What is Early-Onset Bipolar Disorder?

Diagnostic Criteria

Bipolar disorder (formerly known as manic-depressive disorder) is a disorder of the brain that results in mood swings that range from mania to depression. Each individual is unique and may exhibit a different clinical picture, but there is a diagnostic criteria (DSM-IV) used by professionals to establish a diagnosis in children and adolescents and adults.  Following are common diagnostic criteria.

It is important to note that the presentation of bipolar symptoms in children and adolescents differ greatly from the presentation in adults.  Children often present with mixed symptoms that vary throughout the day from irritability, to sadness, happiness, elation or rage.  Insignificant events often set the child or adolescent off.  Families find themselves altering their lifestyles to prevent triggering a mood swing in the child or adolescent with bipolar disorder. 

There are different terms used to describe the state of the child or adolescent with bipolar disorder, which are descriptive of the symptoms that are currently present.  Some of the more common terms that you might hear are: mixed state, mania, rapid cycling, or depression.

Common symptoms

* Chronic irritability, explosiveness, rage, violence & paranoia
The rage of bipolar disorder in children and adolescents can be extreme.  Explosions can last minutes to hours and vary in severity and intensity.  They can arise “out of the blue” and are most often are a reaction to an insignificant event.  These episodes range from yelling, kicking, and biting to damaging property, using a weapon, and injuring themselves or others.  The child may be calm one minute and escalate to a full- blown rage the next.   Parents often describe inflexibility, rigid demands and constant difficulty causes stress in the family’s daily lives.

Sadness- guilt, depression, self harm, suicidality
The sadness seen in bipolar disorder can be severe.  It is not unusual for a child to cry frequently, lose their motivation and \even make statements about wanting to die or end their life.  They may also feel excessively guilty or \worthless and hopeless about life.

Silliness, goofy behavior, excitability, inappropriate humor
While all children and adolescents can get excited, silly or act goofy or inappropriate at times, the silly, goofy, excitable and inappropriate humor that is seen with mania is quite excessive.  In fact, others will take notice or recognize this behavior as “out of the norm” or strange.

Hypersexuality, bathroom humor or masturbation
Children and adolescents with bipolar disorder may experience periods of time in which they are over-stimulated. During these periods of time, they may become more focused on sexualized behavior, inappropriate talk or masturbation.  These children are often referred to psychiatry because of suspected sexual abuse due to the hypersexual symptoms.  It is important to remember that hypersexuality is a symptom of bipolar disorder that abates when the individual is treated properly. 

Decreased need for sleep
During manic periods of time, some children and adolescents will not require many hours of sleep.  They may be up all night or sleep for only a few hours and still have plenty of energy the next day.  They truly do not require much sleep during these times.

Other symptoms:
Racing thoughts
Pressured speech or excessive talking
Hyperactivity, endless energy
More risk-taking behaviors
Elation or grandiose thought. Children may exhibit bragging, bossiness and
controlling behavior

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Diagnostic Criteria

What is Early-Onset Bipolar Disorder?

Diagnostic Criteria

Bipolar disorder (formerly known as manic-depressive disorder) is a disorder of the brain that results in mood swings that range from mania to depression. Each individual is unique and may exhibit a different clinical picture, but there is a diagnostic criteria (DSM-IV) used by professionals to establish a diagnosis in children and adolescents and adults.  Following are common diagnostic criteria.

It is important to note that the presentation of bipolar symptoms in children and adolescents differ greatly from the presentation in adults.  Children often present with mixed symptoms that vary throughout the day from irritability, to sadness, happiness, elation or rage.  Insignificant events often set the child or adolescent off.  Families find themselves altering their lifestyles to prevent triggering a mood swing in the child or adolescent with bipolar disorder. 

There are different terms used to describe the state of the child or adolescent with bipolar disorder, which are descriptive of the symptoms that are currently present.  Some of the more common terms that you might hear are: mixed state, mania, rapid cycling, or depression.

