Psychological Resilience
Program (PREP)
Compass Health Systems
7481 W. Oakland Park Blvd., Suite 100
Lauderhill, FL 33319
(954) 771-7743
Joseph D. Perry, Ph.D., ABPP
Executive Director & Psychologist
Bipolar Disorders in Children
Information for Parents By Joseph D. Perry, Ph.D.,
ABPP
Background. The purpose of this handout is to provide parents with
information from experts about Bipolar Disorders and how to help children with
these disorders. Bipolar Disorders are complex illnesses of the brain that are
inherited. Children who have a parent with a Bipolar diagnosis have up to a 50%
chance of having this disorder. Bipolar Disorders involve changes in mood,
energy, thinking and behavior that are easily noticed to be very different than
the way a child usually feels, thinks and acts. About 1% of teens
are estimated to have a severe Bipolar Disorder and about 5 %
have mild Bipolar Disorders. Children below 12 years of age were
reported to have about one half of the teen rate for this disorder. Bipolar
Disorders may be life threatening due to the reckless behavior and suicide
risks that often occur during mood changes. In fact, medical reports indicated
that children with some types of cancer are more likely to live to adulthood
than children with a Bipolar Disorder. Despite the severe problems caused by
this disorder, many children are not diagnosed until they have a
crisis such as a suicide attempt. Others are often misdiagnosed as having other
conditions such as hyperactivity, depression, and juvenile delinquency. The
high financial and emotional costs of raising a child with this disorder can be
reduced by early identification and treatment. Note: The word
child will be used in this handout to refer to both children and teenagers
unless differences in age are discussed.
How would I know if my child has a Bipolar Disorder? Parents who suspect that their child may have a Bipolar Disorder need to understand the high mood and energy changes that are called “Mania”. At least 3 of the 7 Manic symptoms listed below must be present according to the Diagnostic and Statistical Manual-IV Edition-Text Revision (DSM-IV-TR) that must be used for official diagnosis of a Bipolar Disorder. Recent scientific examples of specific Manic symptoms found to be true of children are also provided.
1. High Self-Esteem or Grandiosity: Sometimes talks about being able to do things that are beyond their ability and may cause harm such as saying “I can fly” and trying to jump from a second floor window.
2. Less Need for Sleep: Sometimes sleeps at least 2 hours less than usual with not being tired during the next day. This reduced sleeping is not due to sleep disorders, medications, or drug abuse.
3.Talks too Much: An increase in talking is observed and the child seems to not be able to stop talking.
4. Has too Many Ideas: Becomes unable think about one topic and says that thoughts are “racing” with poor concentration that is not due to a speech problem.
5. Becomes Suddenly Distractible: Sometimes becomes inattentive and cannot complete homework that they usually could complete in the past.
6. Becomes Able to Complete a lot of Work: Sometimes becomes very attentive with high energy. Works hard to reach high goals such as painting a beautiful picture that is much better than they have ever done before.
7. Begins Doing Risky Things for Pleasure: A major example reported to indicate this symptom is inappropriate sexual behavior with no history of being sexually abused.
Other Bipolar Symptoms: Experts reported that children with this disorder also often have the following symptoms: Depression such as being unhappy with less interest in play, crying for no reason, and talking about death and suicide; “Psychotic Thinking” such as hearing or seeing things that others cannot hear or see; being happy and acting silly that is not due to anything funny that happened nor substance use; dare-devil behavior such as trying to jump out of a moving car; eating a lot of sweets and/or carbohydrates; and severe rages.
Hypomania: This includes the same Mania symptoms listed above but the symptoms are milder than in Mania and do not cause major problems such as the need for hospitalization
Rule-Outs: These involve determining if the above Manic symptoms began after medical conditions, using medications, or substance abuse. If this is true, the child should not be diagnosed with a Bipolar Disorder but rather such diagnoses as a Mood Disorder Due to Medical Condition. Parents should note that stimulant medications for ADHD and antidepressants could cause Manic symptoms in children.
Multiple Disorders often occur in combination with a Bipolar Disorder that are called “Comorbid Disorders”. For children, these especially include ADHD, Oppositional Defiant and Conduct Disorders, Alcohol/Drug Abuse Disorders, and Anxiety Disorders. If children have any of these disorders and also have the Manic symptoms, they should be tested to determine if they also have a Bipolar Disorder.
What are the types of Bipolar Disorders? Experts refer to these disorders as “Bipolar Spectrum Disorders” since there are 34 different Bipolar Disorders. A child with Manic or Hypomanic symptoms may have 1 of 4 major types of Bipolar Disorders according to DSM-IV-TR as described below.
