EARLY-ONSET BIPOLAR DISORDER

Transcription

1 EARLY-ONSET BIPOLAR DISORDER Presented by: Metro Child Care Resource & Referral 2

2 What is Early-Onset Bipolar Disorder? Bipolar disorder (also known as manic-depressive illness) is a treatable brain disorder characterized by severe fluctuations in mood and activity level. This illness affects thoughts, feelings, perceptions and behavior - even how a person feels physically. It is probably caused by electrical and chemical elements in the brain not functioning properly, and is usually found in people whose families have a history of the illness. The onset of bipolar disorder can be triggered by trauma, but often appears with no identifiable cause. Symptoms can appear at any time from infancy onward. Bipolar disorder in children often begins with major depression marked by chronic irritability. Mania (the activated state) may include hyperactivity, difficulty falling asleep, daredevil acts, elation and grandiose thinking. Intense temper tantrums (also called rages ) can occur during depression or mania, and sometimes symptoms of both states occur together or in quick succession. How common is bipolar disorder in children? It is not known, because studies are lacking. However, bipolar disorder affects an estimated 1-2 percent of adults worldwide. The more we learn about this disorder, the more prevalent it appears to be among children: It is suspected that a significant number of children diagnosed with attentiondeficit disorder with hyperactivity (ADHD) have early on-set bipolar disorder instead of, or along with, ADHD. Depression in children and teens is usually chronic and relapsing. According to several studies, a significant proportion of the 3.4 million children and adolescents with depression may actually be experiencing the early onset of bipolar disorder, but have not yet experienced the manic phase of the illness. New Findings: Although once thought rare, recent statistics have shown that approximately 7% of children seen at psychiatric facilities fit the diagnostic criteria for bi-polar disorder. Better diagnostic skills, higher levels of stress in the lives of children, stimulant drug use and the fact that genes express themselves more aggressively in each generation all play a role in the increase of childhood earlyonset bipolar disorder. 3

3 It is extremely difficult to diagnose bipolar disorder in children because over 80% present with a co-occurring behavior disorder. This is called a co-morbid condition and other disorders include ADHD, Oppositional Defiant Disorder, Depression and Anxiety. What are the symptoms of bipolar disorder in children? Bipolar disorder involves marked changes in mood and energy. Persistent states of extreme elation or agitation accompanied by high energy are called mania. Persistent states of extreme sadness or irritability accompanied by low energy are called depression. The illness may look different in children than it does in adults. Children usually have an ongoing continuous mood disturbance that is a mix of mania and depression. This rapid and severe cycling between moods produces chronic irritability with few clear periods of walnut between episodes. Behaviors reported in children diagnosed with bipolar disorder may include the following: An expansive or irritable mood Extreme sadness or lack of interest in play Rapidly changing moods lasting a few hours to a few days Explosive, lengthy and often destructive rages Separation anxiety Defiance of authority Hyperactivity, agitation and distractibility Sleeping little or, alternatively, sleeping too much Bed wetting and night terrors Strong and frequent cravings, often for carbohydrates and sweets Excessive involvement in multiple projects and activities Impaired judgment, impulsivity, racing thoughts and pressure to keep talking Inappropriate or precocious sexual behavior Delusions and hallucinations Grandiose belief in own abilities that defy the laws of logic (ability to fly, for example) Symptoms of bipolar disorder can emerge as early as infancy. Mothers often repot that children later diagnosed with the disorder were extremely difficult to settle and slept erratically. Hey seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event. The word no often triggered these rages. 4

