Child Adolescent Bipolar Disorder, Glaser MD
Bipolar disorder's diagnostic criteria is
entirely based on the study of adults older
than 18 years. The long term outcomes of
the illness treated or untreated is also based
on the study of adults. There are limited
studies utilizing bipolar medications in
children (including teenagers) that do give us
information as towards their safety, side
effects, and efficacy. BUT, making the
diagnosis of Bipolar disorder and trying to
predict the long term outcome of the child's
condition is more of art than science. This is
particularly important when weighing the
pros and cons of medication for your child.
Bipolar disorder typically begins in late teens
to early twenties. (Schizophrenia, an illness
with similar symptoms as bipolar also begins
at this time.) In addition, there are usually
prodromal symptoms. Prodromal means
characteristics of the illness that occur
before the full fledged illness presents itself.
These are subtle and do not meet the criteria
for a positive diagnosis yet. But they are
early signs of the condition.
The symptoms of Bipolar disorder are fully
explained on another page. The diagnostic
criteria, are based on adults. Child
psychiatrists therefore do their best to
extrapolate the data from adult studies to
children. I have reviewed the data on bipolar
disorder in children (and teenagers) and
spoken personally to the leaders in research
and treatment of pediatric bipolar disorder. I
have also evaluated thousands of children for
this diagnosis as well as prescribed
medication for over 15 years. I have thus had
the opportunity to see the long term effects.
I will start by describing how I make the
diagnosis of bipolar disorder and what
differentiates it from other conditions. Then
I will discuss the prognosis of the condition.
Followed by a discussion of the various
medications for bipolar disorder.
HOW DO YOU MAKE THE DIAGNOSIS?
Bipolar disorder has periods of mania (high
energy) and depression (low energy) or
mixed phases (high energy plus depression).
Mania is characterized by extreme sillyness,
hyperactivity, rapid speech, intense mood
swings, anger, euphoria, grandiosity (feeling
like superman), extreme intense desires,
constantly looking for excitement,
disorganization, forgetfullness. This sounds
a lot like normal childhood or even ADHD
(attention deficit hyperactivity disorder).
So this is how I differentiate Bipolar disorder
from normal childhood or other conditions.
First, bipolar disorder sometimes is periodic.
It can come and go in phases. However, in
children this does not usually seem to be the
case. Bipolar disorder causes severe
problems at home and in school. Next, some
symptoms are specific for bipolar disorder.
Hallucinations, usually auditory, are very
specific for this condition or a related
condition called Psychotic disorder N.O.S.
(Psychotic disorder N.O.S. means psychotic
symptoms due to any number of things).
Both bipolar and psychotic disorder are
treated with the same medications pretty
much. Determining if a young child is
hearing voices versus normal childhood
imagination is very tricky and not for the
novice examiner. A child who is delayed is
even more difficult.
Next, is a decreased need for sleep, such as
a child who can stay awake for several days
in a row. Some people have trouble falling
or staying asleep at night but they feel tired
the next day, or they nap in the daytime, or
they want to sleep late in the morning. That
is not decreased need for sleep. Decreased
need means they do not sleep and they do
not feel tired the following day nor make up
for the lost sleep the next night. Time spent
at a slumber party or while under the
influence of drugs does not count. This
occurring for several days in a row or on
more than one occasion is a tell tale sign of
bipolar. Other symptoms of bipolar disorder
such as feeling grandiose can too easily be
normal childhood development.
ADHD (ADHD used to be called ADD)is all too
common now a days in our youth. ADHD
means the patient has trouble with paying
attention to boring tasks such as school work
or household chores. And/or the child is
hyperactive-can't sit still, has an engine that
won't shut off. This does not apply to
playing video games or watching television.
These symptoms of extra energy, easy
distractibility, and disorganization, are very
similar to the manic phase of bipolar
disorder. It is very important to make the
correct diagnosis because the medication
treatments are entirely different. If the wrong
medication is taken, a negative outcome
could result. Therefore, every child being
evaluated for ADHD (ADD) must also be
evaluated for bipolar. Furthermore, some
scientific evidence indicates that the
prodromal symptoms of bipolar disorder and
schizophrenia look like ADHD symptoms.
