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Bipolar Disorder

What is bipolar disorder in children and teens?

Although once thought rare, federally funded studies have shown that approximately 7% of children seen at psychiatric facilities fit bipolar disorder using research standards. In the past, experts thought bipolar disorder was the same in children and adults. But recent studies of children and teens show that their symptoms are different than those of adults, and they need different treatment. Bipolar disorder can occur in children and adolescents as young as age 2.

When children or teens have bipolar disorder, they have mood swings with extreme ups and downs. When they are up (the manic portion of the disorder), they many have brief, intense outbursts or feel irritable several times almost every day. This might look like a child that reacts to something with "more intensity than the situation calls for". They also sustain the reaction for much longer than would seem normal; sometimes going on for 4 to 5 hours. The situation most often occurring before these angry outbursts is telling the child no or somehow limiting them. When they are down (the depression portion of the disorder), they feel sad or uncomfortable, sort of like how we feel which there is a problem hanging over our heads and we can't solve it. Although this is not, in itself, usually enough to diagnose depression in adults, it is enough for children because children don't have the cognitive abilities or prior experiences to draw on to help them solve it. For a bipolar child, these mood swings look very intense and it is not something they are choosing to do; when they encounter situations which they don't have the skills to resolve, stress and anxiety levels increase. When these increase, it causes the neurotransmitters to react and a sort of "chemical warfare" gets worse. When you are a child, this is very confusing because you don't have the same benefits from past experience that an adult would have.

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, or conduct disorder. Always remember that having one of these disorders DOES NOT preclude also having Bipolar Disorder.

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 should do other tests (such as a blood test) to rule out other health problems (thyroid, in particular). He or she may ask if your family has any history of mental illness or problems with drugs or alcohol.

What Increases Your Risk of Developing Bipolar Disorder?

Your child's risk of developing bipolar disorder or other mood disorders increases 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. This may be an indication of self-medication for an underlying psychological disorder, such as bipolar disorder.
Has has several episodes of major depression. At least 15% of adolescents with recurring depression are later diagnosed with bipolar disorder.

Certain factors can trigger depressive or manic episodes in your child, such as:

Erratic sleep or changes in daily routines.
Treatment with antidepressants, which can increase the risk for a manic episode.
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.
Not taking medications as prescribed.
Using alcohol or drugs (substance abuse).
Entering puberty.
Consuming too much caffeine.

Diagnosing Bipolar Disorder

There is no laboratory test to 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 substance abuse 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 (such as hyperthyroidism).
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.

Symptoms of bipolar disorder can emerge as early as infancy. Mothers often report that children later diagnosed with the disorder were extremely difficult to settle and slept erratically. They seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event. The word "no" often triggered these rages.

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 hours, several time almost every day, and this is interrupting the family's usual routine, then it may be a symptoms of mania.

To check your child for mania symptoms, your doctor will use a set of guidelines called FIND. Your child may be diagnosed with mania if the doctor finds more than one symptom that is more sever than the FIND guidelines. The letters in FIND stand for:

Frequency: Symptoms happen most days in a week.
Intensity: Symptoms are sever enough to cause problems with teachers, parents, brother, sisters, and friends.
Number: Symptoms happen 3 or 4 times a day.
Duration: Symptoms last 4 or more hours a day. This time may be spread out during the day rather than happening all at once.

Doctors check to see if a child's symptoms are more severe than the FIND guidelines. Also, more than one symptom has to be more severe than the FIND guidelines to be diagnosed as mania.

Bipolar Disorder according to the DSM-IV-TR (1994)

The Diagnostic and Statistical Manual IV (DSM-IV) still requires that, for a diagnosis of bipolar disorder, adult criteria must be met. There are as yet no separate criteria for diagnosing children. To illustrate how difficult it is to use the DSM-IV to diagnose children, the manual says that a hypomanic episode requires a "distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." Yet upwards of 70 percent of children with the illness have mood and energy shifts several times a day. Some behaviors by a child, however, should raise a red flag:

destructive rages that continue past the age of four.
talk of wanting to die or kill themselves
trying to jump out of a moving car

All types of bipolar disorder consist of cycles of mania (or hypomania, a less severe form of mania) and depression. The different types of bipolar disorder are base on whether an adult person has more sever symptoms of mania or depression and how quickly mood cycles occur.

