Wednesday, April 8, 2009
Although mood changes and other symptoms associated with bipolar disorder are challenging, they can be managed effectively. Treatment usually includes medications (such as mood stabilizers) and professional counseling, and often a combination of both is needed.
Bipolar illness is a serious disorder that has a big impact on both the child and his or her family. Successful treatment requires that the child and family members understand what happens in bipolar disorder and that the family members help make sure that the child follows the treatment.
It can take time for you and your child to accept that the child has a serious, long-term condition that requires ongoing treatment and constant monitoring. However, keep in mind that by working with your child's doctor, you and your child can find effective treatment for the condition.
You and your child's doctor can discuss which treatment is right for your child. Older children and teenagers may want to participate in their own treatment decisions.
The first step in determining appropriate treatment for your child with bipolar disorder is evaluating the severity of his or her symptoms. If your child's behavior is suicidal, aggressive, reckless, or dangerous, or if he or she is out of touch with reality (psychotic) or unable to function, the child may need a period of hospitalization. Also, many medications can make the symptoms of bipolar disorder worse, and if your child is taking one of these, he or she may need to taper off and stop the medication. This should only be done under the supervision of a doctor.
Initial treatment usually includes medications and counseling.
Medications. Medications most often used include:
* Mood stabilizers, such as lithium (for example, Eskalith or Lithobid), divalproex (Depakote), carbamazepine (for example, Tegretol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), or valproate (Depacon).
* Antipsychotics, such as olanzapine (Zyprexa) or risperidone (Risperdal), which your doctor may combine with a mood stabilizer for more effective control of manic episodes.
* Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (for example, Prozac), or other types of antidepressants to control episodes of depression. While antidepressants can be helpful for some children, they might also trigger mania. A doctor will usually prescribe antidepressants with other medications that help regulate mood, and he or she must carefully monitor the child.
Before prescribing medicine to treat bipolar disorder, your doctor will check your child for possible suicidal behavior by asking a few questions. See a list of questions your doctor may ask your child.
Professional counseling.Counseling works best when symptoms of bipolar disorder are controlled with medications. Several types of therapy may be helpful, depending on the age of the child.
* Cognitive-behavioral therapy, which focuses on modifying certain thinking and behavior patterns.
* Interpersonal therapy, which focuses on social and personal relationships and related problems.
* Problem-solving therapy, a brief type of cognitive therapy that helps you find immediate solutions to problems.
* Family therapy, which can help educate and comfort the entire family.
* Play therapy for very young children.
* Psychological education and support groups.
Ongoing treatment of bipolar disorder includes long-term treatment with medications and may include professional counseling.
Some children and adolescents do not respond to the first medication they try, and they may need to try several different medications to find relief from the symptoms. A combination of medication and professional counseling may be the most effective treatment.
An important part of ongoing treatment is making sure your child takes the medication as prescribed. Often people who feel better after taking bipolar medication for a period of time may feel that they are cured and no longer need treatment. However, when a person stops taking medication, symptoms usually return, so it is important that your child follows the treatment plan.
Medications for bipolar disorder have side effects that need to be managed. Some things you cannot change, such as increased urination (common with lithium). But you can deal with some side effects like weight gain (common with several medications used to treat bipolar disorder) by increasing exercise and reducing calorie intake. You can work with your child and his or her doctor to find ways of coping with side effects. If side effects from a medication are intolerable, the doctor may have to change the dose or the medication.
Some medications, such as lithium carbonate (Eskalith or Lithobid, for example) and divalproex (Depakote), require ongoing blood monitoring every few months. Your doctor may have to adjust the amount of medication your child is taking so your child has the right amount of medication for treatment.
During initial treatment, your doctor may prescribe a medication such as an antipsychotic for a short time to help your child deal with immediate symptoms. Once your child's long-term medications kick in and symptoms improve, he or she will need to taper off and stop the short-term medication.
Other ongoing treatment includes:
* Academic adjustments. If your child is in school, he or she may need a reduced homework load or school schedule during severe depressive or manic episodes. You can work with the school to find ways to help your child maintain performance requirements until the symptoms are under control.
* Relaxation and exercise. Steps your child can take at home to improve symptoms include:
o Getting regular physical exercise, such as swimming or walking, to help reduce stress.
o Avoiding the use of drugs, alcohol, tobacco, caffeinated beverages, and energy drinks.
o Eating a balanced diet.
o Getting enough sleep and keeping a regular sleep-wake cycle. (Children and teenagers need more sleep than adults.)
Sometimes treatment for other conditions can make your child's bipolar disorder worse. For example, treating depression with antidepressants can trigger or worsen a manic episode. Treating attention deficit hyperactivity disorder (ADHD) with stimulants may also trigger severe mania, depression, and even psychosis (loss of touch with reality). Treatment with corticosteroids for conditions such as asthma may also trigger a manic episode. Medications that intensify bipolar symptoms may need to be stopped altogether or changed to a different dose or medication. Sometimes an additional medication (such as a mood stabilizer) can solve the problem. However, each child responds to medications differently, and it may take several tries before your doctor can identify an effective medication or combination of medications for your child's conditions.
