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Childhoodonsetbipolar Disorder Essay, Research Paper
Childhood-Onset Bipolar Disorder Childhood Onset Bipolar Disorder (COBPD) is one of the most debilitating mental disorders affecting children today. Bipolar Disorder is a mood disorder usually affecting adults that causes sometimes severe changes in mood. Childhood Onset Bipolar disorder is just what it sounds like, a bipolar disorder that occurs during childhood. Persons suffering from a bipolar disorder experience mood swings ranging from depression to mania. During a depressive episode patients can experience feelings of extreme hopelessness or sadness, inability to concentrate and trouble sleeping. Symptoms of mania include rapidly changing ideas, exaggerated cheerfulness and excessive physical activity. Hypomanic symptoms are the same as in mania, however, they are not so severe as to require hospitalization. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) outlines the diagnostic criteria for mood disorders. According to the DSM-IV, a person must have at least 5 of the following symptoms during the same 2 week period to qualify as a major depressive episode: a depressed mood lasting most of the day for several days; a significant weight gain or weight loss; a loss of interest in activities; difficulty sleeping (insomnia) or an increased need for sleep (hypersomnia); restlessness or slowed pace observable by others; daily fatigue; feelings of guilt or worthlessness; inability to concentrate; or recurrent thoughts of death. These symptoms can only be diagnosed as a depressed episode if they are not better explained by grief, effects of a drug, or a medical condition. The person experiencing these symptoms must, also report an interference in their daily functioning because of the symptoms. Finally, the person s symptoms do not meet the criteria for a mixed state. The criteria for a mixed episode state that the person must display symptoms of depression and mania every day during at least a 1 week period. For an episode to be categorized as manic, the patients mood has been irritable or abnormally elevated for at least 1 week. A person must also exhibit at least 3 of the following symptoms (4 if the mood is only irritable): extreme feelings of personal greatness; a decreased need for sleep, marked talkativeness; distractibility; extreme focus on a goal-directed activity; reports of racing thoughts or a flight of ideas; or excessive involvement in pleasurable activities that have a high potential for painful consequences (i.e. sexual indiscretions or unintelligent business investments). As in the criteria for a depressed episode, the DSM-IV specifies that these symptoms should not be better explained as being a side effect of a drug or illness to qualify as a manic episode. These symptoms must interfere with the person s normal functioning and must not meet the criteria for a mixed episode. As with adults, childhood-onset bipolar disorder has many faces. Children with Bipolar I Disorder have episodes of mania and episodes of depression, sometimes there are long periods of normal moods between episodes. Adults usually tend to have more depressed episodes than manic episodes. However, some children will have chronic mania (symptoms of mania lasting for long periods of time or marked by frequent recurrence) and seldom experience a depressed episode. Bipolar II Disorder causes depressive episodes, sometimes lasting for long periods of time. It can also cause hypomanic episodes, but manic episodes are not present. Unlike Bipolar I Disorder, for persons with Bipolar II Disorder, periods of normal moods are virtually nonexistent. Cyclothymia is characterized by frequent hypomanic episodes and occasional episodes of mild depression only. Some children have repeated hypomanic episodes a year. Person s showing signs of depression and mania at the same time is referred to as being in a mixed state. Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Mixed State Bipolar Disorder are all very rare in children. For many years it was assumed that children could not suffer the mood swings of mania or depression, but as more research has been done, we have realized that bipolar disorder can occur in children, and it is much more common than previously thought. Althoug, the DSM-IV does touch on the subject of children with mood disorders, they are still diagnosed according to adult criteria. In children, mania and hypomania appear as more of an irritable mood. These features come and go throughout the day and are not as persistent as in adults. When bipolar disorder is present in children it is more severe and harder to treat. Children tend to experience