Bipolar Disorder: Does it "Happen" to Children?

by Sandra Smith, Ph.D.

INTRODUCTION:

Bipolar disorder is a serious but treatable illness. In the past it was widely referred to as "manic depression", or "manic-depressive illness". Most experts agree that bipolar disorder is a disorder of the brain. Symptoms include extreme changes in energy, behavior and mood.

It is now widely accepted that bipolar disorder can and often does have its onset in childhood. Until recently, the diagnosis was made only rarely in children. However, mental health professionals are now able to recognize and treat the illness in young children.

How common the disorder is in childhood is unknown, because of the lack of prevalence studies. It has been estimated that, throughout the world, the prevalence of bipolar disorder among adults is 1 – 2%. As more is known about the disorder in young children, the more prevalent it appears to be in this population. It is suspected that a significant group of children diagnosed initially as having Attention Deficit Hyperactivity Disorder (ADHD) may in fact have bipolar disorder, versus or along with ADHD.

Families are invariably bewildered and desperate for information when it is suspected that one of their children may have this problem. In this article, which will be the first in a series about Bipolar Disorder in children and adolescents, the complexity of diagnosing the disorder in young children will be explored. In addition, answers to common questions will be provided in such a manner, which will, hopefully, be of help to informed parents.

Bipolar Disorder—What Is It?

A diagnosis of bipolar disorder requires the following:

An episode of "mania", i.e., a distinct period of abnormally expansive, elevated or irritable mood. This mood must last for at least four days, or for any period if hospitalization is required.
At least three of the following symptoms (four if mood is irritable) during the period of mood disturbance:
•Inflated self-esteem, or "grandiosity".

•Diminished need for sleep.

•Pressured speech.

•Flight of ideas, or "racing thoughts".

•Distractibility

•Increase in goal-directed activity; or involvement in activities with potentially painful or dangerous consequences
The symptoms must produce a marked impairment in the individual’s functioning, which cannot be accounted for by medical conditions, other psychiatric disorders or the effects of substances.

Why Is Bipolar Disorder So Difficult to Diagnose In Young Children?

It is difficult to "fit" the bipolar child into the adult definition of the illness. The first bipolar disorder criterion is a manic episode lasting for at least four days. In many such children mood and energy shifts occur several times each day. Except for certain adolescents who demonstrate the adult-type, prototypical onset of the disorder, young children often present very differently from the formal adult definition of bipolar disorder. This would include individuals with good functioning who experience an abrupt onset of mania, often requiring hospitalization.

Instead, the bipolar child frequently has an ongoing, continuous mood disturbance that is a mixture of mania (defined as elation or agitation, accompanied by a high level of energy) and depression (defined as extreme sadness or irritability, accompanied by a low level of energy). This feature is called "rapid cycling" and it generally results in a kind of chronic irritability. Over time, there are fewer clear periods of the "wellness" which is often seen in adolescents and adults.

The course of the disorder in children often seems to occur almost sporadically. Parents often tell me, especially during the initial onset of the illness, that their child has "good" days or even weeks. These periods, which are often recognizable later as the manic phase of the illness, give rise to hope for longer-term improvement. With the passage of time, however, parents become increasingly concerned about the persistence, and often intensification, of symptoms including moodiness or irritability, disruptive behaviors at home and at school, sleep disorders, diminished concentration and attention span, and hyperactive, impulsive behaviors. Poor frustration tolerance and explosive anger outbursts often occur. Periods of clear depression during which the child may express suicidal thoughts may also ensue. The bipolar child often demonstrates diminishing returns in terms of academic performance.

It is hypothesized that only the most severe cases of bipolar disorder in children come to the attention of physicians or other mental health professionals because manic episodes may be explained and/or tolerated by parents as simply phases of growing up. These episodes are more likely to be dismissed or minimized by parents if the child’s academic performance is unaffected. Certainly, hypomanic or even hyperactive behavior occurs in normal children, and across virtually all developmental stages. The distinguishing factor of this behavior among normal children is the temporary nature of the behaviors, and the absence of depression.

