Bipolar Disorder in Childhood and Adolescence

Transcription

1 Bipolar Disorder in Childhood and Adolescence J. Patrick Bertroche, DO Topic Overview What is bipolar disorder? Bipolar disorder is characterized by extreme mood swings between mania (elevated mood or irritability) and depression. These mood swings are beyond the normal ups and downs that most people experience they greatly affect the lives of those who experience them. Doctors used to think that bipolar disorder symptoms did not appear until the teen or early adult years. They now believe even a young child may show symptoms of bipolar disorder, although the symptoms in children are often different from those of adults. Early diagnosis and treatment can lead to more effective management of bipolar disorder and may reduce the risk of long-term problems that can result when bipolar disorder remains undiagnosed or untreated. Bipolar disorder has also been called manic depression and manic-depressive disorder. What causes bipolar disorder? The cause of bipolar disorder is not known. It runs in families and is likely linked to imbalances in brain systems that help regulate mood. It may also be linked to problems with the endocrine system. Some research shows there may be a problem with the structure or size of certain parts of the brain which might also interfere with mood regulation. If your child has bipolar disorder, stressful or traumatic events may trigger episodes of mania or depression. What are the symptoms of childhood bipolar disorder? The hallmark of bipolar disorder is mood swings that alternate between depression and mania. Mood cycles in children and adolescents are usually rapid, and the moods are intense. Depressive and manic episodes can appear suddenly, without an obvious trigger. Children often experience continuous cycling between depression and mania, sometimes even in the same day. Some children may briefly return to a normal mood between these extremes. Children with mania may be more irritable and prone to temper tantrums than adults with mania. Children may also have chronic mood problems and have episodes of mania or depression that are less clearly defined than they are in adults. In a depressive episode, children may say they feel empty, sad, bored, or "down." They may complain of headaches, muscle aches, stomachaches, or fatigue. They frequently miss school or talk about running away from home. They become isolated and overly sensitive to rejection or criticism. A child or teen with bipolar disorder may use alcohol or drugs and have difficulty maintaining relationships. How is bipolar disorder diagnosed in children and adolescents? Bipolar disorder is diagnosed by a medical history, physical examination, and a mental health assessment. If the health professional suspects your child has bipolar disorder, you and your child

2 may be asked to answer a few questions or complete written tests that identify the child's current mental state and the severity of depression or mania. The health professional may conduct other physical tests (such as a blood test) or mental tests to rule out other possible health problems that could be causing symptoms. How is childhood bipolar disorder treated? Although the mood changes associated with bipolar disorder are challenging, they can be managed effectively. Treatment usually includes medications (such as mood stabilizers) and professional counseling; often a combination of both is needed. Medications to treat bipolar disorder in adults have been well studied; however, studies are just now coming out on the safety and effectiveness of these medications for children and adolescents with this condition. You and your child's doctor can discuss which treatment is right for your child. Older children and teenagers may want to participate in deciding their best treatment. If bipolar disorder is not treated, it can lead to serious illness, longer treatment, and even death due to suicide or reckless behavior. Learning to recognize the early symptoms of manic and depressive episodes helps reduce the impact the moods have on your child's daily life. Bipolar disorder can have adverse effects on the entire family. It can be helpful if all family members learn about the disorder or participate in supportive counseling. Who gets childhood bipolar disorder? It is not clear how many children develop this disorder because few studies have been done on childhood bipolar disorder. Bipolar disorder is common in adults and occurs equally among males and females. It affects about 1% of the adult population, and some researchers believe it affects around the same percentage of children. Your child is at greater risk of developing bipolar disorder if a parent or sibling has the condition, because there is some evidence that it runs in families. Bipolar disorder in children is difficult to diagnose, and the symptoms often resemble those of attention deficit hyperactivity disorder (ADHD). While symptoms can be similar, ADHD is a separate disorder with different treatment. Research is ongoing to determine whether a connection exists between ADHD and bipolar disorder. Cause The cause of bipolar disorder is not well understood. Few studies have been done on bipolar disorder in children and adolescents. It may run in families and be linked to an imbalance of chemicals (neurotransmitters) in the brain that help regulate mood. It may also be linked to problems with how the endocrine system works or with the structure or size of certain parts of the brain that could lead to difficulty with mood regulation. Stressful or traumatic events may trigger episodes of mania or depression in a child with bipolar disorder.