extremely rapid mood swings, often cycling from mania to depression and back to mania several times 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(Facts about COBPD;http://www.mhsource.com/hy/ bipolarch.html). Difficulties with early onset bipolar disorder begin with diagnosis. The rapid cycling of moods in children with COBPD make it difficult to fulfill the duration criteria of Bipolar Disorder. The DSM-IV states that depressive or manic episodes are to last a specific length of time, at least 4 days in a manic episode and at least 2 weeks in a depressive episode. The majority of children suffering from COBPD do experience these ultra-ultra rapid patterns of mood swings. The DSM-IV does include a section entitled Bipolar Disorders Not Otherwise Specified (NOS) , which allows for mood swings not lasting the full duration criteria(DSM-IV- Subaffective disorders: Dysthymic, Cyclothymic, and Bipolar II Disorders in the borderline realm ). However, this is still not an accurate description of COBPD. Many parents of children with COBPD report that their children have seemed different from infancy. They describe difficulties calming their babies, and they relate that their children have always been very sensitive to sensory stimulation, i.e. sounds, lights, touches. Many children have extreme difficulty sleeping and some experience night terrors (Facts about Childhood-Onset Bipolar Disorder). A child suffering from COBPD may be easily frustrated and have terrible temper tantrums lasting until the child is literally exhausted. These children tend to be bossy and have trouble adjusting to new situations, especially situations that they have no control over. Some children with a bipolar disorder are extroverted and very charismatic while other children experience bouts of social phobia (extreme discomfort in a social situation). Without closer observation, hyperactive, irritable, distractible children are believed to have Attention Deficit Disorder with Hyperactivity (ADHD). As a matter of fact, a million children and adolescents in the United States may have COBPD, of these 1 million people, an estimated 23 percent are currently diagnosed with ADHD(Mitzi Waltz, Bipolar Disorders, 1st Edition January 2000) Attention Deficit disorder with hyperactivity and COBPD do have many of the same warning signs and symptoms. Person s diagnosed with ADHD experience an inability focusing attention on a task, or difficulty organizing tasks. They do not seem to listen when spoken to, have difficulty following instructions, avoid tasks that require mental effort, are easily distractible, experience recurrent forgetfulness, and repeatedly lose materials necessary to complete a task, i.e. books, tools, pencils. Dr. Demitri Papolos has stated that over eighty percent of children who have COBPD will meet the full criteria set by the DSM-IV for ADHD (Papolos and Papolos, The Bipolar Child). What differentiates the two disorders is the fact that children with a bipolar disorder exhibit much more irritability, unstable mood, and sleep disturbances than children with ADHD. There are many theories as to what may cause COBPD. Alan S. Brown, MD, and colleagues have proposed that there may be a relationship between prenatal malnutrition and COBPD. Brown and his colleagues studied hospitalization records of Dutch psychiatric patients who were exposed inutero to the harsh climate and extreme food shortage of the 1944 Dutch winter. By looking at hospital records of people exposed to this environment during the first trimester, second trimester, third trimester and a control group (who were not exposed at all), Brown and his colleagues found that men and women exposed inutero to famine and harsh climate during the second and third trimester were more likely to develop a bipolar disorder than those exposed during the first trimester or not exposed at all. Also, the incidence for unipolar disorder (a mood disorder in which a person experiences only depressive episodes) was more significant than for bipolar disorder (Brown AS, Susser ES, Lin SP et al. 1995) in those exposed during the first trimester or not exposed at all. According to more recent studies, one of the main factors in establishing a diagnosis of COBPD is family history. This means that there is a significant link between COBPD and genetics. Dr. Richard Todd and his colleagues at Washington University in St. Louis found increased rates of COBPD when family histories reveal a mood disorder and/or alcoholism on both the maternal and paternal sides. By transferring information from questionnaires into a database, it was found that over 80 percent of children diagnosed with COBPD had this bilineal transmission (Todd et al. 