric Publishing.

4. American Psychiatric Association (2000). Bipolar disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 382–397. Washington, DC: American Psychiatric Association.

5. National Institute of Mental Health (2000). Child and Adolescent Bipolar Disorder: An Update From the National Institute of Mental Health. Available online: http://www.nimh.nih.gov/publicat/bipolarupdate.cfm.

6. Weckerly J (2002). Pediatric bipolar mood disorder. Journal of Developmental Behavior in Pediatrics, 23(1): 42–56.

7. Kent L, Craddock N (2003). Is there a relationship between attention deficit hyperactivity disorder and bipolar disorder? Journal of Affective Disorders, 73(3): 211–221.

8. Sachs GS, et al. (2000). Expert Consensus Guidelines Series: Medication Treatment of Bipolar Disorder. Available online: http://www.psychguides.com/gl-treatment_of_bp2000.html.

9. Stoll AL, et al. (1999). Omega-3 fatty acids in bipolar disorder: A preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 56(5): 407–412.

Other Works Consulted

• Walz M (2000). Bipolar Disorders: A Guide to Helping Children and Adolescents. Cambridge, MA: O'Reilly and Associates.

Author:	Stuart J. Bryson	Last Updated May 27, 2005
Medical Review:	Michael J. Sexton, MD - Pediatrics Lisa S. Weinstock, MD - Psychiatry
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