Bipolar Disorder in Children and Teens
What is bipolar disorder?
Bipolar disorder causes mood swings with extreme ups (mania) and downs (depression). When people with this problem are up, they have brief, intense outbursts or feel irritable or extremely happy ( mania ) several times almost every day. They have a lot of energy and a high activity level. When they are down, they feel depressed and sad.
In the past, experts thought bipolar disorder was the same in children and adults. But symptoms in children and teens are different from those in adults, and they need different treatment.
What causes bipolar disorder?
Experts don't fully understand what causes bipolar disorder.
It seems to run in families. Your child has a greater risk of having it if a close family member such as a parent, grandparent, brother, or sister has it. Parents may wonder what they did to cause their child to have bipolar disorder. But there is nothing a parent can do to cause or prevent it.
What are the symptoms?
In children and teens, moods quickly change from one extreme to another without a clear reason. Some children may briefly return to a normal mood between extremes. Many children change continuously between mania and depression, sometimes several times in the same day. Sometimes children with bipolar disorder have symptoms of both mania and depression at the same time.
Times of mania (ups) or depression (downs) may be less obvious in children and teens than in adults.
- During a time of mania, children and teens
- Feel irritable and throw violent temper tantrums.
- Seem extremely happy and have high energy levels.
- Touch their genitals, use sexual language, and approach others in a sexual way.
- Not sleep much and go about the house late at night looking for things to do.
- Talk very fast.
- During a time of depression, children and
- Say they feel empty, sad, bored, or down.
- Complain of headaches, muscle aches, stomachaches, or fatigue .
- Often spend time alone and may easily feel rejected or criticized.
- Move very slowly.
How is bipolar disorder diagnosed in children and teens?
This disorder can be hard to diagnose in children and teens. The symptoms can look a lot like the symptoms of other problems, such as:
- Attention deficit hyperactivity disorder (ADHD) .
- Alcohol and drug abuse problems .
- Conduct disorder .
Bipolar disorder can often occur along with these problems.
If your doctor thinks your child or teen may have bipolar disorder, he or she may ask questions about your child's feelings and behavior. Your doctor may also give you and your child written tests to find out how severe the mania or depression is.
The doctor may do other tests (such as a blood test) to rule out other health problems. He or she may ask if your family has any history of mental illness or problems with drugs or alcohol. Any of these problems can be linked to bipolar disorder.
Why is early diagnosis of bipolar disorder important?
Children with this disorder are more likely to have other problems. These include alcohol and drug abuse , trouble in school, running away from home, fighting, and even suicide. Treating the disorder as early as possible may keep your child from having these problems.
Watch for the warning signs of suicide, which change with age. Warning signs of suicide in children and teens may include thinking too much about death or suicide. Watch also for things that can trigger a suicide attempt such as a recent breakup of a relationship or the loss of a parent or close family member through death or divorce.
How is it treated?
The mood changes that come with bipolar disorder can be a challenge. But with the right treatment, they can be managed well. Treatment usually includes both medicine (such as mood stabilizers) and counseling .
An important part of treatment is making sure your child takes his or her medicine. Children and teens with this disorder sometimes stop taking their medicines when they feel better. But without medicine, their symptoms usually come back.
Medicines for bipolar disorder in adults have been well studied. But not much research has been completed about how the medicines work and if they are safe for children and teens.
Accepting that your child has bipolar disorder can be hard. The disorder can be a serious, lifelong problem. Your child will need long-term treatment and will need to be watched carefully. By working with your child's doctor, you can find a treatment that works for your child.
Frequently Asked Questions
Learning about bipolar disorder in children and teens:
Living with child bipolar disorder:
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The cause of bipolar disorder is not well understood.
It seems to run in families. Your child is at greater risk of having bipolar disorder if a close family member such as a parent, grandparent, brother, or sister has it.
Stressful or traumatic events may trigger episodes of mania or depression in a child with bipolar disorder. While it is normal for such events to cause mood changes, these reactions are much more extreme for children with bipolar disorder.