3 Sometimes symptoms of mania can occur as a result of another medical condition (such as hyperthyroidism or multiple sclerosis) or as a side effect of some medications (such as corticosteroids or antidepressants). Using drugs or alcohol, consuming too much caffeine, or not getting enough sleep can sometimes trigger a manic episode. Symptoms There are different types of bipolar disorder that are classified according to whether your child Experiences more depression or more mania and how quickly the mood cycles occur. All types of bipolar disorder consist of cycles of depression and mania. In children, the cycles often occur within the same day or can be continuous, rarely returning to a normal mood in between extremes. The rapid and severe mood changes may make your child appear constantly irritable, and they significantly interfere with your child's ability to function at school, at home, and with peers. A combination of depressive and manic mood swings must occur for at least 1 week before considering bipolar disorder. Following are some common symptoms of bipolar disorder in children and adolescents. Depressive symptoms Continuous sad or irritable mood Loss of interest in activities the child once enjoyed, such as hobbies or sports Significant change in appetite or body weight (weight loss or gain) Sleeping too much or too little or having trouble falling asleep Body movements that appear either slowed down or agitated and restless No energy or loss of energy Inappropriate guilt or feelings of worthlessness Difficulty concentrating Recurrent thoughts or talk of death or suicide Manic symptoms Severe changes in mood from being extremely irritable or sad to overly silly and elated Too much energy, such as the ability to keep going without tiring while the child's peers are tiring Decreased need for sleep, such as going for days with very little or no sleep and not being tired Increased talking, such as too much or too rapidly, changing topics too quickly, and not allowing interruptions Increased distraction and constantly moving from one thing to another. Grandiosity, such as an inflated self-esteem or a belief in unrealistic abilities or powers Increased sexual thoughts, feelings, activity, and use of sexual language (such hypersexuality is often seen in children who have been sexually abused; however, a child with bipolar disorder may experience hypersexuality without having been sexually molested) Increased obsession with reaching goals or becoming involved in too many activities

4 On rare occasions, your child may develop symptoms of psychosis, such as having hallucinations during a severe depressed or manic episode. Children with mania may be more irritable and prone to temper tantrums or destructive outbursts than adults with mania. In a depressive episode, children may complain of headaches, muscle aches, stomachaches, or fatigue. They frequently miss school or talk about running away from home. They become socially isolated and overly sensitive to any kind of rejection or criticism. Teenagers with bipolar disorder may show poor judgment, participate in risky activities, and believe they are more powerful or important than they are (delusions of grandeur) during manic episodes. A teen in a depressive episode may withdraw from social activities, do poorly in school, and have problems concentrating and sleeping. A child or teen with bipolar disorder may use alcohol or drugs, be sexually promiscuous, and have difficulty maintaining relationships. Older children and adolescents with undiagnosed bipolar disorder frequently use alcohol and drugs. If your child is using drugs or alcohol and having behavioral problems, you may want to schedule an evaluation to determine whether your child is suffering from a condition such as bipolar disorder. Bipolar disorder can be confused with other conditions with similar symptoms (such as attention deficit hyperactivity disorder). However, ADHD and bipolar disorder have distinct features that can usually be identified with a proper evaluation.

