Bipolar disorder in children: causes, symptoms, diagnosis, treatment

Bipolar disorder in children is characterized by alternating periods of manic, depressive, and normal episodes, each lasting for weeks or months.

In recent years, the term bipolar disorder has also been applied to preadolescent children whose functioning is limited by intense, unstable moods. In these young children, however, a particular mood state lasts from moments to days. In both cases, diagnosis is based on history and mental status testing; treatment includes a combination of mood-stabilizing medications (such as lithium, certain antiepileptic and antipsychotic drugs), psychotherapy, and psychosocial support.

Bipolar disorder typically begins in adolescence and early adulthood. In many cases, the first manifestation is one or more episodes of depression; about two-thirds of children who have a major depressive episode before puberty will develop bipolar disorder in adolescence or early adulthood.

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Causes of Bipolar Disorder in Children

Until now, scientists have not been able to accurately determine the causes of bipolar disorder in children.

Bipolar disorder in children is considered to be hereditary. If a child has close relatives with the disorder, such as a mother, father, grandmother, grandfather, brother or sister, then the child is likely to develop it as well.

If a child has bipolar disorder, tragic events in life can trigger an attack of mania or depression. Although the reaction to a certain event in life may be quite natural, with bipolar disorder it will be excessive.

Sometimes, symptoms of mania may be caused by another medical condition, such as thyroid dysfunction or multiple sclerosis. Symptoms may also be a reaction to certain medications, such as corticosteroids or antidepressants. Also, alcohol abuse, drug abuse, excessive caffeine consumption, and lack of sleep can trigger an attack of mania.

Risk factors

The risk of a child developing bipolar disorder increases if:

• The child has a close relative, such as a parent, sibling, or grandparent, who has had bipolar disorder or any other psychological disorder.
• There was alcohol or drug addiction in the child's family. This may be a sign that the sick relative was trying to cure his or her mental illness, such as bipolar disorder.
• The child had several episodes of acute depression. About 15% of adolescents with frequent episodes of acute depression are later diagnosed with bipolar disorder.

The following factors may trigger an episode of mania or depression in your child:

• Irregular sleep and changes in daily routine
• Treatment with antidepressants, which can trigger a manic episode
• Stressful situations in life
• Irregular medication intake
• Use of alcohol or drugs
• Puberty

Symptoms of Bipolar Disorder in a Child

The hallmark of bipolar disorder in children is the manic episode. During a manic episode, the teenager's mood may be either extremely elevated or irritable, often alternating depending on social circumstances. Speech is rapid and forceful, the need for sleep is reduced, and self-esteem is inflated. Mania can reach psychotic proportions, such as "I have become equal to God." Awareness of danger may be reduced, so the teenager may engage in risky behavior, such as being promiscuous in sexual relations or driving irresponsibly.

In recent years, the term bipolar disorder has also been applied to pre-teens whose abilities are limited by intense, unstable moods. This is controversial and is an area of active research. These children experience sudden mood swings, but they last much shorter, often only a few minutes. The onset is gradual and subtle, with a history of being very temperamental and difficult to manage.

A number of medical and toxic exposures should be excluded by appropriate testing, including toxicology testing for drugs of abuse (e.g., amphetamines, cocaine, and phencyclidines) and environmental factors (e.g., lead). The presence of precipitating events, such as severe psychological stress, including sexual abuse or incest, should also be assessed.

All types of bipolar disorder in children are characterized by phases of mania (or hypomania, a milder form of mania) and depression. Different types of the disorder depend on whether the patient experiences more intense symptoms of mania or depression.

• In bipolar I disorder, the manic and depressive phases alternate, sometimes leaving the sufferer with a sense of normalcy between episodes. Some children with bipolar I disorder experience manic episodes more often than not, and almost never depression.
• In bipolar disorder of the second degree, depression occurs more often than mania, while the attacks of mania are milder and very sharp.

Children and adolescents with bipolar disorder tend to have frequent mood swings or mixed episodes. In the former case, this means that the manic and depressive phases alternate very frequently, sometimes even within the same day. In mixed episodes, symptoms of depression and mania occur simultaneously.

