Could My Child Be Manic Depressive?
By Barbara Smith, M.D.
A: For the past 15 years there has been much debate and confusion in the psychiatric community about bipolar disorder in children and adolescents. There are still some child psychiatrists who feel it does not exist. However, we are all in agreement that we all treat a number of children and adolescents who suffer from severe mood and behavioral dysregulation. Most child psychiatrists have come to recognize this constellation of symptoms as bipolar disorder in children and adolescents. It is also known as pediatric-onset or juvenile-onset bipolar disorder.
One reason this diagnosis has only recently been recognized is because the way the symptoms look depends upon the age and developmental stage of the child. The bipolar symptoms in young people can look very different from the symptoms in adults. For example, in a child age 5, bipolar disorder may present as frequent tantrums and physically acting-out behaviors. In contrast, a 15-year-old may display symptoms with more verbal acting out: cursing, threats, demands and a maddening inability to understand the absurdity in her thinking.
One difference between adult and pediatric onset bipolar has to do with the course of the disorder. In adults one is likely to see distinct periods of mania alternating with distinct periods of normal mood or depression. In youngsters, the manic and depressed mood are often less distinct or rapid cycling. A young person's mood can cycle from a depressed or normal mood to mania many times in one day, making stabilization more difficult. Another difference between adult-onset bipolar disorder vs. pediatric-onset bipolar disorder revolves around how the manic mood itself presents. Mania in adults often looks like euphoria (excessive happiness) with inflated self-esteem. In children and adolescents, the predominant symptoms of mania are severe defiance, oppositional behavior and irritability. We tend to see low self-esteem in these youngsters.
Children and adolescents with bipolar disorder tend to have mood storms or anger storms — prolonged aggressive outbursts that often occur with little provocation or for no reason. These outbursts can last for 15, 30, 60 minutes or more and, like a storm, they can just go away. In pediatric onset bipolar disorder, the continuous predominant mood of the young person is irritable, angry, cranky and whiny. This pervasive mood is punctuated by the outbursts or "storms" as described above. These outbursts can occur once a day, once a week or several times a day. This is often how we gauge the severity of the disorder.
Once an outburst occurs it is usually impossible to stop it. After the "storm" the child often goes back to their normal activity as if nothing happened. Sometimes they feel remorse and shame; sometimes they do not remember the episodes. Families tell me that they have to "walk on eggshells" for fear of outbursts. Parents often feel concerned about the safety of other siblings and sometimes themselves. Children and adolescents with bipolar disorder cannot be managed or redirected like normal youngsters. This often causes parents to feel demoralized about their own parenting skills.
The symptoms of bipolar disorder often overlap with the symptoms of ADHD. Since the two disorders often occur together, this can make the diagnosis of bipolar disorder difficult. However, in ADHD alone, there is no continuous, pervasive mood disturbance. Youngsters with ADHD may become cranky and irritable when frustrated, but this is only temporary. Bipolar disorder also carries with it much more dysfunction. These are the children who are already getting sent to the principal's office or suspended due to aggressive and outrageous behavior. These are the youngsters that other kids refuse to play with because of their behavior. These are also the children that cannot be taken out to a public place for fear of their outbursts.
Bipolar disorder is a chemical imbalance in the part of the brain that regulates the mood. It is as valid a medical problem as hypertension or diabetes. It has a strong genetic component and often runs in families. While stress could make it worse, the disorder often occurs without any obvious precipitant.
We have a number of beneficial medications that can target different areas in the brain. Therefore, we can control the variety of symptoms associated with childhood bipolar disorder and the often-associated psychiatric disorders like ADHD and anxiety. Though the medication choices are too numerous to list here, a child psychiatrist will be able to discuss all of the options with parents. Pediatric-onset bipolar disorder can be effectively treated with minimal side effects. Therapy to help the child learn alternative coping strategies is also beneficial after the medications begin to work. Children and adolescents with bipolar disorder can be well stabilized and are able to lead a normal, productive life.
Submit your questions via e-mail to Sherri.McMillen@mosescone.com. Barbara Smith, MD, is a psychiatrist at Moses Cone Behavioral Health Center.