Childhood Bipolar Disorder

Although it is only in recent years that it has been recognised, it is now estimated that ½-1% of children have bipolar disorder. Bipolar disorder in adults involves mood swings between lowered and elevated mood (depression and mania). Although in adults these swings are relatively infrequent (possibly a couple of times a year), in children the presentation is somewhat different and the swings in mood can occur many times per day. Frequently the main symptom in young children is severe rages that can last for hours, but a number of symptoms are necessary before a diagnosis of bipolar disorder should be considered.

Symptoms

Symptoms associated with a diagnosis of bipolar disorder in children:

٠    Difficulties in infancy (eg lack of sleep, excessive movement in pregnancy)

٠    Precociousness

٠    Separation anxiety

٠    Night terrors (blood & gore dreams, mutilation of body)

٠    Fear of death or annihilation

٠    Raging

٠    Oppositional behaviour

٠    Rapid cycling of mood

٠    Sensitivity to stimuli

٠    Problems with peers (77%)

٠    Temperature dysregulation

٠    Craving for carbohydrates and sweets

٠    Bedwetting and soiling

٠    Impending mania (hypersexuality, grandiosity)

٠    Hallucinations

٠    Suicidal ideas

Some of these symptoms only differ in degree from ‘normal’ behaviour of children, so it is important not to jump to conclusions or self-diagnose. The temperamental or behavioural traits displayed by children with bipolar disorder include:

  • Inflexibility
  • Being argumentative and defiant
  • Extraordinary irritability
  • Periods of explosive rage
  • Tantrumming for hours

Often children reserve their worst outbursts for at home and don’t show their ‘rageful’ side to the outside world. The rages or tantrums displayed by children with bipolar disorder are more extreme and often more long lasting than the normal angry outbursts or tantrums of other children.

Diagnosis

Although childhood bipolar is still a somewhat contentious diagnosis, it is one to consider for children whose behaviour is well out of the ordinary over a prolonged period. Early diagnosis and treatment is recommended to prevent antisocial behaviours becoming habits and to avoid the child being labelled as a problem by others. Parents seeking a diagnosis for their child might find it useful to keep records of the number of tantrums, mood swings, tearful periods, behaviour problems, etc of their child so that they have concrete data to report to the treating professional. It is more difficult for doctors and other professionals to dismiss or minimise concerns when presented with specific examples and numbers of outbursts.

When considering the diagnosis of bipolar disorder in a child, it is important to first rule out any medical conditions, as a number can produce symptoms similar to bipolar disorder. Diagnosis is not easy, and is complicated by the fact that in 80% of cases bipolar disorder occurs in conjunction with other disorders. The majority of children with bipolar disorder also meet the criteria for ADHD (attention deficit hyperactivity disorder). Other disorders, such as conduct disorder, oppositional defiant disorder, obsessive disorder, eating disorders, and Tourette’s disorder are also common. Diagnosis of any of these conditions does not automatically rule out the diagnosis of bipolar disorder.

Diagnosis, which can be made by a paediatrician, child psychiatrist, or psychologist, is not made from any one symptom. Bipolar disorder is likely if there is hyperactivity %2B irritability %2B shifting moods %2B prolonged temper tantrums %2B history of mood disorder and/or alcoholism on both parents’ sides of the family [80% of children with early onset bipolar have families in which there is substance abuse and mood disorders on both sides of the family].

Medication

In severe cases of bipolar disorder, mediations such as Lithium, or other medications that operate to stabilise mood are used to reduce angry outbursts and restrict mood swings. Once this medication is at the therapeutic dose and is being tolerated well, medication for ADHD or an antidepressant can be added if necessary. Antidepressants or stimulants (eg Ritalin) without the addition of a mood stabiliser creates additional secondary problems in children with bipolar, such as anxiety, mania, more frequent cycling of moods (lows and highs or irritability), increased aggression and temper tantrums.

 

Children can be assisted to take their medication regularly by making it part of the daily routine (eg after breakfast, take medication, then clean teeth), developing rituals to go with medication (eg taking it with his/her favourite juice), or obtaining rewards for remembering to take medication a certain number of times without reminders. The use of a dosette box makes it easy to tell whether the medication has been taken that day.

Strategies for parents

When parents have been living in what feels like a battle zone for a long time, it can be difficult to notice improvements when they start to occur. Monitoring moods or keeping a daily rating diary can assist in noticing small improvements and maintaining hope. Setting one clear goal at a time and systematically recording steps towards it can be helpful.

Other suggestions:

  • Work closely with other people involved in your child’s life (eg school, speech therapist, doctor, psychologist) and keep them informed of progress and concerns. Together devise plans for achieving goals so that you each assist the work of the others.
  • If your child is consistently unable to meet the expectations you have for his/her age, change your expectations, rather than continue to punish yourself and him/her.
  • Work out what skills you want your child to have and identify small steps you can take to develop these skills in your child. As these skills are learnt, gradually raise your expectations, but remember to build in plenty of rewards.
  • Make a list of your child’s responsibilities, including self-care, schoolwork, household responsibilities, and behaviour towards others. Start with the most important item on the list and think creatively about how your child can be assisted to consistently meet his/her responsibility in this area.
  • Acknowledge that child has an illness – not to excuse poor behaviour, but so as not to punish him/her for what s/he can’t change.
  • Simplify rules and keep them to a minimum (use a catchy phrase).
  • Be flexible in response to symptoms.
  • Build a ‘tool kit’ of coping strategies and activities for your child by planning strategies for overcoming common and unexpected problems. Include physical, creative, social, and relaxation strategies (eg when your child is feeling frustrated, s/he could go and jump on the trampoline, or talk to the dog, or paint a picture, etc).
  • Be aware that triggers such as noise, heat, hunger, tiredness, over-stimulation, or under-stimulation can set off your child’s behaviour, and plan routines to avoid them whenever possible.
  • Discuss with your child’s school how they will handle symptoms that are likely to cause problems at school – mood changes, frustration, loss of interest, fatigue, concentration lapses, agitation, slowed behaviour and thinking, poor judgement, racing thoughts, pressured speech, etc.
  • Educate people about what bipolar is and what it means for a child.
  • Take time out to look after yourself. Arrange someone to regularly care for your child so that you can have time for yourself, your relationship, or with your other children.
  • Remind yourself that you’re doing the best that you can, but don’t hesitate to seek assistance when you need it.