Bipolar disorder is a specific psychiatric illness that leads to problems with mood. 'Bipolar' refers the tendency of the illness to encompass both depressive episodes as well as periods of abnormal mood referred to as 'manic' episodes; the old terminology called this disorder of opposites 'Manic-Depressive Disorder,' and most people have heard of this. Classically, a patient suffers either from the manic phase or the depressive phase, and alternates over periods of months to years between the two poles. In some cases, particularly children, patients may suffer from 'mixed' manic and depressive episodes at the same time.

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Diagnosis of Bipolar Disorder: What to look for.

Bipolar disorder is a condition that is defined by certain behaviors and thought patterns, some of which are the opposites of one another, yet can exist at the same time. Although the core troubles of Bipolar disorder are the same for children as they are for adults, often the specific behaviors are different, and vary according to the age and developmental level of the child. Importantly, often a child or adolescent is unable to say that they are 'depressed' or 'sad,' or 'angry, ' 'out-of-control,' 'exuberant,' 'irritable,' or 'confused' (all common symptoms of bipolar disorder in children and adolescents). Rather, they may say that they are bored, angry, short-tempered, or 'just don't want to' when it comes to expected chores or duties, like school, extracurricular activities, or friends.

Bipolar disorder in adults and adolescents appears to be a pattern of cyclic recurrence over the lifespan: long periods of normal mood and behavior with episodes of abnormal mood (depressed, manic, or mixed) and behavior. However, in children, bipolar disorder seems to be more of a chronic and persistent alteration in mood and behavior with some periods of time being worse than others, but not usually intervening periods of normalcy. Some experts describe the child at risk for bipolar disorder as those that experience both positive and negative mood states very deeply, intensely and dramatically and who have great difficulty regulating, modulating and controlling their moods and behaviors, leading to noticeable interpersonal and social difficulties.

As examples of how bipolar behavior can be somewhat different in adults versus children, below is a list comparing the major symptoms of bipolar disorder, both in the depressed phase, and the manic phase.

Depressed Phase
Adult Symptom
Child Example
Adolescent Example

depressed/sad mood, Irritable, argumentative, aggressive, whining/crying, Argumentative, aggressive, emotionally sensitive diminished interest/pleasure, inability to feel pleasure not as motivated or playful, not as curious and explorative, school work drops off, boredom Isolative, quits activities, shows no initiative, grades drop, boredom, unintentional weight changes, fails to gain weight normally
Weight changes, sleep changes, Difficulty falling asleep or staying asleep
Difficulty falling asleep or staying asleep, stays up all night being slowed down or sped up, Difficulty concentrating or sitting still, impulsivity, less active or interactive, hyperactive, disorganized
Difficulty concentrating or sitting still, impulsivity, less active or interactive, disorganized,fatigue, Needs rests, naps, complains when is pushed to do things, plays 'sick' , Refuses to participate, lays around a lot, sleeps during day, acts 'sick' a lot, worthlessness and guilt
Makes negative self-comments such as 'You hate me' and 'I'm stupid'
Makes negative self comments such as 'I'm fat' 'I'm ugly' 'Everybody hates me' , poor concentration, can't make decisions
Poor attention and concentration, easily distractible, disorganized
Poor attention and concentration, easily distractible, thoughts of death or suicide, Talks about death, states 'I wish I was never born' or 'I wish I was dead' Obsesses on death and morbid topics, voices wishes to be dead or thinks about/attempts suicide

Psychosis: hearing things, seeing things, or paranoia
Extreme fears for safety, seeing scary images, hearing monsters
Suspiciousness, paranoia, seeing fearful images or hearing their name called

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Manic Phase

Adult Symptom
Child Example
Adolescent Example

'great' mood: feels 'on top of the world' 'never felt better'
Extremely happy or giddy; extremely silly or sociable; may start feeling he has special powers or is a superhero; demands to be the center of attention
Extremely happy and sociable, may suddenly feel she is smarter/better/more beautiful than peers; inflated sense of self esteem

Much increased activity in specific areas, such as work, socializing or hobbies without fatigue
Spends lots more time than usual in activities, playing, helping parents out; everybody is a 'friend' constantly wanting parents' attention
Starts new projects, spends much more time than usual in hobbies, starts making new friends and acquaintances; starts exercising or being busy excessively

