Bipolar Disorder, Early Onset (Childhood)

From WikEd

1 Bipolar Disorder Defined
2 Bipolar Disorder in Infants and Toddlers
3 Bipolar Disorder in Children
4 Bipolar in Adolescents
5 Bipolar in Adults
6 History of Early Onset Bipolar Disorder
7 Challenges in Diagnosing Early Onset Bipolar Disorder
8 Treatment
9 Bipolar Disorder in the School Setting: Impacts on Cognition
10 Accommodations in the Classroom
11 Advocacy & Awareness
12 Evidence - Literature Review
- 12.1 Current Research
- 12.2 Need for Additional Research
13 Critics and Their Rationale
14 Alternative Explanations: What causes Bipolar Disorder?
15 Signed Life Experiences, Testimonies and Stories
16 References
17 Other Links of Interest

Bipolar Disorder Defined

Bipolar Disorder (BD), also called manic depression, is a mental illness that affects a person's ability to experience a normal range of mood (http://www.bipolar.com/whatis/bipolar-disorder.htm). Bipolar affects adults and children. This topic primarily covers bipolar in children, which may also referred to as:

Childhood Onset Bipolar
Early Onset Bipolar
Juvenile Bipolar Disorder
Pediatric Bipolar
Prepubertal-onset Bipolar

According to the American Psychiatric Association (APA) people with bipolar disorder experience severe mood swings, i.e., episodes, that cycle between mania, hypomania, depression, and mixed mood. Adults with bipolar will often remain in one episode for weeks or months. Children, however, experience rapid cycling, during which they can experience extreme shifts between mania, depression or mixed moods within the same day or even hour.

Watch "I Walk Alone" The Face of Pediatric Bipolar Disorder.

Defining Terms

Episode: When a person remains in a state of mania, hypomania, depression, or mixed mood for a period of time. In adults an episode lasts for at least a week. Adult episodes can last for months. Children experience rapid cycling where they cycle between episodes in the same day or hour.

Depression: A major depressive episode is when 5+ symptoms of depression are present for at least 2 weeks in adults. Children experiencing depression are irritable, defiant, and can be suicidal.

Mania: A manic episode is a period where a person has an elevated, expansive, or irritable mood and distorted or psychotic thoughts. During this period, 4+ symptoms of mania must be present, i.e. needing little sleep, talking fast, racing thought, easily distracted, carelessness or recklessness, etc.

Hypomania: There are no psychotic symptoms, i.e. no delusions or hallucinations. The mood during a hypomanic episode must be clearly different from the usual non-depressed mood, with little change in functioning. The change is observable by racing thoughts, for example, but no severe impairment takes place physically,socially or occupationally.

Mixed Mood: A manic episode + a major depressive episode = Mixed Episode. Both episodes must be present simultaneously for an extended period of time.

Rapid Cycling: When a person cycles between episodes within the same 24 hour period.

Bipolar Disorder in Infants and Toddlers

Many parents of bipolar children often state that there were clear signs that something was wrong from the time their children were infants or toddlers. Parents remember their infants being extremely fussy, refusing to take naps during the day, and staying awake for hours during the night (Papolos and Papolos, The Bipolar Child, 1996:8).

Parents of toddlers remember their children as full of energy, walking, and talking very early. Many parents describe their children as being very precocious, exhibiting adult-like behavior (9). The flip side of this energy is a sense of uncontrollable crying in infants and as children get older, rage. Bipolar toddlers have no control over their rage, which is often triggered simply by a parent or caregiver saying "no." The rage can seem almost trans-like and can come on immediately, without warning (12).

A common symptom of bipolar in young children is night terrors. Bipolar children often wake up in the middle of the night screaming uncontrollably, and cannot be comforted. Many children describe in horrifying detail, dreams of blood, gore, death, and murder. Researchers believe that it is possible that these horrifying dreams spill over during the day, leading bipolar children to say shocking things, draw and paint pictures of dripping blood and severed limbs in vivid detail (11).

Bipolar Disorder in Children

Early Onset Bipolar describes symptoms of mania and depression in children under the age of 18. Symptoms can be present in children as young as two years of age. Children with bipolar disorder present a very different set of symptoms. Children often cycle from mania to depression more rapidly than adults. Some cycle many times within a week or month, while others cycle many times within a 24 hour period (Papolos and Papolos, The Bipolar Child, 2006:6).

Children with bipolar are often inflexible, oppositional, and extremely irritable. Many experience explosive tantrums that can last for hours. They have night terrors, are hypersensitive to external stimuli, crave carbohydrates and sweets, and have a higher incidence of bed wetting. More often, children don't usually show these symptoms in public, which makes it very difficult for professionals to diagnose the disorder.

Conversely, children with bipolar are outwardly often very bright and can be very sociable and are often described as precocious, further making diagnosis difficult.

Bipolar Symptoms in Children

Destructive rages that continue past the age of four. These rages differ from a normal temper tantrum in that they are set off by seemingly minor triggers, they can are often violent, can last for several hours, and can occur daily or multiple times per day.
Rapid cycling. Children are happy, sad, raging, all within the same day.
Suicide. Talk of wanting to die or kill themselves. Children with bipolar talk about hating themselves, wanting to die, and may try to kill themselves by jumping out of a moving car, for example.
Sleep Disturbances. Children with bipolar seemingly have endless energy. Spikes in energy often occur before bedtime, making falling asleep difficult. Children with bipolar often do not sleep through the night and may suffer from night tremors.

