Bipolar Disorder in Children and Youth: Information for Families
All of us have changes and swings in our mood which are normal. There are times when our mood is up, and we have more energy and excitement about things. There are other times when our moods are down, and we have less energy.
However, people with bipolar disorder have periods of extreme mood change that cause serious problems in their lives.
In the classic form of bipolar, people have episodes of depression and of mania, when their mood, energy, thinking and behaviour gets stuck for a period of time at a very low or a very high level. Hence the term, "bipolar", which refers to the two ("bi-") different poles of mood ("-polar").
High energy periods, or manic episodes / mania consists of periods with symptoms such as:
- Persistent period of high energy, lasting days to weeks, during which time a person has a decreased need for sleep (e.g. only needs a few hours of sleep, or even none at all, yet still has lots of energy the next day).
- Extremes of mood, which may be excessively "high" (overly good, euphoric mood) and at times extreme irritability.[this would be mixed not manic]
- Racing thoughts, i.e. thought flow increased speed
- Pressured speech, i.e. talking very fast
- Distractibility, can't concentrate well
- Increased self-esteem, which can be the point where one has grandiose, unrealistic ideas about oneself
- Increased activity
- Poor judgment, decision-making and impulsive behaviours such as making large purchases, gambling or other risky behaviours such as doing drugs or increased sex drive.
- Lack of insight that anything is wrong, such that the person may deny that there is a problem. But in a classic manic episode, it is obvious to friends and family that something is wrong as this (behaviour) represents a change for this person. * not sure if we want behaviour persay, but maybe need to be more specific than "this".*
While some individuals with bipolar disorder experience full-blown manic episodes, others also experience a mild to moderate level of mania, known as "hypomania". Hypomania is milder than mania, but it is a major change in functioning for the individual and it may lead into full-blown mania, or major depression.
What goes up must come down, which is why periods of high energy (manic episodes) are typically followed by low energy periods.
Low energy episodes or depressive episodes may occur to the extreme such that the person may have:
- Extremely low energy for days or weeks, with increased need for sleep
- Extremely low, depressed mood that is stuck and not reactive to what is happening around the person
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities
- Due to low mood, the person may have thoughts that life isn't worth living, even to the point of thinking about making attempts to end one's life.
Mood episodes may also get so extreme that the person loses touch with reality, and may have symptoms of psychosis such as:
- Hallucinations, which includes hearing or seeing things which aren't actually there. For example, hearing voices or seeing people.
- Delusions, which are false beliefs with no basis in reality. For example, in a manic phase, one might believe that they can fly, or that they are a famous celebrity. On the other hand in a depressive phase, one might feel extreme irrational guilt.
Why do some people have bipolar? Studies show that the same genes that contribute to bipolar disorder may very well be the same genes linked to intelligence and creativity (Smith, 2015). Throughout human history, there are numerous notable examples of famous people that have had bipolar disorder. Bipolar traits and bipolar disorder may simply be the genetic price for intelligence and creativity.
The exact prevalence of bipolar disorder in children and youth remains controversial (Moreno et al., 2007). On one hand, one study suggested that it occurs in 1% of children/youth at any given time (Costello et al., Lewinsohn et al). On the other hand, in a large UK study there were no cases of bipolar disorder in children (Meltzer, 2000).
With adults, there is less controversy. It is believed that bipolar I or II occurs in up to 4% of adults in the USA (Kessler, 2005).
Bipolar usually starts in late teens or adulthood. In fact, about 50-66% of adults with bipolar report that their symptoms started before age 19 (Chang, 2007).
If you suspect that your child may have bipolar disorder, take your child to be seen by your primary care provider (such as a family doctor or paediatrician) to make sure there aren't any medical problems (such as hormone imbalances) that might be causing or contributing to your child's symptoms.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual used by mental health professionals to diagnose mental health conditions, the main types of bipolar disorder are:
- Bipolar I, classically consisting of manic and depressive episodes. Many individuals present first with major depressive episodes when younger and do not go onto develop manic episodes until older.
- Bipolar II, consisting of hypomanic episodes and major depressive episodes.
- Cyclothymia, consisting of hypomanic episodes with depressive episodes (but not severe enough to be major depressive episodes per se).
- Bipolar Not Otherwise Specified (NOS), which is used to describe individuals with mood swings that cause problems, but which do not fit into any of the other above categories. In the past, many children/youth used to be diagnosed with BIpolar NOS, but it turns out for many of them, the diagnosis of disruptive mood dysregulation disorder (DMDD) may be more appropriate.
In addition, other terms used include:
- Rapid-cycling: when a person has at least 4 episodes per year. This type is seen about 5-15% of patients.
- Mixed state: when a person has both manic and depressive symptoms occurring at the same time
Psychologists and psychiatrists are the main professionals qualified to make a diagnosis of bipolar disorder.
During the assessment, the doctor asks the patient (and family members) about symptoms, the developmental and school history and the family history in order to make a determination about diagnosis and recommendations.