Sometimes symptoms of mania occur as a result of another medical condition, such as an overactive thyroid gland (hyperthyroidism) or multiple sclerosis . Symptoms can also develop as a side effect of some medicines, such as corticosteroids or antidepressants. Using drugs or alcohol, consuming too much caffeine, or not getting enough sleep can also trigger a manic episode.
Bipolar disorder causes cycles of mania (or hypomania, a less severe form of mania) and depression . The different types of bipolar disorder are based on whether a person has more severe symptoms of mania or depression.
- With bipolar I disorder, moods swing between mania and depression, sometimes with periods of normal mood between extremes. Some children with this disorder have episodes of mania and are hardly ever depressed.
- With bipolar II disorder, depression is more prominent than mania, and manic episodes may be less common and less severe.
- With cyclothymia, the high and low mood swings are not as severe as mania and depression seen in bipolar I or bipolar II disorders.
- Bipolar, NOS (not otherwise specified), is diagnosed when symptoms of mania and depression are not frequent or severe enough for the above diagnoses.
In children and younger teens, bipolar disorder tends to be rapid-cycling or mixed cycling:
- Rapid-cycling means that the shifts between depression and mania occur quickly, sometimes within the same day. Often the mood shifts are continuous, rarely returning to a normal mood between extremes.
- Mixed-cycling means that symptoms of both mania and depression occur at the same time.
Following are some common symptoms of bipolar disorder in children and teens. 1
- Continuous sad or irritable mood
- Loss of interest in activities that the child enjoyed in the past, such as hobbies, sports, games, or friends
- Significant changes in appetite or body weight (weight loss or gain)
- Sleeping too much or too little or having trouble falling asleep
- Slowed body movements or restlessness
- No energy, or loss of energy
- Inappropriate feelings of guilt or worthlessness
- Problems concentrating
- Recurrent thoughts or talk of death or suicide
- Headaches, muscle aches, or stomachaches
- Severe changes in mood from being extremely irritable to overly silly and elated
- Too much energy, such as the ability to keep going without tiring while the child's peers are tiring
- Decreased need for sleep, such as going for days with very little sleep and not being tired
- Talking too much or too fast, changing topics too quickly, and not allowing interruptions
- Increased distraction and constantly moving from one thing to another
- Grandiosity, such as inflated self-esteem or a belief in unrealistic abilities or powers
- Increased sexual thoughts, feelings, activity, and use of sexual language (hypersexuality)
- Increased obsession with reaching goals or becoming involved in too many activities
- Risky, wild, thrill-seeking behavior
During severe episodes of mania, your child may suffer from symptoms of psychosis , such as having hallucinations or delusions of grandeur (for example, telling people that a rock band is coming to his or her birthday party).
Untreated bipolar disorder can lead to suicide. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
People sometimes confuse bipolar disorder in children with other conditions with similar symptoms, such as attention deficit hyperactivity disorder (ADHD). Although there is some evidence of a link between ADHD and bipolar disorder, the conditions have distinct features that you can usually identify.
In young children, the symptoms of mania are more than just being a bother to adults and other children now and then. For example, many children can be silly and giggly to a point that it bothers their parents sometimes. This is not considered to be a sign of mania. But if a child is silly and giggly for several hours, several times almost every day, and this is interrupting the family's usual routine, then it may be a symptom of mania.
Often the first signs of bipolar disorder are severe moodiness, unhappiness, or other symptoms of depression. It is common for children with bipolar disorder to be diagnosed first with only depression and then later to be diagnosed with bipolar disorder.
A first manic or hypomanic episode can be triggered by a stressful situation or by certain medicines, or it may occur without an obvious cause.
Children with bipolar disorder may:
- Have trouble getting going in the morning but then have intense energy later in the day.
- Miss school often or talk about running away from home.
- Become socially isolated and overly sensitive to any kind of rejection or criticism.
- Behave irresponsibly, take risks and not think about the consequences, or have trouble making and keeping friends.
Children may have severe, seizure-like temper tantrums when they are told "no." A bipolar child may kick, bite, hit, and make hateful comments, including threats and curses. During tantrums, which may last for hours, a child may destroy property or become increasingly violent.
