Juvenile Bipolar Disorder
Juvenile Bipolar Disorder
Definition
Juvenile bipolar disorder (also called manicdepressive illness) is a chronic condition characterized by repeated swings in mood between mania (a state of elation and high energy) and depression. Early-onset bipolar disorder is manic depression that appears very early in life. Historically it was thought that children could not suffer the mood swings of mania or depression, but recent research has revealed that bipolar disorder (or early temperamental features of it) can occur in very young children, and that it is much more common than previously thought.
Although children with bipolar disorder have not been well studied, the condition is believed to occur as frequently as it does in adults, and it can affect children more severely. Adults typically experience abnormally intense moods for weeks or months at a time, but children can have rapid shifts of mood that commonly cycle many times within the day. This cycling pattern is called ultra-ultra rapid or ultradian cycling, and it is most often associated with low arousal states in the mornings followed by afternoons and evenings of increased energy. Bipolar disorder is often hard to diagnose in children, because its symptoms are difficult to distinguish from those of other mental disorders. If left untreated, bipolar disorder can significantly affect a child’s relationships, overall functioning, and school performance. It also can lead to violence, drug and alcohol use, and suicide attempts.
Description
Juvenile bipolar disorder is a mental condition characterized by repeated episodes of depression, mania, or both symptoms. The child may experience extreme shifts in mood and behavior. For a child to be diagnosed with bipolar disorder, the condition must be severe enough to disrupt his or her normal functioning.
The fourth edition (revised text) of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) identifies three types of bipolar mood episodes (these episodes were defined for adults, not children):
- Manic episodes: an elevated or irritable mood that lasts for a period of at least one week
- Hypomanic episodes: a distinct period of persistently elevated, expansive, or irritable mood that lasts for at least four days
- Mixed episodes: increased energy and agitation, coupled with feelings of sadness and worthlessness
Three major subtypes of bipolar disorder exist—bipolar I disorder (BP-I), bipolar II disorder (BP-II), and bipolar disorder not otherwise specified (BPNOS). The DSM-IV-TR defines these bipolar disorder subtypes as follows:
- BP-I: the occurrence of a manic or mixed episode that lasts for at least one week
- BP-II: alternating depressive and hypomanic episodes
- BP-NOS: cases that do not meet the full criteria for the other two bipolar disorder subtypes but that involve an elevated or irritable mood, plus two or three bipolar symptoms (difficulty concentrating, sleep changes, and so on) that are severe enough to interfere with functioning
Evidence exists that juvenile bipolar disorder is a different and more severe form than adult-onset bipolar disorder. The child may cycle more rapidly from emotional highs (elation) to lows (anger and irritability). Bipolar disorder often can coexist with other emotional and behavioral problems, such as attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), schizophrenia , and anxiety disorders.
Demographics
The lifetime prevalence of bipolar disorder is between 1% and 3%. However, considering borderline cases, the rate may be as high as 6%. Some research suggests that as many as 1% of children may have bipolar disorder. Although the condition affects males and females equally, in children under 13 the cases are predominantly male.
Causes and symptoms
Bipolar disorder has a strong genetic component. Studies suggest that the children or siblings of bipolar individuals have a four-to-six-fold increased risk of developing the disorder. Environmental factors, such as child maltreatment, also may play a role in the development of the condition.
Symptoms of bipolar disorder can be broken down into two categories— manic symptoms and depressive symptoms. Children with bipolar disorder may swing through cycles of these two different types of emotions. Manic symptoms include:
- Extreme shifts in mood, from anger to euphoria
- Bursts of rage
- Irritability
- Increased energy
- Over-inflated sense of self-esteem, grandiose behavior
- Decreased need for sleep, without any apparent drowsiness during the day
- Lack of attention, moving quickly from one topic or task to the next
- Increased sexuality inappropriate to age
- Agitation
- Willingness to engage in risky behaviors
Depressive symptoms are at the opposite end of the mood spectrum. They include:
- Persistent sadness (this can include unexplained crying episodes, reclusiveness, and increased sensitivity)
- Decreased energy
- Low self-esteem
- Sleepiness and increased desire to sleep
- Difficulty concentrating
- Lack of interest in school and other activities
- Persistent thoughts of death or suicide
- Unexplained aches and pains
- Alcohol or drug use
Children and adolescents with bipolar disorder may have difficulty regulating between these two types of moods. They may have explosive outbursts of anger lasting anywhere from a few minutes to a few hours, followed by periods of extreme happiness. Whereas adults can take months to cycle between mania and depression, children can cycle within weeks or even days, so they are more often symptomatic.
It is sometimes difficult to distinguish manic symptoms with those of ADHD, because hyperactivity and irritability can be hallmarks of both conditions, and both often occur simultaneously. Research suggests that more than half of children and adolescents with bipolar disorder also have ADHD. To distinguish bipolar disorder from ADHD, doctors look for symptoms that are unique to bipolar disorder, such as elated mood, decreased sleep, and grandiose behavior.
Diagnosis
Children with symptoms of bipolar disorder should see a psychologist or psychiatrist for evaluation, especially if a first-degree family member has a history of the condition. Evaluation is also important in children who are taking stimulant medications for ADHD and who are experiencing manic symptoms as a result. Children with bipolar disorder should be carefully monitored for associated problems, such as substance abuse , developmental delays, and suicide.
Diagnosis of children with bipolar disorder is often challenging, because the condition can present with other mental disorders, such as depression, and because symptoms (such as boasting and elation) can be difficult to distinguish from other childhood disorders and normal childhood emotions. Doctors often use DSM-IV guidelines to diagnose children with bipolar disorder, but these were developed for adults, and the symptoms can differ.