Symptoms of Bipolar Disorder in Teens

Often, the first symptoms of bipolar disorder in children are a state of intense moodiness, unhappiness, or other symptoms of depression. In most cases, children are first diagnosed with depression, and only after their first episode of mania or hypomania are they diagnosed with bipolar disorder.

The first episode of mania or hypomania may be triggered by a stressful life event or may occur for no apparent reason. It may also be triggered by certain medications. Drugs such as antidepressants or stimulants used to treat depression, ADHD, or obsessive-compulsive disorder are commonly prescribed to children with bipolar disorder, but at a time when the diagnosis has not yet been made. These medications can cause these children to experience mania with bizarre, aggressive, or psychopathic behavior. However, when combined with mood stabilizers, these medications can be effective in treating bipolar disorder in children.

In adults, mood swings usually occur at intervals of a week or even a month. In children, the phases change much more often, sometimes within a single day. Usually, such children have a very hard time fulfilling their duties in the morning, and in the evening they become overly energetic. Often, the mood phases change constantly, without breaks for a normal mood. Sometimes the symptoms of mania, hypomania, or depression appear simultaneously (the so-called mixed state). Such frequent and intense mood swings cause irritation in children, and this in turn affects their life at home, at school, and in their relationships with peers.

Children during a manic episode become more irritable and prone to outbursts of anger than adults. During a depressive state, children complain of headaches, muscle pain, stomach pain, and fatigue. They often skip school and talk about running away from home. They withdraw into themselves and react very painfully to any rejection or criticism.

Although every child is prone to rebellious behavior and making bad decisions, teenagers with bipolar disorder often have poor judgment and often engage in risky behavior, such as breaking the law or having unprotected sex. Also, during mania, teenagers tend to believe that they have super powers and strength and seem more important than they actually are. A teenager during depression becomes withdrawn, fails at school, suffers from inability to concentrate, and sleep disorders.

Sexual obsession is common among adolescents with bipolar disorder. Even young children may touch their genitals, use sexual language, and treat people in a sexually expressive manner. Teenagers, on the other hand, become obsessed with sexuality and may have unprotected sex. This behavior is also common among children who have experienced sexual abuse. But it is not necessary.

Often, bipolar disorder in children is mistaken for conditions such as oppositional defiant disorder or attention deficit hyperactivity disorder. This causes children to be misdiagnosed or diagnosed with one of the above conditions along with bipolar disorder. Although there are some similarities between ADHD and bipolar disorder, a doctor can often differentiate the two conditions from each other.

A child with bipolar disorder behaves irresponsibly, does not think about the consequences of his behavior, and has difficulty keeping or making new friends. Teens with advanced and undiagnosed bipolar disorder are prone to drinking alcohol or using drugs. If your child is abusing alcohol or drugs and is behaving strangely, you should see a doctor to make sure your child does not have bipolar disorder.

Untreated bipolar disorder in a child can lead to suicide. With age, the first signs of suicidal behavior change. In children, this is an obsession with death and suicide and a break in relationships with friends.

Symptoms of Bipolar Disorder in Young Children

Bipolar disorder in children and adolescents is different from bipolar disorder in adults. When depressed, your child may easily have outbursts of anger, become upset easily, and become extremely angry. These behaviors may be symptoms of mania. Young children with bipolar disorder show more vivid displays of happiness and silly behavior than healthy children.

It can be difficult to differentiate between a manic episode and a depressive episode in children, especially if the phases alternate very quickly or occur simultaneously. Irritability may escalate into extreme tantrums and outbursts of anger when the child is told no. A bipolar child may bite, hit, dig, and say hurtful things, including cursing. During such an outburst, the child may damage property or become very violent.

In severe episodes of mania, the child may suffer from psychosis, such as experiencing hallucinations or delusions (for example, believing that a popular rock band is coming to his birthday party).

Very often, bipolar disorder in children develops against the background of other diseases (for example, behavioral disorder). In this case, each of these diseases requires a separate diagnosis and separate treatment.

How to recognize bipolar disorder in a child?

