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The Informed Parent

Bipolar Disorder: Assessment and Treatment in Adolescence; Second in Series

by Sandra Smith, Ph.D.
Published on Jan. 01, 2000


In a previous article, it was acknowledged that bipolar disorder can and, often, does have its onset in early childhood. It was noted that problems in diagnosis included the fact that initially the clinical presentation is often similar to ADHD and/or Conduct Disorder. The absence of long-term studies including prevalence rates in children, and the fact that early bipolar symptoms are often minimized, even by well informed parents, as variants of normal developmental stages also add to the problems.

Nonetheless, certain indicators for children who are "at risk" for bipolar disorder were described. These included children who demonstrated intense emotions and disinhibited behavior, moodiness or irritability, disruptive behaviors at home and school, sleep disorders, diminished concentration and attention span, and hyperactive or impulsive actions. It was noted that these children often demonstrate poor frustration tolerance, and that they are prone to angry outbursts. Behavior toward adult authority figures may be rude, disobedient and intimidating.

Early identification and intervention was described as critical in minimizing the possibility of the later development of personality disorders, unnecessary behaviors including suicide attempts, and residential placements in hospitals, juvenile detention facilities and treatment centers.

As described, there is no definitive tool for the diagnosis of bipolar disorder in children. Parents who suspect that their child may be at risk for this disorder were advised to take daily notes about their child’s moods and behaviors considered to be odd, unusual or alarming. They were to record any statements made by the child, which they considered to be worrisome.

For those children who did appear to demonstrate the signs and symptoms of bipolar disorder, a board-certified psychiatrist was described as the physician of choice to diagnose and initiate treatment. If such a specialist was unavailable, it was recommended that you consult with nearby teaching hospitals. Also an adult psychiatrist who is well-schooled in mood disorders and has provided some treatment to children and/or adolescents can provide enlightenment.

Finally, it was noted that although there is no cure for bipolar disorder, effective treatment often does allow for stabilization in the child’s mood, and, thus, a more optimal level of functioning. A good treatment plan was described as including medication, ongoing close monitoring of symptoms, education for the affected child and his/her family, psychotherapy as necessary for the child and family, and participation in appropriate support networks.

The diagnosis of this disorder in adolescence can be particularly traumatic for the affected individual, as well as his/her family. This article will address the particular difficulties, which characterize the diagnosis and treatment of bipolar disorder in the teen population.

What Are the Symptoms Of Bipolar Disorder In Adolescence?

In the adolescent population bipolar disorder often resembles the adult onset more closely than is the case for younger children. In this population it may resemble any of the following classical, adult presentations of the illness:

I. Bipolar Disorder

In this bipolar disorder the adolescent experiences alternating episodes of intense, sometimes psychotic mania, and depression.

Symptoms of mania include:

  1. elevated, expansive or irritable mood
  2. decreased need for sleep
  3. racing speech and a sense of pressure to keep talking
  4. grandiose delusions (e.g., "I am the greatest rock star that ever lived")
  5. excessive involvement in pleasurable but risky activities (e.g., riding motorcycle at increasingly high speeds)
  6. increased physical and mental activity
  7. poor judgement
  8. hallucinations (severe cases)

Symptoms of depression include:

  1. crying spells and a sense of pervasive sadness
  2. sleep disorders—sleeping too much or inability to sleep
  3. irritability and agitation
  4. withdrawal from activities which were previously enjoyed
  5. inability to concentrate, often with drop in grades
  6. thoughts of death and suicide
  7. low level of energy
  8. significant appetite changes

Period of complete or relative wellness occur between the Manic and Depressive episodes.

II. Bipolar II Disorder

The symptoms of mania and depression are the same in Bipolar II Disorder. However, there are RECURRENT BOUTS or periods of depression in Bipolar II Disorder, with EPISODES OF HYPOMANIA (defined as a markedly elevated or irritable mood with increased physical and/or mental energy) in between. Often, hypomanic episodes are experienced by the adolescent as a time of great creativity.

III. Cyclothymia

Adolescents in this category experience periods of less severe, but definite mood swings.

IV. Bipolar Disorder NOS (not otherwise specified)

Physicians make this diagnosis when it is not clear which type of bipolar disorder is emerging.