Rapid, pressured speech: talks nonstop; others can't get a word in edgewise
Rapid, incessant speech. Doesn't allow others to contribute to conversation
Rapid, nonstop talking without listening to others; holds one-sided conversations

Needs much less sleep than usual
Difficulty going to bed, does not seem to need as much sleep at night as before, doesn't need naps during day
Starts staying up all night, being rested with only a few hours (or none) sleep

Thoughts and ideas seem to be racing, feels extremely creative or brilliant all of the sudden
Can't focus or concentrate on tasks or topics when talking, constantly has 'great' ideas about things
Difficulty concentrating or sitting still, impulsivity, less active or interactive, disorganized

Impulsivity, rash judgments; doesn't think things through
Persistently intrusive and impulsive, can't wait turn, won't listen to parents' demands; very disruptive to others; poor frustration tolerance; rude
Starts disregarding rules of house, impulsive, poor judgment, can't hold himself back from what he wants; very disruptive to others; poor frustration tolerance

Increased sexual behaviors through ideas, speech and action
Shows sudden interest in gender/sexual issues; starts using foul language in a playful way; may masturbate or touch others; vulgar
Shows increased interest in sexual issues and dating; may masturbate in public or fondle others; increased involvement in pornography

Increased irritability and sudden uncharacteristic anger
Short tempered, anger and aggressive outbursts, easily frustrated when told 'no'
Severe mood swings with aggressive outbursts, everything gets on his nerves

Becomes disorganized and inefficient with tasks despite putting much more effort in
Poorly organized behavior; quickly loses interest in demanding tasks; does things and says things that don't quite make sense
Grades drop; unable to do complex tasks or chores; seems to be 'spacey' at times; does and says odd things without rational explanation

Psychosis: hearing things, seeing things, or paranoia
Extreme fears for safety, seeing scary images, hearing monsters
Suspiciousness, paranoia, seeing fearful images or hearing his name called

These problems must lead to significant difficulties in peer interaction, play and recreation, school performance, family interactions, or disturbance of normal development. They must last at least a week continually, and must not be the result of drug or alcohol use, and not be due to an underlying medical condition.

As seen in clinical practice and in some studies, the most common symptoms of bipolar disorder (depressive phase) reported in children and adolescents were sadness, inability to feel pleasure, irritability, fatigue, insomnia, lack of self-esteem, and social withdrawal. Children are as well somewhat more likely than adolescents to suffer from physical symptoms (e.g., stomach aches and headaches), hallucinations, agitation, and extreme fears. On the other hand, adolescents showed more despairing thoughts, weight changes, and excessive daytime sleepiness.

As far as bipolar disorder (manic phase) symptoms go, children typically show a mixed picture consisting of elements characteristic of both depression and mania at the same time: depressed/irritable and distraught type of mood, combined commonly with increased energy, lack of sleep, disorganized behavior, poor frustration tolerance and extreme irritability. Adolescents on the other hand tend to be the more classic manic: elevated mood and self esteem, racing thoughts, rapid speech, impulsive and intrusive behaviors, and lack of a need for sleep.

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Prevalence: How common is Bipolar Illness?

As stated above, in general about 5% of children and adolescents nationally could be diagnosed with Bipolar Disorder at any given time. Further studies have shown that this number changes as children age: about 1% of preschoolers, 2% of school-age children, and 5% of adolescents are affected. About 25 to 50% of all children and adolescents in psychiatric treatment are seen for depression and its related problems. Childhood depression appears to be more common in boys than in girls (about a 5 to 1 ratio, boys to girls) until adolescence, when it becomes more common for girls than boys (2 to 1 ratio, girls to boys).

Children who have biologic relatives that suffer from depression, bipolar disorder, anxiety disorders, and substance abuse disorders have a biologic tendency towards mood disorders (Bipolar illness or Depression), and are more likely to develop clinical mood disturbances than children that do not have biologic relatives with these disorders.

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Comorbidity/Risk factors: What else to look for.

Unfortunately Bipolar Disorder in children and adolescents does not always show up alone: there frequently are one or more problems associated with the mood disturbance, making it important for the doctor to discover and treat. If not, the undiscovered and untreated problems will likely interfere with and complicate the clinical picture.