1. Bipolar I is the most severe and rare type that involves very noticeable changes with high moods and energy as well as sad moods and too little energy that must last for at least 7 days. These changes often result in the need for very close supervision or hospitalization in order to prevent children from harming themselves and/or others. There are 30 Bipolar I Disorders depending on the current mood that may be Manic, Depressed, or Mixed as well as other types of symptoms present such as Psychotic thoughts when the child is diagnosed.
2. Bipolar II includes more frequent and severe Depression than in Bipolar I with occasional high moods that are called Hypomania as described earlier. These Hypomanic and Depression mood changes must last for at least 4 days and not cause major problems in daily living like Bipolar I. There are 2 types of Bipolar II including (1.) Depression as the most recent mood and (2.) Hypomania as the most recent mood.
3. Cyclothymic Disorder is diagnosed when the high and depressed moods are milder than Bipolar I and II but the mood changes are noticeable. These mood changes must last for at least 1 year in children and 2 years in adults with no more than 2 months of no symptoms occurring during the year that the mood changes happened.
4. Bipolar-Not Otherwise Specified (NOS) is diagnosed when it is not clear what type of Bipolar Disorder the child has. This disorder is often used for children since they usually do not meet the requirements from the DSM-IV-TR for Bipolar Disorders that are based on adult symptoms. Children have different symptoms than adults such as more irritable rages and fast mood changes. Since Bipolar-NOS is not a clearly defined diagnosis, it is important to describe the specific Manic and Depression symptoms present when using this diagnosis.
What should be included in a test of Bipolar
Disorders in children?
*It is most important to test a child’s specific symptoms of Mania and Depression and how often these mood changes have happened based not only on the DSM-IV-TR but also but also recent research by experts.
*Problems caused by the mood changes called “impairments” also need to be tested such as the need for close supervision or hospitalization due to being a danger to self or others. This could be used to help determine the severity of the mood changes as needed for diagnosis of the type of Bipolar Disorder that a child may have.
*The Rule-Outs described earlier need to be tested to make sure that the mood changes are due to a Bipolar Disorder and not medical conditions, medications, and substance abuse.
*The related disorders listed earlier need to be tested to determine if a child has other disorders in addition to a Bipolar Disorder.
*It is also critical to determine if a child has other disorders rather than a Bipolar Disorder.
*The family, developmental, and medical history of the child should be reviewed to help determine if a child has the type of background that is often true of those with a Bipolar Disorder.
*Since there has been no test available that accurately measures all of these essential areas, Dr. Perry developed a Mood and Behavior Scale for Youth that includes parent and teacher ratings of all the above areas. Research has indicated that this rating scale provides an accurate test of Bipolar Disorders.
What type of professionals should I choose to help my child? Since these children often have multiple problems, parents should seek professional help in choosing a team of mental health and school staff as needed to meet the unique needs of a child. A child psychiatrist is a major team member who interviews the child and parents as well as plans the most important treatments of medications and hospitalization if needed. Child psychologists could provide further testing to identify specific Bipolar symptoms and related disorders as well as plan for psychological services. Other specialists could also provide services for other needs if present such as substance abuse and legal problems. Parents could refer to a listing of professionals who specialize in this disorder at the website of the Child and Adolescent Bipolar Foundation (www. bpkids.org).
What type of services should be provided for a child with a Bipolar Disorder? The type of services to be planned should be based on the test results indicating the type of Bipolar Disorder in addition to the related disorders and impairments that a child experiences. Services should be provided in order of the importance beginning with helping the child gain self-control and avoid harm as listed below.
1. Medications to improve a child’s mood are the first priority with follow-up monitoring of the child’s response to medications and side effects. There is no single medication that works for all children. Lithium and Depakote were reported to have the most proof of being helpful. Hospitalization may be needed to monitor medications.
2. Substance abuse must also be treated as part of the first priority if this is a child’s related disorder.
3. Psychological services to improve the child’s understanding of positive coping and the parents’ ability to manage the child’s behavior are helpful after the child’s mood has improved with medications.
4. The next step is to plan services for the related disorders described earlier that may be present.
5. Psychological services should be attempted initially for related disorders prior to additional medication to avoid possible interference with the medications used to reduce mood changes.
What can parents do to help their children with Bipolar Disorders? The most helpful thing that parents could do is to find and attend a family support group program for children with Bipolar Disorders. Dr. Mary Fristad developed this type of program and wrote a book about it for parents that is listed at the end of this report. Families with a Bipolar child were provided with 6 weekly 90-minute sessions to learn about Bipolar Disorders and how to cope with them. This program has proof that it is helpful in such ways as the parents being better able to understand a child’s needs and how to get services for their child. The children had improved adjustment and reported improved support from their parents. The suggestions for parents listed below are primarily based on this program.