Young children with bipolar disorder may have more extreme happy or silly moods than most children have.
Manic behavior by a teen with bipolar disorder may result in such problems as:
- Suspension from school.
- Arrest as a result of fighting or drug use.
- An unwanted pregnancy.
- A sexually transmitted infection (STI) from unsafe sexual behavior.
During depressive episodes, a teen may do poorly in school and may stop participating in activities he or she enjoyed in the past, such as a sports team.
Watch for warning signs of suicide, which can include preoccupation with death or suicide or a recent breakup of a relationship.
Substance abuse is common. Your child's doctor may recommend an evaluation for both substance abuse problems and bipolar disorder if your child appears to suffer from either condition.
Treating other conditions
Sometimes treatment for other conditions can make your child's bipolar disorder worse. For example:
- Treating depression with antidepressants can trigger a manic episode or make one worse.
- Treating attention deficit hyperactivity disorder (ADHD) with stimulants may also trigger severe mania, depression, and even psychosis (loss of touch with reality).
- Treatment with corticosteroids for conditions such as asthma may also trigger a manic or depressive episode.
Medicines that intensify bipolar symptoms may need to be stopped or changed to a different dose or medicine. Sometimes an additional medicine (such as a mood stabilizer) can solve the problem. But each child responds to medicines differently. And it may take several tries before your doctor can identify an effective medicine or combination of medicines for your child's conditions.
What Increases Your Risk
Your child's risk of developing bipolar disorder or other mood disorders is higher if the child:
- Has a close relative such as a parent, sibling, or grandparent with bipolar disorder or another mood disorder.
- Has a family history of problems with alcohol or drugs. Such family members may be using alcohol or drugs as a way to deal with a psychological disorder.
- Has had several episodes of major depression . For every 100 teens with recurring depression, at least 15 are later diagnosed with bipolar disorder. 1
When To Call a Doctor
Call 911, the national suicide hotline at 1-800-273-TALK (1-800-273-8255), or other emergency services right away if:
- Your child is thinking seriously of committing suicide or has recently tried to commit suicide. Serious signs include these thoughts:
- Has decided how to kill himself or herself, such as with a weapon or medicines.
- Has set a time and place to do it.
- Thinks there is no other way to solve the problem or end the pain.
- Your child feels he cannot stop from hurting himself or someone else.
Call a doctor right away if:
- Your child hears voices.
- Your child has been thinking about death or suicide a lot but does not have a plan to commit suicide.
- Your child is worried a lot that the feelings of depression or thoughts of suicide are not going away.
Seek care soon if:
- Your child has symptoms of depression, such as:
- Feeling sad or hopeless.
- Not enjoying anything.
- Having trouble with sleep.
- Feeling guilty.
- Feeling anxious or worried.
- Your child has been treated for depression for more than 3 weeks but is not getting better.
Who to see
It is best to establish a long-term relationship with your child's care providers so that when a depressive or manic episode occurs, the care providers can recognize the changes in the child's behavior and provide quick treatment advice.
You may wish to find a doctor who has special training in children's mental health conditions or experience treating bipolar disorder in young people. Bipolar disorder can be diagnosed and treated by a health professional such as a:
- Psychiatrist , preferably a child psychiatrist.
- Pediatrician .
- Family medicine physician .
- Nurse practitioner .
- Physician assistant .
Your child may also benefit from professional counseling to help deal with mood changes and the effects bipolar disorder has on your child's life. A counselor with special training in child mood disorders or experience treating child bipolar disorder may be most helpful. Counseling for bipolar disorder can be provided by a:
Other health professionals who also may be trained in counseling include:
Who to see for family member support
If you are a family member of a child with bipolar disorder, it is very important to get the support and help you need. Living with or caring for someone who has bipolar disorder can be very disruptive to your own life. Manic episodes can be particularly difficult. It may be helpful to seek your own counselor or therapist to help you.