Why Did My Adolescent Get This Disorder?

To the dismay of many informed parents there is no definitive answer to this question.

For some adolescents, the onset of bipolar disorder seems to be tied to a loss, or other traumatic event, which triggers the first episode of depression or mania. Later episodes often appear to occur independently of identifiable stressors, or they may worsen with stress.

We do know that puberty is a time of risk, and the onset of menses in girls may trigger the onset of the bipolar disorder. In those instances, symptoms often vary in intensity and severity with some predictability, based on the girl’s monthly cycle.

What Happens After the Disorder Starts?

Without treatment, episodes will tend to recur and worsen. Several studies suggest that there is often a ten year lag between the time symptoms first occur and the initiation of treatment! This is truly an unfortunate waste for the affected teen.

Informed parents are urged to take their teen for an evaluation if four or more symptoms described above last for more than two weeks. Early intervention and treatment are essential during this critical time of development.

What About Substance Abuse?

The Child and Adolescent Bipolar Foundation states clearly that a majority of teens with UNTREATED bipolar disorder abuse alcohol and drugs. This tendency must reasonably be viewed as the teen’s attempt to control both mood swings and insomnia. Teens who appeared normal until puberty and who experience a comparatively sudden onset of symptoms are thought to be particularly vulnerable to developing addiction to drugs or alcohol.

If substance abuse/addiction does develop, it is of course essential to treat both the bipolar disorder and the substance abuse at the same time.

Is Medication Essential?


Most physicians begin use of medication immediately upon diagnosis, provided that both parents agree. If one parent disagrees, a short period of watchful waiting and charting of symptoms may be helpful. The initiation of medication generally cannot be postponed for long in this population because of the risks of substance abuse and suicide. As described in the previous article relative to bipolar disorder in children, other treatments (including psychotherapy) are often ineffective until mood stabilization occurs.

Physicians often must try several medications alone and in combination before they find the best treatment for your particular teen. This is frustrating for informed parents who are eager for their child to return to a more normal level of functioning. However, it is important to maintain an optimistic attitude during this interim. Two or more mood stabilizers, plus additional medications for symptoms that persist, are often necessary before stability is achieved and maintained. A separate guide for medication that is often used by teens with bipolar disorders will be included in a future article in this series.


A previous article explored the onset of bipolar disorder in children. This article sought to address the particular difficulties, which characterize the diagnosis and treatment of bipolar disorder in the teen population.

The onset of bipolar disorder in adolescence more closely resembles that of adults than is the case with children. In the teen population, the onset of the disorder often resembles that of the adult, "classical" presentations of the disorder. In Bipolar I Disorder, the teen demonstrates alternating episodes of intense, even psychotic mania, and depression. The Bipolar II teen demonstrates more depression, with episodes of hypomania in between the depressive episode. The teen with Cyclothymia demonstrates definite, but less severe, mood swings.

The onset of bipolar disorder in some teens seems to be related to a loss or another traumatic event. Subsequent episodes (of either mania or depression) appear to lack a clear trigger. Puberty is a time of risk. The onset of menses in some girls appears to trigger the onset of bipolar disorder. Without treatment episodes tend to recur and worsen. Informed parents must take their teen for an evaluation if four or more of the symptoms described in this article last for more than two weeks. It is probable that many teens with untreated mood disorders, particularly including bipolar disorder, abuse substances in their attempt to control moods and aid sleep. Any evaluation for substance abuse must necessarily include evaluation for a mood disorder. If substance abuse or addiction has developed, this must be treated concurrently with the bipolar disorder. Medication is essential, once diagnostic certainty is reached, to allow for stabilization of mood and return to a more optimal level of functioning.

In my practice, this is often a very difficult phase for parents. They find it hard to accept that their child not only has a chronic condition, but one that may require treatment with not one but several medications. However, the risks of not treating are so great—drug and alcohol addiction, damaged relationships, school failure and inability to find and maintain employment—that patience and determination are essential during this initial phase of diagnosis and treatment.

As stated, a future article will include a summary of medications often used to treat Bipolar Disorder in children and adolescents. In addition, the issues of parenting and educational needs for this special population will be explored.

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