· Learn as much as you can about Bipolar Disorders in children. There are websites and books listed at the end of this report that provide information about how to help children with Bipolar Disorders.
· Write a diary of the child’s schedule of mood changes and medications taken. Record the child’s responses to medications as well as any side effects of the medications. The child’s daily activities should also be recorded such as times of sleeping and eating. Record any behavior that could cause harm and keep evidence of these problems such as a suicide note that the child may have written.
· Plan to have the child take medications to improve moods consistently for at least 18 months after the moods have improved to make sure that mood changes do not return. A major reason that children fail to improve is not taking their medications as prescribed by the doctor. If this is a problem, seek help from the doctor and the team working with you.
· Plan to help the child manage the side effects of medications such as “dry mouth” and thirst. Have the child drink 6 to 8 glasses of water a day and request that the school permit the child to drink water and use the bathroom as needed.
· Omega 3 Fatty Acids as well as other vitamins and minerals have been recommended for Bipolar children. For more information refer to Omega-Brite www.omegabrite.com (800) 383-2030.
· The style of parenting recommended for helping a Bipolar child is being calm, firm, patient, and caring. Learn how to listen and communicate rather than yell or become upset which will make the child worse.
· Use positive behavior management such as promoting the strengths of your child and help them understand that the Bipolar moods are the problem and not him/her. Praise the child frequently when they try to control mood changes and avoid criticism when they get upset.
· When the child is in a calm mood, teach the skills that will help improve self-control such as naming negative moods as well as how to make positive choices for dealing with mood changes.
· If the child has problems sleeping, try the following: eliminate caffeine beverages that the child may be drinking; remove stimulation in the child’s bedroom such as a computer or TV; use relaxation techniques prior to bedtime; and have the child read books or read to them at bedtime.
· Children with Bipolar Disorders are 4 times more likely to drop out of school than the other kids with no emotional problems and this leads to future problems. If your child has problems at school, talk to the school psychologist about forming a school team to plan ways to help your child at school.
· If special education is needed, have the child served in a program called “Other Health Impaired” which was suggested by experts if the child has medical problems that are often associated with this disorder and medications. The “Seriously Emotionally Disturbed” program may be needed if the child has related conditions such as Conduct and Oppositional Disorders.
· Talk to the child’s psychiatrist or medical doctor about crisis services such as how to hospitalize children if they have possible risks of suicide or harm to others.
· Provide books for children about Bipolar Disorders such as listed below. Read these books to them or discuss the stories after the child has read the books emphasizing how to use the information for help.
Books for Children
The Storm in My Brain by the Child & Adolescent Bipolar Foundation 1-847-256-8525
Brandon & the Bipolar Bear by T. Anglada
My Bipolar Roller Coaster: Feelings Book & Workbook by T. Anglada
Books
for Teens
Everything You Need to Know about Bipolar Disorder & Manic Depressive Illness by M. A. Summers
An Unquiet Mind by K. Redfield Jamison
Books for
Parents
Raising
a Moody Child: How to Cope with Depression & Bipolar Disorders
by M. A. Fristad & J. S. Goldberg-Arnold *Most recommended book with techniques proven to be
helpful.
The Bipolar Child by D. & J. Papalos
New Hope for Children & Teens with Bipolar Disorder by B. Birmaher
Organizations & Websites
for Bipolar Disorders in Children
Child and Adolescent Bipolar Foundation (CABF) www.bipolarkids.org 1-847-256-8525
Depressive
& Bipolar Support Alliance
(DBSA) www.dbsalliance.org
1-800-826-3632
National Alliance for the Mentally Ill (NAMI) www.nami.org 1-800-950-6264
Juvenile Bipolar Research Foundation (JBRF) www.bpchildresearch.org (No Phone)
Parenting Bipolars: A Survival Guide for Parents www.parentingbipolars.com (No Phone)
Therapeutic
Summer Camp (Camp Nuhop) www.nuhop.com
Key
References for the Expert Information in this Handout
Kowatch, R. A., et al., (2005). Treatment guidelines for children and adolescents with bipolar disorders. J. Am. Acad. Child & Adol. Psychiatry, 44:213-235
Lofthouse, N.L.& Fristad, M. A. (2004). Psychosocial interventions for bipolar children. Clin. Child & Family Psychol. Review, 7:71-81.
Pavuluri, N. M. et al. (2005). Pediatric bipolar disorder: A review of the past 10 years. J. Amer. Acad.of Child & Adol. Psychiatry, 44:846-871.
The Mood
and Behavior Scale for Youth could be requested by e-mail at
perry9435@bellsouth.net
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