Bipolar Disorder

Bipolar Disorder is a mood disorder that includes both depressive symptoms and manic or hypomanic symptoms. Often, these symptoms are not so clearly differentiated in children, meaning you do not see week(s) of depression and then week(s) of manic symptoms. The symptoms are often mixed, or the children’s moods cycle rapidly. Emotions can be extreme, and these changes can feel like a roller coaster. The diagnosis in children is often an “Other Specified Bipolar and Related Disorder.” Children with bipolar disorders are at a high risk for suicide and self-harm. They need support at home and school, and psychotherapy in both settings is important.

Children who have significant problems in this area may have any of the following potential disability. *Note, this does not serve as a diagnosis in any way. See Where to Go for Help With Bipolar Disorder for professionals who can diagnose or provide a referral.

A depressive episode is defined by sad or irritable mood or loss of pleasure in things one used to find interesting, accompanied by a number of the following: inability to focus, thoughts of worthlessness, withdrawal, thoughts of death, poor sleep (too little or too much) and poor diet (over or under eating). These symptoms must be observable and cause clinically significant distress that impacts functioning. 

In children, depression may often be marked by irritability. Children may be less able to define their own symptoms. They may have trouble talking about their feelings or may deny them entirely. In children, depression can be defined by irritable mood, loss of interest in activities and by considering parent and teacher reports of these and other depressive symptoms. Glaring symptoms include frequent thoughts of death and suicidal ideation. Large meltdowns that seem way more intense than you would expect may be related to depression.

A manic episode is a period in which elevated mood is remarkable and includes grandiosity, pressured speech, and engagement in dangerous activities. A hypomanic episode includes the same symptoms but fewer and to a lesser degree. Symptoms of mania and hypomania often seen in children include pressured speech and flight of ideas, which is talking rapidly and excitedly and changing topics quickly. Often, children use superlatives like best and greatest to describe everything. They may engage in risky behaviors, such as jumping from high places or participating in risky sports, such as ski jumping. They may stay up all night writing a play or plan to develop a robot to save the world. These children may move a lot in an assessment and may have poor attention and executive functioning. Hypomania includes at least three symptoms, and mania requires a greater number. Having one or two of these symptoms does not meet the criteria for significant mania.

Depression. Feelings of sadness. OR

Irritable Mood. May seem angry, frustrated, have a short temper, cry easily.

Other Symptoms

Loss of Pleasure. Less interest or participation in activities the child used to enjoy.

Inability to focus. Seeming unable to focus on anything. May seem lethargic or spacey.

Thoughts of worthlessness. Your child may make a lot of negative self-statements. “I’m not good enough.” “Everyone else can do that but I can’t.” “I never do anything right.”

Withdrawal. Your child may stop spending time with friends or family and may spend all his or her time quietly in a bedroom. Playdates and interest in others may decrease.

Thoughts of death/ suicidal. May report wishing he or she had not been born, may discuss life without him or her, and may try to give away treasured possessions. May express a desire to hurt him or herself and may share a plan. Be open to listening to your child, and hear his or her feelings instead of saying not to feel that way. Seek support immediately, and make sure not weapons or other dangerous opportunities are available. Keep close supervision of your child.

Poor eating. May not be interested in eating or may eat excessively with a focus on carbohydrates.

Poor sleep. May not be able to sleep or may sleep all the time, generally a disruption in typical sleep patterns.

Mania.

Increased goal-directed activity. A child may spend 12 hours doing math homework packets, plan to write a play or swim in the Olympics. This activity could be very out of the blue and seem poorly planned.

Flight of Ideas. Talk may include a lot of superlatives and be hard to follow, tangential, and fast.

Rapid/Pressured Speech. Speech that is very fast could be a symptom of mania.

Little need for sleep. A child may stay up late into the night and/or wake very early, acting as if driven and energetic despite lack of sleep.

Inflated self-esteem or grandiosity. Statements of greatness, seeing self as more important, e.g., “I’m the next Albert Einstein.”

Poor attention. Distractible, in motion, inability to focus on any one thing.

Involvement in activities with potential for consequences. Risky sports, climbing dangerously, sneaking out at night, trying drugs and alcohol (adolescents).

Many of these mania symptoms could be confused with other psychological conditions, making it so important to have a comprehensive evaluation conducted by someone with expertise in assessment. This expertise can impact treatment significantly.

Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy is a modality with considerable research to support its effectiveness. This therapy is often individual but may also be delivered in a group setting. Some goals of CBT include the following:

Increase Emotional Awareness. Activities to help your child recognize emotions may include drawing emotion faces, role playing and acting out different emotions, and recognizing them in the therapist. If CBT is offered in a group setting, emotions are recognized through engagement with group members. Practice recognizing emotions at home, starting with positive ones and moving to sadness, worry, and other negative emotions. Journaling and completing homework assignments related to the emotional awareness goals can help some children remember and practice their skills at home.

Improve Coping Skills. CBT often teaches and helps kids identify and practice coping skills, such as deep breathing, relaxation, reading, listening to music, taking a walk, jumping on the trampoline, or talking to a friend. Children learn to stop and identify their feelings and take a break instead of yelling or hitting. They work with a therapist to recognize the antecedents, behaviors and consequences associated with their thoughts and feelings.

Work to improve self-confidence. CBT focuses on identifying thoughts that lead to certain behaviors and determining whether those thoughts are valid or whether they are cognitive distortions. Children learn to combat negative thoughts and to see actions and experiences not as global and uncontrollable but as singular instances and under a child’s control.

Mindfulness. Mindfulness involves recognizing and accepting feelings and allowing them to just be. This practice involves scanning the body to notice any tension and working to let that tension go. Awareness of the present time and accepting thoughts and feelings are important in Mindfulness.