(Helliner, et al, 2008; Trudeau, Mental Illness in Children - Part II, 2003)

The Child & Adolescent Bipolar Foundation published this list of "commonly seen behaviors:"

crying for no apparent reason
an expansive or irritable mood
depression
rapidly changing moods lasting a few minutes to a few days
explosive, lengthy, and often destructive rages
separation anxiety
defiance of authority
hyperactivity, agitation, and distractability
sleeping to little or too much
night terrors
strong and frequent cravings, often for carbohydrates and sweets
excessive involvement in multiple projects and activities
impaired judgment, impulsivity, racing thoughts, and pressure to keep talking
dare devil behaviors
inappropriate or precocious sexual behavior
delusions and hallucinations
grandiose belief in personal abilities that defy the laws of logic (e.g., ability to fly, knows more than teacher or principal)
extreme irritability

Bipolar in Adolescents

The early onset of bipolar disorder is can interrupt the normal development of identity, relationship skills, academic success, and autonomy (Morris et al., 2007). Pre-adolescents and adolescents with bipolar often suffer from other mental health disorders and learning disabilities such as attention deficit hyperactivity and anxiety (434), and are at high risk for promiscuity, substance abuse, and suicide.

Symptoms of mania include:

elevated, expansive or irritable mood
decreased need for sleep
racing speech and pressure to keep talking
grandiose delusions
excessive involvement in pleasurable but risky activities
increased physical and mental activity
poor judgment
in severe cases, hallucinations

Symptoms of depression include:

pervasive sadness and crying spells
sleeping too much or inability to sleep
agitation and irritability
withdrawal from activities formerly enjoyed
drop in grades and inability to concentrate
thoughts of death and suicide
low energy
significant change in appetite

(Helliner, et al, 2008)

Bipolar in Adults

History of Early Onset Bipolar Disorder

Symptoms of bipolar in young people were reported as early as 150 AD when Aretauus of Cappadocia described manic behavior in young men in puberty. And, in the 19th to the early 20th century there were reports of childhood-onset "circular insanity" or "mania and melancholia" in European psychiatric literature (CABF, 2006). In 1946 The National Institute of Health was created by President Truman, and in 1952, the first first Diagnostic and Statistical Manual (DSM) was published and included a diagnosis of manic-depressive reaction." It was also in 1952 that the first occurrences of early onset bipolar were reported when J.D. Campbell published a report about 18 cases of adolescent bipolar in the Journal of Nervous and Mental Disorders (CABF, 2006).

Despite advances in medicine by the early 1970's, mental health issues were still grossly misunderstood, as many children with emotional disabilities were institutionalized and discriminated against, i.e., "emotionally disturbed children were not permitted to apply to law school in (CABF, 2006).

It was not until 1975 that The National Institute of Mental Health Conference on Depression in Childhood officially recognized depression in children. That same year, Congress enacted the Education for All Handicapped Children Act "giving all children with disabilities a federally protected civil right to a free appropriate public education that meets their education and related services needs in the least restrictive environment" (CABF, 2006).

In the 1980's, published research clearly indicated the presence of early onset bipolar, but many psychiatrists still refused to acknowledge that bipolar could exist in children. It wasn't until 1994 that Childhood mood disorders were included in the DSM (CABF, 2006).

Throughout the 90's leading researchers from Harvard, Yale, Albert Einstein College of Medicine, and University of Texas-Southwestern Medical School published groundbreaking findings on early onset bipolar. And, in the late 90's the National Institute of Mental Health and the Stanley Foundation started to provide funding for additional research on bipolar in children (CABF, 2006).

There has been a significant increase in the diagnosis of early onset bipolar in recent years. Researchers report that between 1995 and 2000 there was a 67% increase in patients receiving outpatient treatment for early onset bipolar (Moreno, et al., 2007: 1032). This had led many critics to claim that many of these cases are misdiagnosed. Researchers question, however, if early onset bipolar hasn't been under diagnosed or misdiagnosed and if the "shifts in diagnostic practices" have now corrected the problem (1035).

Challenges in Diagnosing Early Onset Bipolar Disorder

Proper diagnosis is the first step in helping the bipolar child to be successful in school and life. Yet, early onset bipolar is often misunderstood and mistreated. There is still a great deal of controversy over whether the illness occurs in children, which leads to high rates of misdiagnoses, prolonged psychosis and suicide (Faedda G.L. et al., 2004).

Between 15 to 18% of adults with bipolar have have had symptoms of mania and depression before the age of 13 years and, between 50 to 66% before the age of 19(Morris et al., 2007). These statistics point out that bipolar occurs during a period of of life when major physical and psychological development occurs. Despite these statistics that clearly point to the existence of bipolar in children, there are still high rates of misdiagnoses (Faedda G.L. et al., 2004)

Difficulties in diagnosing bipolar in children can be, in part, because children present a very different set of symptoms when compared to adults. For example, children do not experience a distinctive sense of euphoria, but tend to experience extreme mood irritability and rapid cycling between anger, hyperactivity, and irritability. Additionally children tend to experience sleep disturbances that include night terrors where adults experience a decreased need for sleep (Faedda G.L. et al., 2004).

