Understanding Bipolar Disorder in Children and Teens

How to identify the signs and symptoms


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Mood disorders are difficult to diagnose in children. Neither a middle-schooler nor a preschooler has the communication tools to fully express his emotional needs as he goes through the mind-boggling process of growing up. It’s a rare 3-year-old who never has a temper tantrum or gets overexcited. And it’s a rare teen who — with hormones flaring and self-awareness emerging — never gets moody or sad.

But what if your daughter’s tantrums are severe and unprovoked? What if your son keeps you awake all night, bouncing off the walls? What if your teen’s mood swings wreak havoc on your daily routine and her work at school?

Bipolar disorder is a mental illness that causes extreme and atypical shifts in mood and behavior, often from manic highs to major depressive lows. Bipolar disorder is uncommon among children and teens, but not insignificant. According to the National Institutes of Health, bipolar disorder affects 2.9 percent of adolescents, although this number varies depending on the study. It is a serious and chronic mental health disorder, and for individuals who are on the bipolar “spectrum,” it needs to be identified, addressed and treated. Early detection can help get symptoms under control, and help prevent dangerous addictive behaviors from developing.


Controversy

Bipolar disorder is at least as old as the terms the ancient Greeks came up with — “mania” and “melancholia” — to describe and link opposing extremes of emotional behavior. Despite this long history of awareness, only during the last 20 years has the psychiatric community concluded that bipolar disorder can be identified in childhood, and that early identification and treatment can potentially reduce symptoms and negative outcomes later in life.

Even having identified pediatric bipolar disorder, experts have struggled with how to properly define it in children, and have disagreed on whether a child with bipolar disorder would present the same symptoms as an adult with the disorder, according to Melissa Brotman, an assistant clinical investigator in the Neuroscience and Novel Therapeutics Unit of the Emotion and Development Branch at the National Institute of Mental Health.

Some psychologists originally assumed it would look different, and diagnosed children who showed symptoms of bipolarity but expressed less precise timing of episodes than what was laid out in the classic adult definition. Often, these children demonstrated constant irritability and hyperactivity, rather than the periodic mood swings typically associated with bipolar disorder. Other psychologists believed young patients were being over-diagnosed with bipolar disorder and worried that bipolar-specific drugs would exacerbate unrelated symptoms.

To resolve this dispute, the NIMH conducted an in-depth study of children who presented the classic, episodic features of bipolar disorder alongside children who presented a more persistent show of symptoms, and determined that only children with the classic symptoms had bipolar disorder as they reached adulthood, while the second group of children with the constant irritability tended to develop unipolar depression. To clarify the difference for professionals, the NIMH worked with the board of the “Diagnostic and Statistical Manual of Mental Disorders, 5th Edition” 9 (DSM-5) to come up with a definition — not for bipolar disorder, but for a new disorder: disruptive mood dysregulation disorder — to address the needs of the children with chronic symptoms.

Thus, for both children and adults, bipolar disorder is associated with episodic manic and depressive moods. In contrast, a child with DMDD would demonstrate constant irritability along with occasional angry outbursts.

“It was an important change, as there are profound implications for treatment,” Brotman says. “If a child has chronic irritability, that child needs completely different medication from one with manic symptoms.”

Brotman feels confident that the new definitions are “specific enough” so that over-diagnosing bipolar disorder can be prevented.


Diagnosis

Bipolar disorder is characterized by periods of mania, periods of depression and periods of relatively “normal” function. In children and teens, these mood swings last at least a week and are severe enough to critically interfere with daily life, sometimes requiring hospitalization.

The DSM-5 describes a manic episode as including at least three or more of these symptoms:
* Inflated self esteem or grandiosity.
* Decreased need for sleep.
* More talkative than usual or pressure to keep talking.
* Flight of ideas or subjective experiences causing racing thoughts.
* Distractibility.
* Increase in goal-directed activity or psychomotor agitation.
* Excessive involvement in activities that have a high potential for painful consequences. 