Available data suggest that onset of bipolar disorder prior to adolescence may be comorbid (exist along with) with ADHD, or conduct disorder; or may have features of ADHD and Conduct Disorder as the initial symptoms.

How Do I Know If My Child Is At Risk For Bipolar Disorder?

Various authors have described the profile of a child who is at risk to develop bipolar disorder as follows:

The bipolar child’s emotions are intense. Whether they experience positive or negative emotions, it is guaranteed that they will be expressed in a very passionate manner.
The bipolar child’s behavior and mood often seem to be dysregulated and disinhibited. The bipolar child may, for instance, become instantly elated at seemingly insignificant news, i.e., that his dog no longer has fleas; or inordinately sad or depressed about the fact that his grandparents’ visit has been delayed by an hour or two. Extreme behaviors, including aggression toward peers with no apparent, external precipitant, may occur. Behavior toward adult authority figures, including parents and teachers, may be intermittently rude, disobedient and even intimidating.
The "predictors" of bipolar disorder in children include a family history of bipolar disorder, a sudden onset of symptoms of either mania or depression, psychomotor retardation (a visible slowing of usual motor tasks) and hypersomnia (excessive sleeping).

Why is "Correct Diagnosis" So Important?

Unfortunately, after bipolar symptoms first appear in children, it is not unusual for months or even years to pass. During this interim, the child’s ability to function at home, school and in the general community, often deteriorates. The results of untreated, or undiagnosed bipolar disorder may include, but are not limited to, the following:

Unnecessary symptomatic behaviors, including destructive behaviors that persist beyond age 4, talk of wanting to die or kill oneself; trying to commit dangerous behaviors, e.g., trying to jump off roofs, or from moving vehicles. These symptoms/behaviors can result in untoward consequences; e.g., suspension from school, placement in a residential treatment center or hospital, or involvement in the juvenile justice system.
The development of personality disorders, which predict a longer term, adult adjustment that is far from optimal.
A worsening of the disorder as the result of improper diagnosis and, possibly, improper medications.
Drug abuse, accidents (due to risk-taking behaviors) and even suicide.

How Can I—An Informed Parent—Help My Child?

There is no blood test, brain scan or other diagnostic "tool" to definitively establish a diagnosis of bipolar disorder in children. It is imperative that parents contact a professional who is well-versed in this disorder in children if their child talks about suicide, or who demonstrates, consistently, the behaviors and moods described above. It is very helpful to the professionals if parents take daily notes about their child’s behavior, mood and any events they consider to be unusual. In addition, parents should jot down any statements made by their child which they consider to be particularly worrisome.

During well-compensated periods, the bipolar child may present to the professional as well-adjusted, energetic and charming. It is for this reason that a solid evaluation for bipolar disorder may take two or more sessions to complete.

How Do I Find A Doctor?

A board-certified child psychiatrist is the first choice. A child psychiatrist is a physician who has completed two years of a child psychiatry fellowship program, in addition to his or her adult psychiatric residency program. There is a shortage of child psychiatrists. Ask your child’s pediatrician. Teaching hospitals with medical schools are a good place to start looking if you are unable to find a local child psychiatrist. Some parents choose to use nationally known doctors at teaching hospitals for diagnosis and stabilization, and then use local professionals for ongoing treatment and psychotherapy. There are physicians listed in the American Academy of Child and Adolescent Psychiatry who describe a special interest or expertise in bipolar disorder.

If you are absolutely unable to locate a child psychiatrist, search for an adult psychiatrist who has an extensive background in mood disorders and who has some experience in treating children and adolescents.

Certain pediatricians in consultation with psychopharmacologists can provide good care if a child psychiatrist is not available. Some pediatric neurologists treat bipolar children; they are familiar with the anti-convulsant medications, which are often used in the treatment of bipolar children.

