Bipolar Disorder in Children: what is it?

Bipolar disorder in children is a psychiatric diagnosis in young patients characterized by mood and behavioral disturbances. When we think of bipolar disorder, we often picture adults experiencing dramatic mood swings, but this complex neuropsychiatric condition can emerge during childhood, presenting unique diagnostic and treatment challenges.

Early-onset bipolar disorder manifests differently from its adult counterpart, often masquerading as other behavioral conditions and creating a complex diagnostic puzzle for mental health professionals.

Children with bipolar disorder experience intense emotional states that go far beyond typical childhood mood swings—these are profound neurobiological shifts that affect their ability to function at school, maintain friendships, and navigate family relationships.

While adult bipolar disorder follows relatively predictable patterns of mania and depression, children might experience more rapid mood fluctuations, intense irritability, and mixed states where symptoms of mania and depression occur simultaneously.

Bipolar disorder (BP) is marked by episodic shifts in mood and activity levels. It can occasionally manifest in childhood but typically appears after puberty or in early adulthood. The diagnosis is based on the same criteria as in adults, and pediatric bipolarity is largely viewed as the same condition found in adults.

Definition of pediatric bipolar disorder

Bipolar disorder is classified into three main categories:

1. BP Type I:
   Characterized by at least one manic episode lasting a minimum of one week, significantly impairing function, often accompanied by depression.
2. BP Type II:
   Involves at least one hypomanic episode lasting a minimum of four days, meeting manic criteria with functional impact but not severe impairment. Depression is common and often more prominent than hypomania, which tends to be shorter.
3. BP NOS (Not Otherwise Specified) and Cyclothymia:
   • BP NOS includes cases within the bipolar spectrum with episodic changes in mood and activity but insufficient duration or incomplete symptom criteria. Examples include hypomanic episodes without depression or short-lived depressive and hypomanic episodes (2–3 days).
   • Cyclothymia refers to at least one year of episodes with hypomanic and depressive symptoms that do not meet criteria for mania, hypomania, or major depression.

Prevalence

Bipolar disorder can emerge before puberty but is rare, with limited prevalence data. Risk increases during puberty. Meta-analyses for ages 7–21 estimate BP spectrum (BP I + II + NOS/cyclothymia) prevalence at 2%, with BP I at 0.5%.

Retrospective prevalence estimates from adult data suggest that 0.5–1% of adolescents may develop BP I or II, with approximately half experiencing their first episode before 18. Early episodes often present as depression, making bipolar disorder difficult to diagnose in its initial stages.

Etiology

• Genetics:
  Bipolar disorder has a strong genetic component, accounting for 70–80% of adult cases, with an even higher genetic contribution in early-onset cases. Children of parents with bipolar disorder have a 5% risk of BP I/II and a 15% risk of BP spectrum disorder before age 20.
• Family Environment:
  A high-conflict, over-involved family dynamic (expressed emotion, EE) increases relapse risk.

Pathophysiology

The core of bipolar disorder in children involves deficits in neural networks regulating emotion and attention. These include:

• Prefrontal Areas: Regulating emotional responses with subcortical structures (thalamus, striatum) and the limbic system (especially the amygdala).
• White Matter Changes: Impaired connections between frontal regions and the limbic system.
• Neurochemical Abnormalities: Alterations in prefrontal levels of glutamate, N-acetyl-aspartate, and myo-inositol.

Treatment studies suggest that mood-stabilizing medication or family therapy improves prefrontal cognitive control of emotions and reduces amygdala hyperactivity. Some evidence points to elevated inflammatory markers in the blood, potentially linked to complications like suicidality, psychotic symptoms, or severe depression.

Symptoms

What are signs of bipolar disorder in children? Bipolar development is typically gradual, often spanning years, with abrupt onset being rare. A family history of bipolar disorder, especially early-onset in parents, substantially increases risk. Pre-pubertal symptoms often include:

• Anxiety
• Depression
• Oppositional behavior

Episodic disturbances, emotional instability, and worsening depressive episodes heighten the risk. Brief and mild hypomanic episodes may signal an impending manic episode.