ADHD, bipolar, and schizophrenia are highly
genetic. Identical twin studies and studies of
families with these disorders indicate genes
account for up to 75% of the condition.
Therefore, a positive family history of one of
these conditions is a good source of
information when making a diagnosis in a
Another sign of bipolar disorder is failed
treatment for either depression or ADHD. If a
child receives a medication for either
depression or ADHD and gets more rageful,
or more hyper, or stays awake for days, then
that is a sign of bipolar.
WHAT IS THE LONG TERM OUTCOME FOR
PEDIATRIC BIPOLAR DISORDER?
Bipolar disorder is a chronic condition that
requires lifelong medication. However, most
diagnosis of bipolar disorder in children are
based on softer evidence than in adults.
Therefore I am not as confident at predicting
the long term nature of the condition. In
adults, UNTREATED patients with bipolar
disorder will eventually, over many years,
loose their minds and become completely
insane. TREATED patients who always take
their medications, do not use any drugs or
alcohol, live healthy lifestyles, and stay in
counseling, do very very well. They live
Symptoms can change over time. Also, as the
child gets older and more mature, their own
description of their thoughts, feelings, and
experiences change. Thus, statements by
children and teenagers such as hearing
voices must be taken with a grain of salt.
However, if your child is in fact hearing
voices, or is having manic episodes, he or
she must receive medication treatment or
severe, permanent brain damage will occur.
MY CHILD HAS SEVERE TEMPER TANTRUMS, IS
THAT BIPOLAR DISORDER?
Anger and rage is a symptom of bipolar
disorder but by itself, it is not enough to
make the diagnosis of bipolar. Other
conditions can have anger problems also.
ADHD (ADD) causes a child to be impatient
so they can get very angry if they don't get
what they want. The common diagnosis for
people with rage problems but no other
symptoms is Intermittent Explosive Disorder.
However, if there is a strong family history of
Bipolar disorder then the rage problems may
be the early signs of a potentially much more
serious condition. Early intervention can
lesson its severity significantly.
SHOULD I MEDICATE MY CHILD?
Untreated bipolar disorder, over many years,
causes brain atrophy. This means that
nerves die and the brain shrinks. The longer
a person has symptoms of bipolar present,
the more outbreaks that occur, the more
brain damage results. The brain can heal
minor injuries but not severe injuries.
Therefore, the longer you wait to treat, the
more damage occurs. Think of it like the
head of a man in the boxing ring. Each time
the child hears voices, or has excessive
manic energy, imagine the man in the
boxing ring getting punched in the head.
The boxer can take a few blows to the head,
but too many blows, the brain gets knocked
The great news is that modern medications
for bipolar likely prevent further damage, and
help the brain heal from past damage. A
recent study examined patients treated with
second generation antipsychotics (abilify,
seroquel, risperdal, zyprexa, geodon). It
found that in schizophrenia patients treated
with medication as soon as the illness
presented itself had good outcomes and had
minimal brain damage. Patients who got
medication later had worse outcomes and
had clear evidence of brain atrophy (damage).
It appears that the medication may even
minimize or prevent the full blown illness
from even occurring. In my own practice, I
have seen a clear difference in outcomes
between patients treated within a few months
of symptom onset versus those treated after
a few years. Schizophrenia and bipolar share
many similarities on the microscopic lever.
The medications that treat schizophrenia are
also FDA approved to treat bipolar. The long
term outcomes of untreated bipolar are the
same as schizophrenia. It is likely the same
benefit with medications will occur with
bipolar disorder. Studies have shown similar
nerve cell destruction in untreated
depression versus treated depression.
This is important particularly if your child is
being treated for ADHD but he/she may
actually have Bipolar disorder. Since the
prodromal signs of Bipolar are likely the
same as ADHD, this error commonly occurs
even with the most experienced
psychiatrists. However, the medications for
ADHD do not help prevent the damage to the
brain that bipolar causes and may in fact
worsen the condition over time.
You may refer to the page labeled Bipolar
Disorder Treatment to review the medication
treatments. Mitchell L. Glaser, MD. Chicago