Bipolar I Disorder: moods swing between mania and depression, sometimes with periods of normal mood between extremes. Some children with type I bipolar disorder predominantly have episodes of mania and are hardly ever depressed.
Bipolar II Disorder: depression is more prominent than mania, and those manic episodes may be less common and less severe (called hypomania).
Cyclothymia: periods of less sever, but definite, mood swings.
Bipolar Disorder NOS (Not Otherwise Specified): Doctors make this diagnosis when it is not clear which type of bipolar disorder is emerging.

Depressive symptoms

Continuous sad or irritable mood.
Marked decrease or loss of interest in activities the child once enjoyed, such as hobbies, sports, games, or friends.
Significant changes in appetite or body weight (weight loss or gain).
Sleeping too much or too little, having trouble falling asleep, or having trouble staying asleep.
Slowed or agitated body movements or restlessness.
No energy or loss of energy.
Inappropriate feelings of guilt or worthlessness.
Difficulty concentrating or periods of being able to concentrate followed by an inability to concentrate.
Recurrent thoughts or talk of death or suicide. The warning signs of suicide change with age.

Manic symptoms

Severe changes in mood from being extremely irritable or sad to overly silly and elated with no clear precipitating event that might cause the shift in mood.
Too much energy, such as the ability to keep going without tiring while the child's peers are tiring.
Decreased need for sleep, typically only 4-6 hours, for days at a time and they do not seem to be tired. These children may stay up all night on the computer or rearrange the furniture in the house.
Talking too much or too fast, changing topics too quickly, and not allowing interruptions. This is sometimes referred to as a "flight of ideas"; when children jump from topic to topic in rapid succession but it is not associated with a special event that has or will happen.
Increased distractibility and constantly moving from one thing to another, beyond that which is normal.
Grandiosity, such as inflated self-esteem or a belief in unrealistic abilities or powers. Grandiose behaviors are when children act as if the rules do not pertain to them. For example, they believe they are so smart that they can tell the teacher what to teach, tell other students what to learn and call the school principal to complain about teacher they do not like. Some children are convinced that they can do superhuman deeds (they are Superman) without getting seriously hurt, such as "flying" out of windows.
Increased sexual thoughts, feelings, activity, and use of sexual language (hypersexuality). This can occur in children with mania without any evidence of physical or sexual abuse. These children may act flirtatious beyond their years, try to touch the private areas of adults, teachers, or other children or use explicit language.
Increase obsession with reaching goals or becoming involved in too many activities.
During severe episodes of mania, your child may suffer from symptoms of psychosis, such as having hallucinations or delusions of grandeur (for examples, telling people that a rock band is coming to his or her birthday party).

Differences between Children and Adults with Bipolar

In adults with bipolar disorder, mood swings usually occur over weeks or even months and there is a return to some "normal mood". Unlike adults (with adult onset), children with bipolar have an increased risk of co-morbidity with other disorders such as ADHD, anxiety, or conduct disorder. In children, cycles usually occur more rapidly, sometimes within the same day (rapid, ultra rapid, or ultradian cycling). The mood shifts in children are often continuous, rarely returning to a normal mood between extremes. Sometimes elements of depressions and mania or hypomania may be present at the same time (a mixed state). These rapid and severe mood changes may make your child appear constantly irritable, and they can significantly interfere with your child's ability to function at school, at home, and with peers.