Mania

The core aspects of mania are:

• Clearly defined episodes of elevated or markedly irritable mood.
• Simultaneously, a distinctly increased energy and activity level.

Additionally, there must also be three (in cases of euphoria) or four (in cases of irritability only) accompanying symptoms that significantly deviate from the individual’s usual functioning:

1. Decreased need for sleep:
   Sleeps two or more hours less than usual but does not feel tired the next day, often feeling more energetic instead. This is a critical diagnostic feature and, aside from mania, is typically only observed with substance use.
2. Increased self-esteem:
   May sometimes be challenging to assess in young people, where self-esteem often fluctuates.
3. Increased talkativeness:
   A symptom that close relatives may find easier to identify.
4. Flight of ideas:
   A subjective experience of racing thoughts that feel uncontrollable.
5. Increased distractibility:
   Can be confused with ADHD; clear episodicity combined with mood shifts is required. Unlike ADHD, individuals can often focus well when not distracted, but lose the ability entirely when distracted.
6. Increased goal-directed activity:
   Can also be mistaken for ADHD, so clear episodicity and mood shifts are essential. In milder forms (hypomania), schoolwork and social interactions may improve, but in mania, activities become chaotic.
7. Poor judgment involving pleasurable activities:
   Can be mistaken for ADHD; episodicity and mood shifts are again crucial. This often leads to significant errors in relationships or financial decisions.

Depression

The core aspects of depression in young people are:

• A newly developed (different from previous functioning) and persistent (present most of the day, nearly every day) feeling of:
  • Sadness or irritability:
    Negative feelings that persist and are disproportionate, even if there are reasons, the sadness is excessive.
  • And/or a loss of ability to feel joy (anhedonia):
    Activities and interests that are usually enjoyable feel significantly less rewarding.

Additionally, there must also be accompanying symptoms that markedly deviate from the individual’s usual functioning. According to DSM-5, a diagnosis of a depressive episode requires five of the nine symptoms to be present most of the time, nearly every day, for at least two weeks. These additional symptoms include:

1. Lack of energy:
   Experiences a lack of mental energy and must force themselves to perform daily tasks that would usually be easy. In the ICD-10 classification, lack of energy is a core symptom alongside sadness and anhedonia.
2. Changed appetite:
   Often both a decreased appetite for food and an increased craving for sweets.
3. Disrupted sleep:
   Often includes difficulty falling asleep, waking up during the night, and increased need for sleep.
4. Psychomotor retardation or agitation:
   Observed as either flattened and slowed expressions and movements or as restlessness and agitation.
5. Difficulty concentrating:
   Particularly noticeable during lessons, reading, or homework, where information doesn’t “stick.” May also struggle to follow conversations or movies.
6. Feelings of guilt and negative thoughts:
   More self-critical than usual, possibly feeling guilt for things clearly outside the individual’s control or responsibility.
7. Thoughts of death:
   Includes thoughts that life isn’t worth living, passive wishes to die, considerations of methods to end one’s life, and possibly having made preparations for a suicide attempt.

Can it overlap with other conditions?

Depressive disorder

Features suggesting that depression may transition into bipolar disorder include many short and abrupt episodes, increased need for sleep, psychomotor retardation, psychotic symptoms, and a family history of bipolar disorder.

ADHD

Many symptoms of depression overlap with ADHD, where affective instability is often also observed. The difference is that ADHD has a chronic, fluctuating course with an onset in early school years. The affective swings in ADHD are reactive and shift throughout the day. In ADHD, low mood might occur due to failures, but there is no loss of the ability to feel joy or a more persistent sadness.

Oppositional defiant (ODD) and conduct disorders

Children with ODD may exhibit an irritable mood and at times be very explosive. They often also have ADHD. The difference compared to bipolar disorder is the chronic course, absence of episodic manic symptoms, and a core pattern of oppositional or rule-breaking behavior.

