Bipolar depression in children and how the treatment differs

"Bipolar depression," referring to the depressive episodes of bipolar disorder, can be seen in children and typically follows periods of elevated mood, called mania or hypomania. Bipolar disorder can be characterized by extreme shifts in mood and behavior, which can impact a person's energy levels, relationships, and daily functioning. Though typically diagnosed in adolescents and young adults, bipolar disorder can be diagnosed in younger children as well. 

Because bipolar disorder is not common in children, it may be challenging to spot the signs of bipolar disorder early on. However, when starting in childhood, treatment for bipolar disorder may be effective. For this reason, learning to identify symptoms and considering professional evaluation can be crucial.

What is bipolar disorder?

Bipolar disorder, also called bipolar affective disorder, is a mental illness characterized by extreme highs and lows. Some people may know about depressive disorders like major depressive disorder. However, they may not know that bipolar disorder can cause significant depressive episodes in people of any age. However, childhood bipolar disorder is extremely rare, with studies reporting rates close to zero in children under adolescent age. 

In addition to depressive episodes, a person with bipolar disorder may experience highs known as mania or hypomania, distinguishing it from depressive disorders. The highs and lows accompanying bipolar disorder can be challenging for an undiagnosed and untreated child, as they can contribute to risky, dangerous, or unhealthy behavior. In a child with bipolar disorder, symptoms can lead to significantly impacted mental health, problems at school, and impairment in everyday functioning. Additionally, bipolar disorder can cause challenges related to substance use later in life. According to the National Institute on Drug Abuse, bipolar disorder co-occurs “at high prevalence” with substance use disorder. 

There are three main subtypes of bipolar disorder: bipolar I disorder, bipolar II disorder, and cyclothymic disorder. Bipolar I disorder is categorized by at least one episode of mania lasting a week or more, with or without depression. Bipolar II disorder is categorized by episodes of hypomania and depression. Hypomania is a less severe form of mania that may not accompany paranoia or delusions as mania does. Cyclothymic disorder may be diagnosed when an individual doesn't meet the criteria for the other diagnoses and has cycling moods that are rapid or long-term and cause mild to moderate functioning difficulties. 

While the exact cause of bipolar disorder is still unknown, a family history of mood disorders and abnormalities in brain structure and function are thought to be primary contributors. Environmental influences may further contribute to the development of the disorder. According to the National Institute of Mental Health, “people with a genetic risk of having bipolar disorder may be more likely to develop the disorder after experiencing trauma or other stressful life events”.

Depressive symptoms of bipolar disorder in children

Although bipolar disorder in children is rare, it can be critical for parents to pay attention if they notice symptoms. Children may not understand what's happening to them, which can cause them to have more extreme reactions to highs and lows or to feel frightened or confused. When depressive symptoms occur, a child’s moods will typically be marked by sadness, restlessness, and a loss of interest in activities once enjoyed. They may exhibit signs of fatigue, irritable mood, trouble focusing, or social withdrawal.

Depressive symptoms are more common in bipolar II disorder than bipolar I disorder. To be diagnosed with bipolar II disorder, a child must have experienced an episode of major depression along with an episode of hypomania. With bipolar I disorder, individuals must have experienced an episode of mania but may or may not have developed depressive symptoms. 

Parents, guardians, and caretakers can help a child receive support by watching for unusual changes in behavior. Symptoms of bipolar disorder can manifest differently in children than in adults, so it may be helpful to familiarize yourself with some of its key signs. In addition, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) notes several key distinctions in child bipolar disorder, including the following.

Mania in children

For a manic episode to be diagnosed in children, the DSM-5 states that mood changes must be “accompanied by abnormally and persistently goal-directed behavior or energy.” Symptoms of manic episodes must be different from normal behavior and present every day for most of the day for a week or more. A child experiencing mania may do risky or reckless things, have frequent outbursts, or otherwise exhibit extreme behaviors. 

Symptoms of a manic episode in children can involve the following: 

• Unusually high-energy in a way that is out of character or doesn't fit the circumstances 

• Frequent episodes of irritability

• Talking more quickly than usual or jumping between topics quickly

• Partaking in risky activities without thought or concern

• Difficulty staying focused 

• Difficulty sleeping due to increased energy 

• Delusions of grandeur

Depression in children

Symptoms of a depressive episode in children may include the following: 

• Extreme sadness or a prolonged low mood

• Changes in eating unrelated to growth 

• Feelings of guilt or shame

• Thoughts of worthlessness or hopelessness 

• Little energy and little to no interest in previously enjoyed activities

• Sleeping excessively or not sleeping at all

• Aches and pains that don't go away with treatment or have no medical cause

DSM-5-TR categorization

In the DSM-5-TR, changes were made to the bipolar disorder category due to overdiagnosis of childhood bipolar disorder, which is rare. A new subtype was added called disruptive mood dysregulation disorder (DMDD), a condition causing symptoms that may have previously been misdiagnosed as bipolar disorder. The symptoms of DMDD include the following:

• Temper outbursts and severe irritability three or more times per week

• Chronic anger for most of the day

• Difficulty functioning in multiple areas of life

• Symptoms that occur steadily for more than 12 months

Unlike bipolar disorder, this condition does not involve mania or hypomania but may co-occur with anxiety, depression, and other mental illnesses common in childhood, which could make it appear similar to bipolar disorder.