In young children:

Both manic and depressive episodes may appear as depression or irritability.
Separation anxiety that is not normal for the developmental level.
Bed wetting or night terrors.
Strong and frequent cravings, typically for carbohydrates and sugar.
During a depressive episode, a young child may become withdrawn, have a short attention span, feel guilty for no reason, and have low energy that can last for hours, days, or weeks.
Your child may throw temper tantrums, become easily frustrated, and become explosively angry. Again, irritability and temper tantrums can also be part of manic episodes.
It might be difficult to tell the difference between a depressive and a manic episode, especially if cycles are rapid or symptoms of depression and mania occur together.
Irritability may progress into severe temper tantrums when the child is 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.
Depressive episodes in children often show up as physical symptoms; complaints of headaches, muscle aches, stomachaches, or fatigue rather than the typical depressive symptoms one thinks of in adults.
Children frequently miss school or talk about running away from home. They become socially isolated and overly sensitive to any kind of rejection or criticism.
Children have difficulty getting going in the morning but then have intense energy later in the day.

In older children or adolescents:

During a manic episode, an older child or adolescent may have high energy levels and feelings of extreme happiness (eupohoria).
They may need less sleep and may talk rapidly and continuously.
Night terrors
Strong and frequent cravings, typically for carbohydrates and sugar.
He or she may be more aggressive than is normal for their age group.
While all teens may be rebellious or make bad choices from time to time, teenagers with bipolar disorder are more likely to show poor judgment. Bipolar teens don't seem to consider consequences before acting. This might result in him or her taking more risks such as getting into fights or breaking the law.
Experience an obsession with sex (hypersexuality) or engage in unsafe sexual practices such as unprotected sex. Even young children may touch themselves, use sexual language, and approach others in a sexual way.
Because of bad choices, they may suffer more consequences from manic behavior such as suspension from school, getting arrested as a result of fighting or drug use, or an unwanted pregnancy or sexually transmitted disease (STD) from unsafe sexual behavior.
They may believe they are more powerful or important than they really are (delusions or grandeur) during manic episodes; they may tell their friends that a famous musician will be at their birthday party.
Have difficulty making or keeping friends.
During depressive episodes, an adolescent may become withdrawn or quiet, do poorly in school, experience difficulty concentrating, or stop participating in activities he or she once enjoyed (such as quitting a sports team).
Adolescents may cry often, sleep too much, and feel that he or she doesn't belong.
He or she may speak of death or suicide.
Substance abuse in adolescents with bipolar disorder is more common as he or she attempts to "quiet the storm" by self medicating.

What are some first signs of Bipolar in children?

Often the first sign 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 after a cycle of mania or hypomania (a less severe form of mania). Times of mania or depression may be less obvious in children and teens than in adults.

One of the biggest challenges has been to differentiate children with mania from those with ADHD (attention deficit hyperactivity disorder). Both groups of children present with irritability, hyperactivity and distractibility. So these symptoms are not useful for the diagnosis of mania because they also occur in ADHD. But, elated mood, grandiose behaviors, flight of ideas, decreased need for sleep and hypersexuality occur primarily in mania and are uncommon in ADHD.

Depression in children and teens is usually chronic and relapsing. According to several studies, a significant proportion of the 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder, but have not yet experienced the manic phase of the illness.

For some adolescents, a loss or other traumatic event may trigger a first episode of depression or mania. Later episodes may occur independently of any obvious stresses, or may worsen with stress. Puberty is a time of risk. In girls, the onset of menses may trigger the illness, and symptoms often vary in severity with the monthly cycle.

Once the illness starts, episodes tend to recur and worsen without treatment. Studies show that after symptoms first appear, typically there is a 10-year lag until treatment begins.

During a time of mania, children and teens may:

Feel irritable and throw temper tantrums. These are different from typical temper tantrums because they are "too much" with respect to the precipitating event, last longer than they should, and there does not seem to be an element of "learning". A child may have a tantrum when his/her sister takes a toy and have the same tantrum later the same day in response to the same thing. This is because the temper tantrum is about the "chemical war", not about a learned behavior. Because the chemicals are out of sync, they don't have the ability to handle the situation to prevent it from getting out of hand.
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. They may also need to sleep at odd times during the day, which they did not do when they were younger.
Seem to have endless amounts of energy.
Be obsessed with a certain topic that they may or may not have cared about in the past.

During a time of depression, children and teens may:

Say they feel empty, sad, bored, or down.
Complain of headaches, muscle aches, stomachaches, or being tired most of the time.
Often spend time alone and may easily feel rejected or criticized.