Other conditions may present symptoms that mimic, or mask the existence of, bipolar. These include: schizophrenia, generalized anxiety disorder, agitated depression, post traumatic stress disorder, borderline personality disorder, conduct disorder, mood disorder due to a medical condition (e.g., thyroid disorders), Tourette's Syndrome, substance abuse, and attention deficit disorder with hyperactivity (ADHD) (McClellan and Werry, 1997; Cogan, 1996).

Bipolar can and often does coexist other disorders such as attention deficit disorder with hyperactivity (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder (ODD), conduct disorder (CD), and generalized anxiety disorder (GAD) (Papolos, Bipolar Child, 2006:29).

And, Bipolar is often misdiagnosed as attention deficit disorder with hyperactivity (ADHD), borderline personality disorder, post-traumatic stress disorder, or schizophrenia (Helliner, et al, 2008). When bipolar in children is misdiagnosed with ADHD, for example, they are often treated with stimulants. Treating a bipolar child with stimulants such as Ritalin can trigger mania or make the condition worse; antidepressants such as Paxil can also trigger mania and violence (Trudeau, Mental Illness in Children - Part III, 2003).

The implications of a proper diagnosis in a school setting are, in part, that a misdiagnosed child may not be getting the services that they need or may have adverse reactions to medications that exasperate bipolar symptoms. Teachers may see reactions to medication as behavioral and use punishment to change behavior. These situations will impact a child's ability to learn and perform up to his or her potential.

Note: school-aged children with bipolar go to great lengths to fit in and often suppress feelings in the classroom. Diagnosis of early onset bipolar cannot be effectively made in the school setting.

The Juvenile Bipolar Research Foundation has developed an online tool for assessing children for bipolar. This is the first diagnostic aid that is written and illustrated to present questions to the child at his or her level.

The Juvenile Bipolar Research Foundation "Jeannie and Jeffrey Illustrated Interview for Children."

Treatment

Bipolar Disorder affects different people in different ways. Once diagnosed, treatment usually begins immediately. Treatment options include prescription medications, psychotherapy or talk therapy, dietary supplements, and other emerging technologies.

Early Intervention

Early intervention is critical in minimizing the impact that bipolar has on the healthy development of children. A misdiagnoses or delayed diagnosis denies the child with bipolar of the appropriate therapy and interventions that they need to be successful in school and life (Berk, 2007).

Bipolar Disorder in the School Setting: Impacts on Cognition

For some children there can be long periods of wellness between episodes. Some students will cycle very rapidly, and other students with bipolar may appear to be very irritable or in a have mixed emotions. In a school setting it can be hard to identify and isolate symptoms.

Often children with bipolar are gifted, yet sometimes they are unorganized, easily distracted, inattentive and have a hard time transitioning, depending on their mood. Often bipolar children have coexisting learning disabilities and problems with executive functioning (Papolos, et al., Educational Issues of Students with Bipolar Disorder, 2002). All of these symptoms affect how a child learns in the classroom.

In addition bipolar children experience have a hard time modulating emotion, can be anxious, depressed, and suffer from periods of low energy. Many bipolar children have trouble sleeping through the night or live with night terrors. All of these and the above symptoms can come and go with the seasons, making consistent success in school an ongoing challenge for all involved.

Sensory Processing

Children with bipolar have difficulty processing information and transitioning from states of attention and arousal. As a result, bipolar children often experience overstimulation which makes it difficult for them to pay attention in school (Papolos and Papolos, The BiPolar Child, 2006: 182).

Executive Functioning

Executive functioning is associated with the pre-frontal cortex and the frontal lobe of the brain of the brain which is responsible for coordinating speech, reasoning, problem solving, strategizing, working memory, attention, self-control, intention, motor sequencing, and other processes central to higher functioning. When these areas of the brain are not working properly, children have trouble with organization, planning, breaking down tasks, sustaining cognition, and metacognition.

Researchers believe that children with bipolar, as do children with ADHD and Tourette's Syndrom, "have deficits in the frontal lobes" (Papolos, et al., Educational Issues of Students with Bipolar Disorder, 2002). Children with these deficits will appear distracted, disorganized, messy, and restless. They will loose books and homework, forget to write down assignments, have difficulty paying attention in class, and be unable to sit still for long periods of time.

Working Memory

Working memory is used to hold information temporarily while the brain searches for a connection to prior information. Research indicates that activity in the frontal lobes increases when the brain is utilizing working memory.

Children with bipolar have difficulty with working memory because their "memory’s ‘filing system’ is a disorganized mess" (Papolos, et al., Educational Issues of Students with Bipolar Disorder, 2002). It takes the bipolar child longer to process incoming information. This can impact activities that require the the constant filing of information with existing knowledge, e.g. reading comprehension, note taking, and test taking.

