Bipolar Disorder, sometimes also called manic depression, is characterized by intense, persistent mood swings ranging between depression and mania–euphoria, poor judgment, and extreme risk-taking activity.

Onset usually occurs in mid-to-late adolescence, cases in children are rare.

1 to 3% of the population may have bipolar disorder. Males and females are affected equally.

These moods are greatly intensified or clearly different from the child’s usual personality and are far out of proportion to events in the environment in intensity and/or duration.

The child experiences the typical signs of depression – helplessness, hopelessness, and worthlessness – and the signs of mania – grandiosity and exuberance.

The disorder may be genetic and caused by a chemical imbalance in the brain.

Bipolar disorder is treatable, but managing the episodes of depression and mania is a lifelong undertaking. Medication can help to moderate the symptoms.

What to Look For

Adolescents with bipolar disorder will show signs of both depression (prolonged sadness, lack of affect and interest in things they previously enjoyed, sleeping too much) and mania (periods of excitability or irritability, dramatically heightened self-confidence, even recklessness).

For some, the onset of bipolar disorder is marked by a depressive episode; in others, it is a manic episode.

Onset can also be a less severe, chronic form of depression called dysthymia or a milder form of mania called hypomania.

The duration of and intervals between depressive and manic episodes are highly variable, particularly in younger people, but there are typically very distinct episodes.

Your child might be having a manic episode if:

  • his personality seems to change drastically
  • he develops an inflated sense of his abilities,
  • he displays grandiose thinking
  • he starts sleeping much less than he normally does
  • he becomes extremely energetic, foolhardy, and voluble.
  • psychotic episodes—breaks from reality—can occur during both manic episodes and severe depressive episodes. During a manic episode, these can include impossible beliefs—”I can fly”—or delusional thinking. For some, a psychotic episode is the first sign of the disorder.

Being on the lookout for symptoms of mania is particularly important if your child already has depressive symptoms. Bipolar disorder with an unnoticed manic component can be misdiagnosed as major depressive disorder, as people are much more likely to seek professional help when gripped by a depressive episode.

When a manic episode hits, a sufferer is often elated, displays poor judgment, and cannot realize that his behavior is irrational.

But depression and bipolar disorder are not the same thing and should be treated differently.

Diagnosis

Diagnostic Dilemma

Part of the problem in diagnosing Bipolar disorder in children is that research has shown us that we, as clinicians, are not very good at it. On the one hand, research suggests that youth who are referred for psychiatric treatment as children or adolescents at increased risk of developing bipolar disorder as adults.   Other prospective studies have shown that as we follow youth with a  bipolar disorder diagnosis into adulthood, the vast majority of them will not meet criteria for bipolar disorder.  So, we are seeing the youth at greatest risk for bipolar disorder, but we are not very good at identifying which youth will actually have adult bipolar disorder.

Current treatments for youth identified as bipolar disorder also suggest we are missing the mark.Treatment of adults with bipolar disorder is successful in reducing symptoms about 70 percent of the time.  Children diagnosed with bipolar disorder who are given similar treatment regimens do not respond as well.

The standard for a diagnosis of bipolar disorder is the presence of a manic episode, though the vast majority will experience depression as part of the disorder:

A manic episode is a sustained period of “abnormally and persistently elevated, expansive, or irritable mood” in a distinct shift from normal functioning—not just “10 minutes of feeling super-good,” as one clinician puts it, but a pattern of behavior. Some of the following symptoms are also usually present: grandiosity; decreased need for sleep; increased talkativeness; racing thoughts; scattered attention; drive to achieve goals; and risk-taking behavior. The behaviors must significantly interfere with normal activities—social life, school, work—or a psychotic episode must be present.

A teenager in a major depressive episode will display either depressed or irritable mood most of the time, or lose interest or pleasure in things he once enjoyed. In addition, he’ll show some of the following symptoms: marked weight loss or gain; sleeping too much or too little; restlessness or lethargy; fatigue; feelings of hopelessness, helplessness, worthlessness, or excessive or inappropriate guilt; cloudy or indecisive thinking; and a preoccupation with death, plans of suicide, or an actual suicide attempt.

Bipolar I. In this form of the disorder, the adolescent experiences alternating episodes of intense and sometimes psychotic mania and depression.Symptoms of mania include:

  • elevated, expansive or irritable mood
  • decreased need for sleep
  • racing speech and pressure to keep talking
  • grandiose delusions
  • excessive involvement in pleasurable but risky activities
  • increased physical and mental activity
  • poor judgment
  • in severe cases, hallucinations

Symptoms of depression include:

  • pervasive sadness and crying spells
  • sleeping too much or inability to sleep
  • agitation and irritability
  • withdrawal from activities formerly enjoyed
  • drop in grades and inability to concentrate
  • thoughts of death and suicide
  • low energy
  • significant change in appetite

Periods of relative or complete wellness occur between the episodes.

