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Bipolar Children and Teenagers

by Amy Otis, BSN, RN

Bipolar Disorder in Children and Teenagers

Bipolar disorder can occur in children and adolescents and has been investigated by federally funded teams in children as young as age six. Although once thought rare, caseloads of patients examined for federally funded studies have shown that approximately seven percent of children seen at psychiatric facilities fit bipolar disorder using research standards.

Symptoms of Bipolar Disorder in Children and Adolescents

One of the biggest challenges has been to differentiate children with mania from those with attention deficit hyperactivity disorder. Both groups of children present with irritability, hyperactivity and distractibility. These symptoms are not useful for the diagnosis of mania because they also occur in ADHD. But, elated mood, grandiose behaviors, flight of ideas, decreased need for sleep and hypersexuality occur primarily in mania and are uncommon in ADHD. Below is a brief description of how to recognize these mania-specific symptoms in children.

Elated children may laugh hysterically and act infectiously happy without any reason at home, school or in church. If someone who did not know them saw their behaviors, they would think the child was on his/her way to Disneyland. Parents and teachers often see this as “Jim Carey-like” behaviors.

Grandiose behaviors are when children act as if the rules do not pertain to them. For example, they believe they are so smart that they can tell the teacher what to teach, tell other students what to learn and call the school principal to complain about teachers they do not like. Some children are convinced that they can do superhuman deeds (e.g., that they are Superman) without getting seriously hurt, e.g. "flying" out of windows.

Flight of ideas is when children jump from topic to topic in rapid succession when they talk and not just when a special event has happened.

Decreased need for sleep is manifested by children who sleep only four to six hours and are not tired the next day. These children may stay up playing on the computer and ordering things or rearranging furniture.

Hypersexuality can occur in children with mania without any evidence of physical or sexual abuse. These children act flirtatious beyond their years, may try to touch the private areas of adults (including teachers), and use explicit sexual language. In addition, it is most common for children with mania to have multiple cycles during the day from giddy, silly highs to morose, gloomy suicidal depressions. It is very important to recognize these depressed cycles because of the danger of suicide.

Treatments, Medications and Psychosocial Effective Therapies

At this time there are several ongoing studies of how to best treat children, but until more scientific data is available clinicians are left using their best judgment on how to manage using medications that have been effective in adults. These are largely three main types of drugs -- Lithium, anticonvulsants (e.g., Depakote or other valproate products) and atypical neuroleptics (e.g., risperidone, olanzapine, ziprasidone, aripiprazole, quetiapine).

Side Effects — Including Those That May Only Occur in Young People.

Side effects that are particularly troublesome and that are worse in children include the following. Atypical neuroleptics (except aripiprazloe) are associated with marked weight gain in many children. One day we hope to have specific genetic tests that will tell us beforehand which people will gain weight on these medications. But right now, it is trial and error. The dangers of this weight gain include glucose problems that may include the onset of diabetes and increased blood lipids that may worsen heart and stroke problems later in life. In addition, these drugs can cause an illness called tardive dyskinesia, which is irreversible, unsightly, repeated movements of the tongue in and out of the mouth or cheek and some other movement abnormalities. Depakote may also be associated with increased weight and possibly with a disease called polycystic ovarian syndrome (POS). In some cases POS is associated with infertility later in life. Lithium has been the market the longest and is the only medication that has been shown to be effective against future episodes of mania and of depression and of completed suicides. Some people who take lithium over a long time will need a thyroid supplement and in rare cases may develop serious kidney disease.

It is very important that children on these medications be monitored for the development of serious side effects. Side effects need to be weighed against the dangers of the manic-depressive illness itself.

At this time, with childhood and adolescent onset the disease regrettably appears more severe and with a much longer road to recovery than is seen with adults. While some adults may have episodes of mania or depression with better functioning between episodes, children seem to have continuous illness over months and years.

Impact on Educational Achievement

It is challenging to educate a child who is seriously too "high" or too "low." Therefore educators need to be aware of the diagnosis and make special arrangements.

Suicide Risk

Any talk about wanting to die, or asking why they were born or wishing they were never born must be taken very seriously as even quite young children can hang themselves in the shower, shoot themselves or complete suicide by other means.

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