5 What Happens Children and early adolescents with bipolar disorder tend to experience rapid-cycling or mixedcycling types of bipolar disorder-meaning the cycles between depression and mania occur quickly, sometimes within the same day. The child might also experience symptoms of both mania and depression at the same time. During severe episodes of mania, your child may suffer from symptoms of psychosis, such as having hallucinations or delusions of grandeur (for example, telling people a rock band is coming to his or her birthday party). Bipolar disorder may frequently occur along with other conditions (such as conduct disorder), and each condition needs appropriate evaluation and treatment. In young children In children younger than 9 years old, bipolar disorder may first appear as depression or irritability. During a depressive episode, your young child may become withdrawn, have a short attention span, have feelings of guilt, and have low energy that can last for hours, days, or weeks. Your child may insist that you wish he or she had never been born; your child may throw temper tantrums, due to becoming easily frustrated, and display explosive anger. However, irritability and temper tantrums are also characteristic of manic episodes. In children, it can be difficult to distinguish a depressive from a manic episode, especially if cycles are rapid or mixed. Irritability may progress into severe, seizure-like temper tantrums when the child is told "no." The child may kick, bite, hit, and say hateful comments, including making threats and cursing, depending on the age of the child. These tantrums may last for hours, and the child may destroy property or become increasingly violent during the tantrum. Destructive tantrums may continue past age 4; however, this does not necessarily mean your child will later develop bipolar disorder-there are many reasons for this kind of behavior. In adolescents and older children Older children and young teens may experience high energy or euphoria during a manic episode. The older child may participate in risky or dangerous activities, including using drugs or alcohol. Substance abuse in adolescents with bipolar disorder is common, and your child's doctor may recommend an evaluation for both conditions if your child suffers from either. During a manic episode, an adolescent may need less sleep and may talk rapidly and continuously. The child may display aggression and get into fights. He or she may have increased sexual thoughts, feelings, or activity or use sexual language (hypersexuality). These young people may suffer consequences from their aggressive behavior, such as being expelled from school or arrested for fighting or drug use. During depressive episodes, an adolescent may become withdrawn or quiet, do poorly in school, and stop participating in activities he or she once enjoyed (such as quitting a sports team). Your adolescent may cry often, sleep too much, and feel that he or she doesn't "belong." He or she may speak of death or suicide. Any threats of suicide should be taken seriously, as children with bipolar disorder are at an increased risk for suicide attempts and completion.

6 What Increases Your Risk Your child's risk of developing bipolar disorder or other mood disorders increases if the child: Has a parent or sibling with bipolar disorder. This condition may run in families. It is also possible that the behaviors of a parent with bipolar disorder are passed down to the child due to family dynamics and observance of these behaviors. Has had several episodes of major depression. At least 15% of adolescents with recurring Depressions go on to develop bipolar disorder. Is entering puberty. Certain factors can trigger depressive or manic episodes in your child, such as: Erratic sleep or changes in daily routines. Treatment with antidepressants, which can increase risk for a manic episode. Stressful life events. Not taking medications as prescribed. Using alcohol or drugs (substance abuse). When to Call a Doctor Call or other emergency services immediately if your child: Shows warning signs of suicide. Hears voices or is having other symptoms of psychosis. Watchful Waiting If you think your child his bipolar disorder, watchful waiting is not appropriate. Schedule an appointment with your child's health professional for evaluation. If your child is currently receiving treatment for bipolar disorder, watchful waiting may be enough if a mood episode has just started and your child is taking proper medications. If your child's depressive or manic mood episodes have not improved within 2 weeks, call your doctor. If your child is experiencing a manic episode and is behaving irrationally, seek help for the child. Who to See It is best to establish a long-term relationship with your child's care provider(s) so that when a depressive or manic episode occurs, the care provider(s) can recognize the changes in the child's behavior and provide quick treatment advice. Since bipolar disorder in childhood and adolescence is just beginning to be recognized and treated, you may wish to find a health professional that has special training in children's mental health conditions or experience treating bipolar disorder in young people. Bipolar disorder can be diagnosed and treated by a health professional such as a:

7 Psychiatrist, preferably a child psychiatrist. Pediatrician. Family practice physician. Internist. Your child may also benefit from professional counseling to help deal with mood changes and the effects bipolar disorder has on your child's life. A counselor with special training in childhood mood disorders or experience treating childhood bipolar disorder may be most helpful. Counselors to consider include a: Psychiatrist. Psychologist. Social worker. Licensed mental health counselor. Who to see for family member support If you are a family member of a child with bipolar disorder, it is very important to get the support and help you need. Living with or caring for someone who has bipolar disorder can be very disruptive to your own life. Manic episodes can be particularly difficult. It may be helpful to seek your own counselor or therapist to help you. There are also national support organizations that may have a local chapter in your area or access to information on the Internet. Examples of such organizations include the National Alliance for the Mentally Ill (NAMI) and the Child and Adolescent Bipolar Foundation. Exams and Tests Currently, the same criteria used to diagnose bipolar disorder in adults are used to identify the disorder in children and adolescents. There is no laboratory test to distinguish bipolar disorder. The diagnosis is made with a combination of: A medical history, to help identify a family history of bipolar disorder. A physical examination, which can rule out other conditions with similar symptoms (such as hyperthyroidism). A mental health assessment, which can help identify your child's current mental state and the severity of depression or mania. Other mental health rating scales (such as Young Mania Rating Scale) might also be used. Treatment Overview Treatment for bipolar disorder generally includes both medications and counseling. Early treatment of bipolar disorder can help reduce the problems this condition can cause in a child's life. Since your child is still developing and learning appropriate social behaviors, it is important to get an accurate diagnosis. Early diagnosis and appropriate treatment assures that your child is able to continue with normal social and behavioral development. Without early detection and proper

