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Bipolar Disorder in Children and Adolescents
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.
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.
The prevalence of bipolar disorder among children and adolescents in the US is 4%, according to the American Academy of Pediatrics (AAP). In other words, at any given time roughly 4% of children and adolescents will be diagnosed with bipolar disorder. The AAP's recent statement on the disorder, focusing primarily on adolescent disease, addresses the clinical issues, describes adolescent bipolar disorder and calls for pediatricians to play a role in the collaborative care of these challenging patients.
Identifying Bipolar Disorder in Children and Adolescents
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?(1) This is another reason why help from professionals with experience with the disorder in children and adolescents is very helpful.
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 and conduct disorder. Pediatric bipolar disorder can disrupt social, family, and school functioning and interfere with normal social development.
The exact cause of BPD is not known. Several factors appear to contribute to it. The illness often runs in families, so genes probably play a role. Research has found abnormal brain functions and structures in those with the illness, but it is not clear whether these are causes or results of the disorder. Finally, anxiety disorders may play a role. Children with anxiety disorders are more likely to develop bipolar disorder.
The Different Types of Bipolar Illness
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.(2)
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. (3)
Hypomania has the same behaviors (grandiosity, etc.) as mania, but is not as extreme and is not severe enough to impair social or occupational functioning, does not necessitate hospitalization and does not have the loss of touch with reality (such as feeling that one has just found the cure for cancer or can leap between two buildings).(3)
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. (3)
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. (4)
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). (3)
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.”(3),(4) 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. (1)