Borderline personality disorder / Emotional instability (EIPS)

The onset after puberty resembles bipolar disorder, but the affective swings are, like in ADHD, short-lived and reactive. The core of borderline personality disorder is impulsivity and conflicted, ‘black-and-white’ relationships rather than episodes of mood disturbance.

Schizophrenia

Psychotic symptoms are not uncommon in Bipolar I disorder, especially in adolescents. Affective symptoms may be overshadowed by prominent psychosis.

A newly onset psychosis during the teenage years, particularly with intense symptoms, should be suspected as part of a manic episode unless it is clearly drug-induced. In contrast, schizophrenia often features withdrawal, suspicion, bizarre but calmer behaviors, and a gradual decline in psychosocial functioning.

Substance use disorder

Stimulants and hallucinogens, in particular, can resemble mania with a rapid onset. A social circle involved in drug use and especially a positive test for substances support the diagnosis of drug-induced psychosis. Sometimes both drug use and a manic episode occur simultaneously. Substance use may then be seen as reckless behavior within the context of mania.

Somatic illness

If the course and symptom profile of mania are atypical, there is no hereditary support, or there are focal or other symptoms that cannot be attributed to mania, it is essential to evaluate whether it may instead be somatic. Temporal lobe epilepsy, brain tumors, encephalitis, hyperthyroidism, MS, SLE, and acute head injuries should be considered, and relevant investigations conducted.

Side effects of medication

Ongoing treatment with antidepressants, central stimulants, steroids, or certain antibiotics such as erythromycin and amoxicillin should be discontinued.

Diagnostics

Screening

Risk groups for screening include young individuals with:

• A family history of bipolar disorder.
• Depression with early onset or an unusual pattern of abrupt episodes or marked by inhibition and increased sleep.

Screening instruments:

• Mood Disorder Questionnaire – Parent Version (MDQ-P)
• Child Mania Rating Scale – Parent Version (CMRS-P)

Diagnostics criteria

Understanding the diagnostic markers of pediatric bipolar disorder requires a careful examination of specific behavioral patterns that differ significantly from typical childhood emotional experiences. Children with bipolar disorder exhibit distinct mood episodes characterized by periods of unusually elevated, expansive, or irritable moods, often accompanied by grandiose beliefs or uncharacteristic risk-taking behaviors.

These episodes must persist for at least four days to meet hypomania criteria or seven days for mania—though in children, episodes often present with rapid cycling patterns that might shift within days or even hours.

The DSM-5 stipulates that for a bipolar diagnosis, these elevated moods must coincide with three or more associated symptoms: decreased need for sleep, racing thoughts, pressured speech, increased goal-directed activity and agitation.

Depressive episodes, which may alternate with manic periods, involve pervasive sadness, loss of interest in activities, significant changes in appetite or sleep patterns, and potentially suicidal thoughts. Notably, children might express their mood disturbances through explosive anger, intense frustration, or severe temper outbursts rather than classic adult presentations.

These symptoms must cause significant impairment in social, academic, or family functioning and cannot be better explained by other medical conditions, medications, or typical developmental stages.

The diagnosis is based on the course and typical symptoms obtained from the patient’s and relatives’ medical history. Diagnosing can sometimes be straightforward, but in young individuals, it is often more challenging than in adults.

Comorbidities, particularly with ADHD, but also with anxiety disorders, are more common in young individuals, and developmental changes during adolescence can obscure milder bipolar syndromes. Overdiagnosing bipolar disorder carries the risk of avoiding simpler and more effective treatments for depression and using medications with significantly greater risks. Therefore, the diagnosis should be made by a specialist in child and adolescent psychiatry experienced in bipolar disorder.

