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

Bipolar disorder in children is characterized by alternating periods of manic, depressive episodes and a normal state, each of which lasts for several weeks or months.

In recent years, the term "bipolar disorder" is also used in pre-adolescent children, whose abilities are limited due to an intense, unstable mood. In such small children, however, a certain state of mood lasts from moments to several days. In both cases, the diagnosis is based on anamnesis and a study of mental status; treatment includes a combination of medications that normalize mood (for example, lithium, certain anti-epileptic and antipsychotic drugs), psychotherapy and psychosocial support.

Bipolar disorder usually begins in adolescents and young people aged 20–25 years. In many cases, the first manifestation is one or more episodes of depression; in about 2/3 of children who have experienced a severe depressive episode before puberty, bipolar disorder will develop in adolescence or young age.

[1], [2], [3]

Causes of Bipolar Disorder in Children

Until now, scientists can not accurately identify the causes of bipolar disorder in children.

It is believed that bipolar disorder in children is inherited. If the close relatives of the child were ill with this disease, for example, mother, father, grandmother, grandfather, brother or sister, then most likely he will also get sick.

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

Sometimes, the symptoms of mania can occur due to another disease, such as dysfunction of the thyroid gland or multiple sclerosis. Similar symptoms may also occur as a reaction to certain medications, such as corticosteroids or antidepressants. Also, abuse of alcohol, drugs, consumption of large amounts of caffeine and insufficient sleep can trigger an attack of mania.

Risk factors

The risk of bipolar disorder in a child is increased if:

• The child has a close relative, for example, parents, brother or sister, or grandparents who have had bipolar disorder or any other psychological disorder.
• Alcohol or drug addiction took place in the family of the child. This may be a sign that a sick relative has tried to cure his mental illness in this way, for example, bipolar disorder.
• The child had several bouts of acute depression. About 15% of adolescents with frequently recurring episodes of acute depression are later diagnosed with bipolar disorder.

The following factors can cause an attack of mania or depression in your child:

• Irregular sleep and change in the daily routine
• Treatment with antidepressants that can cause an attack of mania
• Stressful situations in life
• Irregular medication
• Alcohol or drug use
• Puberty

Symptoms of bipolar disorder in a child

The hallmark of bipolar disorder in children is a manic episode. During a manic episode, the mood of a teenager can be either extremely high, or irritable, and often alternating depending on social conditions. Speech is fast and assertive, the need for sleep is reduced and self-esteem is too high. Mania can reach psychotic dimensions, for example, “I became equal to God.” Awareness of the danger can be reduced, so the teenager can commit risky actions, for example, be illegible in sexual relationships, irresponsible to drive a car.

In recent years, the term "bipolar disorder" is also used in pre-adolescent children, whose abilities are limited due to an intense, unstable mood. This is controversial and represents an area of active research. Such children have sharp mood changes, but they last much shorter, often only a few minutes. A gradual, inconspicuous beginning is characteristic, with a history of indications that the child has always been very temperamental and difficult to cope with.

A number of diseases and toxic effects should be excluded with the help of an appropriate examination, including a toxicological examination for the presence of narcotic drugs (for example, amphetamines, cocaine and phencyclidines) and external factors (for example, lead). It is also necessary to clarify the presence of provocative events, such as severe psychological stress, including sexual abuse or incest.

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 disorders depend on which symptoms of the patient are more intense, mania or depression.

• In bipolar disorder of the first degree, the phases of mania and depression change each other, sometimes giving the patient a normal state during the periods between the attacks. Some children with bipolar disorder of the first degree most often suffer from bouts of mania, and almost never depression.
• In bipolar disorder of the second degree, depression appears more often than mania, while the attacks of mania are lighter and very sharp.

Children and adolescents with bipolar disorder are prone to frequent changes of mood attacks or mixed attacks. In the first case, this means that the phases of mania and depression often change each other, sometimes even during one day. In mixed attacks, the symptoms of depression and mania appear simultaneously.

Symptoms of Bipolar Disorder in Adolescents

Often, the first symptoms of bipolar disorder in children are a state of acute gloom, misfortune, or other symptoms of depression. In most cases, children are first diagnosed with depression, and only the first attack of mania or hypomania is diagnosed with bipolar disorder.

The first attack of mania or hypomania can be caused by a stressful situation in life or it can arise for no reason. It can also be caused by certain medications. Drugs such as antidepressants or stimulants used in the treatment of depression, ADHD, or obsessive-compulsive disorder are usually prescribed for children with bipolar disorder, but at the time when the diagnosis has not yet been precisely made. These drugs can trigger a mania attack in these children with manifestations of strange, aggressive, or psychopathic behavior. But if you combine the use of these drugs with mood stabilizers, they become effective in the treatment of bipolar disorder in children.