Anxiety

Bipolar children may have experienced long term anxiety, leading to a physical and mental stress that impacts attention, comprehension, and memory. Anxiety in bipolar children can manifest itself in oppositional behavior or in taking extreme risks in thinking and action. Bipolar children who seek stimulation, can channel this energy towards intellectual stimulation (Papolos and Papolos, The BiPolar Child, 2006: 199).

Oppositional Behavior

Studies indicate that as many as 80% of children with bipolar are often defiant and oppositional (Papolos and Papolos, The BiPolar Child, 2006: 195). Signs of opposition are that unreasonable demands, refusals, and unprovoked rigidity. It is thought that these signs of opposition are a defense mechanism in response to stressful situations brought on by over stimulation, lack of control over emotions and behaviors, or an attempt to preserve a deteriorating self-identity.

In the classroom, children with bipolar often feel out of control, threatened, distracted and easily aroused. Defiance and oppositional behavior can create a buffer between the child and the environment. Yet, these coping mechanisms can be misunderstood by teachers and peers, further isolating the bipolar child and limiting the chances of the child learning self-control. While the social aspects of oppositional behavior are often obvious, the cognitive aspects may be overlooked. These extreme feelings of isolation and loss of control over emotion interfere with memory and comprehension.

Accommodations in the Classroom

Most students need some reasonable accommodations to help them perform at their best, i.e. extension on homework, tutor, etc.

Teaching Skills

The Child and Adolescent Bipolar Foundation suggests that there are specific teaching skills that enable teachers to be successful in working with bipolar children. They include:

Flexibility in adapting assignment, curriculum and presentation style, as needed.

Patience and the ability to ignore minor negative behaviors with the ability to stay calm and model desired behaviors.

Good conflict management skills to resolve conflicts in a non confrontational, non-combative, safe, and positive manner.

Receptivity to change and working collaboratively with the child's parents, doctors and other professionals to meet the needs of the child.

The ability to laugh at oneself and situations to bring fun and humor into the classroom and reduce the level of stress that students feel.

General Accommodations

General accommodations in the classroom should focus on reducing stress for students with bipolar disorder. Some appropriate accommodations include:

Consistent scheduling, including planned and unplanned breaks.
Seating with few distractions, including buffer space and the presence of model children. Noise can be an issue for children with bipolar, as sensory integration problems are common.

Help filter out distracting, and random noises that can impact concentration. Soft music and soothing background noises such as ocean sounds can help filter out random noises.

Shorter assignments and homework that focuses on quality rather than quantity.
Prior notice to transitions or changes in routines, minimizing surprises.
Plan for unstructured time.
Provide a place for students to go when they need down time. Assign an adult that can talk to student at a moments notice when he or she is having a hard time coping during the day.
Schedule challenging tasks at a time during the day when the child is performing best.
Allow for medication related tiredness and hunger.

Testing

Testing can be a challenge for the bipolar child due issues with memory control, so providing accommodations during testing is critical. Some specific accommodations include:

modified time constraints
altered or simpler instructions
oral testing or the use of a scribe
an altered environment (room with fewer distractions)
multiple-choice or matching rather than open ended questions.
tools such as a calculator or word bank
alternative assessments

Handling Changing Moods

The Child and Adolescent Bipolar foundation recommends a flexible approach to handling changing moods that includes:

Children who are in a manic mood exhibit distractability, increased energy, grandiose thinking, rapid speech, and a strong goal orientation. At this time children have a need for movement. Teachers can help students focus their increased energy on productive, hands-on projects. Students should have the opportunity to move around the classroom, e.g., work on computers, use manipulatives, or other interactive activities. Students may also have a hard time focusing on assignments or may hyperfocus on finishing an assignment. Teachers can reduce the amount of written seat work during these times. If the student is hyperfocused on finishing an assignment, teachers can allow the student extra time to finish with ample notice that the activity will end in order to help the student transition.

Children who are sad or depressed exhibit low energy and distractability. At this time children need help staying on task. Teachers can shorten assignments and check in frequently with students. Students need to know that the teachers cares, showing compassion is important. It's also important to know that during these times it can be extremely hard for students to wake up for school. Students shouldn't be penalized for tardiness that is biologically based. Suicidal thoughts are also more common during times of depression and should be taken seriously and report to the child's parents immediately.

Children who are experiencing a mixed mood are experience both states (manic mood and depression) at the same time. This produces agitation and irritability. This can be the most challenging time for a teacher. Defiance and aggression are common, and the best way to deal with these behaviors is not to take it personally and not to turn it into a power struggle. For example, if students are being rude, ask them to rephrase statements polity. It's important to be firm and consistent, providing children in a mixed state with positive choices. Ultimatums are not beneficial, as they can force a child into making a poor choice.

Special Education Classification

Special Education Classification. The Child and Adolescent Bipolar Foundation advocates for the classification of Other Health Impaired (OHI) when developing an IEP for children with bipolar disorder, which acknowledges the biological nature of the illness.

Advocacy & Awareness

To Learn more about ADA laws and the rights of children with mental to equal access to a quality education, visit Wrightslaw Special Education Advocacy and Law Website.