There are no laboratory tests that can accurately determine if children have bipolar disorder. Doctors make a diagnosis using:

• Your medical history, and asking you about any past or present medical conditions that could cause similar symptoms.
• Questions about your family history of bipolar disorder, other mood disorders, or alcohol or drug addiction. (All of these illnesses are related to bipolar disorder.)
• A thorough medical examination to help rule out other conditions that can cause similar symptoms (such as thyroid dysfunction).
• A mental health assessment that can determine your child's mental state and help determine the severity of the manic or depressive episode.

In young children, symptoms of mania are little more than a cause for concern for parents and their friends. For example, children can sometimes drive their parents crazy with their frequent giggling and silly behavior, but this is not a symptom of mania. However, if this behavior continues for several hours each day and affects the family's daily life, it may mean that the child is ill.

Before prescribing treatment, the doctor should check the child for suicidal behavior. He may ask him a number of questions, such as:

• Has he lost interest in his once favorite activities?
• Has his sleep changed, either in frequency or quality?
• Does he feel depressed, depressed and helpless most of the time?
• Did he ever have thoughts about harming himself?
• Was he so ill that he wanted to die?
• Has he attempted suicide in the past?

Other disorders that have similar symptoms to bipolar disorder in children and adolescents

Several mental illnesses have the same symptoms as bipolar disorder in children and adolescents. At the beginning of the disease, the child may even be misdiagnosed. But bipolar disorder in children has a number of distinctive symptoms that the doctor will definitely notice during a thorough examination.

Conditions that may initially have symptoms similar to bipolar disorder include:

• Attention deficit hyperactivity disorder, a behavioral disorder in which patients have trouble concentrating, are more active than usual, and are prone to rash behavior.
• A behavioral disorder common among children and adolescents in which affected children refuse to follow social rules or cause pain to others.
• Alcohol or drug addiction, despite the fact that drinking alcohol or using drugs can cause unpleasant situations in life.
• Depression is a disease that causes the patient to have a constant feeling of depression and helplessness.
• Schizophrenia, a serious mental illness that, if left untreated, affects the sufferer's ability to think clearly and control their emotions. It causes symptoms such as hallucinations, delusions, paranoia, and disorganized thinking.
• Anxiety disorder is a type of mental illness characterized by excessive anxiety that affects the patient's life.
• Overactive thyroid gland, which can sometimes cause symptoms of mania (eg, excessive energy).
• Neurological diseases. These diseases include:

• Head injuries that can leave lasting effects for days, weeks, or a lifetime.
• Multiple developmental disabilities, a group of disorders characterized by abnormalities in the development of social and communication skills. Examples include autism, Rett disorder, and Asperger syndrome.
• Multiple sclerosis is a chronic neurological disease of the central nervous system that affects the spinal cord and optic nerve.
• Stroke. A stroke occurs when an artery that supplies blood to the brain becomes blocked by a blood clot.
• Seizures are sudden bursts of electrical activity in the brain that affect the patient's muscle activity, movement, speech, vision, and consciousness.

ADHD, anxiety disorder, alcohol or drug addiction, and behavioral disorder may also coexist with bipolar disorder.

Differences Between ADHD and Bipolar Disorder in Children and Adolescents

Bipolar disorder and ADHD in children and adolescents have a number of similar symptoms. It is quite possible for a child to suffer from both diseases at the same time, but there are a number of differences that will help you distinguish one from the other.

Comparing the Symptoms of Bipolar Disorder and ADHD

Symptoms of Bipolar Disorder	Symptoms of ADHD
The child becomes angry and may have outbursts of anger. This state may last for hours. The child digs, bites, breaks or smashes various objects and may threaten to harm another person.	Outbursts of anger usually last a second or a minute and the child does not break anything.
During a tantrum, a child may act as if he or she has lost touch with reality.	During a fit of anger, the child does not lose touch with reality.
Mood swings and strange behavior happen suddenly. A child who was recently depressed and irritable suddenly becomes happy and cheerful.	The child exhibits behavior (e.g. increased activity) that is not consistent. The child may be either very happy or very stupid.
The child's reaction to external events is inadequate and lasts longer than the event itself.	The child reacts normally to external events and his reaction does not last longer than the event itself.
The child exhibits increased sexuality (talks or thinks about sex constantly, has sex, or uses obscene language).	Sometimes a child may show an increased interest in sex, but this behavior is not excessive and the child can easily be switched to another topic.
Sleep disturbances occur periodically. Despite the fact that the child sleeps very little, he is energetic and full of strength.	Sleep disorders manifest themselves over a long period of time (have a chronic nature). The child usually gets tired quickly if he has not had enough sleep.

