About Pediatric Bipolar Disorder
A Guide for Families by the
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|Goals of Treatment|
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Bipolar disorder (also known as manic-depression) is a chronic brain disorder marked by bouts of extreme and impairing changes in mood, energy, thinking, and behavior. The most outwardly apparent symptoms are behavioral; however, the illness often has less visible, but serious, cognitive, cardiac, and metabolic effects. Symptoms may emerge gradually or suddenly during childhood, adolescence, or adulthood. Researchers have identified cases of bipolar disorder in every age group studied, including preschoolers.1
Here, The Balanced Mind Foundation examines bipolar disorder that emerges in childhood or adolescence.
Bipolar disorder does not affect every child in the same way. The frequency, intensity, and duration of a child’s symptoms and the child’s response to treatment vary dramatically. As the child grows up, bipolar disorder may affect the size, shape, and function of brain regions and networks. Recent research suggests that pediatric bipolar disorder is a neurodevelopmental disorder. Parts of the brain mature (or come online) at different rates and times; brain maturation is not complete until an individual is 25 or so. Consequently, the symptoms and diagnosis of a psychiatric illness may change as the child grows.
There is presently no cure for bipolar disorder. Yet, there are reasons for optimism. Research to help children and adults with this illness is ongoing. Genetic discoveries are expected to lead to more accurate diagnosing, better treatments, and perhaps a cure. As always, it is wise to expect the best but prepare for the worst. Learn where the road ahead may lead. Develop strategies and contingency plans while staying flexible and confident in the present. Network with other parents. Be involved in The Balanced Mind Foundation. Most importantly, take care of yourself.
Pediatric Bipolar Disorder
The Diagnostic and Statistical Manual of Mental Disorders, the formal psychatric diagnostic manual referred to as the "DSM-IV", is the standard reference for diagnosing psychiatric disorders. However, when the DSM-IV was first published in 1994, the entire focus was on adult-onset bipolar disorder. In the decade plus since then, rapid research developments in every area of science, especially the brain, have answered many old questions and opened the door to new questions we couldn't even articulate then.
We now understand that children and adolescents can have bipolar disorder. Some of our ill children meet the textbook definition of bipolar disorder. Some of our ill children with severe mood dysregulation might not meet the textbook definition because they don't have distinct episodes of a certain duration or have few clear periods of wellness between episodes. They might have rapid and severe cycling between moods or they might present in a mixed state that produces chronic irritability. Experts have not yet reached consensus as to whether children with chronic irritability and clear mood swings, but without mania, should be classified as having bipolar disorder. The Balanced Mind Foundation urges the research community to agree on a common terminology and a way to communicate with each other and with families about the full spectrum of the severe illness(es) impairing our children. It is imperative that we work together to alleviate the terrible suffering that this disorder wreaks.
The DSM-IV Diagnosis
The DSM-IV describes four types of bipolar disorder.2
Bipolar I. In this form of the disorder, the individual experiences one or more episodes of mania. Episodes of depression may also occur, but are not required to diagnose bipolar disorder.
Symptoms of mania include:
- euphoria (elevated mood)—silliness or elation that is inappropriate and impairing
- flight of ideas or racing thoughts
- more talkative than usual or pressure to keep talking
- irritability or hostility when demands are not met
- excessive distractibility
- decreased need for sleep without daytime fatigue
- excessive involvement in pleasurable but risky activities (daredevil acts, hypersexuality)
- poor judgment
- hallucinations and psychosis
For an episode to qualify as mania, there must be elevated mood plus at least three other symptoms, or irritable mood plus at least four other symptoms.
Symptoms of depression include:
- lack of joy and pleasure in life
- withdrawal from activities formerly enjoyed
- agitation and irritability
- pervasive sadness and/or crying spells
- sleeping too much or inability to sleep
- drop in grades or inability to concentrate
- thoughts of death and suicide
- fatigue or loss of energy
- feelings of worthlessness
- significant weight loss, weight gain or change in appetite
Stable periods occur between episodes of mania and depression. An episode must last at least one week, or, if hospitalization is necessary, may be of any duration.
Bipolar II. In this form of the disorder, the individual experiences recurrent periods of depression with episodes of normal mood (euthymia) or hypomania between episodes. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy. Hypomania can be a time of great creativity and energy and may, but not always, progress into full-blown mania if not treated. Some people with bipolar disorder never develop full-blown mania.
Bipolar Disorder NOS (Not Otherwise Specified).Doctors may make this diagnosis when there is severe mood dysregulation with serious impairment, but it is not clear which type of bipolar disorder, if any, is emerging. Perhaps the individual has always been impaired, with cycling apparent since infancy. Maybe there have been no discernable periods of wellness. Perhaps the child is experiencing the emergence of another neurodevelopmental illness and the symptoms of that disorder have not yet been fully expressed. The inability to pinpoint a diagnosis should not be taken as a dismissal of the severity of the child’s symptoms.
Cyclothymia. This form of the disorder produces recurrent periods of less severe, but definite, mood swings that seriously impair the individual's life. Cyclothymia may progress into full bipolar disorder.
A Child's Behavior
Since its founding in 1999, The Balanced Mind Foundation has reviewed numerous family accounts that repeatedly report similar behaviors. If your child exhibits more than a few of these behaviors and you know something is wrong, follow through with our First Steps plan. This is especially crucial if there is a history of mood disorders or substance abuse in your child's family.
Severe and recurring depression
Explosive, destructive or lengthy rages, especially after the age of four
Extreme sadness or lack of interest in play
Severe separation anxiety
Talk of wanting to die or kill themselves or others
Dangerous behaviors, such as trying to jump from a fast moving car or a roof
Grandiose belief in own abilities that defy the laws of logic (possessing ability to
Sexualized behavior unusual for the child’s age
Delusional beliefs and hallucinations
Extreme or persistent irritability
Telling teachers how to teach the class, bossing adults around
Creativity that seems driven or compulsive
Excessive involvement in multiple projects and activities
Compulsive craving for certain objects or foods
Hearing voices telling them to take harmful action
Racing thoughts, pressure to keep talking
Sleep disturbances, including gory nightmares or not sleeping very much
Drawings or stories with extremely graphic violence