Common symptoms

* Chronic irritability, explosiveness, rage, violence & paranoia
The rage of bipolar disorder in children and adolescents can be extreme.  Explosions can last minutes to hours and vary in severity and intensity.  They can arise “out of the blue” and are most often are a reaction to an insignificant event.  These episodes range from yelling, kicking, and biting to damaging property, using a weapon, and injuring themselves or others.  The child may be calm one minute and escalate to a full- blown rage the next.   Parents often describe inflexibility, rigid demands and constant difficulty causes stress in the family’s daily lives.

Sadness- guilt, depression, self harm, suicidality
The sadness seen in bipolar disorder can be severe.  It is not unusual for a child to cry frequently, lose their motivation and \even make statements about wanting to die or end their life.  They may also feel excessively guilty or \worthless and hopeless about life.

Silliness, goofy behavior, excitability, inappropriate humor
While all children and adolescents can get excited, silly or act goofy or inappropriate at times, the silly, goofy, excitable and inappropriate humor that is seen with mania is quite excessive.  In fact, others will take notice or recognize this behavior as “out of the norm” or strange.

Hypersexuality, bathroom humor or masturbation
Children and adolescents with bipolar disorder may experience periods of time in which they are over-stimulated. During these periods of time, they may become more focused on sexualized behavior, inappropriate talk or masturbation.  These children are often referred to psychiatry because of suspected sexual abuse due to the hypersexual symptoms.  It is important to remember that hypersexuality is a symptom of bipolar disorder that abates when the individual is treated properly. 

Decreased need for sleep
During manic periods of time, some children and adolescents will not require many hours of sleep.  They may be up all night or sleep for only a few hours and still have plenty of energy the next day.  They truly do not require much sleep during these times.

Other symptoms:
Racing thoughts
Pressured speech or excessive talking
Hyperactivity, endless energy
More risk-taking behaviors
Elation or grandiose thought. Children may exhibit bragging, bossiness and
controlling behavior

Fact sheet

• Bipolar disorder is a hereditary illness ranked among the ten most disabling conditions in the world, yet up to 40 percent of adults with bipolar disorder, and an even higher percentage of youth, go untreated. It takes an average of eight to ten years after the first signs of bipolar disorder to obtain a proper diagnosis and treatment.
• It is estimated that one to two percent of adolescents and adults have bipolar disorder and as many as five to seven percent may have bipolar spectrum disorder.  These estimates do not include preschoolers and younger children who were not included in the research studies that measured the prevalence of bipolar disorder.
• An estimated1.5 million children under the age of 15 are severely depressed; many of whom may go on to develop bipolar disorder.
• Bipolar disorder affects people of all ages, sexes, ethnic backgrounds and economic levels.
• Symptoms can emerge at any age from preschool years to adulthood.  The onset of the symptoms may be triggered by a trauma, a very stressful life event, or by a medication taken for another condition.  However, symptoms often appear “out of the blue,” without an identifiable cause.
• With accurate diagnosis, effective medication and proper support, individuals with bipolar disorder can lead very successful, productive and fulfilling lives.
• Children and adolescents with bipolar disorder are at risk of school failure, job loss, social and legal problems, addiction, and suicide, especially if they are not diagnosed and treated in timely fashion.  (40 percent of people who have untreated bipolar disorder abuse alcohol or drugs; 60 percent have marriages that end in divorce). 
• The lifetime rate of mortality is higher in bipolar disorder than in some childhood cancers.
• Bipolar disorder affects males and females at equal rates.

Treatment for Early Onset Bipolar Disorder

Treatment Guidelines: Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder

Bipolar disorder is a hereditary illness that is ranked among the ten most disabling conditions in the world, yet up to 40 percent of adults with bipolar disorder, and an even higher percentage of youth, go untreated. It takes an average of eight to ten years after the first signs of bipolar disorder appear to obtain a proper diagnosis and treatment.

I. Medications for bipolar disorder-helpful with both mania and depression.

Mood stabilizers include lithium, and anticonvulsant medications such as: divalproex sodium (depakote), carbamazepine (Tegretol), oxcarbazepine (Trileptal), lamotrigine (Lamictal), and topiramate (Topamax).

Atypical neuroleptics or second generation antipsychotics include Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodone), Aripiprizole (Abilify) and Clozapine (Clozaril).

Typical antipsychotics include high potency:Haloperidol (Haldol), Fluphenazine (Prolixin), Pimozide (Orap), Trifluoperazine (Stelazine), and low potency: Chlorpromazine(Thorazine), Thioridazine (Mellaril).

