Bipolar Disorder in Children and Teens: What Parents Need to Know

Mood changes are part of growing up. A teenager can be cheerful in the morning, irritated after school, and upset by evening. Stress, lack of sleep, friendships, school pressure, family conflict, and hormonal changes can all affect emotions.

Bipolar disorder is different.

The important difference is not simply that a young person’s mood changes. It is the pattern, intensity, duration, and combination of symptoms. Bipolar disorder involves noticeable episodes in which mood, energy, sleep, thinking, and behavior become significantly different from the child or teenager’s usual state.

Recognizing that pattern can take time, which is one reason bipolar disorder in young people can be difficult to diagnose.

When Mood Changes Are More Than Ordinary Ups and Downs

Parents sometimes become concerned when a teenager seems happy one moment and deeply upset several hours later. Those changes deserve attention, particularly if they are severe, but rapid shifts within a single day do not by themselves establish bipolar disorder.

Clinicians look for a broader pattern.

During a manic or hypomanic episode, a young person may become unusually energetic, excited, confident, talkative, irritable, or driven. During a depressive episode, that same person may become withdrawn, exhausted, hopeless, or unable to enjoy things that normally matter.

The changes are not limited to emotion. Sleep, activity, judgment, concentration, appetite, relationships, and school functioning may change as well.

Duration also matters. Under standard U.S. diagnostic criteria, a manic episode generally lasts at least seven days, or can be shorter when symptoms are severe enough to require hospitalization. Hypomania lasts at least four consecutive days. A major depressive episode lasts at least two weeks.

A previous depressive episode is not required for a diagnosis of bipolar I disorder if a true manic episode has occurred. Bipolar II disorder, however, involves both a history of major depressive episodes and hypomanic episodes, without a history of full mania.

This is why simply waiting for a doctor to personally observe several episodes is not necessary. A careful clinical history can include episodes reported by the young person, parents, caregivers, and sometimes other people who know the child well.

What Depression Can Look Like in a Teenager

Depression in young people does not always look like quiet sadness.

A teenager may become unusually irritable, lose interest in friends or activities, stop caring about school, spend much more time alone, or seem emotionally disconnected from things that used to matter.

Other possible signs include:

• persistent sadness or irritability;
• loss of interest or pleasure;
• low energy and fatigue;
• sleeping much more or much less than usual;
• changes in appetite or weight;
• difficulty concentrating;
• withdrawing from friends or family;
• feelings of worthlessness or excessive guilt;
• hopelessness about the future;
• thoughts about death, suicide, or self-harm.

One behavior should never be treated as a diagnostic test. For example, losing interest in a phone, games, friends, or social activities may happen during depression, but none of these behaviors alone proves that a depressive episode is occurring.

What matters is the overall change from the teenager’s normal level of functioning.

Self-harm or suicidal thinking requires especially serious attention. A young person expressing a desire to die, talking about suicide, or intentionally injuring themselves should receive prompt professional evaluation. If there is an immediate danger, emergency care should be sought.

What Mania or Hypomania May Look Like

The other side of bipolar disorder can sometimes be harder for families to recognize.

A teenager who suddenly seems energetic, confident, sociable, and full of plans may initially appear to be doing very well. The concern begins when the change becomes unusually intense and clearly different from that person’s normal personality.

Possible signs include:

• unusually elevated or intensely irritable mood;
• dramatically increased energy or activity;
• needing very little sleep without feeling tired;
• talking much more or much faster than usual;
• racing thoughts or rapidly changing ideas;
• unusually high confidence or an exaggerated sense of ability;
• beginning many projects or making unrealistic plans;
• becoming unusually impulsive;
• spending money recklessly;
• taking risks that the person normally would avoid;
• increased involvement in potentially harmful or dangerous activities;
• difficulty recognizing the consequences of decisions.

A young person may believe they can accomplish far more than is realistically possible. Plans can become increasingly ambitious while judgment becomes weaker.

Hypomania involves similar symptoms, but they are less severe and do not cause the degree of major impairment associated with mania. Because someone experiencing hypomania may actually feel productive or unusually capable, the young person may not see anything wrong. Family members may notice the change first.

Why Diagnosis Can Take Time

Diagnosing bipolar disorder in children and adolescents can be complicated because many symptoms overlap with other conditions.

ADHD, major depressive disorder, anxiety disorders, disruptive mood dysregulation disorder (DMDD), substance use, behavioral disorders, sleep problems, and some medical conditions can produce symptoms that resemble parts of bipolar disorder.

For example, distractibility and high activity can occur in ADHD. Irritability can appear in depression, anxiety, trauma-related conditions, and several other disorders. Chronic irritability alone is not enough to diagnose bipolar disorder.

A clinician therefore looks beyond individual symptoms and asks a more important question:

Do these symptoms occur together as a recognizable episode that represents a significant change from the young person’s usual functioning?

Evaluation commonly includes the history of mood changes, sleep, energy, behavior, school performance, relationships, family psychiatric history, medication or substance use, and physical health.

