The idea that a child or teenager might show signs of abrupt changes of mood will not surprise most parents. Mood swings are part of growing up. Sometimes these mood swings and the behaviors associated with them become extreme enough that they may be symptoms of bipolar disorder (BPD), a psychiatric diagnosis describing a condition in which people go back and forth between periods of super-energized highs and depression.
The mood swings of bipolar disorder — between mania, an agitated, ebullient state in which people often feel superhuman and depression — can be very quick. One day a person feels on top of the world: they may write or paint or work non-stop, run up credit card bills they have no way of paying, or have wild sexual encounters. A few days later they may feel completely low, perhaps suicidal, flattened by depression. For this reason, the disorder used to be, and is sometimes still, called manic-depressive illness.
It is important for families to know what to look for in their children's changing moods and behaviors to distinguish the normal, and sometimes extreme, ups and downs of development, from the beginnings of a serious psychological disorder that needs to be treated. If you suspect your child has BPD, you should seek help from psychiatrists familiar with the disorder.
Fans of the television series, Homeland, will recognize that these symptoms affect Carrie Mathison, one of the show's main characters. In real life, the actors Carrie Fisher, Catherine Zeta-Jones, Patty Duke and Jean-Claude Van Damme have all discussed their struggles with the illness. The artist Vincent Van Gogh was also affected by bipolar disorder, along with many other people, famous and not.
Bipolar disorder is seen primarily in adults, but it is diagnosed with increasing frequency in children and teens. As every parent knows, mood swings are not unusual for this age group, so it is trickier to diagnose BPD in children and adolescents. It is important for families to know what to look for in their children's changing moods and behaviors to distinguish the normal, and sometimes extreme, ups and downs of development, from the beginnings of a serious psychological disorder that needs to be treated. If you suspect your child has BPD, you should seek help from psychiatrists familiar with the disorder.
There are many questions about how this bipolar disorder, when recognized in childhood and adolescence, relates to adult bipolar disorder. Is it the same condition, and should it be diagnosed according to the same criteria? Is pediatric bipolar disorder simply early onset adult bipolar disorder or does it have unique characteristic and a different course? What are the implications of applying this label to children and teens? And perhaps most important, how does the treatment of pediatric bipolar disorder differ from the treatment of adults with BPD? This is another reason why help from professionals with experience with the disorder in children and adolescents is very helpful.
Pediatric bipolar disorder can disrupt social, family, and school functioning and interfere with normal social development.
The diagnosis and management of bipolar disorder is difficult at any age, however. As its symptoms suggest, BPD is associated with a number of mental health conditions including depression, suicidal thoughts, and impulsive behavior – aggression, sexual promiscuity, drug use and violence. Young patients with bipolar disorder often have other psychiatric disorders including ADHD, anxiety, Oppositional defiant disorder (ODD) and Conduct Disorder. Pediatric bipolar disorder can disrupt social, family, and school functioning and interfere with normal social development.
There are four types of bipolar disorder, all of which have mania as a key feature. Mania is an abnormally elevated and energized mood that is not caused by specific circumstances or events. It is characterized by elation, grandiose behaviors, the rapid flight of ideas, a decreased need for sleep, and hypersexuality. Children may laugh hysterically, be convinced that they can perform superhuman deeds without threat of injury, jump from topic to topic in rapid succession, sleep for only a few hours without displaying fatigue, and act inappropriately flirtatious. Such children may be silly, hyperactive, aggressive, and prone to dangerous behaviors because of their belief that they are invincible.
The four types of BPD are distinguished by the degree and duration of the highs and lows.
Bipolar disorder episodes are significantly different from the person’s normal, day-to-day functioning and mental and emotional states. People with BPD may cycle from extreme highs (mania) to extreme lows (depression). The four types of BPD are distinguished by the degree and duration of the highs and lows.
The Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) details important distinctions between mania and hypomania. Mania is a mood disturbance that is severe enough to impair a person's ability to work, function socially and relate to other people. A person in a manic phase may need to be hospitalized to prevent them from harming themselves or others. Mania may also have psychotic features, with the person seeing, hearing or believing things that have no basis in reality.
Bipolar I disorder is the classic form with cycling between extreme highs and lows. The minimum duration for mania or mixed mania and depressive episodes is seven days in classic BPD I.
Bipolar II disorder is characterized by depression as its major challenge but the patient must also have a current or past episode of hypomania. It has been described as having little ups and big downs as contrasted to the big ups and big downs of bipolar I.
Almost half of patients who were diagnosed with BPD-NOS met criteria for bipolar I or bipolar II within five years.
The third type of bipolar disorder is called cyclothymic disorder, a chronic disorder, lasting at least two years in adults and one year in children and adolescents, of relatively mild hypomanic and depressive symptoms (little ups and little downs).
The fourth type, bipolar disorder, not otherwise specified (BPD-NOS), is a catch-all designation, described in the DSM as “disorders with bipolar features that do not meet criteria for any specific bipolar disorder.”, This would include patients whose manic cycles are less than seven days, their hypomanic cycles are less than four days, who may cycle rapidly within the course of a day or week or who have chronic manic or depressive symptoms. This designation is perhaps most useful for children and is often diagnosed in teens, whose symptoms and cycle frequency and length often don’t fit into classic definitions.