Watch an introduction to Beyond Nuclear: Bipolar Children and Their Families, an educational documentary of the lives of bipolar children and their families. Includes personal stories of children and their families who suffer from bipolar disorder.

Janet Papolos, M.D., is the coauthor of the Book The Bipolar Child and editor of The Bipolar Child Newsletter. In the following presentation Papolos previews her DVD, 24: A Day in the Life of Bipolar Children and Their Families. Papolos recommends that parents and educators watch this video before an IEP or 504 planning meeting so that all parties better understand the illness and what accommodations

Demitri Papolos, coauthor of the Book The Bipolar Child and editor of The Bipolar Child Newsletter Director of research of the Juvenile Bipolar Research Foundation.

For Parents

For Teachers

School Psychologists

School psychologists play a significant role in ensuring that children with bipolar receive the services they need to be successful in school. It is also important for school psychologists to work and empower the parents of bipolar children. Providing parents with support and understanding and working towards effective communication and education about the disorder and how it impacts the individual child is a critical aspect in the overall educational approach. School psychologists can raise awareness in schools and empower parents by, themselves, better understanding the disorder and how it impacts families. Some of the roadblocks in working with parents are:

Feeling Blamed

Bipolar is a life threatening disease. Parents of bipolar children often feel terrified of the severity of the symptoms while at the same time they may feel blamed for the disorder. Researchers working with parents found that parents feel guilt over passing down a "bad gene" or are given the message that the disorder is the result of bad parenting (Mackinaw-Koons and Fristad, 2004). Unfortunately, this same research indicates that the mood affects of this disorder (e.g., euphoria, extreme irritability, decreased need for sleep, racing thoughts, pressured speech, etc.) are not easily suppressed by behavioral management techniques, and attempting to treat the disorder solely based on behavioral management can have an adverse effect.

Communication Breakdowns

Parents often feel that treatment providers don't listen to them. This can also be true in the case of school psychologists to rush to judgment in labeling the child and recommending interventions. It should be noted that the customary diagnostic tools used in schools do not effectively identify bipolar. A comprehensive psychological that includes an emotional evaluation is necessary ( ). Many of the symptoms of bipolar also occur in other disorders such as ADHD and can lead to a child being improperly labeled (Mackinaw-Koons and Fristad, 2004). Communication with parents is key in understanding the symptoms and developing a plan to address the child's needs.

False Positives and False Negatives

Assumptions can be made as to the reason for symptoms. Bipolar children who exhibit hypersexuality (a common symptom), for example, may fall in the criteria of sexual abuse. Children who exhibit symptoms of aggressive behavior may fall within the criteria of child abuse (Mackinaw-Koons and Fristad, 2004: 482). Researchers report incidents of families being "inappropriately" reported to child protective services, adding to the stress and guilt of parents who are dealing with this devastating illness (483).

Lack of Knowledge

There is a tremendous lack of knowledge in schools about childhood bipolar disorder ( ). Often parents who have done their own research know more about the illness than doctors or practitioners(Mackinaw-Koons and Fristad, 2004: 483). School psychologist who specialize in identifying learning disabilities can increase support for parents by being open to information that parents bring to the school.

The following list of Dos and Don'ts was published as a result of multiple studies that included interviews conducted with 135 families and 165 children (ages 8-11). The goal of the study was to identify opportunities to listen (Mackinaw-Koons and Fristad, 2004). This list was written for treatment professionals, but can be applied to the school setting.

Do be a collaborator: Many parents are highly educated about bipolar disorder and "serve as a great sources of information." Take opportunities to share information provided by parents with teachers and other school staff to increase the awareness of the disorder and the needs of bipolar children.

Do listen: Most importantly, parents are experts on their own children, how they learn, how their mood cycles, triggers, effects of medication, etc. Working with parents to develop the best interventions will improve the student's ability to perform in school. Resist the temptation to judge and believe parents when they discuss their child.

Do be empathetic: Bipolar disorder is a very dangerous illness. There is a high risk of suicide that is complicated by extreme behavior and poor judgment. This is "terrifying" for parents. Furthermore, many of the symptoms of bipolar are dealt with in the personal lives of families, as bipolar children put forth great effort to hid their disorder, holding it in until they get home from school when they explode with emotion and often rage. Parents who are also concerned about their child's success in school need support and understanding.

Do separate the child from the symptoms:

Mackinaw-Koons and Fristad indicate that a key indicator of mood disorder is that the behavior is "uncharacteristic of these children when in a healthy mood state" (482). It's important to separate the child from the symptoms. Children with bipolar feel out of control and experience embarrassment and anxiety over the symptoms th that they cannot control. Understanding the time of day or in which season the symptoms occur can increase understanding the illness.

Famous Individuals with Bipolar

List of Famous People Affected by Bipolar Disorder from Wikipedia.

Watch this photo collage of Famous People with Bipolar Disorder.

Evidence - Literature Review

Current Research

Need for Additional Research

Bipolar disorder in children presents very differently. Adults can go for months with highs in lows. Children, however, experience what is called rapid cycling. Where a child can go from extreme highs and lows within a given day. The difficulty in diagnosing and treating childhood bipolar is that all the research that was done to define the disorder for the Diagnostic Statistical Manual were all done on adult bipolar and doctors are applying what diagnostic criteria for adults to children, which leads to the misdiagnosis and underdiagnosis of this condition in children (Papolos, D. in Trudeau, Mental Illness in Children - Part III, 2003).