8 treatment, your child is at risk for serious consequences of manic episodes, such as substance abuse problems, being expelled from school or arrested for fighting or other violent behaviors, and possibly suicide. Although mood changes associated with bipolar disorder are challenging, they can be managed effectively. Treatment usually includes medications (such as mood stabilizers) and professional counseling; often a combination of both is needed. Medications to treat bipolar disorder-in adults have been well studied; however, studies are just now coming out on the safety and effectivenes of these medications for children and adolescents with this condition. You and your child's doctor can discuss which treatment is right for your child. Older children and teenagers may want to participate in deciding their best treatment. Learning to recognize the early symptoms of manic and depressive episodes helps reduce the impact the moods have on your child's daily life. If bipolar disorder is not treated, it can lead to serious illness, longer treatment, and even death due to suicide or reckless behavior. It is also important that your child's other family members learn about the disorder or get supportive counseling because bipolar disorder can have adverse effects on the entire family. Initial treatment Initial treatment of bipolar disorder depends on the severity of your child's condition. If your child's symptoms are severe, such as being suicidal or suffering from loss of reality (psychosis), a brief hospitalization may be necessary to control symptoms. If your child's symptoms are less severe, initial treatment usually includes: Medications. Your child may need one or a combination of medications to control mood swings. Medications most often used include: o Mood stabilizers, which may include lithium, divalproex sodium, and other anticonvulsants. o Antipsychotics sometimes combined with mood stabilizers for more effective control of manic episodes. o Antidepressants, such as selective serotonin reuptake inhibitors (SSRis), to control episodes of depression. While antidepressants can be helpful for some children, they might also trigger mania. Antidepressants are usually prescribed with other medications that help regulate mood, and careful monitoring for mood changes is needed. Professional counseling. Counseling works best when symptoms of bipolar disorder are kept under control with medications. Several types of therapy may be helpful, depending on the age of the child, and may include: o Cognitive-behavioral therapy. o Interpersonal therapy. o Problem-solving therapy. o Family therapy, which can help educate and comfort the rest of the family. o Play therapy, for very young children. o Psychological education and support groups Ongoing treatment Ongoing treatment of bipolar disorder will be needed as long as the child's symptoms are interfering

9 with daily activities and quality of life. Some children and adolescents do not respond to the first medication given and may need to try several different medications to find relief from the symptoms. A combination of medication and professional counseling may be most effective. Generally, ongoing treatment includes: Medications. Your child may need one or a combination of medications to control mood swings. Medications most often used include: o Mood stabilizers, which may include lithium, divalproex sodium, and other anticonvulsants. o Antipsychotics sometimes combined with mood stabilizers for more effective control of manic episodes. o Antidepressants, such as selective serotonin reuptake inhibitors (SSRis ), to control episodes of depression. While antidepressants can be helpful for some children, they might also trigger mania. Antidepressants are usually prescribed with other medications that help regulate mood, and careful monitoring for mood changes is needed. Professional counseling. Counseling works better when symptoms of bipolar disorder are kept under control with medications. Several types of therapy may be helpful, depending on the age of the child, and may include: o Cognitive-behavioral therapy. o Interpersonal therapy. o Problem-solving therapy. o Family therapy, which can help educate and comfort the rest of the family. o Play therapy, for very young children. o Psychological education and support groups. Academic adjustments. If your child is in school, he or she may need a reduced homework load or school schedule during severe depressive or manic episodes. You can work with the School on finding ways to help your child maintain performance requirements until the symptoms are under control. Relaxation and exercise. Steps your child can take at home to improve symptoms include: o Getting regular exercise, such as swimming or walking, to help reduce stress. o Eating a balanced diet. o Getting enough sleep and keeping a regular sleep-wake cycle (children and teenagers need more sleep than adults). o Avoiding the use of alcohol, tobacco, caffeine and other stimulant drinks, and drugs. Sometimes treatment for other conditions can make your child's bipolar disorder worse; for example, treating depression with antidepressants can trigger or worsen a manic episode. Treating attention deficit hyperactive disorder CADHD) with stimulants may also trigger severe mania, depression, and even psychosis (loss of reality) in your child. Learning as much as you can about childhood and adolescent bipolar disorder may help you recognize mood changes in your child as they begin to occur. Catching and treating these mood changes early may help reduce the length of the manic or depressive episode and improve the quality of your child's life. Treatment if the condition gets worse If your child's condition worsens while undergoing treatment for bipolar disorder (including