Antidepressants are used cautiously in treating residual depression once the mania is stabilized.  They need to be introduced slowly and carefully to avoid an exacerbation of mania.

Benzodiazapines may be used to treat anxiety or seizures.  The risk of becoming dependent on benzodiazepines with long term use makes them unattractive for use in children and adolescents.  However, they may be helpful in alleviating severe symptoms on a temporary basis while the individual is waiting for a new medication to become effective.

II. Therapy and other treatments

Psychotherapy is helpful in addition to the medication treatments that are considered to be the first-line treatment for bipolar disorder. The different types of therapy are: cognitive behavioral therapy, psychosocial therapy, psychodynamic therapy, interpersonal psychotherapy, family therapy, and supportive psychotherapy (add dialectical behavioral therapy). Ask your doctor of nurse practitioner which would be the most helpful in addressing the individual needs of your child or adolescent.

Electroconvulsive Therapy (ECT) can be used to treat severe depression and is sometimes used for mania and schizophrenia.

Light Therapy can be particularly helpful with depressive symptoms that are seasonal in nature.

Transcranial Magnetical Stimulation (TMS) is a new treatment that is gaining recognition for the treatment of depression, schizophrenia and obsessive compulsive disorder.

Ask your doctor or nurse practitioner which treatments will be most helpful for your child.

Uses of Medictations in Children and Adolescents with Bipolar Disorder

Important note: If an individual with bipolar disorder becomes so depressed or manic that he or she might hurt himself or others, hospitalization may be indicated. If you believe that an individual is in immediate danger, call an ambulance just as you would for a medical crisis. Most emergency rooms are well equipped to handle mental health emergencies.

Psychopharmacologic treatments are available that decrease the suffering associated with bipolar disorder, by preventing or lessening the severity of symptoms and prolonged episodes of mania and/or depression.

Medications can be very effective in alleviating the symptoms of bipolar disorder. While your child may be one of the lucky ones who responds to the first medication that is prescribed, it is important to understand that many children and adolescents need to try a few different medications before they find the one that is the most effective with the fewest side effects for them. It is also not unusual to need a combination of more than one medication to alleviate the different symptoms.

Make sure that you inform your doctor or nurse practitioner of any medical problems in the past or present, any allergies that you have, and of the medication that you are currently taking. If your child or adolescent has taken psychiatric medications in the past, bring a list when visiting a doctor, which includes the dose that was taken, and how they responded to the medication.

Common Myths of Bipolar Disorder

Myth: The behavior of the bipolar child is largely due to the parent’s inability to be consistent with discipline.

Reality: This is simply not true. It wasn’t very long ago that professionals attributed the cause of schizophrenia to the mother being “cold.”  Parents are often met with criticism and isolation.  No matter how exceptional a parent is, it is impossible to control the behavior of a bipolar child or adolescent when they are manic. 

Myth: Bipolar disorder doesn’t start in childhood.

Reality: Recent research has documented the existence of bipolar disorder in childhood.  There are many researchers dedicated to studying this disorder.  Thanks to the experts, we are learning more about diagnosing and treating bipolar children and adolescents, which will ultimately decrease the suffering and offer hope for better treatment options in the future.

Myth: Children with bipolar disorder are “bad kids”.  They could control their behavior if they really tried.

Reality: Many parents, family members, educational professionals and others in the community label bipolar children and adolescents as “bad kids.” Children and adolescents with bipolar disorder can be quite charming, well behaved, intelligent and creative when they are well. The behavior witnessed when a child or adolescent is manic is a symptom of bipolar disorder, just as someone’s blood pressure rising is a result of his or her hypertensive disorder.  Just as we would never think that a person could control their high blood pressure without medical intervention, we should not assume that a child with bipolar disorder can control the mood and behavior that is associated with bipolar disorder.