In adults, mood swings usually occur at weekly or even monthly intervals. In children, however, the phase change occurs much more often, sometimes for one day. It is usually very difficult for such children to fulfill their duties in the morning, and in the evening they become overly energetic. Often, the phase change of mood occurs constantly, without interruption to a normal mood. Sometimes the symptoms of mania, hypomania or depression occur simultaneously (the so-called mixed state). Such a frequent and intense change of mood causes irritation in children, and this in turn affects his life at home, at school, and in relationships with peers.

Children with an attack of mania become more irritable and prone to outbursts of anger than adults. During a depressive state, children complain of headaches, pains in muscles, in the stomach 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.

Despite the fact that every child is prone to rebellious behavior and making erroneous decisions, adolescents with bipolar disorder often cannot be sober-minded and often lead a risky lifestyle, such as breaking the law or engaging in unprotected sex. Also during the period of mania, adolescents tend to believe that they have more than capacity and strength and seem more significant than they actually are. A teenager in a depression period withdraws into himself, does not have time at school, suffers from an inability to concentrate and a sleep disorder.

Obsession with sex is common among adolescents with bipolar disorder. Even young children can touch their genitalia, use sexual vocabulary and treat people with their sexuality. Teenagers become obsessed with sexuality and may have unprotected sex. Also this behavior is characteristic of those children who have experienced sexual abuse. But this is optional.

Often, bipolar disorder in children is taken for such diseases as oppositional inducing disorder or attention deficit hyperactivity disorder. This causes children to be mistakenly diagnosed or diagnosed with one of the above diseases along with bipolar disorder. Although there are certain similarities between ADHD and bipolar disorder, a doctor can often distinguish these two states from each other.

A child with bipolar disorder behaves irresponsibly, does not think about the consequences of his behavior and it is difficult for him to keep or make new friends. Adolescents with advanced and non-diagnosed bipolar disorder are prone to alcohol or drug use. If your child abuses alcohol or drugs and behaves strangely, you need to see a doctor to see if your child has bipolar disorder.

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

Symptoms of bipolar disorder in young children

Bipolar disorder in children and adolescents is not the same as in adults. During a depression, your child can easily experience anger, quickly get upset and become extremely angry. Such manifestations may be symptoms of mania. Young children with bipolar disorder show brighter manifestations of happiness and stupid behavior than healthy children.

It is very difficult to distinguish an attack of mania from an attack of depression in children, especially if the phases very quickly change each other or appear simultaneously. Irritability can turn into an extreme attack of hysteria and anger when there is no saying to the child. A bipolar child can bite, beat, dig, and say offensive things, including curses. During such an outbreak, a child may harm property or become very violent.

In severe bouts of mania, a child may suffer from psychosis, for example, experiencing hallucinations or illusions (for example, believing that a popular rock band will arrive on his birthday).

Very often, bipolar disorder in children develops against the background of other diseases (for example, behavioral disorder). In addition, 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 the presence of bipolar disorder in children. Doctors diagnose with:

• Your medical record, as well as asking you about all past and present diseases that could cause similar symptoms.
• Questions about cases of bipolar disorder in your family, as well as other mood disorders or alcohol or drug addiction. (All of these diseases are related to bipolar disorder).
• Careful medical examination, which will help to exclude the presence of other diseases that cause similar symptoms (for example, dysfunction of the thyroid gland).
• Conclusions about the mental state, which can determine the mental state of your child and help determine the severity of an attack of mania or depression.

In young children, the symptoms of mania are a little more than a cause for concern for parents and their friends. For example, sometimes children with their frequent giggles and stupid behavior bring parents out of themselves, but it is not a symptom of mania. However, if this behavior continues for several hours every day and affects the daily life of the family, this may mean that the child is sick.

Before prescribing treatment, the doctor should check the child for suicidal behavior. He can put a number of questions to him, for example:

• Did he lose interest in his hobbies once upon a time?
• Has his sleep, his frequency or quality changed?
• Does he feel depressed, depressed and helpless most of the time?
• Did he have thoughts of harming himself?
• Was he so bad that he wanted to die?
• Did he commit suicide in the past?

Other diseases that have similar symptoms with 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 diagnosed with an erroneous diagnosis. But bipolar disorder in children has a number of distinctive symptoms, which the doctor will definitely notice with careful examination.

