Childhood Onset Bipolar Disorder Essay, Research Paper

Childhood-Onset Bipolar Disorder

Childhood Onset Bipolar Disorder (COBPD) is one of the

most debilitating mental disorders affecting children today.

Bipolar Disorder is a mood disorder usually affecting adults

that causes sometimes severe changes in mood. Childhood

Onset Bipolar disorder is just what it sounds like, a

bipolar disorder that occurs during childhood. Persons

suffering from a bipolar disorder experience mood swings

ranging from depression to mania. During a depressive

episode patients can experience feelings of extreme

hopelessness or sadness, inability to concentrate and

trouble sleeping. Symptoms of mania include rapidly changing

ideas, exaggerated cheerfulness and excessive physical

activity. Hypomanic symptoms are the same as in mania,

however, they are not so severe as to require

hospitalization.

The fourth edition of the Diagnostic and Statistical

Manual of Mental Disorders (DSM-IV) outlines the diagnostic

criteria for mood disorders. According to the DSM-IV, a

person must have at least 5 of the following symptoms during

the same 2 week period to qualify as a major depressive

episode: a depressed mood lasting most of the day for

several days; a significant weight gain or weight loss; a

loss of interest in activities; difficulty sleeping

(insomnia) or an increased need for sleep (hypersomnia);

restlessness or slowed pace observable by others; daily

fatigue; feelings of guilt or worthlessness; inability to

concentrate; or recurrent thoughts of death. These symptoms

can only be diagnosed as a depressed episode if they are not

better explained by grief, effects of a drug, or a medical

condition. The person experiencing these symptoms must, also

report an interference in their daily functioning because of

the symptoms. Finally, the person?s symptoms do not meet the

criteria for a mixed state.

The criteria for a mixed episode state that the person

must display symptoms of depression and mania every day

during at least a 1 week period.

For an episode to be categorized as manic, the

patients? mood has been irritable or abnormally elevated for

at least 1 week. A person must also exhibit at least 3 of

the following symptoms (4 if the mood is only irritable):

extreme feelings of personal greatness; a decreased need for

sleep, marked talkativeness; distractibility; extreme focus

on a goal-directed activity; reports of ?racing? thoughts or

a flight of ideas; or excessive involvement in pleasurable

activities that have a high potential for painful

consequences (i.e. sexual indiscretions or unintelligent

business investments). As in the criteria for a depressed

episode, the DSM-IV specifies that these symptoms should not

be better explained as being a side effect of a drug or

illness to qualify as a manic episode. These symptoms must

interfere with the person?s normal functioning and must not

meet the criteria for a mixed episode.

As with adults, childhood-onset bipolar disorder has

many faces. Children with Bipolar I Disorder have episodes

of mania and episodes of depression, sometimes there are

long periods of normal moods between episodes. Adults

usually tend to have more depressed episodes than manic

episodes. However, some children will have chronic mania

(symptoms of mania lasting for long periods of time or

marked by frequent recurrence) and seldom experience a

depressed episode. Bipolar II Disorder causes depressive

episodes, sometimes lasting for long periods of time. It can

also cause hypomanic episodes, but manic episodes are not

present. Unlike Bipolar I Disorder, for persons with Bipolar

II Disorder, periods of normal moods are virtually

nonexistent. Cyclothymia is characterized by frequent

hypomanic episodes and occasional episodes of mild

depression only. Some children have repeated hypomanic

episodes a year. Person?s showing signs of depression and

mania at the same time is referred to as being in a mixed

state. Bipolar I Disorder, Bipolar II Disorder, Cyclothymia,

and Mixed State Bipolar Disorder are all very rare in

children.

For many years it was assumed that children could not

suffer the mood swings of mania or depression, but as more

research has been done, we have realized that bipolar

disorder can occur in children, and it is much more common

than previously thought. Althoug, the DSM-IV does touch on

the subject of children with mood disorders, they are still

diagnosed according to adult criteria. In children, mania

and hypomania appear as more of an irritable mood. These

features come and go throughout the day and are not as

persistent as in adults. When bipolar disorder is present in

children it is more severe and harder to treat. Children

tend to experience extremely rapid mood swings, often

cycling from mania to depression and back to mania several

times a day. The most typical pattern of cycling among those

with COBPD, called ultra-ultra rapid or ultradian, is most

often associated with low arousal states in the mornings

followed by increases in energy towards late afternoon or

evening(Facts about COBPD;http://www.mhsource.com/hy/

bipolarch.html).

