This post is Part One of a six-part series: Pediatric Bipolar Disorder: A Guide for Children’s and Youth Pastors and Volunteers
Child and adolescent psychiatrists and other mental health professionals continue to be engaged in a vigorous debate about the appropriate diagnostic criteria for bipolar disorder in children and teens.
Diagnostic criteria for all mental disorders are currently under review in anticipation of the release of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) in May, 2013. The controversy in the field about pediatric bipolar disorder is focused on whether the current diagnostic criteria apply to children and teens, especially the criteria for duration of mood episodes. Most kids who receive a bipolar diagnosis don’t meet the criteria, primarily because their mood episodes are too short. The vast majority of these kids have been diagnosed with ADHD, experience irritability as their predominant mood state and exhibit frequent and severe episodes of aggressive behavior. Dr. Ellen Leibenluft at the National Institute of Mental Health characterized such children as having “Severe Mood Dysregulation” or SMD. The DSM-V ultimately settled upon the term Disruptive Mood Dysregulation Disorder to refer to the kids described in Dr. Leibenluft’s research. I’ll discuss these kids separately in a future post.
The American Academy of Child and Adolescent Psychiatry (of which I’m a member) has come down on the side of limiting use of term Bipolar Disorder to kids who have had at least one episode of mania or hypomania lasting at least four days and otherwise meet the existing criteria. For the purpose of this discussion, we’ll use the existing criteria:
A distinct period of elevated, expansive or irritable mood lasting at least one week in which three or more of the following are present (four if mood is only irritable):
Decreased need for sleep
Flight of ideas or racing thoughts
Increased goal-directed activity (psychomotor agitation)
Involvement with pleasurable behaviors with the potential for painful consequences
By definition, a person isn’t diagnosed with classic (Type I) bipolar disorder unless they have experienced at least one episode that meets the above criteria. Persons with hypomania experience mood disturbances lasting at least four days meeting the above criteria that aren’t severe enough to cause marked impairment in academic or social functioning, require hospitalization or are associated with psychotic symptoms. Persons with bipolar disorder may also experience episodes of depression (that’s where the term “manic depression” comes from), or episodes in which symptoms of mania are seen concomitantly with symptoms of depression (mixed episodes).
Coming back to our criteria, let’s look at how these symptoms manifest in kids and teens, keeping in mind that these symptoms represent a change from the child’s baseline:
Inflated self esteem, grandiosity: Most kids coming to a practice like mine have poor self-esteem. Kids or teens with bipolar disorder may present with severe bravado (the 80 lb. kid in fourth grade picking a fight with the 120 lb. kid in the seventh grade), an overinflated sense of their own attractiveness, or unrealistic belief in their own abilities (the high school junior who believes he’ll go on tour with a rock band as lead drummer despite never having taken drum lessons or performed publicly). It’s normal for an eight year old boy to believe he’ll play in the NFL. If you’re a third-string lineman as a high school senior on a 3-7 football team, that belief could be a problem.
Decreased need for sleep: Lots of conditions seen in kids and teens (anxiety, depression, ADHD, PTSD) are associated with difficulty falling asleep. Kids in manic episodes have difficulty staying asleep. In the midst of their mood episodes, they may not complain of feeling tired despite little sleep.
Pressured speech: During mood episodes, kids with bipolar disorder talk more, talk louder and talk faster. When I have difficulty understanding a kid’s speech when I could understand it before, I always ask other questions about bipolar disorder. Think about the guy at the end of the car commercials reading the disclaimer.
Flight of ideas, racing thoughts: As opposed to simply being distracted, kids with bipolar disorder may be unable to sustain a train of thought, or skip inappropriately from thought to thought.
Increased distractibility: Kids with concomitant ADHD will have more difficulty than normal paying attention during mood episodes.
Increased goal-directed activity, psychomotor agitation: Bipolar disorder is overrepresented among artists and writers. During episodes, they’ll start lots of projects they don’t finish. Kids with bipolar disorder who also have ADHD will be more fidgety, restless and hyperactive than would be typical for them on a day to day basis.
Involvement with pleasurable behaviors with the potential for painful consequences: Here’s where the big problems come in. Kids with bipolar disorder are prone to exhibit inappropriate sexual behavior in the midst of episodes. I can remember one school-age kid I took care of a number of years ago who needed a therapist to go out to his home during his episodes because he would try to mount his little sister and his parents needed guidance to keep his siblings safe. I had another patient…great kid, great family, active in youth group who was pulled over for driving 85-90 miles/hour in a 35 zone on a country road during a manic episode. Kids who wouldn’t otherwise steal will do so during episodes. Or drink. Or do drugs.
It’s important to note that there are lots of other conditions in which kids might experience some of the symptoms described above. Kids with Borderline Personality traits will experience frequent, dramatic mood swings, self-injurious behavior and often talk about or threaten suicide. Kids with ADHD are often impulsive. Kids who have been sexually traumatized not infrequently demonstrate inappropriate sexual behavior toward others. Illicit drugs or prescription medication may potentiate some of the symptoms described above.
To complicate matters further, kids and teens with bipolar disorder are extremely vulnerable to other emotional and behavioral disorders. 90% of school-age kids and 60% of teens with bipolar disorder have ADHD. 30-40% are identified with specific learning disabilities. 40-50% of adolescents with untreated bipolar disorder develop substance use disorders.
Kids with bipolar disorder often come from homes in which a parent is struggling with bipolar disorder. A child with one parent with bipolar disorder is 4-6X more likely to develop the condition. When both parents have bipolar disorder, the odds of their child developing the condition is 50-75%. Trauma and stressful life events may result in the release of hormones that activate genes linked to bipolar disorder. A recent study reported that kids with bipolar disorder were three times more likely to have been a victim of physical or sexual abuse compared to siblings without the disorder.
The takeaway from this discussion for folks in children’s and youth ministry is that we’re called to serve a population in which 1 out of every 100 kids will develop a condition by adolescence characterized by an episodic, severe inability to self-regulate their emotions and behavior.
Jesus was into lost sheep. See Matt 18:12-14. If he saw value in pursuing the one lost sheep out of a hundred maybe we should too?
Next: What challenges do kids with bipolar disorder face?
Updated February 24, 2016
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What I can say as a parent of 4 children, two of them with bipolar 1 disorder, is that very few doctors truly understand the “energy” of bipolar disease, and no doubt it is difficult to tease out. This disease was “missed” in both of my children for years( one with typical late adolescent onset and my youngest w/very early onset) which lead to both of them placed on SSRIs for what was believed to be anxiety driven behaviors and resulting in manic flips w/psychosis and hospitalization. And, thus is with a known strong family history of bipolar disease in our family. My true feeling is that the majority of cases are probably not bipolar disease, but if this is missed and treated wrong it can have devastating consequences. My daughter(24yr old now), who was hospitalized 3 times for bulemia and significant OCD type behaviors that got soooo much worse on Prozac and destroyed college for her, was finally diagnosed at UCLA….she will tell everyone, doctors don’t understand the “energy”!!!!
Thanks for sharing your family’s story. Kids with bipolar disorder are often very complex…ADHD, anxiety, depressive episodes and OCD often occur comorbidly with bipolar disorder and unfortunately, our insurance-driven healthcare system makes it very hard for mental health professionals working in large systems to take the time needed with kids to tease out all of these complexities that often lead to unsatisfactory treatment options.
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