Children, like adults, experience fear and anxiety from time to time. These feelings usually resolve when the stressor or trigger has passed. But for some children, fear can be excessive and have a significant effect on their life.

Fear of harm (FOH) is a collection of symptoms that are thought to be a phenotype of pediatric bipolar disorder. Phenotypes refer to a person or health condition’s observable characteristics.

FOH is characterized by an obsessive fear of something bad happening and hurting oneself or others. It can also include aggressive outbursts, sleep disturbances, and overheating, especially at night.

FOH is still being studied. It is not a formal diagnosis and is not listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). FOH and diagnosing bipolar disorder in children remain controversial topics.

Let’s take a closer look at what we know so far about FOH in children with bipolar disorder, what symptoms define this phenotype, and what treatment options are being studied.

Pediatric bipolar disorder is a mental health condition thought to affect between 1.8 to 3.9 percent of children and teens. Similar to bipolar disorder in adults, the condition is characterized by periods of depression and mania or hypomania with periods of stable mood in between.

According to the National Institute of Mental Health (NIMH), children with bipolar disorder may have more difficulties in school and their relationships than their peers. They’re also at an increased risk of self-harm and suicide.

Demitri Papolos, a psychiatrist and lead researcher on FOH, told NPR that thousands of children might experience fear of harm as a part of their bipolar disorder.

Papolos is conducting research to understand the condition better, including studying the use of the anesthetic drug ketamine as a possible treatment. He directs the Juvenile Bipolar Research Foundation (JBRF), which lays out the proposed diagnostic criteria and treatment options for FOH.

2013 research found that FOH is common among children with bipolar disorder. This research revealed that approximately one-third of children with bipolar disorder have high levels of FOH symptoms. Another third have low levels, and a final third do not have symptoms of fear of harm.

The research concluded that children with fear of harm are more likely to experience severe cases of mania and depression.

The symptoms of FOH have many dimensions and accompany many possible experiences. Some children have many or all of the symptoms, while others have fewer.

According to 2014 research, the most commonly observed symptoms associated with fear of harm include:

  • intrusive, fearful thoughts of terrible things happening to oneself or others
  • often feeling threatened and reacting to perceived threats with angry outbursts
  • thoughts of self-harm or suicide
  • elevated levels of anxiety, including separation anxiety
  • insomnia, not wanting to go to bed, and racing thoughts at night
  • night terrors or nightmares that may be violent
  • waking up fatigued or being difficult to wake up
  • an inability to regulate your body temperature, especially at night

It’s important to understand that children who have these symptoms are not like this all the time, and these symptoms do not define who they are. As Papolos tells NPR, once an instance or episode of acute symptoms is over, children are often endearing and amicable.

FOH is still controversial as a proposed subcategory of bipolar disorder symptoms in children, and research is ongoing. Because of this, there is no way to officially diagnose children with FOH beyond treating individual symptoms. As mentioned earlier, FOH is not currently listed in the DSM-5.

The JBRF has proposed a DSM criteria for fear of harm. This includes the symptoms discussed in the above section that Papolos and others have observed in their clinical practice and research.

If you believe your child may have FOH symptoms as part of their bipolar disorder diagnosis or has not been diagnosed with bipolar disorder but is showing signs of FOH, contact a pediatrician or child psychologist.

While children experience moods as a natural part of growing up and learning to process their emotions, certain symptoms warrant professional evaluation. Severe changes in mood and signs of FOH can disrupt school and home life. For some, it may cause risks to your child’s mental health and safety.

Licensed mental health professionals, especially those who specialize in treating children and teens, can help you better understand your child’s behavior and get them the help they need.

There are currently no treatments approved by the Food and Drug Administration (FDA) for children experiencing FOH, partly because it’s not an official diagnosis.

Papolos found that general treatments for bipolar disorder alone were not effective at fully addressing FOH symptoms. He proposed that treating FOH with ketamine shows immense promise, claiming it reduced or eliminated FOH symptoms in children he has studied so far.

In 2018, Papolos and his colleagues published a small study about the promising treatment. They surveyed 45 children who received intranasal ketamine over a period of 3 months and up to 6.5 years.

Children showed significant reductions in all FOH symptoms. In particular, a major improvement was found in terms of social skills and school performance.

While ketamine is generally associated with its use as an anesthetic before surgeries, it has been used to treat mental health conditions before.

A nasal form of ketamine called esketamine (Spravato) has previously been FDA-approved to treat depression. However, some experts argue the drug’s risks outweigh its benefits for this use.

Ketamine treatment for FOH and other mental health conditions is still being studied, so research is limited. It’s best to have a professional evaluate your child’s symptoms and come up with an individualized plan of care.

Treatments for bipolar disorder in children

There are several standard treatments for bipolar disorder, although they are slightly different for adults and children.

According to the NIMH, for children with bipolar disorder, management and treatment may consist of:


There are many different types of medications used to treat bipolar disorder. Many people may have to try more than one or use a combination before finding a drug that works for them. It’s important to always have your child take medication as directed by your doctor and report any troubling side effects they may experience. With children, doctors usually try to prescribe the lowest possible dose of medication.

Common medications used to treat bipolar disorder in children include:

Psychosocial therapy

Different therapies focus on helping children develop coping mechanisms, practice social skills and emotional regulation, and provide a safe space for them to express their thoughts and feelings.

This can include:

FOH is still in the preliminary stages of being a proposed phenomenon in children diagnosed with bipolar disorder. Some of the symptoms associated with FOH may be mistaken for those of other mental health conditions.

According to the JBRF, these include:

If you notice extreme moods, excessive worrying, or obsessive behaviors in your child on a regular basis, consider reaching out to a doctor.

The symptoms observed in FOH can be upsetting to witness and affect your child and family’s quality of life. While FOH is not an official diagnosis, you can work with a mental health professional to address and treat symptoms. This may include medication, lifestyle changes, or talk therapy.

A leading voice on FOH, Demitri Papolos, has proposed ketamine as an effective treatment for FOH symptoms. This treatment has not been FDA-approved or studied thoroughly, but ketamine has been used to treat mental health conditions before.

If you suspect that your child is exhibiting signs of FOH, please do not hesitate to reach out to a mental health professional. Your child is not alone in experiencing excess fear, worry, or extreme shifts in mood associated with bipolar disorder. Help is available, and you and your child deserve care and support.