• Genetics supports a suspected diagnosis, but biological markers are still lacking.
• Episodes are the single most crucial aspect of the diagnostic process. These episodes should distinctly differ from the young person’s usual functioning and include newly emerging hyperactivity and euphoria or pronounced irritability. The episodic nature of typical symptoms should, through the history, become evident to the physician, patient, and relatives. In cases of doubt, it is often better to delay the diagnosis and instead assume that the issues may be better understood as stemming from more common conditions, such as ADHD or depression.
• Mood diaries can aid in diagnosing by prospectively tracking patterns of new episodes of depression or mania.

Physical examination

• Baseline values for planned medication: Before initiating lithium, neuroleptics, or antiepileptics (except lamotrigine), blood tests should be taken to establish baseline values for monitoring follow-up results.
• Metabolic risk: Bipolar disorder is an important risk factor for cardiovascular disease later in life. Height, weight, waist circumference, BMI, pulse, blood pressure, and baseline metabolic tests (glucose, blood lipids) required for neuroleptics should be monitored.
• Differential diagnostics: Focus on history. Routine thyroid tests should be performed, while more advanced laboratory investigations, MRI, or EEG should be directed by specific suspicions.

Risks with bipolar disorder in children

The risk of suicide is approximately 20 times higher than in the general population, and 8–20% eventually die by suicide, particularly if untreated. When bipolar disorder begins in adolescence, suicide attempts are more common compared to adult-onset. The evaluation should map out the most critical risk factors for suicide or suicide attempts:

• Family history of suicide.
• Previous suicide attempts.
• Self-harm behavior.
• Substance abuse.
• Thoughts of death and suicide.

Comorbidities

Bipolar disorder often coexists with other psychiatric diagnoses, more so in adolescents than in adult-onset cases. Comorbidities should always be screened during diagnosis and included in the treatment plan after the affective symptoms subside. Consider assessing anxiety disorders from periods prior to or free from affective symptoms.

• ADHD and conduct disorders: Early onset is more frequently associated with ADHD than adult-onset cases.
• Anxiety disorders: All anxiety disorders (social phobia, generalized anxiety, and panic disorder) are common in bipolar disorder.
• Obsessive-compulsive disorder (OCD).
• Borderline personality disorder: Can be both a differential diagnosis or a comorbidity.
• Substance abuse: Includes alcohol and illegal drugs, which may precede onset or emerge later, worsening the course of illness.
• Eating disorders: Increased occurrence, especially binge eating and bulimia.
• Autism: Possibly higher prevalence.

Treatment

The foundation of treatment involves a comprehensive assessment conducted collaboratively and transparently shared with the patient and relatives. This serves as the basis for long-term cooperation, considering the prolonged course of illness, stepwise treatment, and risks of not achieving recovery.

Psychoeducation is initially conducted individually with the patient and relatives. It should be integrated into ongoing treatment and can also be delivered in group settings.

Psychoeducation should cover:

• The diagnosis, including comorbidities.
• The course of illness, highlighting the high risk of new episodes and their potential consequences.
• Effects and side effects of pharmacological treatment.
• The importance of:
  • Sleep.
  • Physical activity.
  • Stable daily routines.
  • Avoiding substance use.
  • Maintaining a calm emotional environment.

Pharmacological treatment

Bipolar mania treatment

In cases of acute mania, pharmacological treatment is absolutely essential alongside measures to protect the patient from serious risks and mistakes. Care under the Compulsory Psychiatric Care Act (LPT) should be considered.

Lithium

Lithium is the first-line treatment for acute mania, for relapse prevention, and in combination with neuroleptics for acute mania requiring hospitalization. A high-quality RCT study now supports its use in mania among teenagers and it is generally effective in clearly episodic bipolar disorder, especially if hereditary factors support lithium efficacy. The effect develops gradually over weeks, and experiences are also extrapolated from adult data, where lithium prevents relapses into both depression and mania and reduces the risk of suicide. Lithium often causes hypothyroidism, always increases urine volume, and can exacerbate acne if present. Baseline tests, including TSH and thyroid antibodies, should be conducted.