Learning as much as you can about childhood and adolescent bipolar disorder may help you recognize mood changes in your child as they begin to occur. Catching and treating these mood changes early may help reduce the length of the manic or depressive episode and improve the quality of your child's life.
Treatment if the condition gets worse
If your child's condition gets worse while he or she is undergoing treatment for bipolar disorder (including medications, counseling, and lifestyle changes), the doctor may give additional treatment. You and your doctor should:
* Make sure your child is taking medications as prescribed and following other treatment recommendations.
* Determine whether ongoing symptoms are caused by another disorder (such as attention deficit hyperactivity disorder or post-traumatic stress disorder), and treat the other condition if necessary.
* Identify and reduce stresses that may be making symptoms worse.
* Adjust the dose of medications if the current dose is not effective.
* Add or change medications if the current ones are not working.
A brief hospital stay may be necessary, especially if your child is showing any warning signs of suicide. The warning signs of suicide change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
For older children with severe bipolar symptoms who have not responded to medications, electroconvulsive therapy (ECT) may be an option. In this procedure, brief electrical stimulation to the brain is given through electrodes placed on the head. The stimulation produces a short seizure that is thought to balance brain chemicals
Often the first signs of bipolar disorder are severe moodiness, unhappiness, or other symptoms of depression. It is common for children with bipolar disorder to be diagnosed first with only depression and then later to be diagnosed with bipolar disorder after a cycle of mania or hypomania (a less severe form of mania).
A first manic or hypomanic episode can be triggered by a stressful situation or may occur without an obvious cause. It can also be started by certain medications used to treat other conditions. Drugs (such as antidepressants or stimulants) that are used to treat depression, attention deficit hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD) are sometimes prescribed to children with bipolar disorder who have not yet been correctly diagnosed. These drugs can trigger sudden bouts of mania, sometimes with bizarre, aggressive, or psychotic behavior. (However, these medications are sometimes effective for children with bipolar disorder when they are combined with a mood-stabilizing drug.)
In adults with bipolar disorder, mood swings usually occur over weeks or even months. In children, cycles usually occur more rapidly, sometimes within the same day (rapid, ultra rapid, or ultradian cycling). Frequently, children with bipolar disorder have difficulty getting going in the morning but then have intense energy later in the day. Often the mood shifts are continuous, rarely returning to a normal mood between extremes. Sometimes elements of depression and mania or hypomania may be present at the same time (a mixed state). These rapid and severe mood changes may make your child appear constantly irritable, and they can significantly interfere with your child's ability to function at school, at home, and with peers.
Children with mania can be more irritable and prone to temper tantrums or destructive outbursts than adults with mania. In a depressive episode, children may complain of headaches, muscle aches, stomachaches, or fatigue. They frequently miss school or talk about running away from home. They become socially isolated and overly sensitive to any kind of rejection or criticism.
While all teens may be rebellious or make bad choices from time to time, teenagers with bipolar disorder are more likely to show poor judgment, take risks such as breaking the law or having unprotected sex, and believe they are more powerful or important than they really are (delusions of grandeur) during manic episodes. A teen in a depressive episode may withdraw from social activities, do poorly in school, and have problems concentrating and sleeping.
Obsession with sex (hypersexuality) is common in children and teens who have bipolar disorder. Even young children may touch themselves, use sexual language, and approach others in a sexual way. Adolescents with bipolar disorder may be obsessed with sexuality and engage in risky sexual behavior. Hypersexual behavior is common in children who have been sexually abused; however, many children with bipolar disorder experience hypersexuality without having been molested.
People sometimes confuse bipolar disorder in children with other conditions with similar symptoms, such as oppositional defiant disorder, anxiety disorders, or attention deficit hyperactivity disorder (ADHD). Frequently children with bipolar disorder are misdiagnosed with another such disorder or are diagnosed with one of those conditions and bipolar disorder.
There is some evidence of a link between ADHD and bipolar disorder, the conditions have distinct features that you can usually identify.
A child or teen with bipolar disorder may behave irresponsibly, take risks and not think about the consequences, or have difficulty making and keeping friends. Older children and adolescents with undiagnosed bipolar disorder frequently use alcohol and drugs. If your child is using drugs or alcohol and having behavioral problems, you may want to schedule an evaluation to determine whether your child is suffering from a condition such as bipolar disorder.
In young children
Bipolar disorder in children may be different than in teens and adults. They may outgrow the disorder and no longer have this diagnosis later in life. In children younger than age 9, bipolar disorder frequently appears as depression or irritability. During a depressive episode, a young child may become withdrawn, have a short attention span, feel guilty for no reason, and have low energy that can last for hours, days, or weeks. Your child may throw temper tantrums, become easily frustrated, and become explosively angry. Irritability and temper tantrums can also be part of manic episodes.