Difficulties with early onset bipolar disorder begin

with diagnosis. The rapid cycling of moods in children with

COBPD make it difficult to fulfill the duration criteria of

Bipolar Disorder. The DSM-IV states that depressive or manic

episodes are to last a specific length of time, at least 4

days in a manic episode and at least 2 weeks in a depressive

episode. The majority of children suffering from COBPD do

experience these ultra-ultra rapid patterns of mood swings.

The DSM-IV does include a section entitled ?Bipolar

Disorders Not Otherwise Specified (NOS)?, which allows for

mood swings not lasting the full duration criteria(DSM-IV-

?Subaffective disorders: Dysthymic, Cyclothymic, and Bipolar

II Disorders in the ?borderline? realm?). However, this is

still not an accurate description of COBPD.

Many parents of children with COBPD report that their

children have seemed different from infancy. They describe

difficulties calming their babies, and they relate that

their children have always been very sensitive to sensory

stimulation, i.e. sounds, lights, touches. Many children

have extreme difficulty sleeping and some experience night

terrors (Facts about Childhood-Onset Bipolar Disorder). A

child suffering from COBPD may be easily frustrated and have

terrible temper tantrums lasting until the child is

literally exhausted. These children tend to be bossy and

have trouble adjusting to new situations, especially

situations that they have no control over. Some children

with a bipolar disorder are extroverted and very charismatic

while other children experience bouts of social phobia

(extreme discomfort in a social situation).

Without closer observation, hyperactive, irritable,

distractible children are believed to have Attention Deficit

Disorder with Hyperactivity (ADHD). As a matter of fact, a

million children and adolescents in the United States may

have COBPD, of these 1 million people, an estimated 23

percent are currently diagnosed with ADHD(Mitzi Waltz,

Bipolar Disorders, 1st Edition January 2000)

Attention Deficit disorder with hyperactivity and COBPD

do have many of the same warning signs and symptoms.

Person?s diagnosed with ADHD experience an inability

focusing attention on a task, or difficulty organizing

tasks. They do not seem to listen when spoken to, have

difficulty following instructions, avoid tasks that require

mental effort, are easily distractible, experience recurrent

forgetfulness, and repeatedly lose materials necessary to

complete a task, i.e. books, tools, pencils. Dr. Demitri

Papolos has stated that over eighty percent of children who

have COBPD will meet the full criteria set by the DSM-IV for

ADHD (Papolos and Papolos, The Bipolar Child). What

differentiates the two disorders is the fact that children

with a bipolar disorder exhibit much more irritability,

unstable mood, and sleep disturbances than children with

ADHD.

There are many theories as to what may cause COBPD.

Alan S. Brown, MD, and colleagues have proposed that there

may be a relationship between prenatal malnutrition and

COBPD. Brown and his colleagues studied hospitalization

records of Dutch psychiatric patients who were exposed

inutero to the harsh climate and extreme food shortage of

the 1944 Dutch winter. By looking at hospital records of

people exposed to this environment during the first

trimester, second trimester, third trimester and a control

group (who were not exposed at all), Brown and his

colleagues found that men and women exposed inutero to

famine and harsh climate during the second and third

trimester were more likely to develop a bipolar disorder

than those exposed during the first trimester or not exposed

at all. Also, the incidence for unipolar disorder (a mood

disorder in which a person experiences only depressive

episodes) was more significant than for bipolar disorder

(Brown AS, Susser ES, Lin SP et al. 1995) in those exposed

during the first trimester or not exposed at all.

According to more recent studies, one of the main

factors in establishing a diagnosis of COBPD is family

history. This means that there is a significant link between

COBPD and genetics. Dr. Richard Todd and his colleagues at

Washington University in St. Louis found increased rates of

COBPD when family histories reveal a mood disorder and/or

alcoholism on both the maternal and paternal sides. By

transferring information from questionnaires into a

database, it was found that over 80 percent of children

diagnosed with COBPD had this bilineal transmission (Todd et

al. 1997).