Diseases that may first have symptoms similar to bipolar disorder include:

• Attention deficit hyperactivity disorder, a behavioral disorder in which patients cannot concentrate, are active more than usual and are prone to rash actions.
• The behavior disorder that is common among children and adolescents is that sick children do not want to follow social rules or hurt other people.
• Alcohol or drug addiction, despite the fact that the use of alcohol or drugs can cause unpleasant situations in life.
• Depression, a disease that causes the patient a constant feeling of depression and helplessness.
• Schizophrenia, a serious mental illness that, without proper treatment, affects the patient's ability to think soberly and control his emotions. It causes symptoms such as hallucinations, illusions, paranoia, and disorganized thinking.
• Anxiety syndrome, a type of mental illness that is expressed by excessive anxiety, which affects the life of the patient.
• Hyperfunction of the thyroid gland, which can sometimes cause symptoms of mania (for example, excessive energy).
• Neurological diseases. These diseases include:

• Head injuries, which can lead to the fact that the consequences will be felt for a few days, a week or a lifetime.
• Multiple developmental disorders, a group of disorders that are characterized by deviations in the development of social and communication skills. For example, autism, Rett disorder and Asperger syndrome.
• Multiple sclerosis, a chronic neurological disease of the central nervous system that affects the spinal cord and optic nerve.
• Stroke. A stroke occurs when the artery that delivers blood to the brain is blocked by a blood clot.
• Convulsions are sudden flashes of electrical activity in the brain that affects the patient’s muscular activity, movement, speech, vision, and consciousness.

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

Differences between ADHD and Bipolar Disorder in Children and Adolescents

Bipolar disorder t ADHD in children and adolescents have a number of similar symptoms. It is likely that a child may suffer from both diseases at the same time, however there are a number of differences that will help you to treat one disease from another.

Comparison of symptoms of bipolar disorder and ADHD

Symptoms of Bipolar Disorder	Symptoms of ADHD
The child becomes angry and can flare with anger. This condition can last for hours. A child digs, bites, breaks or breaks 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 flash of anger, a child may behave as if it is losing touch with reality.	During a flash of anger, the child does not lose touch with reality.
Mood swings and strange behavior occur suddenly. A child who has recently been depressed and irritable at one moment becomes happy and cheerful.	A child exhibits behavior (for example, increased activity) that cannot be called consistent. He can be either very happy or very stupid.
The reaction of the child to external events is inadequate and lasts longer than the event itself.	The child responds normally to external events and at the same time his reaction does not last longer than the event itself.
A child demonstrates heightened sexuality (says or thinks about sex all the time, has sex or uses obscene words).	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.
Periodically manifested sleep disturbance. Despite the fact that the baby sleeps very little, he is energetic and full of energy.	Sleep disturbances occur for a long time (they are chronic). The child usually gets tired quickly if he doesn’t get enough sleep.

What if a child has bipolar disorder?

Call a doctor immediately or call an ambulance if:

• Your child threatens to harm himself or other people or shows suicidal behavior;
• Your child hears voices (has sound hallucinations);
• You are a young man 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, then waiting does not suit you. Be sure to consult your doctor to assess the situation.

If your child is undergoing treatment, taking the appropriate medication, and the seizure has not gone into the acute phase, then monitoring him will be enough. 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 appear differently depending on the age of the patient. In children, such signs include an obsession with death and a rupture of relationships with friends.

Who to contact?

It is very important that your child be treated by one doctor. Thus, as soon as the child has an attack of mania or depression, the doctor will be able to recognize changes in the child’s behavior and prescribe an effective remedy.

Since bipolar disorder began to be diagnosed in children relatively recently, you may wish to see a doctor with experience with bipolar disorder or specializing in mental disorders in children. Bipolar disorder in children can be diagnosed by doctors such as:

• Psychiatrist, preferably child psychiatrist
• Pediatrician
• Family physician therapist
• Nurse with the right of medical practice
• Medical Assistant

Psychotherapy sessions can also help a child, during which he learns to cope with his mood and the influence that bipolar disorder will have on his life. The best doctor in this case will be a psychiatrist specializing in mood disorders in children or who will have experience treating bipolar children. Psychotherapy sessions can be conducted:

• Psychiatrist
• Psychologist

Also, psychotherapy can be carried out by specially trained doctors, for example:

• Social workers
• Licensed psychiatrist
• Psychiatric Nurse

Who to contact for family support?

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. It will be especially difficult for you during attacks of mania. That is why it was not a bad thing to turn to a specialist who will help you come to terms and cope with all the difficulties that this disease brings.