Getting a proper diagnosis is important. Because bipolar disorder is generally treated with medications, giving someone a diagnosis will generally lead to medication treatment. Misdiagnosing someone with bipolar disorder when they don't have it can lead to unnecessary medication use along with medication side effects. At the same time, not diagnosing someone who truly has it means that that person will miss out on potentially life-changing treatment.
At this time, there is not yet any blood test, brain scan or other diagnostic test that can help with the diagnosis of bipolar disorder.
There are other conditions that can also contribute to mood problems (e.g. mood swings, anger or rage). If any of these are present, they can be addressed as well:
Disruptive mood dysregulation disorder (DMDD)
- For children and youth who have severely unstable moods, but who do not actually have bipolar disorder, there is a diagnosis known as disruptive mood dysregulation disorder (DMDD) (DSM-5, 2013).
- Thyroid problems
- Seizure disorders
- Tourette's syndrome or tic disorders
Attention-deficit hyperactivity disorder (ADHD):
- ADHD is defined as severe problems with inattention and distractibility, and individuals with ADHD may have constant problems with anger and low frustration tolerance
Sensory processing disorders (SPD):
- SPD is a condition where individuals can be overwhelmed by sensory input (e.g. touch, sound, light), reacting with anger, mood swings and rages
Autistic spectrum disorders (ASD)
- ASD is a condition where individuals have extreme difficulties understanding other people, and tend to be extremely rigid and inflexible
Learning disorders (LD)
- LDs are conditions where individuals have problems with learning, and as a result, this can be extremely frustrating, leading to anger and mood problems particularly at school
Fetal alcohol spectrum disorders (FASD)
- FASD occurs when a developing baby is exposed to alcohol while still in the womb
There are various ways to treat bipolar disorder, and can include:
- Teaching the patient and family members about bipolar disorder, and self-help (i.e. coping strategies)
- Ensuring that the child/youth has a strong support network at home, and/or school and/or work.
- Counselling / psychotherapy (talk therapy)
Studies show that individuals with bipolar disorder have brain differences compared to other people. In other words, bipolar disorder is not your child's fault, nor is it due to choice or bad behavior, just like the way in which other brain conditions such as epilepsy, multiple sclerosis are also similarly not the person's fault.
Because bipolar disorder has such a strong biological basis, medications are often necessary in the treatment of (true) bipolar disorder.
Common medications used in the treatment of bipolar disorder include:
- Divalproex (trade name Epival)
- Lamotrigine (trade name Lamictal)
- Olanzapine (trade name Zyprexa)
- Quetiapine (trade name Seroquel)
- Risperidone (trade name Risperdal)
- Aripiprazole (trade name Abilify)
For more information about medications, speak to your doctor.
The following strategies are particularly important for people with bipolar disorder, though note that these strategies are safe and healthy for anyone's brain:
Keep regular, daily routines, which will help set your child's internal clock (Frank, 2007). As much as possible, set the same times every day (weekends and weekdays) for:
a) Your child's bedtime and wakeup time.
b) What time your child sees the first person in his/her day
c) Mealtimes, like breakfast, lunch, dinner
Ensure your child is getting enough sleep. The average child/youth needs at least 9-11 hours of sleep. Unfortunately, all too many children/youth (and adults) use electronic devices in the evening, which tricks the brain into thinking it is daytime.
Try your best to:
Limit the electronics, and come up with a good sleep routine to ensure sleep.
Keep the same times on weekends as well as weekdays. People with bipolar disorder should not be staying up late on weekends, because this can be very disruptive for their internal clock -- it is like having ‘mini' jet lag every weekend. Note that a study showed the effectiveness of "dark therapy", i.e. exposing patients to darkness from 6 PM to 8 AM for a few days helped improve manic symptoms such that patients had less need for medication and were discharged earlier from hospital (Barbini, 2005).
Regular physical activity, ideally outdoors. Studies show the effectiveness of being active, particularly outside. For more information on how to become more physically active, contact the website of the Public Health Agency of Canada at http://www.phac-aspc.gc.ca/pau-uap/paguide/. For youth that have trouble with team sports, individual sports (such as weightlifting, martial arts) may be more helpful.
Healthy diet with regular meals. Ensure that your child has regular meals and snacks. Not only is this important for good nutrition, but also helps set the body's internal clock.
Omega-3 fatty acids. Some evidence suggests that Omega-3 fatty acids (found in fish or flax seed oils) may be helpful for bipolar disorder (Stoll, 1999).
Avoid stimulants because they may trigger manic episodes in bipolar. This includes: street drugs such as amphetamines, ‘uppers' or ‘speed'. Even milder stimulants such as coffee or prescription medications for ADHD (such as methylphenidate) need to be monitored closely by a physician.
Be cautious if your child is prescribed antidepressants. For people with bipolar, the use of antidepressant medication carries a risk of causing manic episodes, so close monitoring is required by a physician. For someone with a true diagnosis of bipolar, if antidepressants are used, they are usually used in conjunction with a mood stabilizer such as lithium.
Children with bipolar disorder tend to have troubles with "emotional regulation", the ability to regulate and control their feelings. The good news is that there are many things that you can do, that over time, will help your child to develop emotional regulation skills.
