Bipolar Disorder in Children and Teens - What Happens

What Happens

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 Children and Teens.

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.)⁴

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.⁵ Although there is some evidence of a link between ADHD and bipolar disorder,⁶ 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

Bipolar disorder in children may be different than in teens and adults. They may outgrow the disorder and no longer have this diagnosis later in life. In children younger than age 9, bipolar disorder frequently appears as depression or irritability.⁷ 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.⁵ 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.⁷ 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) 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.⁷

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.

Watch for the warning signs of suicide. These 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.