Childhood-Onset Bipolar Disorder is a somewhat of a new

concept. The DSM-IV is not scheduled for revision in the

near future, but there have been some guidelines set that

experts can use to make recognition of COBPD a bit easier.

For example, a Washington University team of researchers use

a structured diagnostic interview called Wash U KIDDE-SADS,

which is more sensitive to the rapid cycling patterns of

children with a bipolar disorder (CABF Learning Center-

About Early Onset Bipolar Disorder). The criteria, though

not formal, are the same as in adult bipolar disorder but

there are two differences. First, the cycling between mania,

hypomania and depression occurs many times each day. Second,

these episodes are short, rarely lasting more than a day

before cycling to another state (Childhood Onset Bipolar

Disorder; http://www.klis.com/chandler/pamphlet/bipolar/

bipolarpamphlet.htm).

For children with COBPD, a correct diagnosis is

extremely important. This disorder, left untreated or

improperly treated due to a misdiagnosis, can lead to severe

impairments. Children who are not treated, or not treated

properly experience an increase of symptoms. The behavior

exhibited by children with COBPD, if not understood and

dealt with, can lead to a removal from school,

hospitalization, and sometimes even placement in the

juvenile justice system. Misdiagnosis can lead to

personality disorders and perhaps drug abuse. Childhood

Onset Bipolar Disorder is extremely difficult to deal with

for the child suffering. Most children report guilty

feelings, and feelings of not belonging anywhere. Left

untreated, COBPD worsens and a correct diagnosis is the only

way to start an effective treatment plan.

There is no miracle cure for bipolar disorder. There

is, however, reasonable probability that a good treatment

plan can lead to a virtually symptom free life. A good

treatment plan includes medication, close monitoring of

symptoms, education about the illness, counseling or

psychotherapy for the child and their family, stress

reduction, good nutrition, regular sleep and exercise, and

participation in a network of support (CABF Learning Center-

Facts about Early Onset Bipolar Disorder).

Medication is usually the first course of action in an

effective treatment plan. Similar to the differences between

COBPD and bipolar disorder affecting adults pertaining to

diagnosis, there are drugs that have been proven to work on

adults that are not as effective in children. One of these

drugs is the mood stabilizer, Lithium.

Lithium and other mood stabilizers cause changes in the

balance of chemicals in the brain. The difficulty with

prescribing a mood stabilizer to a child with COBPD is that,

while being effective on manic and hypomanic episodes, they

are not effective in decreasing depressive episodes. In

other words, taking a mood stabilizer may cause a child?s

cycling pattern to stop, but the child will still experience

the depressive episodes. Lithium, as with other mood

stabilizers, is also not as effective in children as it is

in adults.

Recently, mood stabilizers have become the second

string of drugs used to combat bipolar disorder. The reasons

being that the newer drugs (called Atypical Antipsychotics)

are more effective, they work faster, are easier to use, and

have less side effects.

The most studied of the newer atypical antipsychotics

is Risperdal (Risperidone). This drug has been found to be

85% effective in combating the symptoms of Childhood Onset

Bipolar Disorder (CABF Learning Center). Risperdal not only

treats the mood swings occurring with bipolar disorder, but

it also calms down the irritability and rages that these

children often experience. As with all drugs, there are some

side effects with Risperdal, with most people reporting a

significant weight gain, but they are not common.

With bipolar disorder affecting over a million people

in this country, researchers are constantly looking for

safer, faster, more effective drugs.

In a recent study, Dr. Michael H. Allen composed a

group study of fifty-nine hospitalized patients exhibiting

manic episodes. Dr. Allen was interested in finding a

treatment that would work rapidly and prevent

hospitalization (Keck PE Jr., Hirschfeld RMA, Allen MH et

al., Safety and efficacy of rapid-loading divalproex sodium

in acutely manic patients).

For comparison, patients were assigned randomly to a

ten day treatment schedule of loading doses of Depakote (a

mood stabilizer), or non-loading doses of Depakote or

Lithium. In the loading strategy, 20 patients received 30 mg

per day of Depakote for days 1 and 2, and then dropped back

to 20 mg per day in divided doses. In the non-loading

strategy, 20 patients received 750 mg of Depakote daily in

divided doses. In the Lithium strategy, 19 patients received

300 mg of the drug 3 times a day.