Your doctor should have the following characteristics:

Knowledgeable about mood disorders with a strong background in psychopharmacology.
He or she should welcome information from the parents regarding their child’s behavior; should work closely with the parents and should value their ongoing input.
Should have a good rapport with the child.
Explains medical matters and medications clearly, and repetitively if necessary.
Willing to advocate for the child with the school and with managed health care companies if necessary.

What Is The Treatment For Bipolar Illness In Children?

There is no "cure" for bipolar disorder. Treatment can, however, stabilize the child’s moods and thus allow for control of symptoms. Stated differently, bipolar disorder can be effectively managed. A good treatment plan should include the following:

Medication.
Close, ongoing monitoring of symptoms.
Education for the child and the child’s family about the disorder.
Counseling or psychotherapy for the child and family. This is especially important during the initial onset of the illness. Counseling or psychotherapy alone will not be sufficient. In fact, this component of treatment will probably be ineffective, except for educational purposes, until mood stabilization occurs with use of medication.
Education about the value of nutrition and sleep patterns, regular exercise, and stress reduction.
Participation in a support network.

What Is My Role As An Informed Parent?

Learn all you can! Read; there is a wealth of information on the Internet, from which much of the summary information in this article was obtained. Join support groups—this will provide you with even more information , and will allow you to network with other affected parents.

Manage relapses—at the first sign of recurrence or worsening of symptoms, obtain prompt professional intervention. This will provide invaluable modeling for your child, who will ultimately need to learn to manage the disorder himself.

Summary

It is now widely recognized that bipolar disorder can and does have its onset in early childhood. Diagnosis of bipolar disorder in children is particularly difficult because of the absence of long term studies including prevalence rates; the similarity, at least initially, with other disorders (including most notably ADHD and Conduct Disorder); and the variability in presentation of children with bipolar disorder. In addition, parents may dismiss all but the most severe manic or depressive symptoms as simply a developmental phase.

The child who is at risk for bipolar disorder demonstrates very intense emotions and disinhibited behavior. Symptoms may include moodiness or irritability, disruptive behaviors at home and at school, sleep disorder, diminished concentration and attention span, and hyperactive, impulsive actions. Poor frustration tolerance and angry outbursts are not unusual. Behavior toward adult authority figures may be rude, disobedient and even intimidating.

Correct diagnosis is critical. Early identification and intervention can ward off the development of later personality disorders, and unnecessary symptomatic behaviors including suicidal attempt and residential placement in treatment centers, hospitals or juvenile detention facilities.

There is no definitive tool to diagnose bipolar disorder in children. Parents who suspect that their child is at risk should take daily notes about their child’s behaviors and moods. They should also make a record of any statements made by their child which seem particularly worrisome.

A board-certified child psychiatrist is the physician of choice to diagnose and initiate treatment for children who demonstrate the signs and symptoms of bipolar disorder. If unavailable, consult with nearby, teaching hospitals; an adult psychiatrist who is well schooled in mood disorders and has provided some treatment to children and adolescents; your child’s pediatrician; or a pediatric neurologist. Look for certain characteristics about your child’s doctor, including his or her willingness to consider all information you present.

Although there is no "cure" for bipolar disorder, effective treatment can stabilizer your child’s moods and, therefore, allow for a more optimal level of functioning. A good treatment plan should include medication, ongoing, close monitoring of symptoms, education, psychotherapy or counseling for the child and his or her family, and participation in support networks.

In future articles, the onset of bipolar disorder in adolescents will be addressed. In addition, parenting and educational needs of this special population will be explored. Learning that one’s child has a bipolar disorder can be traumatic. However, early diagnosis and treatment can be a critical juncture for the child and his or her family. Energy can now be directed toward obtaining proper treatment, and allowing the child and family to develop coping mechanisms, which will assist the child in moving toward a better adjustment.

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