Bipolar Disorder: Differences in Children and Adolescents with Bipolar Disorder

Bipolar disorder, commonly known as manic-depression, is a brain disorder characterized by extreme changes in mood, thinking and behavior. In extreme cases, these changes can be accompanied by delusions or hallucinations. These changes, or cycles, can be slow or rapid and symptoms vary widely in severity. This variety can make it difficult to reach a diagnosis, especially in childhood or adolescence. It is a common mis-perception that bipolar disorder typically appears in young adulthood but that is not the case.

Research shows a higher incidence and earlier age of onset in every generation for the past 60 years. On average a sufferer will experience their first episode of this disease 10 years earlier than their parent's generation. The reason for this earlier onset is unknown but could be partially due to a growing awareness of mental health issues and increased accuracy of diagnosis.

Psychiatrists and other mental health professionals go by standards set forth in the Diagnostic and Statistical Manual IV (DSM-IV). This book gives the criteria that must be met in order to diagnose any known mental illness. The criteria for bipolar disorder, along with recommended standards of treatment, were written based only on data from adults with the disease.

There are three main obstacles to recognizing and diagnosing bipolar disorder in adolescents. Symptoms in children and young teenagers often do not precisely fit into the adult criteria in the DSM-IV. Often symptoms can resemble of even co-occur with symptoms of other common childhood onset mental disorders. This can often lead to misdiagnoses or partially correct diagnoses. Especially in adolescence, many symptoms get overlooked as "normal" teenage rebellion and moodiness.

Cycles and Symptoms

Victims of bipolar disorder typically cycle from episodes of mania to episodes of depression. Sometimes they will have periods of relative wellness between these cycles but some cycle from one state to another without discernible gaps. Children and young adolescents usually exhibit an ongoing, continuous mood disturbance that is a mix of manic and depressive symptoms. This rapid and severe cycling between moods tends to produce chronic irritability with few clear periods of wellness. Later onset of bipolar tends to begin suddenly with a classic manic episode and remain more episodic with relatively stable periods between episodes.

Manic symptoms are more likely with a family history of bipolar disorder. Signs of mania include severe mood changes where the person tends to be extremely irritable or overly silly/elated. Often manic people will experience increased energy and a decreased need for sleep. They commonly have the ability to go with very little or no sleep for days without tiring. Mania frequently produces an over-inflated sense of self-esteem or grandiosity where the person feels they can do anything. This leads to a disregard for risk and indulgence in risky or dangerous behaviors. Other symptoms noted are distractibility, talking faster and not able to be interrupted, and hyper-sexuality.

Depressive symptoms involve a persistent sad or irritable mood with a loss of interest in activities the person once enjoyed. There may be significant changes in appetite or body weight. When in a depressive state, victims of bipolar disorder may have difficulty sleeping or sleep excessively and can exhibit a marked decrease in energy. The person will usually have difficulty concentrating and may show signs of physical agitation or even slowing. There are often feelings of worthlessness or inappropriate guilt. While in a depressive episode, there are frequently recurrent thoughts of death and suicide.

Differences of Symptoms in Children and Adolescents

Evidence indicates that early onset bipolar disorder tends to be different and more severe than later onset. Bipolar disorder in children and young teens is often characterized by rapid-cycling, chronic irritability, and a mix of symptoms between the two states as opposed to distinct cycles of mania vs. depression. This state often co-occurs with disruptive behavior disorders such as oppositional-defiance disorder (ODD) or conduct disorder (CD) which can cloud the diagnostic process.

Children and adolescents with bipolar disorder are much more likely to be irritable and prone to disruptive outbursts than becoming elated or euphoric. Many experience explosive, lengthy and often destructive rages in response to minor or imagined issues. It is common for adolescents to have frequent absences from school and give a poor performance when they do attend. They also will talk about running away from home as well as be more likely to make the attempt. In general, they exhibit a marked defiance of authority that is not limited to their parents.

Younger children with bipolar disorder are more likely to suffer from night terrors and bed wetting beyond the normal age. They tend to complain frequently and/or have bouts of unexplained crying. As they get older, they are more likely to have physical complaints such as stomachaches or headaches. Often they experience strong cravings, usually for carbohydrates or sweets.

Especially in adolescents, there is a notable lack of judgment as well as increased impulsivity. They are more likely to experience social isolation, particularly due to poor communication, and extreme sensitivity to failure or rejection. Adolescents often show precocious or inappropriate sexual behaviors including explicit language or even sexual acts. They are also much more likely to engage in dangerous activities or take extreme risks.