Because mood shifts in children and adolescents may make parents wary of bipolar disorder, it may be best to speak to a licensed mental health professional for an official analysis based on the DSM-5 criteria, as this condition is rare. The onset of bipolar disorder often occurs in young adulthood but may sometimes be present in children.

How is bipolar disorder diagnosed in children? 

Regardless of their age, your child may be going through many transitions in life as they age. They might start acting differently as they age, make new friends, learn their interests, and explore their identity. The behavioral changes and mood swings that most children experience can make diagnosing bipolar disorder difficult. However, the symptoms of manic and depressive episodes are different. Bipolar disorder symptoms may be more extreme than the behaviors that are present when a child acts out to test boundaries or try a new personality. For these reasons, determining whether a child is living with bipolar disorder requires careful and thorough evaluation from a qualified mental health professional or similar provider. 

Early diagnosis can help increase the chances of a child experiencing positive treatment outcomes. However, the younger a child is, the more difficult it may be to diagnose bipolar disorder accurately. In some cases, bipolar disorder may be misdiagnosed as another mental illness, developmental disorder, or behavior disorder—such as generalized anxiety disorder, attention-deficit hyperactivity disorder (ADHD), or conduct disorder—as these conditions are more common. 

There is no way to diagnose bipolar disorder through blood tests or a scan. Currently, to have bipolar disorder diagnosed in a child, a medical or mental health professional must observe the child and talk to them about their symptoms and experiences. If your child shows signs of extreme changes in mood, poor judgment, or other symptoms described above, consider having them evaluated by a professional. 

When you attend your child's psychological appointment, their psychologist may ask you both questions about their mood, feelings, and behavior. If the professional thinks the child's symptoms are undeniably due to bipolar disorder, they may make a diagnosis. In some cases, children are monitored by a professional for a few years before a sure diagnosis is made. 

Treating a child’s symptoms of bipolar disorder

A treatment plan for bipolar disorder at any age will typically involve a combination of medication and therapy. Children may benefit from different types of therapy or additional treatment options, so work with your healthcare provider to determine your next steps.  

Medication

Medications may balance out the emotions your child is experiencing and help them mitigate the emotional extremes bipolar disorder can cause. Not all children take medication for bipolar disorder, and some children experience enough side effects to negate the helpfulness of these resources. However, the potential benefits of medication mean that some psychiatrists and doctors may recommend it. 

Therapy

Children with bipolar disorder can attend therapy to learn problem-solving skills and explore their symptoms to manage them as they age. Even if a child is too young to benefit from therapy, it can be helpful for caregivers, parents, and guardians to pursue professional guidance to gain more insight into how to support their child best. A commonly utilized therapeutic modality for children with bipolar disorder is family-focused therapy—a form of family therapy centered around problem-solving, education, and communication.

If your child attends therapy, encourage them to be honest with their therapist. Remind them that what they say in therapy is between them and the therapist. A small child may not understand what they are experiencing or how to articulate it, but it can help to encourage them to talk about it anyway, reminding them their therapist is not there to judge them. 

The prognosis for children with bipolar disorder 

Bipolar disorder is a lifelong mental illness. Even with treatment and long periods of complacency, the disorder's symptoms can return. For this reason, it may be beneficial to enroll your child in treatment as early as possible. Allowing them the connections to receive medical advice, continuous care, and long-term support can be beneficial even if they don’t have bipolar disorder.

Remind your child to watch for symptoms throughout their life, as well. The symptoms of a person's bipolar disorder may change as they age, so it's possible that what may have been the norm in the past may shift into a new symptom. A child with bipolar disorder may also be more likely to develop other mental health conditions in conjunction, so being aware of changes in behavior, mood, and energy levels can help them catch changes in their mental health as teens and adults.

Support options for parents 

Navigating a mental health diagnosis in your family may be challenging. You may not have expected your child to live with bipolar disorder, or you may also have the condition and want to know how to receive support. In these cases, talking to a therapist may be beneficial. 

Online therapy through a platform like BetterHelp can be a significant resource for parents. Through an online platform, you can outline your goals when signing up to find someone who understands your mental health concerns. In addition, you don't have to leave home for sessions, which may save you money on gas, childcare, and parking. 

Studies show that online therapy can be effective in treating mental health conditions. In a recent review analyzing online cognitive-behavioral therapy (CBT), researchers found treatment could lead to significant improvements in mental health symptoms related to anxiety, depression, PTSD, and other conditions with results similar to in-person options.