Lithium is commonly used for the treatment of bipolar disorder in children and adolescents in the United States. The target serum levels for lithium typically range from 0.8–1.2 mEq/L when measured at a 12-hour trough level. For hospitalized teenagers, treatment can begin with Lithium Carbonate (Lithobid) at an initial dose of 300 mg twice daily, taken with food to reduce gastrointestinal side effects.

Serum lithium levels should be checked on the fifth day of treatment to ensure steady-state levels are achieved and therapeutic targets are met. Adjustments to the dosage should be made based on the serum levels and the patient’s clinical response. Frequent monitoring of renal function, thyroid levels, and electrolytes is also recommended during treatment.

Neuroleptics (antipsychotics)

Neuroleptics are also first-line treatments and act faster than lithium. Their efficacy in young people is well-established and good in the short term. A key difference compared to adults is the greater sensitivity of young individuals to appetite and weight gain, increasing the risk of metabolic disorders, including the onset of diabetes mellitus.

Olanzapine poses a particularly high risk and should therefore never be a first-line treatment, but it may be used as acute medication for mania, as briefly as possible. All neuroleptics require baseline metabolic testing, including fasting blood lipids, glucose, liver function, height, weight, and waist circumference. Young people are also more prone to acute dystonias.

Drug choices:

• Risperidone: Target dose of 2–3 mg/day (approximately 0.03–0.05 mg/lb/day for a 100 lb individual).
• Aripiprazole: Target dose of 10–15 mg/day (approximately 0.1–0.15 mg/lb/day for a 100 lb individual).
• Quetiapine: Target dose of 400–600 mg/day (approximately 4–6 mg/lb/day for a 100 lb individual).
• Ziprasidone: Target dose of 80 mg/day (approximately 0.8 mg/lb/day for a 100 lb individual).

Antiepileptics

Examples include valproate and carbamazepine. Evidence supports the efficacy of valproate, but the data is more limited, and like lithium, its effect is not as rapid as neuroleptics. Valproate should be avoided in girls due to risks of endocrine side effects, including amenorrhea. However, it can be a good option for boys instead of lithium, for example, in cases of severe acne or lack of lithium efficacy. Carbamazepine has fewer data for use in young people and more side effects, such as sedation, and interacts with many other drugs, limiting its use.

• Sodium Valproate (Depakote): Target dose is 15–20 mg/kg/day, which translates to approximately 6.8–9.1 mg/lb/day in a two-dose regimen.
• Trough serum levels: The reference range is 450–700 μmol/L (which equals 64.8–100.8 μg/mL in U.S. units).

Bipolar depression treatment

The evidence for medication is weaker compared to mania. Several studies have shown significant improvement with placebo. Additionally, family therapy is well-supported, and together this makes medication a smaller part of treatment or something to consider after psychotherapeutic interventions. Based on evidence from RCT studies, lurasidone is currently the first-line option.

Neuroleptics

• Lurasidone (Latuda): Target dose is 37 mg once daily, equivalent to approximately 1.3 oz/day. It has shown moderate efficacy and a mild side effect profile in young people in a large randomized controlled trial (RCT). It lacks efficacy for mania.
• Quetiapine (Seroquel): Target dose is 300 mg/day, approximately 0.01 oz/day. While it has strong support among adults for depression, mania, and sleep, it has shown poor results in child and adolescent studies due to high placebo response rates. It carries a moderate risk of weight gain and metabolic disturbances.
• Olanzapine + Fluoxetine (Symbyax): This combination has shown moderate efficacy in a youth RCT. However, it is associated with significant side effects, including weight gain and metabolic disturbances.

