by Talia Rudkin, B.A., Psychological Services Diagnostic Extern

Pediatric bipolar disorder (PBD) has been given a considerable amount of attention in recent years.  Even though pediatric bipolar disorder has yet to find its individual place in the Diagnostic Statistical Manual (DSM), there has been a recent influx in the number of children and adolescents being diagnosed with bipolarity.  This can be an alarming diagnosis for parents, as it is one that is often given to adults.  In fact, bipolar disorder is so much more common in adults that the DSM-V does not distinguish adult-onset from pediatric-onset symptoms of bipolar, despite clinically significant differences in the presentation and duration of symptoms(^3,5,6,7).  However, a growing interest in this topic has led to an increase in research and treatment options for how to best care for a bipolar child. 

What is Bipolar Disorder? 

Bipolar disorder is a mental illness that alters thoughts, feelings, perceptions and behaviors.  It has an identifiable genetic component and affects all socioeconomic levels and ethnic groups.  Behaviors exhibited by most bipolar children can often be categorized as manic or depressive; however, in order to be considered bipolarity, there must be manic symptoms.  Children experiencing mania may feel “up” or extremely happy and energized; they may talk very fast and have racing thoughts, which can make it difficult for them to speak in a coherent manner.  The National Institute of Health identified a decreased need for sleep, unstable self-esteem and grandiosity, hypersexuality, elated mood, pressured speech and racing thoughts, and goal-directed activity as manic symptoms that are highly specific to bipolar disorder (⁶).  Those displaying depressive symptoms typically feel sad or “down,” and often lose interest in associating with friends and engaging in previously pleasurable activities.  

Mood changes for children with bipolar disorder can be distinguished from the normal ups and downs of children and adolescents due to the frequency and severity of these episodes.  Children with bipolarity often experience extreme mood lability, where their emotions rapidly cycle from happiness and excitement to depression and irritability, sometimes repeatedly throughout the day.  It is important to understand that children and adolescents can display several behaviors that are common in PBD at some point during their development.  Even if your child exhibits one or a few of these symptoms frequently, it does not necessarily indicate that he or she has PBD.  An evaluation by a licensed clinician can help to determine whether symptoms are sufficient and severe enough to warrant a diagnosis.  

Distinguishing PBD from Attention Deficit/Hyperactivity Disorder

While there are many overlaps between PBD and attention deficit/hyperactivity disorder (ADHD), they are fundamentally different in that ADHD is a condition involving an attention deficit whereas bipolarity is an affective disorder related to mood dysregulation (^2,7).  These two disorders share many similar features, such as distractibility, impulsivity, impaired judgment, restlessness, talkativeness and excessive energy; however, in bipolar disorder, these symptoms are often accompanied by elevated mood, grandiosity and other specific bipolar features1. In contrast to those with ADHD, who typically have strong emotional reactions to events in their lives, bipolar individuals can experience mood shifts that come and go without any apparent connection to life events (⁶).  In addition, mood reactions exhibited in ADHD are usually congruent with the trigger (i.e. pleasurable events often elicit excessive excitement and happiness), which is not always the case with bipolar disorder.  The majority of children with bipolarity experience a mood cycling pattern called ultradian cycling, where they have mood shifts several times a day (^2,6,7).  This cycling has also been found to be associated with low arousal states in the morning (typically having great difficulty getting up and starting the day) followed by increased energy in the afternoon and evening (^6,7). 

It is not only difficult to distinguish PBD from ADHD due to the number of shared symptoms between the two but also due to the high comorbidity of ADHD and several other disorders (^1-7).  Many times, pediatric bipolar disorder is misdiagnosed as ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, separation anxiety, or obsessive compulsive disorder (to name a few) (^1,6).  According to the Juvenile Bipolar Research Foundation, “Children with bipolar disorder are often severely ill, receive multiple other diagnoses and are often disadvantaged for a very long time before a proper diagnosis is made." This can lead to children receiving ineffective and inappropriate treatment, which could potentially worsen their condition.  Despite the difficulties in diagnosing PBD, the most effective treatments are contingent on an accurate diagnosis; therefore, if you feel that your child has PBD and may have been misdiagnosed, you should consider seeking a second opinion.  