Also, some national support organizations may have a local chapter in your area or provide information on the Internet. Examples of such groups include the National Alliance for the Mentally Ill (NAMI) and the Child and Adolescent Bipolar Foundation.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
There is no lab test that can diagnose bipolar disorder. Doctors make the diagnosis through a combination of:
- A medical history, asking questions to help identify other past and present health conditions that could cause the symptoms.
- A family history to identify bipolar disorder, other mood disorders, or drug or alcohol problems in close relatives. (All of these conditions are linked to bipolar disorder.)
- A physical exam, which can rule out other conditions with similar symptoms.
- A mental health assessment, which can help identify your child's current mental state and the severity of depression or mania .
- Other written or verbal mental health tests.
Before prescribing medicine to treat bipolar disorder, your doctor will ask questions about possible suicidal behavior.
Mood changes and other symptoms of bipolar disorder are challenging, but they can be managed effectively. Treatment usually includes medicines (such as mood stabilizers) and counseling. Often a combination of both is needed.
An important part of treatment is making sure your child takes his or her bipolar medicine. Often people who feel better after taking their medicine for a while think they are cured and no longer need treatment. But when a person stops taking medicine, symptoms usually return, so it is important that your child follow the treatment plan.
Counseling works best when symptoms of bipolar disorder are controlled with medicines. For more information on the types of counseling used to treat bipolar disorder, see Other Treatment.
Home treatment includes helping your child get regular exercise, eat a balanced diet, and get enough sleep.
If your child's behavior is suicidal, aggressive, reckless, or dangerous, or if he or she is out of touch with reality ( psychotic ) or unable to function, the child may need to go into the hospital for a while. Also, many medicines can make the symptoms of bipolar disorder worse. If your child is taking one of these, he or she may need to taper off and stop the medicine. This should only be done under the supervision of a doctor.
Impact on the family
Bipolar disorder has a big impact on both the child and his or her family. Successful treatment requires that the child and family members know what happens in bipolar disorder and that the family members help make sure that the child follows the treatment.
It can take time for you and your child to accept that the child has a serious, long-term condition that requires ongoing treatment and constant monitoring. But keep in mind that by working with your child's doctor, you and your child can find treatment that works.
Bipolar disorder can't be prevented. But there are ways to help manage or prevent mood changes.
The first and most important preventive measure is to make sure that your child takes his or her medicines as directed. Bipolar disorder is a long-term condition and often requires lifelong treatment with medicines.
Reducing stress, getting regular sleep and exercise, and staying on a daily routine may help prevent mood swings and can help with the symptoms of depression and mania.
Learning as much as you can about bipolar disorder may help you recognize mood changes in your child as they begin to occur. Catching and treating these mood changes early may help reduce the length of the manic or depressive episode and improve the quality of your child's life.
There are steps you can take at home to reduce your child's symptoms.
- Keep your child's room quiet, and have your child go to bed at the same time every night.
- Control the amount of stress in your child's life. You may need to seek ways to help your child reduce academic requirements during severe mood swings.
- Learn to recognize the early warning signs of your child's manic and depressive mood episodes.
Steps your child can take to help control moods include:
- Getting enough exercise. During a depressive episode, your child may feel like doing only gentle exercises, such as taking a walk or swimming.
- Getting enough sleep and keeping a consistent sleep schedule.
- Eating a balanced diet.
- Avoiding the use of alcohol or drugs. Substance abuse makes bipolar disorder worse.
- Avoiding beverages that contain caffeine, including coffee, tea, colas, and energy drinks.
- Learning to recognize the early warning signs of manic and depressive mood episodes.
- Asking for help from friends and family when needed.
For some children with bipolar disorder, depression can cause debilitating symptoms. For information about managing childhood depression, see the topic Depression in Children and Teens.
Medicines for bipolar disorder in adults have been well studied. But not much research has been completed about how well the medicines work and if they are safe for children and teens.
When you and your child's doctor are deciding which types of medicines to use, consider:
- The side effects of each medicine and how well your child can tolerate them.
- How often your child will need to take the medicines.
- Whether your child is being treated for other illnesses or disorders and how those medicines will interact with medicines for bipolar disorder.
