Bipolar Disorder is being diagnosed in children and adolescents with increasing frequency. This phenomenon has lead many concerned Mental Health Professionals to delve deeper into their clients’ experience in an effort to understand, diagnose and treat this disease with greater sensitivity and skill. What has been learned thus far is that Bipolar Disorder is a biologically based disease of mood regulation that affects the stability of one’s emotional experience. As the name suggests, individuals who suffer from this disease tend to experience extreme shifts in their emotions, shifting quickly from euphoric and energized experiences of mania to debilitating bouts of depression. These mood swings tend to be episodic in nature, lasting anywhere from a week to many months. In order to qualify as a manic or depressive episode, the mood symptoms must have a marked impact on the individual’s ability to function over a certain period of time. However, to characterize a child’s experience of Bipolar this way can be somewhat misleading.
Research has shown that children who struggle with Bipolar disorder tend to present differently than their adult counterparts. To be diagnosed as Bipolar (or one of the subtypes of Bipolar), one must display evidence of a manic episode for at least one weeks time. The following is a list of the classic hallmarks of a Manic episode:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Extremely talkative, or pressured speech
- Racing thoughts
- Increased distractibility
- Increase in goal-directed activity
- Increase in Psycho-motor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (spending sprees, gambling, sexual indiscretions)
The adult experience of mania is often characterized as an experience of soaring self-esteem, impulsive and foolish decision making, and an abundance of energy (imagine doing a Jim Carry impression for a whole week without stopping). Children however, are seldom euphoric during the manic phase of their illness but are often irritable, edgy, and at times, explosive. Mania in children is most frequently characterized by a flurry of activity and energy combined with an intense level of irritability that can often turn into rages lasting up to several hours.
In addition, there is almost always an element of grandiosity present in the child’s thought process during the manic phase of an episode. While this is a more traditional hallmark of mania, grandiose thoughts and feelings often look different in children than they do in adults. A parent of a Bipolar child recently reported the following episode involving her nine year old son:
“He was clearly manic… anxiously darting around the house, hitting his sister for no reason, laughing to himself, even cursing at times. In the middle of playing a video game, he got up, dashed out the front door, and yelled over his shoulder that he was going to ‘White Hen’. White Hen was approximately 3 miles away, he was in shorts and a tee-shirt, it was in the thirties, and it was raining.”
While this may appear on the surface to be a very hyperactive and impulsive child, his actions betray a belief that he would not be affected by the distance, weather, or his lack of protection from strangers. This belief is clearly not rational. It is in fact quite grandiose. What is important for parents and professionals to recognize is that this child’s grandiose beliefs and his resultant behaviors are imbedded in a feeling state made up of intense emotions of excitement, anxiety, elation, and agitation. This feeling state is what we refer to as mania.
An important note is that many bipolar children and adolescents are extremely sensitive people who are often vulnerable to feeling embarrassed and ashamed (just as they are vulnerable to feeling most emotions with great intensity). Therefore, it is quite common for these individuals to put tremendous effort into hiding their symptoms while in school or out in public, only to come home and “blow up” with their families. As a result, teachers and counselors are often unfamiliar with the entire range of the student’s symptom presentation.
Frequently, the primary symptoms at school resemble inattention, hyperactivity, and impulsivity. It is for this reason that children often begin their relationships with mental health professionals seeking treatment for Attention Deficit/ Hyperactivity Disorder. This misdiagnosis can cause significant set backs to the treatment in that the medications used to treat ADHD not only leave Bipolar symptoms untreated, but can often intensify them. The following is a list of distinguishing characteristics between the two disorders:
BIPOLAR VS ADHD
- ADHD moods are more congruent or related to the situation.
- ADHD symptoms are always present. Bipolar symptoms fluctuate.
- ADHD destructiveness is usually due to carelessness. Bipolar has a more intentional (but non-productive) quality related to rage.
- Bipolar rages have intense physical and emotional energy which can damage people or property.
- ADHD outbursts usually calm down in 30 minutes or less. Bipolar rages may act disproportionately angry for hours.
- Bipolar children may have no memory of the rage.
- Triggers for ADHD children are usually sensory and emotional over-stimulation. Bipolar triggers are usually a reaction to limit setting.
- ADHD children do not usually show depression and irritability as prominent symptoms nor do they have as many physical or “somatic” complaints.
- ADHD children may have accidents due to inattention but bipolar children tend to deliberately provoke, misbehave, and take risks.
- Bipolar children have more sleep disturbances with severe nightmares and night terrors often containing themes of explicit gore and bodily mutilation.
- Bipolar children may often grossly misinterpret emotional events.
- ADHD children usually maintain reality contact.
- Bipolar children may have strong and early sexual interest/behaviors.
- Bipolar children usually have a positive family history for the disorder in first degree relatives.
- ADHD children usually have a family tree with multiple cases of ADHD.
When one combines the diagnostic complexity of Bipolar Disorder with the intensity of its symptoms and the stress and strain it can cause on a family, it is not hard to see why treating this disease demands flexible and intensive intervention on multiple fronts. While not exhaustive, the following treatment areas are vital parts of an effective treatment plan:
- Medication is often the first line of attack in an effort to help stabilize a child’s mood swings and intense emotions.
- Psycho-Education is aimed at increasing understanding of the nature of the disease and its impact on the many facets of the family’s life.
- Counseling sessions seek to teach skills for coping with intense emotions, managing rapid mood changes, recognizing triggers, and learning how and when to talk to family and friends about the disease.
- Coordination and communication between mental health professionals, school and support staff is essential to maintaining the continuity of treatment.
- Parents must become informed advocates for their children at school and in the community at large.
- Lastly, it is vital for parents and care takers of children with Bipolar to find forums for connecting with others who have had to struggle with the challenges of living with Bipolar.
Seth Allison MA, LCPC