How to Help at Home and School 

• Psychoeducation about PBD is likely the most important tool in caring for a child with PBD. Understanding the disorder and common behaviors associated with it can help parents and teachers be more empathetic, understanding and attentive to the child’s needs. This can decrease tension and frustration for both the child and others involved. 
• Behavior programs are often a necessary component for addressing impulse control difficulties, particularly when there are behavioral problems (e.g., the child acts in a physically or socially impulsive fashion). It is important to appreciate that, by definition, children with inhibitory control difficulties cannot consider potential consequences of their actions in the moment, even though they may demonstrate appropriate knowledge of consequences. Therefore, behavioral programs geared toward controlling stimuli that precede or lead to impulsivity are likely to be more successful than those that focus on the consequences following an impulsive action.
• Controlling antecedents, or what occurs prior to an impulsive behavior, is often an important method of reducing problematic behaviors.  Parents and teachers can anticipate times when the child is likely to act in a disinhibited manner. Intervening at that point may be more effective than attempting to apply consequences during or after a problem. Limiting stimuli or situations where the child might be impulsive can be important, or discussing the likelihood of impulsive behaviors and expectations may also be helpful.  For example, if a child has difficulty with behavioral control during unstructured time, he or she might meet with the teacher for a few minutes before joining peers to discuss expectations and actions that the child or teacher might take to avoid problems.  
• The use of appropriate behavioral management and coping strategies can help children and adolescents to regularly monitor their moods and become aware of triggers that provoke mood dysregulation.  Having a coping plan established for when the child becomes emotionally disinhibited can help him or her regain control more quickly. Meditative practices (e.g. deep breathing), self-monitoring, and recognizing and labeling feelings are effective coping strategies for affective regulation.  In addition, cognitive restructuring techniques, such as thought stopping (interrupting recurrent troublesome thought patterns), positively reframing situations and positive self-talk, can be helpful in reducing negative thoughts that often accompany depressive episodes in PBD.  
• Consequence-based systems may be an effective support for your child.  While he may have difficulty considering consequences in the moment, reinforcement for appropriate behaviors and repercussions for inappropriate behaviors (such as loss of privileges) may be helpful and necessary.
• It is important that any behavior program be implemented across settings for consistency.  Parents, teachers and other involved individuals should be consistent in their use of behavioral techniques. 
• It is important for children and adolescents with PBD to follow a consistent and predictable routine. Disturbances in routine can trigger or intensify mood dysregulation. Incorporating activities that the child enjoys into their daily schedule can also be helpful in managing mood problems.
• Social difficulties are often a problem for children and adolescents with bipolar disorder.  Children who behave impulsively with peers, may say or do inappropriate things and peers will learn to keep their distance.  It is important to cultivate the child’s social skills to avoid negative effects on his self-esteem.  Some suggestions include:

-Employing cross-age tutoring or mentoring with an older student who can explain and model appropriate social behaviors can be an effective means of increasing social success.

-Small group activities with more focused and well-controlled peers. Peers can serve as role models, but may need adult guidance in ways to respond to the child’s impulsive behaviors.

-Guided observations of peer interactions may be helpful for the child as a means of learning more appropriate social skills. A teacher or parent might meet with the child briefly at the outset of an activity and discuss how other children are behaving.

-More structured versus unstructured activities in the home and at school. The child may need more limited time in unstructured activities in order to maintain appropriate behavior. He might join an activity with a prearranged expectation to take a break from the activity after a set period of time. This break time can be used to review successes and any areas of difficulty before returning to the activity. Children and adolescents who receive greater supervision are less likely to engage in risky behaviors, such as substance use and promiscuity (8).