  • No one symptom indicates bipolar disorder, however if a child has number of symptoms listed above, and they are interfering with functions at home, school, and friends, have them evaluated by a professional.

Bipolar disorder is not the easiest diagnosis to make, particularly in young children. Many of the symptoms are similar to those associated with other disorders, including attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, depression, and conduct disorder. Children and adolescents with bipolar disorder can also have signs and symptoms of a second disorder, such as substance abuse or anxiety disorders. This is why it’s particularly important to get a comprehensive evaluation by a mental health professional who has specific training and expertise in the diagnosis and treatment of complex child psychiatric disorders.

Treatment

Treatment

Psychopharmacology

Medication is the key to  treatment of a child with Bipolar Disorder. Mood stabilizers can help curtail current symptoms of an episode, and can decrease the frequency and severity of future episodes for close to 80% of  adults treated. Children and adolescents do not respond as well to treatment, but studies show that when medications are effective, it is very important to CONTINUE treatment. Among the variety of other drugs, medications used to treat depression can also be helpful.

Psychoeducation

Medication management should be accompanied with education about the disorder, stressing the importance of continuation of the medication. Noncompliance is common due to youngsters’ perception that they don’t need medication any more or a wish to re-experience the mania.

Psychotherapy. Several types of therapy may be helpful.

  • Cognitive behavioral therapy. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. In addition, cognitive therapy teaches about bipolar disorder and its treatment and what may trigger bipolar episodes.
  • Family therapy. Family therapy can help identify and reduce stressors within the family. It can help the family improve its communication style and problem-solving skills and resolve conflicts.
  • Group therapy. Group therapy provides a forum to communicate with and learn from others in a similar situation.

Several recent studies have emphasized the importance of maintaining a healthy social rhythm–a regular sleep-wake cycle, a regular social-interactive routine in reducing episodes of depression and mania.

Other Concerns

Recurrence:

Although this disorder is highly treatable, 90% of those who discontinue medication have a recurrence within 18 months

Alcohol and other drug abuse

Without treatment, individuals with Bipolar Disorder are at risk for alcohol and drug abuse.

Suicide:

  • 15% of those with Bipolar Disorder commit suicide
  • Suicide is the third leading cause of death among adolescents and young adults aged 15 to 24.
  • Never ignore signs of suicidal behavior or ideation, which include:
  • drastic changes in eating habits, sleep patterns, or personality
  • marked neglect of personal appearance; giving away personal belongings
  • sudden happiness after a period of depressed mood
  • talk of suicide or of “going away” or “not being a problem anymore.”

If you think your child or adolescent is suicidal, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911

Don’t hesitate—the risk of suicide in children and adolescents is very real.

How to Stabilize Moods

How to Stabilize Moods

There are four basic keys to maintaing mood stability:

  1. sleep 8 hrs nightly: This is part of maintaining a healthy social rhythm. Erratic sleep-wake patterns exacerbate bipolar disorder tremendously.
  2. minimize stress through lifestyle changes
  3. exercise regularly
  4. participate in cognitive behavioral therapy : This is an important way to avoid the cognitive distortions that can lead to the ups and the downs. It is also an important way to monitor and gain feedback that mood is becoming unstable.

Invest in loving, trusting relationships.

One of the things that happens with bipolar disorder is that when a person with bipolar disorder starts to feel hypomanic that they lose insight about their illness.  They are not aware that symptoms of illness are beginning to appear. In part, this is because being hypomanic feels good! If a person with bipolar disorder has trusting and loving relationships with others, they may be more willing to hear from them that their mood is destabilizing.  The earlier the symptoms are identified, the less severe they are, and the less havoc they can wreak!

The people a person with bipolar disorder trusts can sit down with them and help them identify specific signs that may help to identify mania. Examples could be developing several new plans for activities at or after work or  sleeping fewer hours and feeling good about it, or even believing that medication is no longer necessary.

Better still is if this person can provide your physician with specific examples, either in writing or by coming with you to your appointment, so that your physician will gain an understanding of where you are at.

Track your mood.

Aside from depending on those you trust, another important tool for staying better is to track your moods. There are several mood trackers, either electronic or paper. These may include recording how many hours you’ve slept, recording a number on a scale to determine how up or down your mood is, and identifying any reasons or stressors that may be contributing to a change in your mood, and how fast you feel your thoughts are moving (crawling, walking, running, driving, flying, for example).   Women may also wish to record their menstrual cycles, since mood is often related to this.

Develop a plan to manage days that feel overwhelming, anxiety-provoking, and stressful.