Help your child express pleasant feelings by labelling and validating those feelings. When your child is happy, validate the happy feelings, for example:
Child/youth: "Look, I got to the next level in the game!" (looking excited)
Parent: "It looks like that makes you so happy... I'm glad to see you're so happy..."
It is possible that you may not agree with why your child is so happy (e.g. video game binge or doing drugs), but at least you can start with connecting by agreeing that they want to be happy.
Validate your child's feelings and emotions when your child is upset. When your child is upset, help your child label and express their feelings. This is not always easy, particularly if your child is angry or upset at you.
Child: "I hate you! You're the worst parent ever!"
Parent (to child): "Wow! You're so angry right now... You're angry at me because I said no... I know, its not easy when I say no..."
You may not agree with the reason why your child is angry, but helping your child use his/her words is one of the first steps to helping your child regulate the anger...
Tell your child that you are concerned about him or her, and be available and support your loved one with bipolar disorder. Ask your child how s/he would like to be supported.
Parent: "I'm concerned about you and want to be there for you. How can I support you? How do you want me to be help?"
Typical ways that teens want parents to support them are simply 1) listening to the child, without giving advice, 2) listening and giving advice, 3) simply spending time together, or doing fun activities.
Don't give advice if your child isn't ready to receive it. Advice is better accepted when the other person gives you permission to receive it. Simply lecturing or telling the other person what to do may not work as well, particularly with independence-seeking teens, because this may lead him/her to withdraw.
You might say: "I'm worried about you... Can I give you some advice?"
If it is a serious situation where one's physical safety is at risk, you may have to intervene.
But if it is not, you may have to just back off, and focus on building up the trust until your child/youth is ready for your advice. You might then say: "That's okay. I respect that you want to be independent. I'm here, whenever you're ready..."
Later on, continue building up your relationship with your child by ensuring that you spend 1:1 time together with your child.
Help the person get connected with professional help. Talk to your child about seeing a doctor, and take your child to see a doctor, for example:
Parent: "Its been awhile since you've seen the doctor for a checkup, so I think it would be a good idea for you to go."
If your child/youth has a strong need for independence, then perhaps give your child/youth some limited choices, for example:
Parent: "Its non-negotiable that we are seeing your doctor. But you can choose when we go... Do you want the appointment in the morning or the afternoon?"
- Bipolar Disorder, National Institutes of Mental Health, retrieved Feb 22, 2008 from http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-publication.shtml.
- Survival Strategies for Parenting the Child and Teen With Bipolar Disorder, by George T. Lynn , 2000
- The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder, by Demitri Papolos, 2002.
- Bipolar Disorders: A Guide For Helping Children And Adolescents, by Mitzi Waltz, Published By O'Reilly & Associates, 2000.
For children and youth
- Turbo Max: A Story for Siblings of Children with Bipolar Disorder
- Brandon and the Bipolar Bear: A Story for Children with Bipolar Disorder
- My Bipolar Roller Coaster Feelings Book
Barbini et al.: Dark therapy for mania: a pilot study, Bipolar Disorder, Feb 2005: 98-101.
Chang K, Adult bipolar disorder is continuous with pediatric bipolar disorder, Can. J. Psychiatry 2007; 52: 418-425.
Duffy A: Does Bipolar Disorder Exist in Children? A Selected Review. In Canadian Journal of Psychiatry 2007;52:409-417.
Frank E. Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy, 2007.
Geller B, Tillman R, Craney JL, Bolhofner K. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Arch Gen Psychiatry. 2004;61:459-467.
Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627
Lam, R.W & Levitt, A.J, editors (1999). Canadian consensus guidelines for the treatment of seasonal affective disorder. Vancouver: Clinical and Academic Publishing. Retrieved May 2, 2008 from http://www.apollolights.com/pdf/ canadian_sad_light_therapy.pdf
Papolos, D.F., Fann, C., Tresker, S., & Papolos, J.D. (2002). Pediatric mania: Prodromal symptoms and antecedent conditions. Manuscript submitted for publication.
Pavuluri M et al.: Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder: Development and Preliminary Results. Journal of the American Academy of Child and Adolescent Psychiatry, 2004; 43(5): 528-537.
Smith D et al.: CHildhood IQ and risk of bipolar disorder in adulthood: prospective birth cohort study (2015). Aug 2015, 1(1) 74-80; DOI: 10.1192/bjpo.bp.115.000455.
Stoll AL, Locke CA, Marangell LB, Severus WE. Omega-3 fatty acids and bipolar disorder: A review. Prostaglandins, Leukotrienes and Essential Fatty Acids. Volume 60, issues 5-6, May-June 1999, pages 329-337.
Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9).
Written by the eMentalHealth.ca Team and Partners.
Special acknowledgements (in alphabetical order) to:
- Keli Anderson, Executive Director of the FORCE Society for Kids Mental Health, www.bckidsmentalhealth.org
- Dr. Anne Duffy, Psychiatrist, Canada Research Chair in Child Mood Disorders, Associate Professor, McGill University
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Oct 8, 2016