Critics and Their Rationale

Medical Diagnosis or Misdiagnosis

There is an increase in the diagnosis of bipolar in children which has led to a debate about the accuracy of these diagnosis (Moreno et al.). Part of the issue is that the Manual for Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association does not provide a separate diagnosis for Children that outlines the difference of symptoms between adults and children.

Over prescribing Medication

Bipolar children take very strong medications. What do we know about what this does to the developing brain, and who is responsible for keeping children safe?

"Six million American children are taking psychiatric drugs, but most have never been tested on children. Is this good medicine -- or an uncontrolled experiment?" Watch this Frontline Series, The Medicated Child (2008).

"A mother is on trial for killing her daughter with prescription drugs for bipolar disorder. Katie Couric talks to her and investigates the effects of increased diagnoses of the disease in children." Watch Bipolar: Dangerous Diagnosis? (2007).

Suicidal Ideations

Black Box warnings have been put on anti-depressants to warn about the potential of "d effectively treat mental illness in children.

Industry Bias

Much of the research is funded by the drug industry. How has this influenced diagnosis and treatment?

Alternative Explanations: What causes Bipolar Disorder?

Genetic Disposition

There is a likelihood that there is a genetic cause for bipolar disorder because it is prevalent in throughout different families. 80-90% of people with the illness have a relative with either depression or BD, a rate that is 10-20 times higher than that found in the general population (APA).

Genius

There is a strong link between genius and mental illness, in particular with bipolar disorder (Lythgoe, 2005).

Traumatic Brain Injury

Poisoning

Illness

Anti-depressants

Other Environmental Factors

Signed Life Experiences, Testimonies and Stories

My younger brother has been diagnosed with BD. He is 41 years old and a very bright, affable person. Looking back there were signs that he might have some problems back in High school, but the family dismissed that idea choosing to believe that he was just a wild child/baby of the family that Mom and Dad had never really disciplined. By the time he reached his senior year he was using drugs and alcohol heavily and we again figured that was the problem. He ended up quitting school his last semester in high school even though he was only failing one class Civics. He just couldn’t seem to make his afternoon classes.

By summer end he had completed his GED and decided to go to Lake Land College where he made the tennis team as a walk-on. He went on to be part of their best doubles team and then just quit school. He married a girl he had dated in high school and moved to Champaign, IL. and held a series of jobs from janitor to night store manager at an IGA. Each time he would seem to get his life in order he would just completely drop everything for no apparent reason. He continued drinking and taking drugs. Eventually it landed him in minor trouble with the law and he would be sent to jail, only to be bailed out time and again by my parents, my sister, and me. We just couldn’t understand how a very bright person that people seemed to like could continue to mess up. By 25 he was on his second marriage and had 4 children. As his life continued to spiral out of control he was truly on the verge of loosing EVERYTHING including his life. He checked himself into a detoxification center and stayed there for 6 months. He could have left after 3 but he told me that he wanted to stay until he knew he could handle being sober. He to thought it was the drugs and alcohol that were ruining his life.

After he left rehab he joined AA and has helped and continues to help many more people than I will ever know. He has now been sober and clean for over 12 years. During that time however he has yet to hold a job for more than a year. He still exhibited erratic behavior from time to time like betting a whole paycheck at the Off Track Betting Parlors, or taking off in the middle of the night to drive to Mississippi to go mushroom hunting.

Finally about 3 years ago he was diagnosed with BD. Since then they have been experimenting with different kinds and combinations of drug therapy. That has been and still is an ongoing frustration that has had mixed results at best. It is only now that I am beginning to understand the struggle my brother has lived with. He finds solace in helping others. He is a very good person, a great father to his children, and I hope that someday soon they find the right combination of drugs and therapy to even his life out. I understand now that he is trying his best. ---Kim Snyder

I have much experience in coping with people with manic depression or bipolar disorder. My mother was clinically diagnosed with the disorder at age 40,a few years after she had my younger sisters, (twin girls). It started when my younger sister, Lorrai, died at 9 months old or at least that is when I noticed it. My mother had a tremendous time with taking care of her daily routine of life after that point. Her health deteriorated, (diagnosed with diabetes), not to mention she was the breadwinner of the household. She had to support a family of 5 alone. She did have some help from our father but he was hurting more than helping because he was a drug addict. As well as that, all of her siblings where drug addicts. All of this pressure got to her and she started to slip into a severe depressive state. Her hair started to fall out, her diabetes where out of control and she wished death upon herself. It made it worst that I was not at home when at the peak of her sad mental state. I was at private school 5 hours away then went straight to college the summer after that.

I noticed that she was most happy when I was home because I would take the load off. I would cook, clean, take care of my sister, etc. I also made sure her glucose levels where under control.

I remember staying with her the summer after graduation. I guess it was a good week when I came home because she was energetic and happy. She accomplished many chores and much of her paper work for her job. But then about 2.5 weeks later, I noticed she had been sleeping way too much and not eating. She was not responsive when I would talk to her. She would just stare at the television and fall asleep. Come to find out, she was on prescription anti-depressants called Paxil and 2.5 weeks prior she was not taking them. WOW! A total shock to me!