Assessment should include personal and family histories of depression and mood disorders, and identification of mood changes. Diagnostic interviews and questionnaires, such as the Diagnostic Interview for Children and Adolescents-revised (DICA-R), the Diagnostic Interview Schedule for Children (DISC), and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) can be useful for diagnosis. Clinical rating scales, such as the Mania Rating Scale, can help doctors initially identify illness severity and later assess the effects of treatment on the child’s symptoms.
When diagnosing mania episodes, 2005 treatment guidelines from the Academy of Child and Adolescent Psychiatry (AACAP) suggest that doctors use Frequency, Intensity, Number, and Duration (FIND) as a guide:
- Frequency: Symptoms occur most days of the week
- Intensity: Symptoms are severe enough to cause extreme disturbance in one area of a child’s life, or moderate disturbance in two areas
- Number: Symptoms occur three to four times per day
- Duration: Symptoms last for four hours a day (not necessarily contiguous)
Treatments
Most treatment recommendations for children with bipolar disorder are made based on adult research data, because little research has been done on the safety and efficacy of mood stabilizing medications in children. Doctors typically use two types of drugs to treat children with bipolar disorder: mood stabilizers (lithium, divalproex, carbamazepine , valproate) and atypical antipsychotics (olanzapine, quetiapine, risperidone ). These drugs have only been approved by the U.S. Food and Drug Administration for bipolar disorder in adults, with the exception of lithium, which has been approved for children age 12 and older.
The AACAP panel recommends that doctors treat their patients with medication for a minimum of four to six weeks and reassess if there is a lack of response. Doctors should carefully monitor their patients who are taking these medications, because of the risks of side effects. According to the AACAP practice parameters, doctors should consider effectiveness, phase of illness, tolerability, and patient history of medication response, among other factors, when prescribing these medications. Atypical antipsychotics can cause marked weight gain in some children, which can lead to heart problems and diabetes later in life. They have also been linked to a rare but serious condition called tardive dyskinesia , which is characterized by abnormal movements (such as of the tongue).
Drugs used to treat other mental health conditions, such as antidepressants for depression and stimulant medications used to treat ADHD, may lead to manic symptoms. If a child becomes manic while taking antidepressants or stimulants, he or she may require treatment for bipolar disorder.
Some children with bipolar disorder may benefit from a combination of medication and psychotherapy , including cognitive-behavioral therapy , which teaches children how to recognize and cope with the emotions that are leading to their condition.
KEY TERMS
Attention deficit hyperactivity disorder (ADHD) —A behavioral disorder occurring during childhood that is characterized by poor concentration and hyperactivity.
Atypical antipsychotics —A class of newer generation antipsychotic medications that are used to treat schizophrenia, bipolar disorder, and other mental disorders.
Conduct disorder —A pattern of disruptive behaviors that violate rules or the rights of others. These behaviors can include bullying, lying, destroying property, and stealing.
Hypomania —A milder form of mania that involves increased mood and a decreased need for sleep. Mania—A condition involving excessive elation or irritability, difficulty focusing, restlessness, and a decreased need for sleep.
Mixed episodes —Periods in which mania and depression coexist.
Rapid cycling —A condition that occurs with bipolar disorder, in which the person cycles rapidly between manic and depressive symptoms.
Schizophrenia —A mental disorder in which a person experiences hallucinations, delusions, and displays unusual behavior.
Tardive dyskinesia —Abnormal involuntary movements that can occur with the long-term use of certain antipsychotic medications.
Ultra-ultra rapid or ultradian cycling —Most often associated with low arousal states in the mornings followed by afternoons and evenings of increased energy.
Prognosis
Children with bipolar disorder will typically require ongoing treatment with medication to prevent a relapse , and some will require a lifetime of treatment. Even with medication, bipolar disorder can be chronic, with symptoms persisting for many months or even years. In adolescents, bipolar disorder tends to be more chronic and treatment-resistant than it is in adults. The rate of relapse in young people can be greater than 50%.
Prevention
Although the initial onset of bipolar disorder is not preventable, there are strategies to help avoid a relapse. The family of the bipolar child can learn ways to identify relapse symptoms and how to avoid factors that may trigger relapse (such as substance abuse, stress , medication noncompliance, or sleep deprivation). Families also may be taught communication skills to improve their interpersonal relationships.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.
Faedda, Gianni L., and Nancy B. Austin. Parenting a Bipolar Child: What to Do and Why. Oakland:New Harbinger Publications, 2006.
Lombardo, Gregory T. Understanding the Mind of Your Bipolar Child: The Complete Guide to the Development, Treatment, and Parenting of Children with Bipolar Disorder. New York: St. Martin’s Press, 2006.
Mash, Eric J., and Russell A. Barkley, eds. Treatment of Childhood Disorders. 3rd ed. New York: The Guilford Press, 2006.
Suppes, Trisha, MD, PhD, and Ellen B. Dennehy, PhD. Bipolar Disorder: The Latest Assessment and Treatment Strategies. Kansas City: Compact Clinicals, 2005.
ORGANIZATIONS
Child & Adolescent Bipolar Foundation, 1000 Skokie Boulevard, Suite 570, Wilmette, IL 60091. (847) 256-8525. <http://www.bpkids.org>.
Depression and Bipolar Support Alliance, 730 N. Franklin Street, Suite 501, Chicago, IL 60610-7224. (800) 826-3632. < http://www.dbsalliance.org>.
Mental Health America, 2000 N. Beauregard Street, 6th Floor, Alexandria, VA 22311. (800) 969-6642. <http://www.nmha.org>.
National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201-3042. (800) 950-6264. <http://www.nami.org>.
National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (866)615-6464. <http://www.nimh.nih.gov>.
Stephanie N. Watson