Bipolar

Bipolar has become more prevalent in children over the years. Understand the diagnosis and find options for support.

Understand the diagnosis, what to do next and access resources

Does your child go through intense mood changes? Most children do however does your child go through these moods to the point that they are unable to function normally at school and at home? If so, they may have bipolar disorder.

Bipolar disorder is a serious condition where a persons mood can swing from feeling very happy or “up” to very sad and “down.” The “up” mood is known as manic episode and the “down” mood is called a depressive episode. The fluctuation between the two of these moods can cause a child to be hyper productive one moment and show signs of depression the next. While it can be diagnosed in children it is usually developed later during the teen years or early adulthood. Bipolar usually lasts a lifetime. There is no known cause for Bipolar disorder.

Children with bipolar disorder can have other problems including: substance abuse problems, ADHD and Anxiety disorders. Suicidal thoughts can also be a problem.

Bipolar diagnostic criteria

Here is the criteria for diagnosis from the DSM-5 (Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition).

Bipolar I and II; The Behavioral Episodes

A Major Depressive Episode includes at least 5 of the following symptoms occurring over the same 2-week period and must include either #1 or #2:

  1. Depressed mood most of the day, nearly every day, as reported by self (i.e. I feel sad or empty) or others (i.e. he appears tearful) Note: in children and adolescents, can be irritable mood.
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
  3. Significant weight loss or gain, or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains.
  4. Insomnia or hypersomnia nearly every day (difficulty or delay in falling asleep or excessive sleep).
  5. Psychomotor agitation (such as pacing, inability to sit still, pulling on skin or clothing) or retardation (such as slowed thinking, speech or body movement) nearly every day that can be observed by others.
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive, inappropriate, or delusional guilt nearly every day.
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

    A Manic Episode includes a period of at least one week during which the person is in an abnormally and persistently elevated or irritable mood. While an indiscriminately euphoric mood is the classical expectation, the person may instead be predominately irritable. He or she may also alternate back and forth between the two. This period of mania must be marked by three of the following symptoms to a significant degree. If the person is only irritable, they must experience four of the following symptoms. A Hypomanic Episode is very similar to a manic one, but less intense. It is only required to persist for 4 days and it should be observable by others that the person is noticeably different from his or her regular, non-depressed mood and that the change has an impact on his or her functioning.

  1. Inflated self-esteem or grandiosity (ranges from uncritical self-confidence to a delusional sense of expertise).
  2. Decreased need for sleep.
  3. Intensified speech (possible characteristics: loud, rapid and difficult to interrupt, a focus on sounds, theatrics and self-amusement, non-stop talking regardless of other person’s participation/interest, angry tirades).
  4. Rapid jumping around of ideas or feels like thoughts are racing.
  5. Distractibility (attention easily pulled away by irrelevant/unimportant things).
  6. Increase in goal-directed activity (i.e. excessively plans and/or pursues a goal; either social, work/school or sexual) or psychomotor agitation (such as pacing, inability to sit still, pulling on skin or clothing).
  7. Excessive involvement in pleasurable activities that have a high risk consequence.

A Mixed Episode would fulfill the symptom requirements for both a Major Depressive Episode and a Manic Episode nearly every day but the mixed symptoms only need to last for a 1-week period.

For all four of these episodes, the symptoms must have an impact on the person’s ability to function and can’t derive from some other circumstance or illness that would logically, or better, account for its expression.

The main difference between BP I and BP II is full mania (7 days) v. hypomania (4 days). Once a person experiences a full manic episode, they will receive a BP I diagnosis.

Bipolar I and II; The Difference

Bipolar I Disorder

The Bipolar I diagnosis, (with Manic Episode), gets broken down into six different sub-diagnoses which are not important to detail here. Broadly, they are defined by which type of episode the patient is currently in or has most recently experienced and which types of episodes (if any) they have experienced in the past. Two of the six diagnoses do not require the experience of any Major Depressive Episodes.

Bipolar II Disorder

For a Bipolar II diagnosis, (no Manic Episode) the person must have experienced at least one Major Depressive Episode and at least one Hypomanic Episode.

Diagnosis is confirmed. Now what?