In children, it can be difficult to tell the difference between a depressive and a manic episode, especially if cycles are rapid or symptoms of depression and mania occur together. Irritability may progress into severe, seizure-like temper tantrums when the child is told "no." A bipolar child may kick, bite, hit, and make hateful comments, including threats and curses. During tantrums, which may last for hours, a child may destroy property or become increasingly violent.
In older children and adolescents
During a manic episode, an older child or adolescent may have high energy levels and feelings of extreme happiness (euphoria). He or she may need less sleep and may talk rapidly and continuously. He or she may be aggressive and get into fights and may use sexual language when it is not appropriate or engage in risky sexual behavior. An adolescent with bipolar disorder may suffer consequences from manic behavior such as suspension from school, arrest as a result of fighting or drug use, or an unwanted pregnancy or sexually transmitted disease (STD) from unsafe sexual behavior.
During depressive episodes, an adolescent may become withdrawn or quiet, do poorly in school, and stop participating in activities he or she once enjoyed (such as quitting a sports team). Your adolescent may cry often, sleep too much, and feel that he or she doesn't belong. He or she may speak of death or suicide. You should take any threats of suicide seriously, because children with bipolar disorder have an increased risk of suicide.
Substance abuse in adolescents with bipolar disorder is common, and your child's health professional may recommend an evaluation for both substance abuse problems and bipolar disorder if your child appears to suffer from either condition.
Watch for the warning signs of suicide. These change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
When children older than age 6 or teens have bipolar disorder, they have mood swings with extreme ups and downs. When they are up, they have brief, intense outbursts or feel irritable (mania) several times almost every day. When they are down, they feel depressed and sad.
In the past, experts thought bipolar disorder was the same in children and adults. But recent studies of children and teens show that their symptoms are different than those of adults, and they need different treatment.
What causes bipolar disorder?
Experts don't fully understand what causes bipolar disorder.
It seems to run in families. Your child has a greater risk of having it if a close family member such as a parent, grandparent, brother, or sister has it. Parents may wonder what they did to cause their child to have bipolar disorder. But there is nothing a parent can do to cause or prevent it.
What are the symptoms?
Children and teens with bipolar disorder have mood swings with extreme ups (mania) and downs (depression). These intense moods quickly change from one extreme to another without a clear reason. Some children may briefly return to a normal mood between extremes. Many children change continuously between mania and depression, sometimes several times in the same day. Sometimes children with bipolar disorder have symptoms of both mania and depression at the same time.
Times of mania or depression may be less obvious in children and teens than in adults.
* During a time of mania, children and teens may:
o Feel irritable and throw violent temper tantrums.
o Touch their genitals, use sexual language, and approach others in a sexual way.
o Not sleep much and go about the house late at night looking for things to do.
* During a time of depression, children and teens may:
o Say they feel empty, sad, bored, or down.
o Complain of headaches, muscle aches, stomachaches, or fatigue.
o Often spend time alone and may easily feel rejected or criticized.
How is bipolar disorder diagnosed in children and teens?
This disorder can be hard to diagnose in children and teens. The symptoms can look a lot like the symptoms of other problems, such as attention deficit hyperactivity disorder (ADHD), alcohol and drug abuse problems, or conduct disorder. Bipolar disorder can often occur along with these problems.
If your doctor thinks your child or teen may have bipolar disorder, he or she may ask questions about your child’s feelings and behavior. Your doctor may also give you and your child written tests to find out how severe the mania or depression is. The doctor may do other tests (such as a blood test) to rule out other health problems. He or she may ask if your family has any history of mental illness or problems with drugs or alcohol. Any of these problems can be linked to bipolar disorder.
Why is early diagnosis of bipolar disorder important?
Children with this disorder are more likely to have other problems. These include alcohol and drug abuse, trouble in school, running away from home, fighting, and even suicide. Treating the disorder as early as possible may keep your child from having these problems.
Watch for the warning signs of suicide, which change with age. Warning signs of suicide in children and teens may include thinking too much about death or suicide. Watch also for things that can trigger a suicide attempt such as a recent breakup of a relationship or the loss of a parent or close family member through death or divorce.
How is it treated?
The mood changes that come with bipolar disorder can be a challenge. But with the right treatment, they can be managed well. Treatment usually includes both medicine (such as mood stabilizers) and counseling.
An important part of treatment is making sure your child takes his or her medicine. Children and teens with this disorder sometimes stop taking their medicines when they feel better. But without medicine their symptoms usually come back.
Medicines for bipolar disorder in adults have been well studied. But not much research has been completed about how the medicines work and if they are safe for children and teens.
Accepting that your child has bipolar disorder can be hard. The disorder can be a serious, lifelong problem. Your child will need long-term treatment and will need to be watched carefully. By working with your child's doctor, you can find a treatment that works for your child.