It is possible that BPD-NOS is an early presentation of bipolar I or II. Studies have shown that almost half the patients diagnosed with BPD-NOS met criteria for bipolar I or bipolar II within five years.
As mentioned above, the diagnosis of pediatric bipolar disorder is challenging and is most accurately made by skilled professionals with extensive experience. The Academy of Pediatrics recommends a full psychiatric evaluation and discourages general pediatricians from initiating treatment in newly-diagnosed cases.
What is important, however, is that general practitioners and families become attuned to aspects in patients’ histories or behaviors that warrant further investigation and possible referral to specialists for further diagnosis. Here are the “red flags” to be aware of, whether they are occurring currently, or in the recent or distant past:
Outbursts of rage or verbal or physical aggression. While rage itself is not a bipolar symptom, the AAP statement notes that it is common in adolescents who are experiencing mania or chronic severe mood dysregulation. The adolescent feels on edge and is easily frustrated and easily provoked.
Little need for sleep. Even after several nights affected adolescents may require at least two hours less sleep than is typical and still remain at their full energy level.
Spontaneous mood shifts. Without any obvious triggering event, the teen shifts from contented, to giddy, to depressed or angry. The mood shift may occur several times a day.
Excessive involvement in pleasurable activities that have a high potential for painful consequences, such as running away, sneaking out at night, spending money, and hypersexuality.
Grandiosity. The child exhibits a greatly exaggerated belief that he or she has special talents or abilities, such as believing that one is never in danger regardless of the activity.
It is important for parents to recognize that all these red flags represent behavior that is very different from normal and interfere with normal interactions at school, home, work and with friends.
Depression, rather than mania, may be the first symptoms of bipolar disorder. When this is the case, pediatricians and families may be the first to identify signs of depression, characterized by a low mood that is beyond the range of normal sadness. It can be manifested by irritability, persistent sadness, frequent crying, thoughts of death or suicide, lack of enjoyment in activities which are normally pleasurable, physical complaints of pain and aches, low energy level, poor concentration, and changes in eating and sleeping patterns.
Because of the mood swings of bipolar disorder, treatment will necessarily be multi-faceted. Psychotherapy, medications, and sometimes, hospitalization, are all used.
One of the most important aspects of treatment involves educating the patient and his or her family about the condition. Not only are there quite a few treatment options to consider and medications to try, but BPD often takes a chronic/relapsing course. Children and their parents need to be prepared for this possibility, so they do not become discouraged. And patients need to fully understand that they must keep up with treatment even when they are symptom-free. Otherwise, when a manic phase hits, people with BPD may feel they can handle everything themselves, no help needed, or they may feel treatment will only bring them down from a fantastic mood.
Individual psychotherapy can help people with BPD handle the impact of the disease on their lives, providing coping strategies. Cognitive behavioral therapy, which focuses on irrational beliefs and distorted thoughts, can be helpful in dealing with both mania and depression.
Family and group therapy can address disruptions in social and family functioning. Patients often have trouble regulating their emotions, get poor grades in school, have few friends, and difficult relationships with parents and siblings. Therapy can strengthen social skills and communication techniques. Academic as well as occupational functioning must be assessed and addressed to decrease BPD-related disruptions in school and the workplace.
Patients with bipolar disorder are often prescribed several medications so that they can take lower doses of each individual medication and prevent toxicity, target specific symptoms, or to treat additional disorders that may arise during the course of the illness. Because these medications have been approved for use in adult bipolar disorder, and not all medications have been tested specifically for pediatric use, there is concern about their use in children. Yet children and teens are often severely impaired by their symptoms and deserve the benefit of pharmacological treatment when those benefits outweigh the risks. An approach to weighing those risks and benefits has been proposed by the American Academy of Child and Adolescent Psychiatry. It suggests the following guidelines to ensure a careful consideration of pros and cons:
Medications should be chosen based on:
- the evidence of their effectiveness
- the phase (mania, hypomania, mixed episode, depression) of the illness
- whether the patient has psychotic symptoms (loss of touch with reality)
- the safety and adverse effect profile of the drug
- the of patient’s past history of response to medications
- the patient or family preference.
Every drug prescribed should be monitored scrupulously for its effectiveness and side effects. Ideally, any adjustments to medication should be made one drug at a time to have as clear a picture as possible of the outcome.
During the course of the illness, as symptoms evolve and other conditions arise, medications may need to be adjusted. As mentioned earlier, getting patients to stay on their medications can be difficult, but it is critical. Regular follow-up and ongoing education are essential to keep children and teens (adults, too) who are feeling better from going off their medications because they have decided that the sometimes unpleasant side effects of treatment outweigh the benefits.
Patients with bipolar disease may require hospitalization if the symptoms appear to be severe enough to cause self-destructive behavior, a risk of suicide, aggressive behavior toward others or, if mania is very severe, threaten the patient’s safety.
The debate (and research) will continue as to whether pediatric bipolar disease is a separate entity, or an earlier presentation of classic adult bipolar. But the existence of conditions of dysregulated moods and cyclic highs and lows that interfere with and impair successful functioning of children and teens is a reality. Currently, bipolar disease in adolescence presents a somewhat clearer picture than BPD in early childhood. The American Academy of Pediatrics would like pediatricians to play a role in the diagnosis and care of children and teens diagnosed with bipolar disorder so that they, and their parents, receive safe and evidence-based educational, psychotherapeutic, and pharmacological treatments.