A depressive episode includes five or more of these symptoms, according to the Mayo Clinic:
* Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, a depressed mood can appear as irritability).
* Marked loss of interest or feeling no pleasure in all — or almost all — activities.
* Significant weight loss when not dieting, weight gain, or decrease or increase in appetite.
* Either insomnia or sleeping too much.
* Either restlessness or slowed behavior.
* Fatigue or loss of energy.
* Feelings of worthlessness, or excessive or inappropriate guilt.
* Decreased ability to think or concentrate, or indecisiveness.
* Thinking about, planning or attempting suicide.

Based on these symptoms, there are four levels of bipolar disorder, with bipolar 1 being the most severe, while bipolar 2, cyclothymic disorder and “bipolar not otherwise specified” cover cases in which symptoms exist but are progressively less severe. Eric Youngstrom, a professor of psychology and psychiatry at UNC-Chapel Hill, sees these gradients as a “spectrum,” similar to how autism is viewed as a spectrum.

“There are no sharp lines between these diagnoses,” he says.


A Tricky Diagnosis

While the DSM-5 has clarified pediatric bipolar disorder, it is still a tricky diagnosis for at least three reasons.

First, children are children. Any child can experience intense moodiness or display silly behavior.

“There’s some confusion about bipolar disorder because the term has become a part of pop culture,” says Dr. Bettina Bernstein, D.O., a child and adolescent psychiatrist specializing in mood disorders at the Children’s Hospital of Philadelphia. “You occasionally hear a teen say, ‘OMG, I’m totally bipolar today,’ In truth, having a typical teenage mood swing, or getting irritable with a friend, is nothing close to being bipolar.”

She describes a true manic episode as something that “goes over the line.” “They run into street, they strip off their clothes, they might be standing on the roof and think they can fly because they feel invincible, their speech is rapid and agitated, they think highly of themself but are not really doing that well. If they’re able to calm down, then it’s not bipolar disorder.”

Second, bipolar disorder has characteristics that are similar to those of other disorders. The mania associated with bipolar disorder can be similar to the hyperactive manner of attention deficit hyperactivity disorder. The depressive state of bipolar disorder can be mistaken for major depression or anxiety. In addition, bipolar disorder is sometimes confused with substance abuse. (See the sidebar for tips on distinguishing bipolar disorder from other disorders.)

Third, bipolar disorder is often “comorbid” with other mood disorders. That is, a child with bipolar disorder has a high likelihood (80 percent, according to Brotman) of having another mood disorder, like ADHD, obsessive compulsive disorder, oppositional defiance disorder, depression or an addiction. When comorbidity exists, it is important, says John Curry, professor of psychiatry and behavioral sciences at the Duke Institute for Brain Science, to diagnose and treat the most serious disorder.

“The clinician has to make a full diagnosis, but then has to decide the order of treatment; that is, which disorder is causing the most trouble, and treat that first,” he says. “If there’s a suicidal tendency, you’ve got to treat that first. If there’s substance abuse, you’ve got to treat that upfront. Treat depression before anxiety, etc.”

In order to receive an appropriate diagnosis, you will need to get a full psychiatric report from a professional for your child. Sara Salter, a child and teen psychologist at Wynns Family Psychology in Cary, recommends keeping a detailed log of your child’s behavior. Experts look carefully at time span and frequency of episodes, compared with your child’s baseline behavior, to distinguish bipolar disorder from other disorders.

Genetics also play a large role in mood disorders, so if there’s a family member who suffers from bipolar disorder, or even a family member who has been suicidal, experienced serious depression or addiction, or been hospitalized for symptomatic episodes, it is important that the evaluating doctor know this.

“Cast a wide net,” Youngstrom says. “Your information provides the analyst an important context for evaluating your child.”

Brotman points out that a child’s teacher is an important source of information as well. “We have to see that this is not just a failure to get along with a parent,” she explains. “A child must display symptoms in other settings: at home, at school and in a social context. It must be an impairment across settings.”