- Whether your child has used any of the medicines before and whether they worked.
Before prescribing medicine to treat bipolar disorder, your doctor will ask questions about possible suicidal behavior.
Be sure to use all medicines exactly as your child's doctor has prescribed them. If your child has intolerable side effects from any medicine, call your doctor immediately.
Medicines most often used to treat bipolar disorder in children and teens include:
, such as:
- Lithium (for example, Eskalith or Lithobid).
- Divalproex (Depakote).
- Carbamazepine (for example, Tegretol).
- Lamotrigine (Lamictal).
- Valproate (Depacon).
, such as:
- Quetiapine (Seroquel).
- Risperidone (Risperdal).
- Aripiprazole (Abilify).
- Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac, for example).
While antidepressants can be helpful for some children with bipolar disorder, they can also trigger mania . Doctors usually prescribe antidepressants along with mood stabilizers or antipsychotics to help prevent a manic episode. And the doctor needs to carefully monitor the child for mood changes. Antipsychotics can be used alone, or they may be combined with mood stabilizers for more effective control of manic episodes.
Medicines for bipolar disorder have side effects that need to be managed. Some things you cannot change, such as increased urination (common with lithium). But you can deal with some side effects like weight gain (common with several medicines used to treat bipolar disorder) by increasing exercise and reducing calorie intake.
You can work with your child and his or her doctor to find ways of coping with side effects. If side effects from a medicine are intolerable, the doctor may have to change the dose or the medicine.
The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. Talk to your doctor about possible side effects and the warning signs of suicide.
Most children who have bipolar disorder need medicine. But other forms of treatment used along with medicine play an important role in balancing mood and improving quality of life. Counseling, education about the disorder, and stress reduction can help.
Other treatment choices
Counseling along with medicine has been used effectively to manage bipolar disorder. Types of therapy that counselors use to treat bipolar disorder include:
- Cognitive-behavioral therapy , which focuses on modifying certain thinking and behavior patterns.
- Interpersonal therapy , which focuses on social and personal relationships and related problems.
- Problem-solving therapy , a type of cognitive therapy that helps you find immediate solutions to problems.
- Family therapy , which can help educate and support the entire family.
- Play therapy for very young children.
- Psychological education and support groups.
- Dialectical-behavioral therapy , which focuses on building skills to manage mood swings.
In some cases, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals.
Complementary medicine is a term used for a wide variety of health care practices that may be used along with standard medical treatment. Omega-3 fatty acids found in fish oils have been getting some attention as a possible complementary treatment of bipolar disorder. But more research is needed to prove the effectiveness of omega-3 fatty acids in treating this condition in children, teens, and adults.
Other Places To Get Help
|Depression and Bipolar Support Alliance|
|730 North Franklin Street|
|Chicago, IL 60654-7225|
|Phone:||1-800-826-3632 includes a hotline for help with depression and bipolar disorder|
The Depression and Bipolar Support Alliance publishes brochures, books, and videotapes about the treatment of mood disorders, all available free of charge or for a nominal fee. It also has an information and referral line, and its website contains helpful tools and information, including personal wellness tools and links to research studies.
|Mental Health America|
|2000 North Beauregard Street, 6th Floor|
|Alexandria, VA 22311|
|Phone:||1-800-969-NMHA (1-800-969-6642) referral service for help with depression
Mental Health America (formerly known as the National Mental Health Association) is a nonprofit agency devoted to helping people of all ages live mentally healthier lives. Its website has information about mental health conditions. It also addresses issues such as grief, stress, bullying, and more. It includes a confidential depression screening test for anyone who would like to take it. The short test may help you decide whether your symptoms are related to depression.
|National Alliance on Mental Illness (NAMI)|
|3803 North Fairfax Drive|
|Arlington, VA 22203|
|Phone:||1-800-950-NAMI (1-800-950-6264) hotline for help with depression
The National Alliance on Mental Illness is a national self-help and family advocacy organization dedicated solely to improving the lives of people who have severe mental illnesses such as schizophrenia, bipolar disorder (manic depression), major depression, obsessive-compulsive disorder, and panic disorder. NAMI focuses on support, education, advocacy, and research. The mission of the organization is to "eradicate mental illness and improve the quality of life of those affected by these diseases."