There is no blood test or brain scan that can independently diagnose bipolar disorder.

Why Parents’ Observations Matter

Parents often remember changes that a teenager does not consider important.

They may recall a period when their child barely slept yet remained extremely energetic, suddenly became unusually social, made unrealistic plans, spent money impulsively, became reckless, or acted noticeably different for several days.

Those observations can be valuable during an evaluation.

It can help to keep a simple mood record that includes:

• mood;
• hours of sleep;
• energy level;
• significant behavior changes;
• school functioning;
• appetite;
• stressful events;
• medications;
• periods of unusually high or unusually low activity.

A mood chart is not meant to diagnose the condition at home. Its purpose is to make patterns easier to recognize and discuss with a qualified health care professional.

What Happens Between Episodes?

Some people with bipolar disorder return close to their usual level of functioning between episodes. They may again sleep normally, study, socialize, enjoy activities, and feel emotionally stable.

However, a completely symptom-free period between every episode is not required. Some young people continue to experience milder symptoms between more severe episodes.

This is another reason diagnosis depends on the complete clinical picture rather than one rigid pattern.

Treatment Is About More Than Stopping One Episode

Bipolar disorder is generally treated as a long-term condition, but long-term does not mean hopeless.

Treatment for children and adolescents may include medication, psychotherapy, family education, and practical strategies for maintaining stable daily routines. The exact plan depends on the young person’s symptoms, age, medical history, and type of bipolar disorder.

Medication decisions should be made and monitored carefully by an appropriately trained health care professional. When bipolar disorder is suspected, treatment of depressive symptoms also requires careful evaluation because the medication strategy may differ from treatment for depression without bipolar disorder.

Psychotherapy can help a young person recognize mood changes, manage stress, improve relationships, cope with the emotional consequences of the illness, and develop healthier routines.

Sleep deserves particular attention. Large disruptions in sleep can accompany mood episodes, so maintaining a reasonably consistent sleep-wake schedule can become an important part of managing the condition.

Learning to Recognize the Pattern

One of the most useful skills a young person and family can develop is learning to recognize early changes.

Over time, someone may begin to notice that sleeping less, becoming unusually energetic, withdrawing from people, losing interest in everything, or developing increasingly negative thoughts often comes before a more serious episode.

That awareness can make it easier to seek professional help earlier rather than waiting until symptoms become overwhelming.

A depressive episode can make the future feel permanently dark. Mania can make limits seem unnecessary. Neither state gives a completely reliable picture of what life will look like later.

With appropriate treatment and continued monitoring, many children and teenagers with bipolar disorder can improve their functioning, understand their symptoms better, and build stable, meaningful lives.

The goal is not to label every emotional change as an illness. It is to notice when mood changes become intense, persistent, and different enough from a young person’s usual behavior that they deserve a closer look.

References

• National Institute of Mental Health. (2023). Bipolar Disorder in Children and Teens. NIH Publication No. 23-MH-8081. Revised 2023.
  This U.S. federal resource explains pediatric bipolar symptoms, manic and depressive episodes, differential diagnosis, treatment, family involvement, and the usefulness of daily mood and sleep tracking. It also emphasizes that bipolar mood episodes involve significant changes in mood, energy, activity, sleep, thinking, and behavior. Pages: Online publication; no fixed page numbers.
• American Academy of Child and Adolescent Psychiatry. (2017). Bipolar Disorder in Children and Teens. Facts for Families, No. 38. Updated March 2017.
  Provides an accessible description of manic and depressive symptoms in children and adolescents and explains why careful observation and a comprehensive psychiatric evaluation are important. It also discusses medication, psychotherapy, and family education as parts of treatment. Pages: Online fact sheet; no fixed page numbers.
• McClellan, J., Kowatch, R., Findling, R. L., & Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(1), 107–125. doi:10.1097/01.chi.0000242240.69678.c4
  Reviews assessment, differential diagnosis, clinical presentation, and treatment of bipolar disorder in children and adolescents. It is particularly useful for understanding why pediatric presentations can be complex and why symptoms must be considered within their developmental and clinical context. Pages: 107–125.
• Goldstein, B. I., Birmaher, B., Carlson, G. A., et al. (2017). The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disorders, 19(7), 524–543. doi:10.1111/bdi.12556
  Summarizes evidence on pediatric bipolar disorder, including symptoms, differential diagnosis, illness course, assessment, medication treatment, psychosocial treatment, and areas where misconceptions about bipolar disorder in young people have developed. Pages: 524–543.
• Youngstrom, E. A., Birmaher, B., & Findling, R. L. (2008). Pediatric bipolar disorder: Validity, phenomenology, and recommendations for diagnosis. Bipolar Disorders, 10(1 Pt 2), 194–214. doi:10.1111/j.1399-5618.2007.00563.x
  Reviews how bipolar disorder presents in children and adolescents and examines which symptoms are most useful when distinguishing bipolar disorder from other conditions. The publication discusses episodic mood changes, irritability, elevated mood, developmental differences, and the importance of information from multiple observers. Pages: 194–214.