10 medications, counseling, and lifestyle changes), additional treatment may be given and might include: A brief hospital stay, especially if your child is showing any warning signs of suicide. Electroconvulsive therapy (ECT). This procedure is used only for severe symptoms of bipolar disorder that have not been helped by other treatment. This is rarely performed on young children. Your child is at high risk for completed suicide if you have a gun in your home. Overdosing on medication is the most common way adolescents attempt suicide. If your child is depressed, remove all guns (even if they are locked up) and potentially fatal medications from your home, especially if your child has shown any warning signs of suicide. Prevention Bipolar disorder cannot be prevented. However, there are ways to manage mood changes. The first and most important preventive measure is to make sure your child takes his or her medications as directed. Evidence shows that about 1 in 3 adults remain completely free of symptoms of bipolar disorder just by taking mood-stabilizing medicines, such as carbamazepine, divalproex sodium, or lithium, for life; there are no statistics available for children. Reducing stress, getting regular sleep and exercise, and trying to stick to daily routines may help prevent a mood swing. Home Treatment There are steps you can take at home to reduce your child's symptoms of bipolar disorder. Keep your child's room quiet, and have the child go to bed at the same time every night Control the amount of stress in your child's life. You may need to seek ways to help your child reduce academic requirements during severe mood swings. Learn to recognize the early warning signs of your child's manic and depressive mood episodes. Steps your child can take to help control moods include: Getting enough exercise. During a depressive episode, your child may feel like doing only gentle exercises, such as taking a walk or swimming. Getting enough sleep and keeping a consistent sleep schedule. Eating a balanced diet. Avoiding the use of alcohol or drugs. Substance abuse makes bipolar disorder worse. Learning to recognize the early warning signs of your child's manic and depressive mood episodes. Asking for help from friends and family when needed.

11 Medications While medications to treat bipolar disorder have been well studied for use in adults, there are few long- term studies that confirm the effectiveness and safety of mood stabilizers in children and adolescents with bipolar disorder. Be sure to use all medications exactly as your child's doctor has prescribed them. If your child develops intolerable side effects to any medications, call your health professional immediately. Medication Choices Medications most often used to treat bipolar disorder in children and adolescents include: Mood stabilizers, which may include lithium, divalproex sodium, and other anticonvulsants. Antipsychotics sometimes combined with mood stabilizers for more effective control of manic episodes. Antidepressants, such as selective serotonin reuptake inhibitors (SSRis), to control episodes of depression. While antidepressants can be helpful for some children, they might also trigger mania. Antidepressants are usually prescribed with other medications that help regulate mood, and careful monitoring for mood changes is needed. What to Think About Deciding which medications to use when treating bipolar disorder in children and adolescents can be a complicated issue. Be sure to discuss all the options and side effects with your child's doctor. Your child may have to try several medications or combinations of medications before finding what works best. If the mood stabilizer lithium carbonate is prescribed, your child will need regular blood tests to monitorthe amount of lithium in the blood. Too much lithium may lead to serious high lithium carbonate side effects. Regular blood tests are also needed to monitor the amount of carbamazepine and divalproex sodium in the blood when these medications are used. When you and your child's doctor are deciding which types of medications to use in the treatment of bipolar disorder, consider: The side effects of each medication and how well your child can tolerate them. How often your child will need to take the medications. Whether your child is being treated for other illnesses or disorders and how those medications will interact with medications for bipolar disorder. Whether your child has used any of the medications before, and whether they worked. FDA Advisory. The US Food and Drug Administration (FDA) have issued an advisory to patients, families, and health care providers to closely monitor adults and children taking antidepressants for signs of suicide. This is especially important at the beginning of treatment or when doses are changed. The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation,