• In school, the child would likely benefit from preferential seating, as children and adolescents with bipolar disorder often struggle with distractibility. Placing the child’s seat near the teacher provides greater opportunities to observe when the child is adequately focused, and when he or she appears to be inattentive; in those instances, redirection or additional support can be quickly and easily implemented without disturbing other students.  Also, seating the child away from highly active or noisy parts of the classroom (e.g. by a pencil sharpener, noisy air conditioner or supply area) may help to avoid overwhelming sensory input.
• Many times children with PBD experience sleep disturbances.  It may be helpful to coordinate a schedule with the child’s teacher that allows them to arrive late to class or have a shorter school day.  Scheduling less demanding academic subjects earlier in the day and more difficult subjects later may help to increase academic success. 

Services for a Bipolar Child 

Child and family-focused cognitive-behavioral therapy is a psychosocial treatment model that combines cognitive-behavioral therapy (CBT) and psychoeducation into family-focused therapy.  This model is called RAINBOW therapy: 

R-routine

A-affect regulation

I-“I can do it!”

N-no negative thoughts

B-be a good friend

O-oh how can we solve the problem?

W-ways to find social support 

JCFS Chicago offers a full range of counseling and psychological services for children, teens, adults, couples and families, including cognitive behavior therapy. To schedule an appointment, or to learn more about our services, please call  855.ASK.JCFS (855.275.5237) or visit jcfs.org.

Websites

Pediatric Mood Disorders Program in the Department of Psychiatry at the University of Illinois at Chicago. Phone: (312) 355-1203; 

Institute for Juvenile Research, Pediatric Brain Research Program and Intervention (BRAIN) Center in the Department of Psychiatry at the UIC College of Medicine. Phone: (312) 413-1710;

Juvenile Bipolar Research Foundation

Books & Articles

The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder; by Demitri F. Papolos & Janice Papolos
http://www.amazon.com/Bipolar-Child-Definitive-Reassuring-Misunderstood/...

Help Your Child or Teen Get Back on Track: What Parents and Professionals Can Do for Childhood Emotional and Behavioral Problems; by Kenneth H. Talan
http://www.amazon.com/Help-Your-Child-Teen-Track/dp/184310914X?ie=UTF8&k...

What Works for Bipolar Kids: Help and Hope for Parents;by Mani Pavuluri & Susan Resko
http://www.amazon.com/What-Works-Bipolar-Kids-Parents-ebook/dp/B00597P1H...

“Crying Alone with my Child:” Parenting a School Age Child Diagnosed with Bipolar Disorder; by Josephine Wade in Issues in Mental Health Nursing (27), 885-903. https://www.researchgate.net/publication/6849535_Crying_alone_with_my_ch...

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Aravind, V. K., & Krishnaram, V. D. (2009). Pediatric Bipolar Disorder. Indian Journal Of Psychological Medicine, 31(2), 88-91. doi:10.4103/0253-7176.63579

3. Consoli, A., Deniau, E., Huynh, C., Purper, D., & Cohen, D. (2007). Treatments in child and adolescent bipolar disorders. European Child and Adolescent Psychiatry, 16(3), 187-198. 

4. Mattis, S., Papolos, D., Luck, D., Cockerham, M., & Thode, H. C. (2011).Neuropsychological factors differentiating treated children with pediatric bipolar disorder from those with attention-deficit/hyperactivity disorder. Journal of Clinical and Experimental Neuropsychology, 33(1), 74-84. 

5. Papolos, D. F. (2006). The bipolar child (3rd ed.). New York, NY: Broadway Books.

6. Washburn, J. J., West, A. E., & Heil, J. A. (2011). Treatment of pediatric bipolar disorder: A review. Minerva Psichiatrica, 52(1), 21–35.

7. Zegler, G. (2011) Differentiating between ADHD and bipolar disorder in children [Powerpoint slides]. Retrieved from http://www.naminc.org/nn/Conferences/2011presentations/ADHDvBPD.pdf

8. Mcgregor, S. (2015). The Home Environment for the Bipolar Child. Psych Central. Retrieved from http://psychcentral.com/lib/the-home-environment-for-the-bipolar-child/