1997). Childhood-Onset Bipolar Disorder is a somewhat of a new concept. The DSM-IV is not scheduled for revision in the near future, but there have been some guidelines set that experts can use to make recognition of COBPD a bit easier. For example, a Washington University team of researchers use a structured diagnostic interview called Wash U KIDDE-SADS, which is more sensitive to the rapid cycling patterns of children with a bipolar disorder (CABF Learning Center- About Early Onset Bipolar Disorder). The criteria, though not formal, are the same as in adult bipolar disorder but there are two differences. First, the cycling between mania, hypomania and depression occurs many times each day. Second, these episodes are short, rarely lasting more than a day before cycling to another state (Childhood Onset Bipolar Disorder; http://www.klis.com/chandler/pamphlet/bipolar/ bipolarpamphlet.htm). For children with COBPD, a correct diagnosis is extremely important. This disorder, left untreated or improperly treated due to a misdiagnosis, can lead to severe impairments. Children who are not treated, or not treated properly experience an increase of symptoms. The behavior exhibited by children with COBPD, if not understood and dealt with, can lead to a removal from school, hospitalization, and sometimes even placement in the juvenile justice system. Misdiagnosis can lead to personality disorders and perhaps drug abuse. Childhood Onset Bipolar Disorder is extremely difficult to deal with for the child suffering. Most children report guilty feelings, and feelings of not belonging anywhere. Left untreated, COBPD worsens and a correct diagnosis is the only way to start an effective treatment plan. There is no miracle cure for bipolar disorder. There is, however, reasonable probability that a good treatment plan can lead to a virtually symptom free life. A good treatment plan includes medication, close monitoring of symptoms, education about the illness, counseling or psychotherapy for the child and their family, stress reduction, good nutrition, regular sleep and exercise, and participation in a network of support (CABF Learning Center- Facts about Early Onset Bipolar Disorder). Medication is usually the first course of action in an effective treatment plan. Similar to the differences between COBPD and bipolar disorder affecting adults pertaining to diagnosis, there are drugs that have been proven to work on adults that are not as effective in children. One of these drugs is the mood stabilizer, Lithium. Lithium and other mood stabilizers cause changes in the balance of chemicals in the brain. The difficulty with prescribing a mood stabilizer to a child with COBPD is that, while being effective on manic and hypomanic episodes, they are not effective in decreasing depressive episodes. In other words, taking a mood stabilizer may cause a child s cycling pattern to stop, but the child will still experience the depressive episodes. Lithium, as with other mood stabilizers, is also not as effective in children as it is in adults. Recently, mood stabilizers have become the second string of drugs used to combat bipolar disorder. The reasons being that the newer drugs (called Atypical Antipsychotics) are more effective, they work faster, are easier to use, and have less side effects. The most studied of the newer atypical antipsychotics is Risperdal (Risperidone). This drug has been found to be 85% effective in combating the symptoms of Childhood Onset Bipolar Disorder (CABF Learning Center). Risperdal not only treats the mood swings occurring with bipolar disorder, but it also calms down the irritability and rages that these children often experience. As with all drugs, there are some side effects with Risperdal, with most people reporting a significant weight gain, but they are not common. With bipolar disorder affecting over a million people in this country, researchers are constantly looking for safer, faster, more effective drugs. In a recent study, Dr. Michael H. Allen composed a group study of fifty-nine hospitalized patients exhibiting manic episodes. Dr. Allen was interested in finding a treatment that would work rapidly and prevent hospitalization (Keck PE Jr., Hirschfeld RMA, Allen MH et al., Safety and efficacy of rapid-loading divalproex sodium in acutely manic patients). For comparison, patients were assigned randomly to a ten day treatment schedule of loading doses of Depakote (a mood stabilizer), or non-loading doses of Depakote or Lithium. In the loading strategy, 20 patients received 30 mg per day of Depakote for days 1 and 2, and then dropped back to 20 mg per day in divided doses. In the non-loading strategy, 20 patients received 750 mg of Depakote daily in