What to do if your child develops bipolar disorder?

Call your doctor or emergency medical services immediately if:

• Your child threatens to harm themselves or others or exhibits suicidal behavior;
• Your child hears voices (has auditory hallucinations);
• You are a young person and you feel that you cannot protect yourself from harming yourself or other people;

Waiting and watching

Waiting and watching is also a treatment method. However, if you suspect bipolar disorder in your child, waiting is not an option. Be sure to consult a doctor to assess the situation.

If your child is undergoing treatment, taking the appropriate medication, and the attack has not progressed to the acute phase, then observation will be sufficient. If after one or two weeks the symptoms of depression or mania have not improved, you should consult a doctor.

Watch for signs of suicidal behavior. These signs vary depending on the age of the person. In children, these signs include an obsession with death and a break in relationships with friends.

Who should I contact?

It is very important that your child be treated by the same doctor. That way, as soon as your child begins to experience mania or depression, the doctor will be able to recognize changes in your child's behavior and prescribe effective medication.

Because bipolar disorder is relatively new to children, you may want to see a doctor who has experience with bipolar disorder or who specializes in mental health issues in children. Bipolar disorder in children can be diagnosed by doctors such as:

• Psychiatrist, preferably a child psychiatrist
• Pediatrician
• Family doctor therapist
• Nurse with the right to practice medicine
• Physician's assistant

Your child may also benefit from psychotherapy sessions to learn how to manage their moods and the impact bipolar disorder will have on their life. The best therapist for this type of therapy is a psychiatrist who specializes in mood disorders in children or who has experience treating bipolar children. Psychotherapy sessions may be conducted by:

• Psychiatrist
• Psychologist

Psychotherapy can also be carried out by doctors specially trained in this field, for example:

• Social workers
• Licensed Psychiatrist
• Psychiatric nurse

Who can I contact for help with family support issues?

If you are a close relative of a child who suffers from bipolar disorder, you definitely need the help of a specialist. Living with a sick child or taking care of him is not an easy task at all. It will be especially difficult for you during attacks of mania. That is why it would be a good idea to contact a specialist who will help you come to terms with and cope with all the difficulties that this disease brings with it.

Treatment of bipolar disorder in a child

Although mood swings and other symptoms of bipolar disorder can be difficult to manage, they can be managed. Treatment usually involves medications (mood stabilizers) and psychotherapy, both used simultaneously.

Bipolar disorder is a complex disease that affects not only the child but also his family. Effective treatment is when the child and his relatives clearly know all the manifestations of bipolar disorder, and all family members ensure that the child strictly adheres to the medication schedule.

It may take some time for all family members, including the sick child, to come to terms with the presence of such a serious and long-term illness that requires constant treatment and monitoring. But remember, only by working closely with your doctor can you choose the most effective treatment.

You can discuss with your child's doctor the treatment method that will best suit your child. Your child may also want to be involved in this choice.

Initial treatment

The first step in choosing a treatment is to determine the severity of your child's symptoms. If your child is suicidal, aggressive, reckless, or dangerous to others, or is unable to process reality (psychotic), then the patient will need to be hospitalized. Also, remember that some bipolar medications can worsen symptoms of bipolar disorder, and if this happens to your child, he or she should stop taking the medication. However, you should only stop taking any medication under the supervision of a doctor.

Initial treatment usually involves taking medication and attending psychotherapy sessions.

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Medications for Bipolar Disorder in Children

In both adolescents and young children, mood-stabilizing medications are used to treat manic episodes or the excited phase, while psychotherapy and antidepressants are used to treat depressive episodes. Mood-stabilizing medications can be roughly divided into three categories: antiepileptics, antipsychotics, and lithium. All mood-stabilizing agents have the potential to cause bothersome or even dangerous side effects. Therefore, treatment must be individualized. Moreover, medications that are highly effective in the initial stabilization period may be inappropriate for maintenance treatment due to side effects, the most notable of which is weight gain. Antidepressants are usually used in combination with mood-stabilizing medications because they can trigger a “switch” from depression to mania.