Well, the disorder got worse and worse. It was in my opinion that the prescription was not working. She was not seeking psychotherapy either. Until the day she died, (car accident), she had never sought proper treatment. If she could afford it, i think she would have still been here today. She died almost 3 years ago, age 46. ---Ty Martin

Even though my mother hasn't been clinically diagnosed many people within our family believe she is Bipolar. She has many of the symptoms, characteristics,etc. She is in denial and refuses to seek a doctor's opinion. Life has definitely been rough because of this. She has run so many people out of her life because of her behavior. She won't seek help and refuses to listen to anyone.--M.Hicks

My good friend's sister was tragically murdered by her husband who was BiPolar. This is an extreme case of what can happen when people don't seek help or follow recommendations. Her two children were left behind to live with my good friend and her family. The husband is now in jail and not receiving proper treatment for his disease. It is so important for people to seek medical advice if they suspect they or someone they know may be affected by this disorder. ---S. Peduzzi

I had a student who was diagnosed as BiPolar the summer before the child entered my classroom. From conversations with the child's mother, I learned the doctors basically tried to figure out the diagnosis by prescribing different medications and doses. Based upon feedback from the child's mother, the doctors would then decide whether or not to try out a different drug. When the child was finally given a drug associated with Bipolar disorder, the child apparently responded to it in the acceptable manner. I found this very disturbing that the child had to experience these little experiments with body chemistry at such a young age. Throughout the year I really questioned whether or not the child was accurately diagnosed. My classroom experiences with the child were no where near the experiences the child's mother described she had with her child at home. While the child could sometimes be non-compliant and cause some problems in the classroom by initiating poor behavior in other students, I recognized that most of the time the child's outbursts would come when the child did not feel a sense of control, belonging, and competency. ---Tricia Pearl

I had a student with BP in my classroom this past year. He had not been diagnosed upon his arrival to my classroom. He came from a different district and we knew nothing about his records did not follow quickly. This seemingly sweet and exuberant boy was fine for several weeks and then he began exhibiting very strange behaviors. He would have outbursts in the middle of class and eventually he was trying to kill himself in my classroom. It was one of the most frightening experiences of my life. --KK

My daughter was diagnosed with Early Onset Bipolar when she was eight year's old. At 18 months of age she fell of a couch on a concrete floor and suffered a closed head concussion. After the accident, she started to experience night tremors, extreme irritability, uncontrollable crying, extreme hyperactivity, and risk taking. She also stopped talking at the time and became extremely frustrated with even the most basic tasks.

We spent several years taking her to specialists and she was diagnosed and re-diagnosed with many different disorders. At age three we had her evaluated by our local school district, which resulted in several months of advocating on her behalf to ensure she received appropriate services. In pre-school, she was placed in a self-contained classroom with several non-verbal autistic children. We appealed the decision and won; she was then placed at a preschool that had a mix of regular and special ed students. In K-2nd grade she had a one-on-one aide and was very successful in school. In second grade she started showing signs of depression, and her psychiatrist prescribed a small dose of Paxil, which sent her into an episode of rapid cycling that lasted over a week and resulted in an overnight hospital stay. At the time we did not know that anti- depressants could cause mania in bipolar patients; we didn't even know she was bipolar.

She is now 11 years old and is very successful, even though she still struggles with issues of bipolar. We have decided to take her off all medications (the side effects of the medication can be as debilitating as the symptoms of bipolar), and we are now treating her condition with diet and therapy with great success. We have to be very aware of our daughter's changing chemistry going this route, and I wouldn't consider not having her on medication if she were not seeing a therapist on a weekly basis. More often, medication is often a critical aspect of treatment for a bipolar child.

Our daughter's symptoms present very differently in school verses at home. Many young children cycle between mania and depression (the latter of which looks very different in a child) many times in one day. Some children can handle their emotions better during the day, but break down in the evenings. It is not uncommon for children, especially for children of high intelligence, to go to great lengths to hide their emotions during the school day and then explode when they get home. This can cause teachers and doctors to question a diagnosis of bipolar even though these situations are well documented. Even worse, there are times that professionals blame the parents for their child's behavior, which can be detrimental to parent and child (Mackinaw-Koons and Fristad).

Currently, we struggle with getting appropriate accommodations for her in the classroom, i.e., allowing her extra time on assignments, providing a place for her to go if she is really upset, not criticizing her for mistakes that she can't avoid, etc. Many teachers do not see our daughter as needing accommodations because her emotions are often hidden within the very delicate shell of her public self. Despite these challenges, she has had great success in school and has a bright future.

When I see other children with similar symptoms, I want to reach out to their parents and offer my assistance. I want to give them hope and support. Early Onset Bipolar can be very scary, and the symptoms are very different from that of adult bipolar, so it is hard to diagnose. But, with appropriate treatment and early intervention, including accommodations in the classroom, bipolar children can experience a normal childhood. ---M.T.

