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The bipolar challenge

Most children have occasional difficulty controlling their impulses and dealing with frustration. That's normal. But sometimes, extreme behavior is indicative of a more serious issue. If children experience severe mood and energy level changes, going from irritable and aggressive to silly and elated, to periods of extreme withdrawal, they may have bipolar disorder.

Bipolar disorder is a serious but treatable mental illness.

Children as young as 5 years old can suffer from the manic highs and deep lows that characterize the disease. If untreated, it could lead to a host of social and health-related problems, such as failing at school, addiction and, in severe cases, even suicide.

According to Joseph Gonzalez-Heydrich, MD, chief of Children's Hospital Boston's Psychopharmacology Program, diagnosing bipolar disorder in children can be a huge challenge. In fact, Dr. Gonzalez-Heydrich says children with the disorder are frequently misdiagnosed, so pediatricians should be familiar with the unique ways that it can afflict children and present in an office visit.

"Children usually exhibit signs of mixed mania and depression," says Dr. Gonzalez-Heydrich. "They're simultaneously dysphoric, angry and irritable, with severe oppositionality, and can be aggressive and violent during rages." These rages are usually severe and prolonged compared with the outbursts by children with attention-deficit hyperactivity disorder (ADHD) or impulse control disorder. Those are typically brief, impulsive and of mild-to-moderate intensity, according to Dr. Gonzalez-Heydrich.

Fast facts about bipolar disorder

According to the American Academy of Child and Adolescent Psychiatry, up to one-third of the 3.4 million children and adolescents diagnosed with depression in the United States may actually have bipolar disorder. The onset of bipolar disorder may be triggered by a trauma, but often appears with no identifiable cause. Useful link: www.stepup4bpkids.com

And while adults with bipolar disorder usually experience severe mood swings over a span of weeks or months, with periods of health in between, children with the disorder can continuously have extreme spikes of highs and lows—sometimes many times during a single day—called a rapid cycling of moods.

Complicating the diagnosis of bipolar disorder in children is the fact that many of its symptoms overlap with those of ADHD, including distractibility, hyperactivity, grandiosity, flight of ideas, risky behaviors, decreased need for sleep and a rapid speech pattern.

According to Dr. Gonzalez-Heydrich, these symptoms present differently in children with bipolar disorder than in children with ADHD. For example, a hyperactive child with bipolar disorder is usually more goal-directed compared with the scattered hyperactivity of a child with ADHD, and symptoms may be more episodic.

Further diagnostic difficulty is caused by the prevalence of ADHD among children with bipolar disorder. Dr. Gonzalez-Heydrich says that about 70 percent of children with bipolar symptoms before adolescence may also have ADHD, compared to about 30 percent of children who present with the symptoms as adolescents.

The child's family history is also an important clue for the diagnosing physician. Many children with bipolar disorder have a parent who either has it or depression, suggesting that the illness may have genetic origins.

Though diagnosis may be difficult, a delay in diagnosing the disorder—or worse, misdiagnosis—can have dangerous consequences, since it worsens over time. Misdiagnosis may lead to the wrong course of treatment and may actually exacerbate the child's symptoms because stimulant medications frequently prescribed for ADHD can actually trigger mania in children with bipolar disorder. Similarly, anti-depressant medicines may increase mania and violence in some bipolar children.

Because of these risks, Dr. Gonzalez-Heydrich suggests consulting with a mental health professional when ADHD, depression or bipolar disorder are suspected. "We're very familiar with these disorders at Children's because we see so many cases," he says. "These are very serious conditions and difficult to diagnose, so we strongly recommend referrals before prescribing medications."

Once a diagnosis has been made, treatment typically includes medications such as lithium, divalproex and/or a second generation antipsychotic agent.

Dr. Gonzalez-Heydrich says it's important to note that no single medication is effective in all children. Families should expect a trial-and-error process that can last weeks or even months as doctors find the best treatment for a particular child. During this period, the pediatrician should monitor the child's physical health closely, since weight gain is a common side effect of many of the mood-stabilizing medications used to treat bipolar disorder. It may be helpful to set up nutritional counseling and/or an exercise program from the start. For more information, visit www.childrenshospital.org/psych.

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