The most common drugs include:

• Mood stabilizers, such as lithium, divalproex, carbamazepine, lamotrigine, or valproate.
• Antipsychotics, such as aripiprazole or risperidone, which your doctor may combine with mood stabilizers to more effectively control your manic episode.
• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, or other types of antidepressants to relieve depression. Although they are quite effective, these drugs can trigger a manic episode. Antidepressants are usually prescribed with mood stabilizers, and the doctor monitors the patient while taking them.

Before prescribing treatment for bipolar disorder, a doctor should screen a child for suicidal behavior.

Psychotherapy

Psychotherapy is most effective when combined with medication. Depending on the patient's age, several types of psychotherapy can be used:

• Cognitive behavioral therapy, which focuses on changing specific patterns of behavior and thinking.
• An interpersonal therapy that focuses on the patient's personal and social relationships and the problems associated with them.
• Problem-solving therapy, a simplified version of cognitive therapy, helps the patient find an immediate solution to the problem.
• Family therapy will help relatives to better understand the disease and learn to help the patient.
• Play therapy, a therapy used in the treatment of very young children.
• Psychological preparation and support groups.
• Logical behavioral therapy, which focuses on teaching the patient to cope with mood swings.

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Supportive care

Maintenance treatment consists of long-term treatment with medication and psychotherapy.

Sometimes, a child does not respond to the first medication prescribed to him, so he will have to try several medications until the best one is found. A combination of medications and psychotherapy sessions may be the most effective treatment method.

The most important thing in maintenance therapy is that the child strictly adheres to the medication schedule. Very often, when patients feel well, they think that they are cured and do not need any more medication. But when patients stop taking medication, the symptoms usually return, which is why it is so important to adhere to the course of treatment.

Medications, despite their effectiveness, also have a number of side effects. There are side effects that you cannot get rid of, such as increased urination (with lithium). But effects such as weight gain (which is more common when taking multiple bipolar medications) can be managed with exercise and eating fewer calories. Together with your child and his or her doctor, you can find a way to manage the side effects. If the side effects are severe and cannot be managed, the doctor will try changing the dose or the medication.

If you are taking medications such as lithium or divalproex, you will need to have regular blood tests. Using these tests, your doctor will select the dose of the drug that will be safe for your child.

In the initial treatment, the doctor will prescribe neuroleptics so that the patient can quickly cope with the symptoms. But after the symptoms improve, the child will need to either reduce the dose of these drugs or stop taking them altogether.

Maintenance therapy also includes:

• Coordination with the school program. If your child is in school and suffers from bipolar disorder, then during episodes of depression or mania, he or she may need to reduce the amount of homework or change the school schedule. Therefore, you and the school administration should coordinate these issues so that they do not affect the overall educational process of the child.
• Relaxation and exercise. While at home, your child can follow these tips to help manage symptoms:
  • he can do regular physical exercise, such as swimming or walking, to reduce stress
  • he should avoid using drugs, alcohol, tobacco products, caffeinated beverages and energy drinks
  • he should follow a nutritious and balanced diet
  • he should get enough sleep and make sure he goes to bed and wakes up at the same time (children and teenagers need more sleep than adults)

Sometimes, when a child is being treated for another illness, the symptoms of bipolar disorder only get worse. For example, taking antidepressants to treat depression can cause an attack of mania or make it worse. Also, medications for attention deficit hyperactivity disorder can provoke mania, depression, or psychosis. Drugs used to treat asthma can also cause an attack of mania. It is recommended to either stop taking medications that provoke a worsening of bipolar disorder symptoms or reduce their dose. Sometimes this problem can be solved with the help of mood stabilizers. However, we must not forget that each child reacts to medications differently. And before the doctor selects an effective drug or combination of different drugs, the child will have to try several different medications.

The more you know about childhood and adolescent bipolar disorder, the sooner you can recognize the onset of an attack. This quick recognition of an attack will help you cope with mania or depression more quickly and reduce the duration of these attacks. And this, in turn, will help improve the quality of life for your child.

