Judith Lederman's son tried to jump off a pier in his first suicide attempt. He was 5 years old. "A psychologist said he was just trying to get attention," Lederman recalls. "He was 8 years old when he had his first full-blown manic episode," says Lederman. "He stopped sleeping for days on end, became very hostile, was pulling knives on us, and tried to attack his brother."
Lederman and her husband took their son to the hospital, where he was admitted for a three-day evaluation. At the end of the three days, he had been diagnosed with bipolar disorder.
From that day forward, the Lederman family's life changed. And even though their son's condition is now stable, it requires "constant vigilance," says Lederman, author of the forthcoming book, Swing Shift: The Ups & Downs of Parenting a Bipolar Child.
Previously known as manic-depression, bipolar disorder is a mood disorder marked by extreme changes in mood, energy levels, and behavior. Although symptoms typically emerge in adolescence or adulthood, they can be seen in children as young as 7 or 8, says Robert Kowatch, MD, professor of psychiatry and pediatrics at Cincinnati Children's Hospital Medical Center.
Until recently, young people were rarely diagnosed with this disorder. Yet up to one-third of the 3.4 million children and adolescents with depression in the U.S. may actually be experiencing the early onset of bipolar disorder, according to the American Academy of Child and Adolescent Psychiatry.
Bipolar disorder begins with either manic or depressive symptoms. Like children with depression, children with bipolar disorder are likely to have a family history of the illness -- as was the case with Judith Lederman's son. Her husband's father also suffered from the condition.
The National Mental Health Association lists the following signs and symptoms and recommends that you seek medical help if you see a child struggling with any combination of these symptoms for more than two weeks.
- Severe changes in mood -- from unusually happy or silly to irritable, angry, or aggressive.
Unrealistic highs in self-esteem. May feel indestructible or believe they can fly, for example.
Great increase in energy level. Can go without sleep for days without being tired.
Excessive involvement in multiple projects and activities. May move from one thing to the next and become easily distracted.
Increase in talking. Talks too much, too fast, changes topics too quickly, and cannot be interrupted. This may be accompanied by racing thoughts or feeling pressured to keep talking.
Risk-taking behavior such as abusing drugs and alcohol, attempting daredevil stunts, being sexually active, or having unprotected sex.
- Frequent sadness or crying.
Withdrawal from friends and activities.
Decreased energy level, lack of enthusiasm, or motivation.
Feelings of worthlessness or excessive guilt.
Extreme sensitivity to rejection or failure.
Major changes in habits such as oversleeping or overeating.
Frequent physical complaints such as headaches and stomachaches.
Recurring thoughts of death, suicide, or self-destructive behavior.
Many of these symptoms can be indicative of conditions other than bipolar disorder, but it's important to have the child evaluated to reach the right diagnosis, says Tim Lesaka, MD, child psychiatrist with The Staunton Clinic in suburban Pittsburgh. Many cases previously thought to be attention deficit hyperactive disorder (ADHD) may, in fact, be bipolar disorder, he says.
"With kids with bipolar disorder, it's a matter of extremes," says Lesaka. "With an ADHD kid, there's a five-minute tantrum and then an apology. With the bipolar child, it can be eight hours of rage with no apology. There is an explosiveness ... followed by a super-depression."
Treatment for bipolar disorder -- in kids as well as in adults -- usually consists of a combination of medications that may include one or more of the following: mood stabilizer, antipsychotic drug, antidepressant, or antiseizure drug. Medication does work, Kowatch says, but there's always the problem of getting kids to stay with the program. "It's a real pain for them," he says. "The drugs have side effects ... but the alternative is to wind up in the hospital."
Researchers at Ohio State University are looking into other treatment options in two new studies, one funded by the National Institute of Mental Health and the other by the Ohio Department of Mental Health.
The researchers are studying a promising new treatment called psychoeducation that they believe can help children with early-onset bipolar disorder and their families.
Though there have been a few studies evaluating medication in children, none has examined psychosocial treatments, says Mary Fristad, PhD, leader of the studies and a professor of psychiatry and psychology at Ohio State.
"Medications are vital for helping children with bipolar disorder, but they can't do everything," says Fristad.
"If you have your first mood disorder as an adult, you have already learned a lot of coping skills that can help you, such as how to hold a conversation and how to treat friends," says Fristad. "But when you get a mood disorder as a child, you often have never had a chance to develop these interpersonal skills. We help kids 'catch up' with these skills, which in turn helps them manage their symptoms."
While acknowledging that bipolar disorder in children does indeed exist, Barry Cohn Markell, PsyD, a licensed clinical psychologist in Park Ridge, Ill., adds a note of restraint. "It's talked about more, but it's still very rare." (According to Kowatch of Cincinnati Children's Hospital Medical Center, approximately 1% of children in the general population suffer from bipolar disorder.)
Cohn Markell is concerned that an inaccurate diagnosis of bipolar disorder can "label" a kid for life. "Many of the symptoms that are listed for bipolar disorder can be caused by other things from abuse and neglect to physical illnesses such as epilepsy, encephalitis, brain tumor, or head injury."
When parents bring a child with severe mood swings to him, Cohn Markell learns about the child's environment -- by observing the child himself and/or by giving the parents and teachers an observational scale ("If the behavior isn't the same at home and at school, then something else might be going on," he says). He also takes a history to determine how long the symptoms have been present and refers the child to a pediatrician to rule out physical illness.
If a child is diagnosed with bipolar disorder, says Cohn Markell, he recommends counseling, special classes or schools, and support services for the child and family.
Judith Lederman agrees. "There's so much to know and so much to deal with," she says. But it's important to know that you're not alone. There is support out there. But you have to seek it out."
Reviewed by Michael W. Smith, MD, August 22, 2002.