A child’s pediatrician is a great place to start. He or she can provide perspective and recommend a psychologist for a detailed evaluation.


Treatment

Mood stabilizers and intensive therapy are, Curry says, the “mainstay of treatment” for bipolar disorder. “However, many of these medications have only recently begun to be used in children with the condition, so not a lot of data about their use in childhood bipolar disorder exists.”

This lack of long-term data, along with the fear of stigma of “labeling” a child as bipolar, may make a parent hesitant to seek treatment for his or her child. On the other hand, bipolar disorder is a chronic, lifelong disorder, which can be life-threatening if left untreated.

“There is a higher rate of suicide among those with bipolar disorder,” Brotman says. “And often the comorbidities — drug addiction, extreme risk-taking, failure to engage in society, depression — can be devastating.”

Brotman is hopeful that the DSM-5 provides the right level of specificity in helping professionals properly diagnose mood disorders. She encourages parents to seek help.

“Don’t make your criteria as high as ‘really serious,’” she says. “Lower the threshold for seeking help. It can’t hurt to get an expert’s opinion, even if it’s just talking with your pediatrician.”

While Salter points out that there is limited research about using mood-stabilizing drugs with pediatric patients, she agrees that parents should seek help. “In general, therapists are very careful when prescribing medication to children,” she says.

According to April Harris-Britt, a psychologist at the AHB Center for Behavioral Health and Wellness in Durham, when a child is diagnosed with a mood disorder, he will benefit the most by having a team of treatment providers who are all collaborating to support his needs. The team should include: a psychologist to provide therapeutic support and skill-building for the child and parents; a psychiatrist if medications are warranted; the child's pediatrician to monitor his overall medical health in regard to nutrition, sleep and illness, which can impact symptoms; and finally, school personnel to provide emotional, social and academic support in his educational environment.

Harris-Britt also recommends that parents engage in “parent coaching” to learn more about their child's diagnosis, and to discuss a long-term plan for parenting strategies. Sara describes parent coaching as a form of behavioral therapy.

“Parents learn effective strategies for dealing with a mood disorder, such as setting up a predictable environment for the child, and establishing effective and positive boundaries.”


Looking Ahead

While there is not a lot of data yet, more is coming. Indeed, when Youngstrom started out in this field 20 years ago, there was no research on pediatric bipolar disorder. Now, he says, there are over 10,000 scholarly articles on the subject. “It’s coming so quickly it’s hard for even practitioners to keep up with it,” he says.

At the NIMH, Brotman is working on new treatments for pediatric mood disorders, including a cognitive behavioral therapy specific for bipolar disorder, as well as computer-based treatment trials.

Bernstein is also seeing some “very exciting” uses of technology in treatment, such as apps that track phone use and text messages to help identify when someone is starting to cycle into mania. “This cycling is not something the person is aware of, so it can be incredibly helpful to have that information,” Bernstein says.

Technology has also been used as a diagnostic tool. “We have a program that takes family history data along with a diagnostic checklist, and combines them into a risk score that reveals the probability that an individual will have bipolar disorder,” Youngstrom says.

In addition to the high-tech aids, there are some back-to-basics, low-cost lifestyle changes that have been shown to help manage symptoms. “We are learning that it’s likely that improvement in diet — like adding fish oil — along with regular exercise and sufficient sleep combine to have a measurable, positive effect on heart heath and brain health,” Bernstein says.

Youngstrom applauds this research as being good “both for children diagnosed with a disorder as well as for a child or teen who shows mood symptoms but doesn’t meet criteria for bipolar disorder. Now we can work to improve their sleep and other lifestyle choices to help them develop good habits, and hopefully decrease their chances of developing a full-blown mood disorder. … It’s a hopeful time to be bipolar.”



Caitlin Wheeler is a writer and mom in Durham.

 

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Duke Energy Center for the Performing Arts
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