It can be helpful to have a plan to help avoid a downward spiral, or to avoid past more maladptive decisions (such as self-medicating with substances, or attempting to seek rapid gratification (such as with sex, shopping, or gambling)

Some people do well with a short-term treatment of their anxiety with a benzodiazepine–but with a history of substane abuse this may not be an appropriate plan!

Some people may choose to work out longer, or contact their pastor for prayer, or phone a friend who is understanding.

Bipolar Disorder vs. Temper Dysregulation Disorder

Bipolar disorder, a mental illness that causes extreme shifts in mood, energy and functioning, was once considered a rare condition in children.

  • Since the mid-1990s, the number of kids diagnosed with it  increased by 4,000 percent. That dramatic upsurge sparked controversy among clinicians and researchers, with many arguing that children were being misdiagnosed—and were consequently receiving unnecessary antipsychotics.
  • In an effort to address this, the upcoming (2013) draft of the Diagnostic and Statistical Manual of Mental Disorders (DSM) proposes an alternative diagnosis, called temper dysregulation disorder with dysphoria (TDD). TDD is characterized by severe temper outbursts alternating with negative mood states, but unlike bipolar disorder, doesn’t include any symptoms of mania, nor is it a life-long disorder.

Over the last 15 years, there’s been much debate about how to categorize children with serious behavior problems—with irritable, angry, grumpy and sad moods.

  • Some research suggested that these children were experiencing a childhood version of classic bipolar disorder, and so the adult concept of bipolar disorder was expanded to include a wide range of children with dysregulated or bad behaviors and/or sad/grumpy or irritable moods.
  • Unlike the adult disorder, having symptoms of mania were no longer required.
  • This resulted in a major explosion in the rates of diagnosis of bipolar disorder.

There are problems with this diagnosis of pediatric bipolar disorder:

  1. Long term studies do not suggest that most children diagnosed with bipolar disorder have the disorder as an adult: A child diagnosed with childhood bipolar  should continue to exhibit signs of bipolar disorder as they grow into adulthood. Most studies have shown that kids diagnosed with childhood bipolar disorder (the broad type) are no more likely to develop classic bipolar than their peers. While it’s clear that these children do have a legitimate mood disorder, it doesn’t appear to be bipolar disorder.
  2. Analyses of psychiatric diagnoses in clinical practice suggest that many of these bipolar diagnoses in children are NOT being made based on clinical criteria. In fact, many of these youth, when administered a KSADS or other controlled interview, actually meet criteria for other diagnoses, such as ADHD and oppositional defiant disorde
  3. Treatment of many children diagnosed with the more broad and encompassing bipolar disorder diagnosis do not respond to treatment for bipolar disorder.

The new diagnosis of TDD  contains the core symptoms of what was formerly diagnosed as the broad type of childhood bipolar disorder:

The proposed criteria include:

  • severe recurrent temper outbursts that are grossly out of
  • proportion to the intensity of the situation
  • frequency of at least three temper outbursts a week
  • temper outbursts ongoing for at least one year
  • temper outbursts present in at least two settings (for
  • example, at home and at school)
  • onset before age 10

Unlike bipolar, TDD isn’t seen as a lifelong condition. It also doesn’t respond well to the classic drugs prescribed for bipolar disorder and warrants a different treatment approach. Researchers expect that many of these children will continue having difficulties into adulthood—they just won’t have bipolar disorder.

Does classic bipolar disorder exist in children?

  • Although most people are in agreement that classic bipolar can present in childhood, it’s extremely rare.
  • At specialty centers for pediatric mood disorders, clinicians are often  un-diagnosing 65 to 80 percent of the children coming in for a second opinion.

What are some of the consequences of children being misdiagnosed as bipolar?

  • Many children were treated with a variety of powerful antipsychotic and anti-epileptic medications.
  • Unfortunately, these drugs don’t appear to be effective for many children and have significant side effects.
  • Finally, labeling children bipolar at a young age is quite stigmatizing, as most people think of bipolar disorder (as known in adults) as an extremely serious lifetime condition.

How can a diagnosis of TDD lead to different treatment and outcomes for children with mood dysregulation?

  • Since these children do not respond to the medications intended for the treatment of bipolar disorder, then acknowledging that  TDD is not simply bipolar disorder in children will pave the way for new research about effective treatment for this syndrome.
  • The treatment for children with TDD, as with other mental health treatment,  should be multidimensional and should never be solely pharmacological., with a goal of helping the child develop the tools he needs to deal with life and the world.
  • Hopefully, physicians will match the intensity of the intervention with the severity of the child’s presentation, so that psychosocial interventions can be utilized alone when appropriate, and so that more modest medications can be used prior to using the more powerful medications .