Navigating Insurance

Negotiating with your health insurance company
by Michael Sullivan

Helpful hints:

Read and understand the coverage details of your health insurance plan
Question those items that don’t make sense
Use the appeal process when necessary. I didn’t win all the time, but I did win sometime
Remember who you’re fighting for and push hard to get what you want

When my son Matt was six years old, my wife and I received a call from his school requesting our presence at a meeting with his teacher and the school principal to discuss his chronic behavior problems. We were well aware of our son’s high energy level, but we just figured he was a very active little boy. The officials at school told us otherwise, and that his behavior had become intolerable. Based on their experience with children, they suspected that he had ADHD. This was the beginning of the journey…

First, we sought help from our son’s pediatrician. He was reluctant to start treating Matt with medication immediately because this was not his area of expertise. I respected his opinion and agreed with his suggestion that Matt be seen by a specialist in pediatric developmental disorders. Fortunately, this specialist was listed in my health insurance plan directory of participating physicians. Per the rules of the plan, all we needed was a written referral from the pediatrician to the specialist and the visits would be covered by my health insurance. We received the referral and brought Matt to see the specialist. All his visits were covered by insurance with no issues.

After approximately a year, Matt’s condition became much worse. My wife and I were at wits end and didn’t know what to do. The doctor had diagnosed Matt as having ADHD and was treating him with several medications, but nothing was working. Thank God this doctor didn’t try to be hero and realized that Matt’s case was beyond him. He referred Matt to a pediatric psychopharmacology specialist at Massachusetts General Hospital in Boston. He said that Matt needed to be seen by the best in this field and the best were at MGH. I checked my health insurance directory of participating physicians and MGH doctors were not listed. I needed an out-of-network referral. This is when the fun started…

I received the out-of-network referral and proceeded to make an appointment for Matt at MGH for treatment. He was going the initial evaluation in a few days, however there was a problem with the insurance company. When I called them to make sure Matt’s visits would be covered, they didn’t want him to go to MGH for treatment. They wanted him to go to New England Medical Center. I told them that he needed to be seen right away and that he was referred to MGH by another “plan” physician. They again insisted on New England Medical Center and I said yes on one condition, they needed to get me an appointment in two days or I was keeping the appointment at MGH. Because they couldn’t find the same specialist available at New England Medical Center, they agreed to pay for the first visit only at MGH.

Matt’s first visit with the specialist at MGH was an eye opening experience. After a thorough evaluation, he was diagnosed with Bipolar Disorder, ADHD, OCD, ODD and depression. Our beautiful little boy had mental illness beyond my comprehension. My wife and I wanted to cry, but we were very grateful that he was being treated by the best specialists in the country, if not the world.

I checked in the insurance company again and they still had not found a pediatric psychopharmacologist at New England Medical Center who could see Matt right away. I told them that I was going to continue to bring Matt to MGH for treatment. They agreed to pay for several more visits until they found a “plan” specialist.

A month passed, and I finally got the call from the insurance company telling me that they found a specialist who could see Matt. I refused. I told them that it now was a continuity of care issue and that I was not going to bounce my son to a new specialist and start all over. They proceeded to tell me that they wouldn’t cover the visits to MGH any longer. I told them that I will continue to bring Matt for treatment at MGH and would deal with them later. The treatment of Matt’s mental health was much more important and I needed time to think.

A few days or a week later, I noticed an article in the Boston Globe that reported the CEO of my health insurance company was getting a monstrous raise and would be making an annual salary in the millions of dollars. This lit the fire in my gut and primed me to go to war with the insurance company. I called and told them that as my health insurance company, they would be covering all my son’s visits to MGH and if they disagreed I would be coming to Boston to complain directly to the CEO of the company. As I remember, there were several more conversations and emails, but eventually, they agreed to cover Matt’s visits to MGH. Trying to be reasonable, I made a deal with them that I would pay for Matt’s visits and submit receipts monthly for reimbursement, so as not to burden them with having to cut me a check weekly.

Health insurance companies with all their policies, rules and procedures can be a major roadblock to getting the best care needed for your child. You have got to push very hard to get what you want. The story I told is a condensed version, I didn’t mention the dozens and dozens of emails, phone calls and letters that were required to get what I wanted for my son. I basically made an absolute giant pain in the ass of myself to reach my desired results. My efforts paid off, and Matt is living proof.

Related Websites and Resources for Parents and Professionals

http://www.cehl.org/bipolar.shtml
The Meaning of “Bipolar”: Perspectives of a Parent and Health Professional