Other options

• Lamotrigine has shown efficacy in preventing relapse in bipolar depression among teenagers. It must be introduced slowly due to the risk of skin side effects. The effect develops slowly and is often mild. It has a favorable side effect profile aside from the risk of allergic skin reactions.
• Lithium is considered effective for depression based on adult data. The dosage can be kept lower, with serum levels around 0.6 mmol/l. It can be combined with lamotrigine, valproate, or neuroleptics.
• Antidepressants (fluoxetine, escitalopram, sertraline, or bupropion) may be used cautiously and preferably for short durations in bipolar disorder, only after the risk of mania has been controlled by neuroleptics, lithium, or valproate.

ECT

ECT is an option for severe depression, particularly with psychomotor retardation or psychosis.

Comorbidities

• ADHD should be treated with psychoeducation and pharmacological intervention after remission of mania and depression, following the same guidelines as ADHD in young people.
• Anxiety disorders should primarily be treated with cognitive behavioral therapy, but SSRIs at cautious doses may be considered as a secondary option.

Psychological treatment

Family therapy is well-supported, particularly for bipolar depression, in both individual and group formats. Families with high emotional expression (Expressed Emotion, EE) benefit significantly from this approach. The treatment reduces EE while also supporting the optimal use of medication and other care interventions. It includes:

• Psychoeducational elements (see above).
• Skill training at the family level, including:
  • Clear communication.
  • Problem-solving.
  • Methods for emotional regulation.
• Work to prevent relapse and recurrence of illness.

Schooling of patients with pediatric bipolar disorder needs to be adjusted to be therapeutic without being overwhelming, as excessive stress can increase the risk of relapse. Healthcare providers should assist by providing psychoeducational information to schools and school health services to facilitate a gradual return to schooling with adequate support measures. Once an acute episode subsides, schooling should resume promptly to establish vital and stabilizing social connections and daily routines. However, it should begin part-time and, initially, without demands for tests or assignments.

Follow-up should be active and incremental, monitoring symptom reduction and functional improvement. Treatment should always prioritize manic symptoms first, followed by depression, potential psychotic symptoms, and then ADHD if present. Anxiety disorders are addressed later in the treatment process.

The goal should, in most cases, be full recovery, including both symptom resolution and restored functional levels. Manic symptoms are best monitored with detailed history-taking, ensuring nightly sleep of at least eight hours.

The Young Mania Rating Scale (YMRS) can support this assessment.

Depression can be tracked through self-report scales, such as the Montgomery-Åsberg Depression Rating Scale (MADRS-S) or the Quick Inventory of Depression Symptoms – Adolescent Version (QIDS-A17-SR).

Pharmacological treatment requires careful monitoring to balance side effects and achieve the desired effect within an expected timeframe. Neuroleptics should be supervised with the same rigor as lithium. Weight, BMI, and waist circumference should be monitored within one month, and metabolic labs every three months during the first year, then annually.

Functional levels—including schooling, peer relationships, leisure activities, daily living skills (ADL), and home life—should be evaluated alongside symptoms and side effects. A functional scale like the Children – Global Assessment of Functioning (C-GAS) helps track progress and maintain attention on these critical aspects of recovery.

Neurocognitive testing may be indicated if persistent difficulties with schooling and daily life management occur despite stabilization of bipolar episodes.

Bipolar disorder has an episodic course, with a high risk of new episodes, especially if treatment is inadequate or cooperation falters. Over time, stable periods and depressions are more prevalent, while manic episodes tend to be shorter. Cognitive levels and functioning are typically normal or often strong before the onset of the disorder.

There is a risk of neurocognitive decline, especially in executive functions, if the illness progresses, particularly in cases of:

• Prolonged episodes.
• Repeated manic episodes.
• Long-term subsyndromal depression.
• Psychotic symptoms.

Physical health is also negatively impacted over time in bipolar disorder, with an increased risk of cardiovascular diseases, which, along with suicide, are the leading causes of premature death.

With early identification, rational use of psychoeducation and medication, and consistent family support, the ambition level should be high. Full remission should be the goal, with rare and mild relapses. The focus should be on long-term efforts to fully restore school and social functioning.