Treatment of bipolar disorder in a child

Although it is quite difficult to deal with mood changes and other symptoms of bipolar disorder, you can still cope with them. Typically, the treatment consists of medications (mood stabilizers) and psychotherapy, while these methods are used simultaneously.

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

It is possible that all family members, including the sick child, need some time to come to terms with the presence of such a serious and prolonged illness that needs constant treatment and observation. But remember, only by working closely with your doctor, you can find the most effective treatment.

You can discuss with your child’s doctor the treatment that best suits your child. Perhaps the child himself will want to take part in this choice.

Initial treatment

The first step in choosing a treatment should be to determine the degree of complexity of the child’s symptoms. If a child shows suicidal behavior, he is aggressive, reckless or carries a danger to others, or he / she is unable to perceive reality (a psychotic state), then such a patient will need to be hospitalized. Also, do not forget that some of the bipolar medications may worsen the symptoms of bipolar disorder, and if this happened to your child, he should stop taking this medication. However, it is necessary to stop taking this or that medicine only under the supervision of a physician.

Initial treatment usually includes medication and psychotherapy sessions.

[4], [5]

Medicines for bipolar disorder in children

In adolescents and young children, mood-stabilizing drugs are used to treat manic episodes or the arousal phase, while psychotherapy and antidepressants are used to treat depressive episodes. All mood stabilizing drugs can be roughly divided into 3 categories: antiepileptic, antipsychotic and lithium preparations. All mood stabilizing agents can potentially cause anxiety or even dangerous side effects. In this regard, the treatment must be individualized. Moreover, drugs that are highly effective in the period of initial stabilization may be unacceptable for supportive treatment due to side effects, the most notable of which is weight gain. Antidepressants are usually used in combination with mood stabilizing drugs, as they can trigger a “switch” from depression to mania.

The most common drugs include:

• Mood stabilizers such as lithium, divalproex, carbamazepine, lamotrigine, or valproate.
• Neuroleptics, such as aripiprazole or risperidone, which the doctor can combine with mood stabilizers to better control the onset of mania.
• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, or other types of antidepressants to relieve depression. Despite the fact that they are quite effective, these drugs can cause an attack of mania. Antidepressants are usually prescribed with mood stabilizers, and the doctor monitors the patient for the duration of their intake.

Before prescribing treatment for bipolar disorder, the doctor should check the child for suicidal behavior.

Psychotherapy

The most effective psychotherapy is in combination with medication. Depending on the age of the patient, several types of psychotherapy can be used:

• Cognitive-behavioral therapy that focuses on changing certain patterns of behavior and thinking.
• 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 that helps the patient find an immediate solution to the problem.
• Family therapy will help relatives learn more about the disease and learn how to help the patient.
• Play therapy, therapy that is used in the treatment of very young children.
• Psychological training and support groups.
• A logical-behavioral therapy that focuses on teaching the patient how to deal with mood swings.

[6], [7]

Supportive treatment

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

Sometimes, the child does not respond to the first medication prescribed for him, so he will have to try several medications until the most suitable medication is found. A combination of medication and psychotherapy can be the most effective treatment.

The most important point in maintenance therapy is the fact that the child clearly adheres to the schedule of medication. Very often, feeling well, patients feel that they have already recovered and do not need more medication. But when patients stop taking medicines, the symptoms usually return, which is why it is so important to follow the course of treatment.

Medicines, despite their effectiveness, also have a number of side effects. There are some side effects that you can not get rid of, such as increased urination (with lithium). But with such effects as gaining excess weight (which is more common when taking several bipolar medications) you can cope with exercise and eating fewer calories. Together with the child and his doctor, you can find a way to deal with the side effects. If the side effects are very intense and it is impossible to cope with them, the doctor will try to change the dose or the drug.

If you are taking drugs such as lithium or divalproex, you should take a blood test regularly. With the help of these tests, the doctor will select the dose of the drug that will be safe for your child.

In the initial treatment, the doctor prescribes antipsychotics so that the patient has the opportunity to quickly deal with the symptoms. But after improving the symptoms, the child will need to either reduce the dose of these drugs, or stop taking them altogether.