4 Misdiagnoses: Due to the present of co-existing behavior disorders, properly identifying this illness has been a serious challenge for the psychiatric community. Common misdiagnoses are ADHD, Depression and/or Oppositional Defiant Disorder because both conditions include irritability, hyperactivity and distractibility. However, children suffering from bipolar disorder also display behaviors such as elated mood, grandiose behaviors, decreased need for sleep and hypersexuality. It is these symptoms that signal a possible bipolar diagnosis. Since it is common for children to have multiple cycles during the day from giddy, silly highs to morose, gloomy depressions it is critical that a child be properly evaluated by a medical professional! Misdiagnosis together with improper medication can have serious adverse affects on a child. Note the following statistics: Over 80% of children who have bipolar disorder meet the diagnostic criteria for ADHD. Since the ADHD symptoms may appear first, children are often times prescribed a stimulant such as Ritalin which can actually deepen an existing manic cycle or trigger a new one! If a child is assessed when in the low phase of the bipolar cycle, a misdiagnosis of depression may occur. Some researchers believe that almost 50% of children diagnosed with depression may really be suffering from bipolar disorder. Treating a child with antidepressants, like Prozac may trigger mania. Symptoms of mania and depression in children manifest through a variety of different behaviors. Manic (high s) children, in contrast to adults, are more likely to be irritable and destructive rather than elated or euphoric. When depressed (low s), there may be tiredness, frequent absences from school, irritability, complaining, unexplained crying and isolation. Again, the need for a professional diagnosis is critical. What role does genetics or family history play in bipolar disorder? The illness tends to be highly genetic, but there are clearly environmental factors that influence whether the illness will occur in a particular child. Bipolar disorder can skip generations and take different forms in different individuals. A group of studies that have been done vary in the estimate of risk to a given individual: For the general population, a conservative estimate of an individual s risk of having full-blown bipolar disorder is 1%. 5

5 When one parent has bipolar disorder, the risk to each child is 15-30%. When both parents have bipolar disorder, the risk increases to 50-75%. The risk in siblings and fraternal twins is 15-25%. The risk in identical twins is approximately 70%. In every generation since World War II, there is a high incidence and an earlier age of the onset of bipolar disorder. On average, children with bipolar disorder experience their first episode of illness 10 years earlier than their parents generation did. The reason for this is unknown. Diagnosing Bipolar Disorder in Children: Healthy children often have moments when they have difficulty staying still, controlling their impulses or dealing with frustration. The diagnostic and Statistical manual IV (DSM-IV) still requires that, for a diagnosis of bipolar disorder, adult criteria must be met. There are as yet no separate criteria for diagnosing children. Some behaviors by a child, however, should raise a red flag: Destructive rages that continue past the age of four Talk of wanting to die or kill themselves Trying to jump out of a moving car To illustrate how difficult it is to use the DSM-IV to diagnose children, the manual says that hypo-manic episodes require a distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days. Yet upwards of 70% if children with the illness have mood and energy shifts several times a day. Since the DSM-IV is not scheduled for revision in the immediate future, experts often use some DSM-IV criteria as well as other measures. For example, a Washington University team of researchers uses a structured diagnostic interview called Wash U KIDDE-SADS, which is more sensitive to the rapidcycling periods commonly observed in children with bipolar disorder. psychiatric disorders. The need for prompt and proper diagnosis: Tragically, after symptoms first appear in children, years often pass before treatment begins, if ever. Meanwhile, the disorder worsens and the child s functioning at home, school, and in the community is progressively more impaired. 6

6 The importance of proper diagnosis cannot be overstated. The results of untreated or improperly treated bipolar disorder can include: An unnecessary increase in symptomatic behaviors leading to removal from school placement in a residential treatment center, hospitalization in a psychiatric hospital, or incarceration in the juvenile justice system. The development of personality disorder such as narcissistic, antisocial, and borderline personality. A worsening of the disorder due to incorrect medications. Drug abuse, accidents and suicide. It is important to remember that a diagnosis is no a scientific fact. It is a considered opinion based on the behavior of the child over tie, what is know of the child s family history, the child s response to medications, his or her developmental stage, the current state of scientific knowledge and the training and experience of the doctor making the diagnosis. These factors can change as more information becomes available. Competent professionals can disagree on which diagnosis fits an individual best. Diagnosis is important, however, because it guides treatment decisions and allows the family to put a name to the condition that affects their child. Diagnosis can provide answers to some questions but raises others that are unanswerable given the current state of scientific knowledge. Finding the right doctor: If possible, have a board-certified child psychiatrist diagnose and treat your child. A child psychiatrist is a medical doctor who has completed two to three years of an adult psychiatric residency and two additional years of a child psychiatry fellowship program. Unfortunately, there is a severe shortage of child psychiatrists, and few have extensive experience treating early-onset bipolar disorder. Treatment for children diagnosed with bipolar disorder: Medication: Mood stabilizers such as lithium are common in treating children with bipolar disorder. These medications reduce 50% of the symptoms. Anticonvulsant drugs such as depakote and laical calm mania. Antidepressants such as Prozac are risky yet can be used with other medications. Lifestyle: Children with bipolar disorder need a consistent routine, a healthy diet, and little or no caffeine. This has been shown to improve functioning and reduce psychosocial stressors. 7

