Question:
What is childhood- onset bipolar disorder (COBPD), and how does it differ
from bipolar disorder (manic-depression) in adults?
Answer:
All those with bipolar disorder experience mood swings that alternate
from periods of severe highs (mania) to severe lows (depression).
However, while these abnormally intense moods usually last for weeks or
months in adults with the illness, children with bipolar disorder can
experience such rapid mood swings that they commonly cycle many times
within a day. The most typical pattern of cycling among those with COBPD,
called ultra-ultra rapid or ultradian, is most often associated with low
arousal states in the mornings followed by increases in energy towards
late afternoon or evening.
It is not uncommon for the initial episode of COBPD to present itself as
major depression. But as clinical investigators have followed the course
of the disorder in children, they have observed a significant rate of
transition from depression into bipolar mood states.
Is COBPD usually inherited?
Yes. One of the most important factors in establishing the diagnosis is
family history. According to several recent studies, a history of mood
disorders (particularly bipolar disorder) and/or alcoholism on both the
maternal and paternal sides of a family appears to be commonly associated
with COBPD.
How early in childhood does the disorder start? What are some common
early symptoms?
Many parents report that their children have seemed different since early
infancy. They describe difficulty settling their babies, and they note
that their children are easily over-responsive to sensory stimulation.
Sleep disturbances and night terrors are also commonly reported.
Later in a child's development, hyperactivity, fidgetiness, difficulties
making changes, and high levels of anxiety (particularly in response to
separation from the child's mother) are commonly seen. Additionally,
being easily frustrated, having difficulty controlling anger, and
impulsiveness (difficulty waiting one's turn, interrupting others) often
result in prolonged and violent temper tantrums.
Are there other childhood psychiatric conditions that can co-occur with
bipolar disorder?
Yes. Rarely does bipolar disorder in children occur by itself. Rather, it
is often accompanied by clusters of symptoms that, when observed at
certain points of the child's life, suggest other psychiatric disorders
such as attention-deficit/hyperactivity disorder (ADHD),
obsessive-compulsive disorder (OCD), oppositional defiant disorder, and
conduct disorder.
An estimated 50 percent to 80 percent of those with COBPD have ADHD as a
co-occuring diagnosis. Since stimulant medications often prescribed for
ADHD (Dexedrine, Adderall, Ritalin, Cylert) have been known to escalate
the mood and behavioral fluctuations in those with COBPD, it is important
to address the bipolar disorder before the attention-deficit disorder in
such cases. Some clinicians suggest that the prescription of a stimulant
for a child genetically predisposed to develop bipolar disorder may
induce an earlier onset or negatively influence the cycling pattern of
the illness.
What is the difference between ADHD and COBPD?
Several studies have reported that more than 80 percent of children who
go on to develop COBPD have five or more of the primary symptoms of
ADHD-distractibility, lack of attention to details, difficulty following
through on tasks or instructions, motor restlessness, difficulty waiting
one's turn, and interrupting or intruding upon others. In fact,
difficulties with attention are so common in children that ADHD is often
diagnosed instead of bipolar disorder. Actually, ADHD often appears
before a clear development of the frequent alternating mood swings and
prolonged temper tantrums associated with COBPD.
While the symptoms of COBPD and ADHD may be similar, their origins
differ. For instance, destructiveness and misbehavior are seen in both
disorders, but these behaviors often seem intentional in those with COBPD
and caused more by carelessness or inattention in those with ADHD.
Physical outbursts and temper tantrums, also features of both disorders,
are triggered by sensory and emotional overstimulation in those with ADHD
but can be caused by limit-setting (e.g., a simple "No" from a parent) in
those with COBPD. Furthermore, while those with ADHD seem to calm down
after such outbursts within 15 to 30 minutes, those with COBPD often
continue to feel angry, sometimes for hours. It is important to note that
children with COBPD are often remorseful following temper tantrums and
express that they are unable to control their anger.
Other symptoms, such as irritability and sleep disturbances often
accompanied by night terrors with morbid, life-threatening content (e.g.,
nuclear war or attacking animals), are commonly seen in those with COBPD
but are rarely associated with ADHD.
How does the illness affect school performance and social relationships?
Deficits in shifting and sustaining attention, as well as difficulties
inhibiting motor activity once initiated, can strongly influence both
classroom behavior and the establishment of stable peer relationships.
Distractibility, daydreaming, impulsiveness, mischievous bursts of energy
that are difficult for the child to control, and sudden intrusions and
interruptions in the classroom are also common features of the COBPD.
Stubborn, oppositional, and bossy behavior, usually appearing between the
ages of six to eight, pose significant problems for parents, educators,
and peers. Risk-taking, disobedience to authority figures, and the
likelihood of becoming addicted to psychoactive drugs such as marijuana
and cocaine also present serious concerns to those affected by a child
with COBPD. Furthermore, a high percentage of children with COBPD have
co-occurring learning disabilities, a problem that can negatively affect
school performance and self-esteem.
Should parents tell teachers?
Teachers need to be educated about the common behaviors, symptoms, and
nature of COBPD. Most families have found that many teachers can be
sympathetic allies when they fully understand the day-to-day problems of
the child. A teacher's view of a child is limited to the period of day
when most bipolar children are less easily aroused and can tolerate and
be responsive to social rules set by the teacher. Teachers often see only
the child's attention problems, fidgetiness, and occasional abundance of
mischievous energy, not the explosive tantrums.
How is COBPD treated?
The first line of treatment is to stabilize the child's mood and to treat
sleep disturbances and psychotic symptoms if present. Once the child is
stable, therapy that helps him or her understand the nature of the
illness and how it affects his or her emotions and behavior is a critical
component of a comprehensive treatment plan.
Some medications have also proved useful. Since few treatment studies
have been conducted in children, though, most clinicians use drugs that
have been tested and proved successful in adult forms of bipolar
disorder. For mood stabilization these include: lithium carbonate
(Lithobid, Lithane, Eskalith), divalproex sodium (Depakote, Depakene),
and carbamazepine (Tegretol). Newer agents such as gabapentin
(Neurontin), lamotrigine (Lamictal), and topirimate (Topamax) are
currently under clinical investigation and are being used in children.
(Lamictal is not recommended for those under the age of 16.)
For the treatment of psychotic symptoms and aggressive behavior,
risperidone (Risperdal) and olanzapine (Zyprexa) are commonly used newer
agents, while thioridazine (Mellaril), trifluperazine (Trilafon), and
haloperidol (Haldol) are old standbys. Clonazepam (Klonopin) and
lorezapam (Ativan) are also used to treat anxiety states, induce sleep,
and put a brake on rapid-cycling swings in activity and energy.
What about the use of antidepressant drugs?
It's very risky. Several studies have reported very high rates of the
induction of mania or hypomania (rapid-cycling) in children with bipolar
disorder who are exposed to antidepressant drugs of all classes. In
addition, the child may experience a marked increase in irritability and
aggression. The course of the disorder may be altered if antidepressants
are prescribed without mood stabilizers.
I thought it was the best single summary that I had seen. IMO we parents
with BP should be particularly vigilant on behalf of our children to
recognize the onset of BP symptoms and seek out effective treatment for
them. Hopefully they won't have to go through the years of agony that we
went through either undiagnosed or misdiagnosed.