The researchers found that all of the patients showed

decreased signs of manic symptoms by day 3 of the study, but

the patients assigned to the loading doses of Depakote

showed improvement by day 2. In addition, the difference

between treatment groups was accentuated in patients with

more severe manic symptoms (Keck et al., 1999).

Of course, no one medication works for all children

with COBPD. Sometimes 2 or more are needed collectively to

reach and maintain mood stability. Parents should expect a

trial and error period in which their child?s doctor may

have to try many different medications in different

combinations before the best treatment is found.

One way to speed up the trial and error process toward

an effective medication is through the use of cycle charts.

Cycle charts are a way of keeping track of your child?s mood

throughout the day, along with what medication is given and

how often. These charts can be extremely important to the

doctor when prescribing the medications as well as to the

therapist conducting the psychotherapy. Recording a child?s

moods in the form of a simple graph, these cycle charts

provide a visual display of the course of the illness and

brings into focus the symptoms and behaviors that define the

condition (Papolos and Papolos, 1999).

The second phase of treatment is psychotherapy. This is

a very important stage and the reason it usually occurs

after medication has stabilized the child?s mood is because

children experiencing rapid mood swings have not been found

to benefit from counseling alone. Therapy issues include

dealing with the stress that may trigger or worsen manic and

depressive episodes. Counseling can also ensure the patients

willingness to follow the prescribed course of treatment. A

good therapy plan should include support and education about

the illness.

Children with a bipolar disorder have other needs that

need to be taken into consideration. One of the main

problems facing these children is the difficulties they face

in school. The medication necessary to stabilize their moods

often leaves them feeling fairly sedated. The child?s

functioning can vary throughout the school year, sometimes

it varies daily, and they can easily fall behind other

students. Parents should suggest a meeting between the

special education staff of their child?s school, the child?s

therapist, and themselves. Together, the best way to insure

the child?s educational development progresses smoothly is

to put into action an Individualized Educational Program

(IEP). This plan contains goals and objectives based upon

the childs? present educational level. The IEP also includes

when the plan will begin, how long it will last, and the way

in which the child?s progress will be evaluated (LD OnLine:

IEP: The Process).

Bipolar disorder has left it?s mark on history. Many

famous people have had symptoms of bipolar disorder; Abraham

Lincoln, Theodore Roosevelt, Tolstoy, and Hemingway to name

a few. In fact, the biography of Beethoven discloses severe,

recurrent mood swings beginning in childhood.

In short, coming to a correct diagnosis of Childhood

Onset Bipolar disorder can be very difficult and finding an

effective treatment plan can be a long, drawn out process.

However, if these obstacles are overcome, children suffering

with a bipolar disorder can lead very normal, productive

lives.

RESOURCES

Todd, Richard D. ?The link between parental alcoholism and

childhood mood disorders: A family/genetic perspective.?

Medscape Mental Health 2 (1997)

DSM-IV. ?Journal of clinical psychopharmacology 16,

supplement 1.? (1996)

Keck PE Jr., Hirschfeld RMA, Allen MH et al. (1999), Safety

and efficacy of rapid-loading divalproex sodium in acutely

manic patients.

Ryan, Neal MD; Bhatara, Vinod S. MD; Perel, James M.

PhD.?Mood stabilizers in children and adolescents.? Journal

of the American academy of child & adolescent psychiatry,

Volume 38, Number 5 (May 1999)

Papolos, Demitri MD; Papolos, Janice. ?The Bipolar Child.?

(1999)

Waltz, Mitzi. ?Bipolar Disorders.? (1st edition Jan. 2000)

CABF Learning Center- About Early Onset Bipolar Disorder:

http://www.cabf.org/learning/about.htm

Bipolar Affective Disorder (Manic Depressive Disorder) in

Children and Adolescents: http://www.klis.com/chandler/

pamphlet/bipolar/bipolarpamphlet.htm

Child and Adolescent Bipolar Disorder; An update from the

national Institute of Mental Health: http://www.nimh.nih.

gov/publicat/bipolarupdate.cfm

Facts About Childhood Onset Bipolar Disorder: http://www.

mhsource.com/hy/bipolarch.html

LD OnLine: IEP Individualized Education Program: The

Process- http://www.ldonline.org/ld_indepth/iep/

iep_progress.html