7 Family Therapy: Families need to learn about this illness in order to help their children. Education should include learning how to identify symptoms, behavior patterns and cycle changes. Additionally, parents must learn specialized parenting and conflict resolution skills. These skills must be shared with caregivers! Co-occurring disorders: Learn to recognize and treat the conditions that are likely to occur alongside bipolar disorder such as ADHD. Caring for children with bipolar disorder: Children with bipolar disorder struggle to regulate an emotionally and biologically compromised system! The following strategies will be critical in helping maintain a normal lifestyle. Help the child anticipate, avoid, or prepare for stressful situations by developing specific coping strategies. Learn to recognize the child s symptoms and patterns of behavior to become better at predicting when a episode is about to occur. Learn to differentiate the symptoms and behaviors related to bipolar disorder from those that are related to disruptive disorders, misbehavior and ageappropriate behavior. When we know that a child suffers form a mental health disorder, we sometimes perceive all the child s behavior as symptoms of the disorder when it may be age-appropriate behavior. Use music, water and massage to help the child relax. Build communication and rapport -every child needs to feel special. Learn the child s behavior patterns and try to catch a manic episode before it gets out of control. Set firm limits. Establish external boundaries and rules to manage the child s poor impulse control and to ensure the child s safety. Prioritize battles - let go of less important matters. Don t respond immediately, respond neutrally and slowly. Decide if this is a demand that you are willing to accept. Focus on the task at hand and speak in short, direct phrases. Model calm, cool behavior and speak quietly and slowly. Teach the child flexibility. Children with bipolar disorder do not realize that their thinking is rigid. Use statements such as let s figure out a better way next time so we don t get angry at each other, or I would love to do that if I could but this is one of those times I can t. 8

8 What are the educational needs of a child with bipolar disorder? A diagnosis of bipolar disorder means the child has a significant health impairment that requires ongoing medical management. The child needs and is entitled to accommodations in school to benefit from his or her education. Bipolar disorder and these medications used to treat it can affect a child s school attendance, alertness and concentration, sensitivity to light, noise and stress, motivation, and energy available for learning. The child s functioning can vary greatly at different times through the day, season, and school year. Examples of accommodations helpful to children and adolescents with bipolar disorder include: Preschool special education testing and services. Small class size or self-contained classrooms with other emotionally fragile children for part of all of the day. One-on-one or shared special education aides to assist child in class. Back and forth notebook between home and school to assist communication. Homework reduced or excused and deadlines extended when energy is low. Late start to school day if fatigued in morning. Recorded books as alternative to self-reading when concentration is low. Designation of a safe place at school where child can retreat when overwhelmed. Designation of a staff member to whom the child can go as needed. Unlimited access to bathroom and drinking water. Art therapy and music therapy. Extended time on tests. Use of calculator for math. Extra set of books at home. Regular sessions with social worker or school psychologist. Social skills groups and peer support groups. Learning that one s child has bipolar disorder can be traumatic. Diagnosis usually follows months or years of the child s mood instability, school difficulties, and damaged relationships with family and friends. However, diagnosis can and should be a turning point for everyone concerned. Once the illness is identified, energies can be directed towards treatment, education, and developing coping strategies! 9

9 Early Onset Bipolar Disorder Additional Resources 1. The Bipolar Child, Demitri Papolos. 2. To Childhoods Most Misunderstood Disorder, 3. Bipolar Disorder: A Guide to helping Children and Adolescents, Mimi Waltz. 4. About Juvenile Bipolar Disorder, 5. The Challenging Child, Stanley Greenspan, M.D. 6. Taming the Dragon in your Child, Meg Eastman, Ph.D. 7. The Infinite Mind: The Bipolar Child, Fred Goodwin, M.D. 8. Survival Strategies for Parenting Children with Bipolar Disorder, George Lynn. 10