Frequent psychiatric illnesses that accompany or can mimic bipolar disorder include anxiety, phobias, obsessive compulsive disorder, childhood schizophrenia, ADHD, substance abuse, oppositional defiant disorder, learning disorders, and delinquent behaviors.

From a medical standpoint, evaluation for the existence of hormonal disease, seizure disorders, neurologic conditions, toxic states (such as lead and arsenic poisoning), autoimmune or infectious disease are all necessary when clinically suspected.

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Course of Illness: Will the mood problems come back again?

For the majority of children, the answer is Yes. However, it is not known when mood episodes may recur or how severely. Mood disturbance that goes untreated may last . With treatment, the length of the abnormal mood episode is much shorter, and the child will recover more quickly. This results in less disruption to the child's life and quicker return to normal function at home, with friends and family, at school, and in the normal course of development. It is believed that treatment of bipolar illness as well can serve to reduce the likelihood of mood episodes recurring; or if an episode does return, treatment seems to delay the return of symptoms and reduces the severity of symptoms overall. From a statistical point of view, about 70% of children and adolescents will have another episode of depression or mania within 5 years of the first one. Fortunately, if the child and his family sought treatment previously they are very educated about bipolar illness and its signs, and so can be on the lookout for the earliest, most subtle changes associated with a returning depression and can immediately seek help and early treatment.

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Treatments: What can be done?

Successful treatment of childhood and adolescent bipolar disorder has proven to require interventions on several strategic fronts:

thorough and accurate diagnostic evaluation of the child. As bipolar illness in childhood is commonly confounded by multiple disorders, it is vital to the treatments success that all disorders be discovered and addressed. Many of these disorders can be helped with appropriate use of medications, such as mood stabilizers, antianxiety medications, antidepressants, neuroleptics, and stimulants. Also, individual and family therapy is often beneficial for the patient, and can specifically help with issues of family conflict, self-esteem, relaxation strategies, mood and anger control, and better communication.
evaluation of the school environment and its impact on the current situation. Very frequently school and peer issues can lead to and/or perpetuate an environment in which the child's mood disturbances can take root and grow. It is important, therefore, that assessment of the school be done so that modifications to the demands placed on the child may be appropriately completed so as to best create an environment that fosters recovery while not unduly affecting the educational process. This usually involves the interaction of the school counselor, principal, psychologist, teachers, and parents. Some interventions include psychoeducational testing, speech and occupational therapy, in-school counseling, curriculum modification, resource classes, behavioral modification systems, ARD meetings, self-contained classrooms, and alternative placements.
evaluation of the home/parental environment and its impact on the current situation. Home life can also contribute to the development and/or continuance of a child's or adolescent's bipolar illness. Like school modification and intervention, family and home modification may be necessary to best create an environment that fosters recovery while minimizing the disruption to the family and child's lives. Family therapy and couples therapy are often very useful in this regard, and can address issues of parental roles, parental modeling, interfamily conflict, better communication, behavioral reward systems, and defining family members' roles and responsibilities.
Education (also known as psychoeducation) about childhood bipolar disorder and its associated illnesses, and nature and expectable course of the disorder(s), the importance and limitations of specific treatment modalities.
Support: Where to look for help.
There are several convenient sources of information and support, many of which can be found on the internet or in your community's libraries. Below are several good internet starting points. Additionally, your physician, nurse, pastor or counselor can be good sources of information.

American Academy of Child and Adolescent Psychiatry: Information is provided as a public service to aid in the understanding and treatment of the developmental, behavioral, and mental disorders which affect an estimated 7 to 12 million children and adolescents at any given time in the United States. You will find information on child and adolescent psychiatry, fact sheets for parents and caregivers, current research, practice guidelines, managed care information, awards and fellowship descriptions, meeting information, and much more.
Mental Health Net: the most comprehensive source of online mental health information, news and resources.
Online Psych: Online Psych gives you a variety of interactive tests, quizzes, and surveys to challenge, inform, intrigue, and educate you. You'll find everything from online screening tests for mental health issues to fun surveys about relationships.
Knowledge Exchange Network: The Center for Mental Health Services (CMHS) Knowledge Exchange Network (KEN) provides information about mental health