12 irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviors in children who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses. The FDA has not recommended that people stop using antidepressants, but simply to monitor those taking 'the medications and, if concerns arise, to contact a health professional. Surgery There is no surgery to treat bipolar disorder. Other Treatment Most children who have bipolar disorder need medication. However, other forms of treatment used along with medications play an important role in balancing mood and improving quality of life. Counseling, education about the disorder, and stress reduction can help children with bipolar disorder. Other Treatment Choices Counseling along with medications has been used effectively to manage bipolar disorder. Types of counseling used to treat bipolar disorder include: Cognitive-behavioral therapy. Interpersonal therapy. Problem-solving therapy. Family therapy, which can help educate and comfort the rest of the family. Play therapy, for very young children. Psychological education and support groups. Another effective treatment for severe bipolar disorder is electroconvulsive therapy (ECT). Even though it sounds frightening, ECT can effectively reduce severe symptoms in those children who have not been helped by other treatment. It is rarely used in younger children. For older children who have not responded well to medications or who cannot take medications for some reason, ECT may be a good option. Discuss ECT with your doctor for more information. Complementary therapy Omega-3 fatty acids have been getting attention as a possible complementary treatment of bipolar disorder in adults; however, there is currently no evidence to suggest this is helpful for treating bipolar disorder in children and adolescents. More research is needed to prove the effectiveness of omega-3 fatty acids in treating this condition. Talk with your doctor before trying omega-3 fatty acids for bipolar disorder. What to Think About Deciding which medications to use to treat childhood and adolescent bipolar disorder is an important decision for you, your child, and your child's doctor. Both you and your child need to

13 understand how taking the medications and not taking the medications will affect the child's life. It is important that your child continue taking any medications prescribed by the doctor to avoid a return of depressive or manic episodes. Your child should establish a long-term relationship with a health professional both of you like. The health professional will then be able to help recognize personality changes that indicate when your child is moving into a mood episode. Getting early treatment can reduce the length of the mood episode. Encourage your family to seek support as well. Bipolar disorder greatly affects family members. They will need to understand the disorder and what they can do to help the child, as well as themselves, in dealing with the disorder. Related Information Attention Deficit Hyperactivity Disorder (ADHD) Bipolar Disorder Borderline Personality Disorder Depression in Childhood and Adolescence Hyperthyroidism Panic Disorder Post-Traumatic Stress Disorder Schizophrenia Teen Alcohol and Drug Abuse References Citations 1. Muller-Oerlinghausen B, et al. (2002). Bipolar disorder. Lancet, 359: Weller EB, et al. (2002). Bipolar disorders in children and adolescents. In M Lewis, ed., Child and Adolescent Psychiatry, 3rd ed., pp Philadelphia: Lippincott Williams and Wilkins. 3. American Psychiatric Association (2002). Practice guideline for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry, 159 (Suppl 4). 4. American Psychiatric Association (2000). Bipolar disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp Washington, DC: APA. 5. National Institute of Mental Health. Child and adolescent bipolar disorder: An update from the National Institute of Mental Health. Available online: 6. Weckerly J (2002). Pediatric bipolar mood disorder. Journal of Developmental Behavior in Pediatrics, 23:

14 7. Biederman J, et al. (2001). National Institute of Mental Health Research Roundtable on Prepubertal Bipolar Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8): Sachs GS, et al. (2000). The Expert Consensus Guidelines Series: Medication Treatment of Bipolar Disorder. A Postgraduate Medicine Special Report. Also available: Other Works Consulted Walz M (2000). Bipolar Disorders: A Guide to Helping Children and Adolescents. Cambridge, MA: O'Reilly and Associates. For more information, go to: and click on "Find a HealthBanks Physician" to find patient education from your physician.