For maintenance therapy also include:

• Harmonization of the school program. If your child attends school and has bipolar disorder, then during bouts of depression or mania, he will need to reduce his homework or change his school schedule. Thus, you should coordinate these questions together with the school management so that they do not affect the overall educational process of the child.
• Relaxation and exercise. While at home, the child can follow these tips in dealing with the symptoms of the disease:
  • he can exercise regularly, such as swimming or walking to reduce stress
  • he should avoid using drugs, alcohol, tobacco, caffeinated beverages and energetic beverages
  • he has to eat a nutritious and balanced diet
  • he should get enough sleep and watch him go to bed and wake up at the same time (children and teenagers need more sleep than adults)

Sometimes, when a child is treated in parallel for another disease, the symptoms of bipolar disorder only get worse. For example, taking antidepressants for treating depression can cause an attack of mania or worsen it. Also, medications for attention deficit hyperactivity disorder can provoke mania, depression or psychosis. Drugs used in the treatment of asthma can also cause an attack of mania. Taking medications that provoke worsening of the symptoms of bipolar disorder is recommended to either stop or reduce their dose. Sometimes this problem can be solved with the help of mood stabilizers. However, we must not forget that every child responds to medicines in different ways. And before the doctor selects an effective medicine or a combination of different drugs, the child will have to try several different medicines.

The more you know about childhood and adolescent bipolar disorder, the faster you will be able to recognize the onset of an attack. Such rapid recognition of an attack will help you to quickly deal with mania or depression and reduce the duration of these attacks. And this in turn will help improve the quality of life of your child.

Treatment in the event of disease progression

If your child is undergoing treatment for bipolar disorder, but his condition only worsens, the doctor may prescribe additional treatments. But before you and the doctor should be convinced of the following:

• Make sure the child takes medication regularly and follows all the doctor's prescriptions, including the psychotherapist.
• Ensure that such deterioration is not caused by a parallel other disease (for example, attention deficit hyperactivity disorder or post-traumatic syndrome), which will also require parallel treatment.
• Install and try to avoid those stressors that make the symptoms worse
• Change the dose of the drug being taken, perhaps the reason
• Add or change a drug if the drug being taken does not give any result.

If a child demonstrates a desire to commit suicide, it may be necessary to hospitalize him. With age, signs of suicidal behavior change. 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 a shock therapy. During this procedure, a slight electrical impulse is transmitted to the patient's brain through electrodes attached to his skull. It is believed that during this procedure, electricity causes a slight cramp in the brain, which should balance the chemical elements of the brain.

Home treatment

In addition to medical treatment, you can take a few simple steps at home to reduce the symptoms of bipolar disorder in children, for example:

• Keep calm and quiet in the baby’s room and make sure that the baby goes to bed every night at the same time.
• Control stressful situations in your child’s life. You may need to find a way to help your child cope with his studies during an attack.
• Learn to recognize the first signs of an attack of mania or depression in your child.

The child, for his part, may do the following:

• Exercise regularly. Even if the child has a bout of depression and he does not want anything, support him and try to convince him to stroll or swim in the pool more often.
• Watch your sleep. He should sleep well and go to bed and wake up at the same time.
• Balanced eat.
• Avoid alcohol or drug use. Alcohol and drug abuse only worsen his illness.
• He should avoid drinks that contain caffeine, including coffee, tea, cola and energy drinks.
• He should be able to recognize the first signs of an attack of mania or depression.
• He must, if necessary, ask for help from friends or relatives.

Alternative treatments

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

• Cognitive-behavioral therapy that focuses on changing certain patterns of behavior and thinking.
• 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 that helps the patient find an immediate solution to the problem.
• Family therapy will help relatives learn more about the disease and learn how to help the patient.
• Play therapy, therapy that is used in the treatment of very young children.
• Psychological training and support groups.
• A logical-behavioral therapy that focuses on teaching the patient how to deal with mood swings.

In some cases, electroshock therapy is used. During this procedure, a controlled electrical charge is passed through the electrodes that are mounted on the patient's skull. This charge should provoke a slight spasm in the brain, which is able to balance the chemical elements of the brain.

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Additional therapy

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

How to prevent bipolar disorder in children?

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

The first and most important method to prevent 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, the child will be able to alleviate the symptoms of depression and mania, as well as control his mood, when he keeps his daily routine, stressful situations in his life decrease, he will exercise regularly and get a good sleep.

The prognosis for bipolar disorder in a child

The prognosis for bipolar disorder that began in adolescence is different. In patients with mild or moderate severity of symptoms, good response to therapy, who continue treatment, the prognosis is very good. However, the response to treatment is often incomplete, and adolescents are not known to be inclined to comply with doctor's prescriptions. The long-term prognosis for these patients is not as good. Currently, there is little information about the long-term prognosis of young children who have been diagnosed with bipolar disorder on the basis of extremely unstable and tense mood.