Treatment of Bipolar Disorder in Children and Adolescents

For best control of bipolar disorder, it is recommended to combine medication with therapy. Medication is used to bring the person to relative stability before therapy will be very effective. Finding the proper medication or combination of medication for each person can take weeks or even months. Partially this is because of known drug therapy regimens having been developed for adults and partially it is because individual patients respond differently to medications.

Mood stabilizing drugs such as lithium or valproate can help reduce the rapidity and severity of cycles. Often it can take two medications combined to be optimally effective. Many will benefit from adding an antidepressant drug along with the mood stabilizing medication. While a few people find relief taking just an antidepressant, this is not usually recommended as taken alone, an antidepressant can induce mania in some patients. Stimulants given for treatment of ADHD can worsen manic symptoms, especially in adolescents. Full effect of mood stabilizers can take weeks to come about so changes must be gradual and it will take time to find the optimal drug regimen for the best control of symptoms.

There are several factors influencing the outcome of drug therapy for adolescents with bipolar disorder. Since there is little data on effectiveness and safety of mood stabilizing drugs for youths, doctors must go by adult treatments which can be ineffective when used for teenagers or even dangerous. Another thing that can be problematic is getting the adolescent to recognize that they have a mental disorder that needs treatment. Teenagers are naturally more sensitive to what others think of them and are prone to deny having a mental illness of any sort. One important factor that can cause stumbling blocks for patients is that many psychoactive drugs can have annoying side effects.

Common side effects of mood stabilizing medications include stomach upset, drowsiness, low energy, headaches and weight gain. Generally the most annoying side effect for teenagers tends to be with weight gain. One of the most common and safest mood stabilizers is valproate (Depakote) but this drug almost always causes at least some weight gain. For some patients it can be a significant amount of weight. Often a teenager will fight against taking the drug because of fear of weight gain and it is the most common reason for an adolescent to refuse further medication.

Mood stabilizers can help bring symptoms under control but therapy will be needed for optimal long-term management of bipolar disorder. A good therapist will help educate the patient and teach them how to monitor their progress of gaining control over their disease. Therapy can teach tools to enable the sufferer to cope with the effects of the disease and also help them deal with any problems created by bipolar disorder. The more knowledge a person has about their disorder then the more control they will gain over their symptoms and course of the disease.

Early Intervention and Treatment is Key to Achieving Stability

There are high risks associated with undiagnosed bipolar disorder. Suicide rates are upwards of 10% in those left untreated. There is also a high incidence of school failure and substance abuse, along with failed relationships and difficulty holding jobs later in life. Early intervention and treatment are the keys to achieving stability for those suffering from early onset bipolar disorder.

Children and young adolescents are at the most risk of being left untreated. They are often misdiagnosed as having borderline personality disorder, post-traumatic stress disorder (PTSD), or even schizophrenia. There are also common diagnoses that often co-occur with bipolar disorder. Many times these disorders are diagnosed and treated while masking the underlying bipolar condition. The most frequent of these are ADHD, oppositional-defiance disorder (ODD), and conduct disorder (CD). These disorders are often treated with stimulant medications such as Ritalin or Adderall which can worsen symptoms.

If a child has four or more of the symptoms of bipolar disorder and these symptoms have persisted for more than two weeks, the parent urgently needs to have them evaluated. The parent should look for a doctor who is familiar with early-onset bipolar disorder and mood disorders in general. The doctor should also have a good familiarity with psycho-pharmacology. Parents should take notes on their child's mood, behavior, sleep patterns, unusual events, and any statements of concern (such as talk of death) and should share these with the doctor. A good evaluation will entail at least two appointments and a detailed family history.

Parents should learn all they can about bipolar disorder. Finding a good support group can be very beneficial as it gives the parent the opportunity to network with other parents. Dealing with constantly shifting moods, continuous irritability, and frequent defiance can leave parents extremely frustrated. Parents also can easily become isolated due to concerns over how their child is going to behave in front of others. Many find individual or family therapy can be helpful in finding new ways to cope with the effects of their child's disease.

Some Strategies For Parents

Parents should provide an environment that is consistent and as stress-free as possible. Allow the child a great deal of freedom within safety levels. The more rules there are then the more defiance the parent will see. An important skill for a parent will be learning to pick their battles. Focus on the serious issues and learn to let the smaller issues go. As in normal children, many behaviors are exhibited just to aggravate the parent. By ignoring the smaller things (such as swearing or constant complaints), parents often find that those behaviors decrease as the child realizes they are not getting a reaction. Parents need to remember to take time for themselves, as well. Coping with the stress of gaining control over bipolar disorder can be a long, frustrating, and exhausting job.