Treatment in case of disease progression

If your child is being treated for bipolar disorder and his or her condition is getting worse, your doctor may prescribe additional treatments. But first, you and your doctor should make sure that:

• Make sure that your child takes medication regularly and follows all doctor's orders, including those of a psychotherapist.
• Make sure that such deterioration is not caused by another concurrent medical condition (for example, attention deficit hyperactivity disorder or post-traumatic stress disorder), which will also require concurrent treatment.
• Identify and try to avoid those stressors that make your symptoms worse.
• Change the dose of the medication you are taking, this may be the reason
• Add or change medication if the medication you are taking does not produce any results.

If a child demonstrates a desire to commit suicide, hospitalization may be necessary. Signs of suicidal behavior change with age. In children and adolescents, such signs include an obsession with death and a break in relationships with friends.

For older children who do not respond to medication, the doctor may prescribe electroconvulsive therapy. During this procedure, a small electrical impulse is sent to the patient's brain through electrodes attached to the patient's skull. During this procedure, the electricity is thought to cause a small seizure in the brain, which is intended to balance the brain's chemicals.

Treatment at home

In addition to medication, there are some simple steps you can take at home to help reduce the symptoms of bipolar disorder in children, such as:

• Keep your child's room calm and quiet and make sure your child goes to bed at the same time every night.
• Manage stressful situations in your child's life. You may need to find a way to help your child cope with schoolwork during episodes.
• Learn to recognize the early signs of mania or depression in your child.

The child, on his part, can do the following:

• Exercise regularly. Even if your child is depressed and doesn't feel like doing anything, support him and try to convince him to go for walks or swim in the pool more often.
• Monitor your sleep. He should get enough sleep and go to bed and wake up at the same time.
• Eat a balanced diet.
• Avoid alcohol or drug use. Abusing alcohol or drugs will only make his illness worse.
• He should avoid drinks that contain caffeine, including coffee, tea, cola and energy drinks.
• He must be able to recognize the first signs of an attack of mania or depression.
• He should ask for help from friends or relatives if necessary.

Alternative treatments

For a long time, a combination of psychotherapy sessions and medications has been effectively used in the treatment of bipolar disorder. Here are examples of psychotherapies that are used in the treatment of bipolar disorder in children:

• Cognitive behavioral therapy, which focuses on changing specific patterns of behavior and thinking.
• An interpersonal therapy that focuses on the patient's personal and social relationships and the problems associated with them.
• Problem-solving therapy, a simplified version of cognitive therapy, helps the patient find an immediate solution to the problem.
• Family therapy will help relatives to better understand the disease and learn to help the patient.
• Play therapy, a therapy used in the treatment of very young children.
• Psychological preparation and support groups.
• Logical behavioral therapy, which focuses on teaching the patient to cope with mood swings.

In some cases, electroconvulsive therapy is used. During this procedure, a controlled electrical charge is passed through electrodes that are attached to the patient's skull. This charge is intended to cause a minor seizure in the brain, which can balance the brain's chemicals.

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Complementary therapy

Adjunctive therapy is a term used to describe all additional treatments to the main course. For example, it has been determined that omega-3 fatty acids found in fish oil can be used as an adjunctive drug to the main course of treatment for bipolar disorder in children. However, this dietary supplement requires additional research on its effectiveness in treating children and adolescents.

How to Prevent Bipolar Disorder in Children?

Bipolar disorder in children cannot be prevented. However, there are ways to prevent and manage mood swings.

The first and most important method of preventing mood swings in a child is to regularly take all prescribed medications. Bipolar disorder in children is a disease that can last a lifetime and therefore requires constant treatment.

In addition, a child will be able to alleviate the symptoms of depression and mania, as well as control his mood, when he sticks to a daily routine, stressful situations in his life are reduced, he will regularly exercise and get a good night's sleep.

Prognosis for Bipolar Disorder in Children

The prognosis for bipolar disorder that begins in adolescence varies. Patients with mild to moderate symptoms, a good response to therapy, and who continue treatment have a very good prognosis. However, treatment response is often incomplete, and adolescents are notoriously poor at following treatment. The long-term prognosis for these patients is not as good. Little is currently known about the long-term prognosis of young children diagnosed with bipolar disorder based on highly unstable and intense mood.