I chose to develop this section on Early Onset Bipolar in part because of my life experience and because Bipolar Disorder in children is widely misunderstood and misdiagnosed. As I discussed above, my daughter started showing symptoms of early onset bipolar at 18 months after a traumatic brain injury that resulted in a concussion. After the accident, she stopped talking, became very irritable, had night terrors, cried uncontrollably for hours, and was hypersensitive to touch, sound, and light. It was a very scary time for my husband and I, and we immediately sought help for her. At the time her doctors felt that it was the brain injury that was causing her symptoms. Her symptoms, however, kept getting worse. At the age of three we had her evaluated by the special ed group at our home school so that she could attend Barbara Vick Early Childhood Center in Chicago, a special preschool for at risk students. This school had regular and special ed students and had three teachers per classroom and an early family intervention team that operated in the community. Her IEP team, however, recommended that she be placed in a self-contained classroom with seven other children with severe autism. We knew that this was not an appropriate placement for her and filed an appeal with the local school board.

At the same time, we were having her evaluated by one of the best neurologists in the City of Chicago, Dr. Peter Huttenlocher, who prescribed several mood stabilizers to help with her night terrors and hypersensitivity. The medication helped control her moods immensely, but her night terrors persisted. Later that year we won the appeal with the school district and our daughter was placed at the Barbara Vick Early Childhood Center in Chicago. The early intervention that she received at this school was instrumental in providing educational services that paved the way for her long-term success in school.

Even though we were getting appropriate support for our daughter , her doctors and the school did not agree on her diagnosis. The many diagnosis we received included Traumatic Brain Injury (TBI), Obsessive Compulsive Disorder (OCD), Attention Deficit Hyperactivity Disorder (ADHD), and Sensory Integration Dysfunction. Not one doctor mentioned Early Onset Bipolar. In third grade she started exhibiting symptoms of Severe Depression. Her psychiatrist prescribed her Paxil. At the time we did not know that anti-depressants could cause severe mood shifts in children with bipolar (Lewis). After two weeks on the medication, she went into an episode of mania that lasted for a week, gradually worsening as each day passed. She ended up in the hospital, and we found a new Doctor. Our new doctor discussed Early Onset Bipolar with us, and I started my own research. It was one of those moments where everything clicked. Her symptoms were right on. While the mood stabilizers that she had been taking for years were the right medication, putting her on an anti-depressant actually made her symptoms worse, which is common in bipolar children and, unfortunately, often the point in time when proper diagnosis is made.

Our daughter is now in sixth grade and because of early intervention and proper diagnosis is very successful in and out of school. Intelligence testing shows that she is in the gifted range, and she finds the intellectual stimulation of school to be very rewarding. She channels her excessive energy into studying hard, has developed exceptional metacognition skills for her age, and has ambitions of becoming a brain surgeon. She studies guides on how to improve memory and how to be successful in school, is extremely organized, and would rather read her sister's high school biology book than her own text books on the same subject. Because of the support we received early, she has been able to develop emotionally and cognitively at a normal rate, she has a healthy sense of self, and has learned to navigate the social climate of school successfully. She still struggles with periods of depression, which cause her to be extremely sad and angry at the world. During these times she finds it very hard to function in school and comes home most days very stressed and upset. Even though there are specific accommodations listed in her 504 plan for situations like this, a few of her teachers do not understand the disorder and are not as accommodating as they could be.

Our success story is not the norm; many children that suffer from mood disorders are not diagnosed, do not receive special services at school, and do not develop normally. There are many professionals and especially educators who do not understand Early Onset Bipolar, instead believing that children are spoiled or there are other problems at home that are causing these children to act out in school. Bipolar disorder is not something that can be diagnosed at school; however, informed schools can make recommendations to parents to seek the help of professionals who specialize in childhood mental health disorders. It is in this vain that I prepared this wiki page. It is my hope that the information provided within will assist educators and parents in identifying and referring children who present symptoms of bipolar, which are very different from the symptoms presented in adults.

One of the criticisms that this diagnosis often receives is that it is the "new disorder," the new label, and, as ADHD was over diagnosed in the 1990's, now doctors are rushing to label children as bipolar. I didn't find this at all in my experience. In fact, I found it to be the opposite. Very few doctors that we consulted knew much about Early Onset Bipolar. It is my experience that it is under diagnosed. To support my claim, I included a history of bipolar disorder in children in my wiki that shows that mental illness in children was not acknowledged until recent history, and that the increase in diagnosis of bipolar children may represent a more accurate count of those that suffer with this disorder.

As part of this project, I did extensive research on the subject of Early Onset Bipolar, including its impact on cognitive functioning. It should be noted that additional research could be done on the impact on cognitive function. My experience is that it is difficult for teachers to know what symptoms are because of bipolar vs. symptoms that are part of normal development because the symptoms are not always present. Children with bipolar, for example, may have a hard time focusing during manic or depressive episodes. There are extended periods of time, however, where these same children do not present any symptoms. Because the symptoms are not always present, teachers may rule out ADHD, for example. They may think the child is acting because of behavioral issues. They may think there are problems going on at home. Yet, it is these very inconsistencies that define early onset bipolar, i.e., severe mood swings with periods of wellness or mixed moods. --M.T.

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