|National Institute of Mental Health (NIMH)|
|6001 Executive Boulevard|
|Bethesda, MD 20892-9663|
The National Institute of Mental Health (NIMH) provides information to help people better understand mental health, mental disorders, and behavioral problems. NIMH does not provide referrals to mental health professionals or treatment for mental health problems.
|National Suicide Prevention Lifeline|
The National Suicide Prevention Lifeline is a 24-hour, toll-free suicide prevention service. Crisis centers are located in 130 locations across the United States. Each caller is routed to the closest provider of mental health and suicide prevention services.
|The Balanced Mind Foundation|
|566 W. Lake St.|
|Chicago, IL 60661|
The Balanced Mind Foundation is a national, parent-led, not-for-profit, Web-based membership organization of families raising children diagnosed with, or at risk for, mood disorders. This organization provides resources to help families better understand childhood and adolescent bipolar disorder.
- American Psychiatric Association (2000). Bipolar disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 382–397. Washington, DC: American Psychiatric Association.
Other Works Consulted
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- American Academy of Child and Adolescent Psychiatry (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(1): 107–125. Available online: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters.
- American Academy of Child and Adolescent Psychiatry (2009). Practice parameter on the use of psychotropic medication in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9): 961–973.
- Ascherman LI, et al. (2006). Mental development and behavioral disorders. In FD Burg et al., eds., Current Pediatric Therapy, 18th ed., pp. 1213–1219. Philadelphia: W.B. Saunders.
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- Birmaher B, et al. (2006). Clinical course of children and adolescents with bipolar spectrum disorders. Archives of General Psychiatry, 63(2): 175–183.
- Birmaher B, et al. (2007). Bipolar disorder. In A Martin, FR Volkmar, eds., Lewis's Child and Adolescent Psychiatry, 4th ed., pp. 513–528. Philadelphia: Lippincott Williams and Wilkins.
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- Correll CU, et al. (2009). Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA, 309(16): 1765–1773.
- Geddes J, Briess D (2008). Bipolar disorder, search date July 2006. Online version of Clinical Evidence: http://www.clinicalevidence.com.
- Geller B, et al. (2008). Child bipolar I disorder: Prospective continuity with adult bipolar I disorder; Characteristics of second and third episodes; Predictors of 8-year outcome. Archives of General Psychiatry, 65(10): 1125–1133.
- Goldstein TR, et al. (2007). Dialectical behavior therapy for adolescents with bipolar disorder: A 1-year open trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7): 820–830.
- Miklowitz DJ, et al. (2008). Family-focused treatment for adolescents with bipolar disorder. Archives of General Psychiatry, 65(9): 1053–1061.
- Mondimore FM (2007). Mood disorders. In NH Fiebach et al., eds., Principles of Ambulatory Medicine, 7th ed., pp. 329–349. Philadelphia: Lippincott Williams and Wilkins.
- National Institute of Mental Health (2008). Bipolar Disorder in Children and Teens. Available online: http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-easy-to-read/complete-index.shtml.
- Post RM, Altshuler LL (2009). Mood disorders: Treatment of bipolar disorders. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 1744–1813. Philadelphia: Lippincott Williams and Wilkins.
- Sass AE, Kaplan CW (2012). Adolescence. In WW Hay Jr et al., eds., Current Diagnosis and Treatment: Pediatrics, 21st ed., pp. 113–152. New York: McGraw-Hill.
- Wagner KD, Brent DA (2009). Depressive disorders and suicide. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 2, pp. 3652–3663. Philadelphia: Lippincott Williams and Wilkins.
|Primary Medical Reviewer||John Pope, MD - Pediatrics|
|Specialist Medical Reviewer||David A. Axelson, MD - Child and Adolescent Psychiatry|
|Last Revised||April 12, 2011|
Last Revised: April 12, 2011
Author: Healthwise Staff
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