divided doses. In the Lithium strategy, 19 patients received 300 mg of the drug 3 times a day. The researchers found that all of the patients showed decreased signs of manic symptoms by day 3 of the study, but the patients assigned to the loading doses of Depakote showed improvement by day 2. In addition, the difference between treatment groups was accentuated in patients with more severe manic symptoms (Keck et al., 1999). Of course, no one medication works for all children with COBPD. Sometimes 2 or more are needed collectively to reach and maintain mood stability. Parents should expect a trial and error period in which their child s doctor may have to try many different medications in different combinations before the best treatment is found. One way to speed up the trial and error process toward an effective medication is through the use of cycle charts. Cycle charts are a way of keeping track of your child s mood throughout the day, along with what medication is given and how often. These charts can be extremely important to the doctor when prescribing the medications as well as to the therapist conducting the psychotherapy. Recording a child s moods in the form of a simple graph, these cycle charts provide a visual display of the course of the illness and brings into focus the symptoms and behaviors that define the condition (Papolos and Papolos, 1999). The second phase of treatment is psychotherapy. This is a very important stage and the reason it usually occurs after medication has stabilized the child s mood is because children experiencing rapid mood swings have not been found to benefit from counseling alone. Therapy issues include dealing with the stress that may trigger or worsen manic and depressive episodes. Counseling can also ensure the patients willingness to follow the prescribed course of treatment. A good therapy plan should include support and education about the illness. Children with a bipolar disorder have other needs that need to be taken into consideration. One of the main problems facing these children is the difficulties they face in school. The medication necessary to stabilize their moods often leaves them feeling fairly sedated. The child s functioning can vary throughout the school year, sometimes it varies daily, and they can easily fall behind other students. Parents should suggest a meeting between the special education staff of their child s school, the child s therapist, and themselves. Together, the best way to insure the child s educational development progresses smoothly is to put into action an Individualized Educational Program (IEP). This plan contains goals and objectives based upon the childs present educational level. The IEP also includes when the plan will begin, how long it will last, and the way in which the child s progress will be evaluated (LD OnLine: IEP: The Process). Bipolar disorder has left it s mark on history. Many famous people have had symptoms of bipolar disorder; Abraham Lincoln, Theodore Roosevelt, Tolstoy, and Hemingway to name a few. In fact, the biography of Beethoven discloses severe, recurrent mood swings beginning in childhood. In short, coming to a correct diagnosis of Childhood Onset Bipolar disorder can be very difficult and finding an effective treatment plan can be a long, drawn out process. However, if these obstacles are overcome, children suffering with a bipolar disorder can lead very normal, productive lives.
RESOURCES Todd, Richard D. The link between parental alcoholism and childhood mood disorders: A family/genetic perspective. Medscape Mental Health 2 (1997) DSM-IV. Journal of clinical psychopharmacology 16, supplement 1. (1996) Keck PE Jr., Hirschfeld RMA, Allen MH et al. (1999), Safety and efficacy of rapid-loading divalproex sodium in acutely manic patients. Ryan, Neal MD; Bhatara, Vinod S. MD; Perel, James M. PhD. Mood stabilizers in children and adolescents. Journal of the American academy of child & adolescent psychiatry, Volume 38, Number 5 (May 1999) Papolos, Demitri MD; Papolos, Janice. The Bipolar Child. (1999) Waltz, Mitzi. Bipolar Disorders. (1st edition Jan. 2000) CABF Learning Center- About Early Onset Bipolar Disorder: http://www.cabf.org/learning/about.htm Bipolar Affective Disorder (Manic Depressive Disorder) in Children and Adolescents: http://www.klis.com/chandler/ pamphlet/bipolar/bipolarpamphlet.htm Child and Adolescent Bipolar Disorder; An update from the national Institute of Mental Health: http://www.nimh.nih. gov/publicat/bipolarupdate.cfm Facts About Childhood Onset Bipolar Disorder: http://www. mhsource.com/hy/bipolarch.html LD OnLine: IEP Individualized Education Program: The Process- http://www.ldonline.org/ld_indepth/iep/ iep_progress.html