Once the diagnosis is confirmed it will be important to begin treatment as soon as possible. The earlier the treatment begins the better for your child. It is documented that children, with early treatment, get better over time. Begin by working with your physician to determine what treatment option will work best for your child. Bipolar, like other mental health diagnosis, manifest themselves differently in each child. The length of manic and depressive episodes will vary as will the intensity. You will need to do a lot of monitoring of your child before and during treatment. It is helpful for parents to document things by keeping a daily journal of your child’s moods and behaviors over a course of time. This will help determine if your child exhibits more manic or depressive features and how best to address them. Parents are the first line of treatment and can provide a foundation for treatment that is successful for the child. Be aware. Be informed. Be active.

There are two main treatment options for Bipolar disorder: mental health therapy and medication

therapy

Different kinds of psychotherapy can help children with Bipolar disorder. The following approaches are the most effective when treating Bipolar disorder:

  • Behavioral therapy: This focuses on behaviors that decrease stress.
  • Cognitive Behavioral Therapy: This type of approach involves learning to identify problem thinking and to modify behaviors to correct that thinking pattern.
  • Interpersonal Therapy: This focuses on relationships with the goal of reducing strain the illness may place on the individual.
  • Social Rhythm Therapy: Sleep. This approach is focused on helping maintain a normal routine sleep schedule. Predictability is helpful for children with mental disorders.

Parents should be prepared to accept that the therapy approaches will change over time. Parents should engage in treatment when necessary and provide feedback to the therapist about progress. Parents should evaluate if the therapy is working and make changes if they do not see progress within a reasonable amount of time. Effective therapy will help a child learn coping skills and strategies that will help decrease the severity of the mood swings. This may also result in decreasing the dosage of medication over time. This is, of course, under the direction of the physician managing treatment.

Medication

There are several types of medications that can help children. All children respond differently to medication so the right medication and dosage will vary. Children should take the least amount of medication necessary to address issues. Physicians will help determine what works. As mentioned before, parents can play a very key role in treatment by keeping a daily journal. The daily journal can should list the date, behaviors, responses and medication intake. This information will be helpful for the physician when deciding on medication treatment.

Consideration

The role of parents is very important in treatment for Bipolar disorder. They will gauge both the progress of the child with treatment and the effectiveness of treatment for the child. Parents should be actively seeking for new information on treatment and if necessary, move treatment in a different direction if things are not going well.

​Parents can implement some parenting skills to help at home. The recommended skills for parents to master with children who have been diagnosed with Bipolar Disorder are: The ABC’s of Behavior and Preventive Teaching.

Customizing the ABC’s for Bipolar

This concept is especially helpful for children to connect their feelings with their behaviors and the ultimate consequences of those behaviors. Watch the following video.

Tips for parents on using this concept for Bipolar Disorder:

Discuss with your child how thoughts and feelings lead to behaviors and consequences.

Help create a vocabulary, either uniquely your own or using familiar terms to describe specific feelings. This will help them learn how to openly communicate about what they are feeling with you and others.

Establish specific behaviors that they can do when they feel a certain way. Do this by allowing them to come up with those options first. Provide additional insight later.

Customizing Preventive Teaching for Bipolar Disorder

Tips for parents on using this skill for Bipolar Disorder:

Create and establish a safe environment for your child by preparing them for the future. This can be stated in the following way, “I know you may feel very down at times. When you feel down, I need you to let me know by telling me.” Or use a predetermined way of communicating this which may include moving a magnet on a refrigerator from one location to another, marking it on a chart, etc. This gives you information for their daily journal and establishes a precedence for what to do in a given situation.

Set up specific times of the day when your child will have to report how he/she is feeling. By setting up a routine, it makes it easier and less of a hassle for you as a parent to remember what to do.

Prepare them for days of feeling “down” and “up” by telling them it will happen. Children who can anticipate what may happen are more likely to recognize when it happens and address the behaviors more appropriately.

There are additional tips, ideas, games and activities associate with these concepts to help children of all ages learn these lessons. Feel free to explore the Smarter Parenting lessons page for more information on these and other skills. Once you and your child have mastered these skills, feel free to implement another lesson until you have learned them all.

​The following resources may be helpful

The National Institute of Mental Health provides further insight into Bipolar Disorder with videos, testimonials, and where to find help in your area.

The Depression and Bipolar Support Alliance provides an online community for parents and children with Bioplar Disorder.

Help Guide provides tips for how to support someone who is suffering/taking care of someone with Bipolar Disorder.




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