Why is early diagnosis of bipolar disorder important?

Children with this disorder are more likely to develop other problems down the road. If you don't help your child sort this out now, they will find a way to help themselves later. Being young, children don't have the cognitive abilities in place or the rational voice of experience to steer them in the right direction. In addition, most children don't know how to explain it to their parents. As a result, most children try to solve adult problems with child type solutions. Typical solutions include alcohol or drug abuse, development of eating disorders (bulimia, anorexia, and over eating), trouble in school, running away from home, fighting, and even suicide. The majority of parents don't like these solutions, which will require 10 times the resources to correct not only these problems, but also the bipolar disorder.
Treating the disorder as early as possible can prevent further damage down the road from the continued chemical imbalances occurring every day. As we all know, water is harmless over the course of a week, but can carve an entire canyon if left alone. Allowing the chemicals to reach abnormal levels will cause more damage the longer they are out of balance.
Watchful waiting is a wait-and-see approach. If you think your child may have bipolar disorder, watchful waiting is not appropriate. Schedule an appointment with a Child Psychiatrist who has experience in treating children with bipolar.

How is it treated?

Current research points to a biological basis for Bipolar Disorder. That mean bipolar disorder is a brain disorder; based on changes in brain anatomy and brain chemistry.

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 medications (such as mood stabilizers) and counseling. Psychotherapy may not be effective until mood stabilization occurs. In fact, stimulants and antidepressants given without a mood stabilizers (often the result of misdiagnosis) can cause havoc in bipolar children, potentially inducing mania, more frequent cycling, and increases in aggressive outbursts. Currently, there is no medication that contains both a mood stabilizers and an antidepressant, so these are typically prescribed separately.

An important part of treatment is making sure your child takes his or her medicine. Once they begin to feel better, they will want to stop taking their medications. In addition, there are side effects that may cause problems for them in other areas of their lives, such as weight gain or anxiety. But without medication their symptoms usually come back. Recent research shows that multiple cycles of relapse-medication-relapse can decrease the potential of attaining a positive outcome.

Medications for bipolar disorder in adults have been well studied. But not much research has been completed about how they work and if they are safe for children and teens because it is much more difficult to get permission to study children in general.

Your child will 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 childhood mood disorders or experience treating childhood bipolar disorder would be most helpful.

Accepting that your child has bipolar disorder is very difficult. The disorder can be a serious, lifelong problem. Your child will need long-term treatment and will need to be watched carefully. 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.

There are also national support organizations that may have a local chapter in your area or provide information on the Internet. Examples of such organizations include the National Alliance for the Mentally III (NAMI) and the Child and Adolescent Bipolar Foundation.

Medications

For the manic symptoms, there are largely two groups of medications - Mood stabilizers/anticonvulsants and antipsychotics/atypical neuroleptics. Antidepressants are used for the depressive symptoms. Generally, there are three main types - Reuptake inhibitors such as the SSRI's/SNRI's/SNDRI's and the norpinephrine and dopamine reuptake inhibitor; MAOI's; and tricyclic antidepressants. MAOI's are rarely used anymore because of the potentially fatal interactions they have with certain types of foods. SSRI's have become the standard medication today. Trazodone (trade names Desyrel, Molipaxin, Trittico, Thombran, Trialodine, Trazorel) is a psychoactive compound with sedative and antidepressant properties and is often prescribed along with other medications if the patient is also having difficulty sleeping.

While antidepressants can seem helpful initially for a child with bipolar disorder, they will eventually trigger mania in a child that has bipolar disorder. It is very important for your doctor to take a thorough history so that a bipolar child is not misdiagnosed with depression. Theses cases tend to make headlines when a child that has been misdiagnosed with depression and placed on medication for depression either commits homicide or suicide. It is not the medication, per se, that caused the behavior, but the act of misdiagnosis and treatment with the wrong medication. Properly diagnosed, the doctor will usually prescribe antidepressants with other medication that help regulate mood, and he or she must carefully monitor the child.