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NetWellness provides the highest quality health information and education services created and evaluated by faculty of our partner universities.
Friday, November 21, 2008
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NetWellness provides the highest quality health information and education services created and evaluated by faculty of our partner universities.
Friday, November 21, 2008
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Bipolar disorder (previously known as manic-depression) has been referred to by a variety of terms in child/adolescent psychiatry including pediatric, juvenile, early-onset, childhood and prepubescent bipolar disorder. As the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders " 4th edition (DSM-IV) describes four types of bipolar diagnosis, we prefer the term early-onset bipolar spectrum disorders (EOBPSD) to refer to this group of disorders.
The number of children with EOBPSD is not presently known, however, studies estimate 1-6% (3-18 million) adolescents in the U.S. suffer from symptoms of manic-depressive illness. While the exact cause(s) of EOBPSD is not currently known, substantial evidence suggests a biological basis involving genetics, an imbalance of neurotransmitters and abnormal development in various areas of the brain. Children/adolescents (hereafter referred to as children) with EOBPSD frequently are described by their parents as having been colicky babies, toddlers who never quite left behind the "terrible 2's" and sensitive school-children who can "rage" for several hours at the drop of a hat. Many of these children often have other behavioral-emotional problems with hyperactivity, impulsivity, inattention, compliance, anger and anxiety long before they are actually diagnosed with EOBPSD. Overtime, children with EOBPSD typically experience greater conflict with their families at home, academic and behavioral problems at school, problems interacting with peers in formal and informal settings, suicidal thoughts, plans or attempts, and increased use of mental health services, including multiple hospitalizations.
Although EOBPSD appears to have a biological cause, its development over time may be exacerbated by environmental factors such as family, teacher and peer conflict, academic stress, and disruption in the sleep-wake cycle. Conversely, while EOBPSD is not caused by poor parenting, its onset may be delayed and/or course of illness lessened by improving relationships in the family, at school and with peers, implementing educational interventions and providing stable sleep routines.
A manic episode is defined as a four-to-seven day period of excessively elevated (i.e., inappropriately happy) or irritable (i.e., temper-tantrums and rages out of proportion to events) mood. This change in mood is accompanied by three or more (four, if the mood is irritable) of the following symptoms:
An episode of depression is characterized by a two-week or longer period of sad or irritable mood or markedly diminished interest/pleasure in most activities. This "low" is accompanied by four or more of the following symptoms:
Mood symptoms wax and wane (i.e., cycle), often "come out of the blue" and represent a significant change from the child/adolescent's usual behaviors. On occasion, severe mania or depression may lead to psychotic symptoms such as paranoia (e.g., an adolescent truly believes someone is spying on her), delusions (e.g., a child believes the war in Iraq was his fault) and auditory or visual hallucinations (e.g., an adolescent hears voices telling her to do "bad things" or sees skeletons playing basketball). Psychotic symptoms in the presence of manic or depressive symptoms do not mean your child/adolescent has schizophrenia or a related psychotic disorder. Rather, these symptoms should disappear when mood symptoms improve.
Manic moods in children are often expressed as intense irritability, rather than euphoria. Furthermore, children are less likely than adults to report discrete cycles of manic and depressive symptoms over several months. Instead, children/adolescents often experience both manic and depressive symptoms at the same time, continuously or multiple times within the same day (i.e., a mixed or rapid cycling presentation). Children diagnosed with EOBPSD frequently have co-occurring diagnoses, such as Attention-Deficit/Hyperactivity Disorder (ADHD: dysfunctional levels of inattention, impulsivity and activity), Oppositional Defiant Disorder (ODD: severe and impairing noncompliant and hostile-irritable behaviors), Conduct Disorder (CD: serious and delinquent antisocial behavior such as stealing, vandalism and physical violence), various anxiety and learning disorders, and/or substance abuse.
Everyone feels "really good" or "down" at one time or another during their lives. However, if your child is experiencing intense, chronic and distressful mood swings that cause impairment at home, school or with their peers, seek help. Furthermore, if your child is having frequent thoughts about hurting herself or someone else, you should seek immediate help.
Much like another chronic illness, diabetes, there is no cure for EOBPSD. However, its symptoms can be managed and often prevented from recurring by a combination of effective pharmacological, psychosocial and school-based interventions.
Pharmacological intervention, or using medications, is the foundation of effective treatment for EOBPSD. Research and clinical practice indicate that most children require multiple medications to alleviate symptoms of mania, depression, and co-occurring conditions. Although medications have not been adequately studied in children/adolescents with EOBPSD, clinical practice indicates their potential usefulness.
Mood stabilizers (e.g., Depakote®, Lithium, Tegretol®, Gabitril®, Lamictal®, Topamax®, & Trileptal®) are considered the first line of pharmacological intervention. Anti-psychotic medications (e.g., Abilify®, Clozaril®, Geodon®, Risperdal®, Seroquel®, & Zyprexa®) may help reduce aggressive or psychotic symptoms, whereas anti-hypertensive medications (e.g., Clonidine® and Tenex®) are sometimes used to improve the sleep-wake cycle.
After your child/adolescent's mood has been stabilized with a mood stabilizer, low-dose anti-depressant medications (e.g., Celexa®, Lexapro®, Luvox®, Prozac®, Remeron®, Serzone®, Wellbutrin®, & Zoloft®) may be added to reduce depressive and anxiety symptoms.
Similarly, after a mood stabilizer has effectively evened out mood, adjunctive psychostimulants (e.g., Adderal®, Concerta®, Dexedrine®, Focalin®, Metadate®, & Ritalin®) and nonstimulants (e.g., Strattera®) may reduce ADHD symptoms of inattention, impulsivity and hyperactivity. Since both anti-depressants and psychostimulants pose a risk of activating manic symptoms, they must be monitored carefully.
Finally, while dietary interventions (e.g., Omega-3 fatty acids, high intensity vitamin-mineral complexes) have been tried in children, their efficacy is still being tested.
Psychosocial interventions might include some combination of family therapy, individual therapy, parent guidance, group therapy, school-based intervention, home-based treatment, respite, out-of-home placement, and web-based support. Research has shown both psychoeducation and skills development to be effective treatment components. Psychoeducation helps parents and children/adolescents increase their understanding about: the disorder, co-occurring symptoms, medications, and mental-health, community/school-based treatment teams and services. Skills development helps parents and children/adolescents build skills to manage symptoms. These skills might include:
Although no research supported school-based interventions currently exist for EOBPSD, a number of astute clinical and educational recommendations for school difficulties are available. These might include arranging for a Multi-Factored Evaluation (MFE) and/or Functional Behavior Assessment (FBA) to identify special education needs, behavioral-emotional difficulties and associated triggers and events that precede manic-depressive symptoms. After a MFE or FBA, an Individualized Educational Plan (IEP), a 504 plan and/or behavior plan can be developed to provide educational accommodations and modifications to help your child manage problems at school.
Finally, it is important not to lose hope. Although EOBPSD is a chronic but variable disorder that often wreaks havoc on family life, peer relationships and school functioning, many effective treatment tools exist and continue to become available at a rapid rate.
This article is a NetWellness exclusive. 
Last Reviewed: May 02, 2007
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Mary A. Fristad, PhD, ABPP Director of Research & Psychological Services Child and Adolescent Psychiatry Department of Psychiatry College of Medicine The Ohio State University |
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Nicholas Lofthouse, PhD Clinical Assistant Professor of Psychiatry Child and Adolescent Psychiatry Department of Psychiatry College of Medicine The Ohio State University |
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