Relaxation and Meditation. Breathing and relaxation are encouraged in mindfulness and can make a big difference in reducing anxiety and the presence of negative, distorted thoughts.

Accepting Thoughts. Mindfulness focuses on acceptance and not the immediate push to change and criticize ourselves.

Play Therapy. For young children, play therapy utilizes toys and art to allow a child a safe setting to act out their feelings and experiences. Guided play therapy can introduce coping skills and emotional awareness into the play themes.

Many tests and measures may be part of a psychological evaluation to determine whether bipolar is a relevant diagnosis. This evaluation can be challenging with children who are sometimes less able to report on their symptoms directly.

Projectives. Questions, open-ended sentences, and drawing tasks can allow a child to express their emotions and experiences indirectly. Themes can emerge related to sadness or rejection, and some insight may be derived from the collection of these measures.

Story Telling. Tests like the Roberts or TAT involve presenting story cards to an individual and having him or her tell a story about the vague card. Again, themes and emotional content are noted as well as the support of self and support from others.

Rating Scales. Sometimes it is easier for children to express their feelings by answering questions. Parents and teachers can also complete questionnaires to provide a sense of how each child appears and performs in different settings. This feedback adds to the data because an evaluation is conducted in one setting that is not natural to the individual.

Play observation. Watching a child play with toys can provide insight into their feelings of sadness by attending to themes introduced by the child. Pressured speech, inattention, goal-directed activity and flight of ideas may be clearly observed.

Observation during testing. Looking for depressed mood, sad facial affect, slow processing, verbal fluency, body language and noting interactions with examiners can provide insight into depression. Looking for pressured speech and grandiosity can clarify manic symptoms.

Executive functioning and processing speed measures. Often, depressed individuals have diminished performance on tasks. A child tested during a depressive episode is likely to process slowly and to have difficulty with executive functioning skills, such as planning, problem-solving, and attention. A year later, after treatment, some of these areas may be vastly improved. With mania, attention tasks may be impacted because focus is greatly impacted when a child is grandiose and tangential.

WHERE TO GO FOR HELP WITH BIPOLAR DISORDER

A referral for a comprehensive neuropsychological evaluation may be warranted to confirm bipolar and to better understand your child’s strengths and weaknesses. This type of assessment includes an evaluation of your child’s cognitive ability, adaptive skills, language skills, social skills, mood, and anxiety. Other areas may be evaluated as concerns arise. Referrals may include Applied Behavior Analysis (ABA) therapy, Psychotherapy, group therapy, parent consultations, and an Individualized Educational Plan (IEP) or a Section 504 plan.

Psychotherapy. Psychotherapy occurs in an office with a psychologist or therapist and is often focused on improving emotional awareness, coping skills, and restructuring negative thoughts. The psychotherapy modality that has the most research for treating depression is cognitive behavioral therapy (CBT). Other modalities that may be helpful include play therapy (for young children) and mindfulness, which teaches awareness of emotions, acceptance, relaxation, and meditation.

Parent Consult. Parent consultation can follow a CBT or a Family Systems model and can provide guidance to parents on strategies to use to hear and support their child and to help them feel understood. It also may focus on principles of reinforcement by noting that punishment is not effective for depressed children. Consultation can also focus on the parent’s experience and emotional well-being.

School Services. School-based supports, such an IEP or a Section 504 plan, can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report to any of these professionals will help them to get an understanding of your child. It will be important to think about how these therapies fit together and about how different skills are being built and addressed to best support your child. Emotional disabilities like bipolar can impact school performance and social skills. Individual meetings with the school counselor or school psychologist may provide emotional support, assignment of a peer buddy or mentor at school can help as positive event scheduling, and a lunch bunch or social group may also help build peer support. In order to write a formal plan, your school team will need to find an educational impact of depressive symptoms in some aspect of your child’s education. It may be easier to obtain support through a Section 504 plan if your child’s grades and test scores are not at all impacted. A 504 Plan requires a medical condition that impacts functioning, but academics and test scores need not be directly impacted. An IEP is a more detailed document that does require a clear educational impact of symptoms. In addition to emotional supports, goals in an IEP would also address challenges in reading, writing, math or communication. Ask your school about both an IEP and a 504 to determine which plan would best serve your child.

Psychiatrist. Often, children with bipolar do take medication prescribed by a psychiatrist. Usually, this medication is to stabilize their mood and to decrease the intensity of their anger and frustration. Medications can be quite effective for these symptoms. Keep your pediatrician in the loop about your child’s mental health, and request a referral to a child psychiatrist to learn more about the benefits and side effects of medication.

Bipolar is challenging, and symptoms can be lifelong. But, it can be treated. Taken together, it is valuable to obtain a diagnosis and to engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see improvement in depressive and manic symptoms, better coping skills and emotional awareness, and the potential to live a happy life.

• Aggression
• Anger
• Labile mood
• Emotional regulation
• Interacting
• Conversation
• Adaptive Skills
• Domestic
• Sleep Problems
• Manners
• Disordered eating
• Sensory seeking
• Focused attention
• Selective attention
• Inhibition
• Planning
• Flexibility
• Suicidal ideation
• Depression
• Self-Injury
• Impulsivity
• Rigid behavior

[1] Papolos, Demitri & Papolos, Janice (2007). The Bipolar Child: The definitive and reassuring guide to childhood’s most understood disorder, 3^rd Edition.

Amazon: https://www.amazon.com/Bipolar-Child-Definitive-Reassuring-Misunderstood/dp/0767928601

[2] Beck, Judith S. & Beck, Aaron T. (1995). Cognitive behavior therapy, 2nd edition: Basics and beyond.

Amazon: https://www.amazon.com/Cognitive-Behavior-Therapy-Second-Basics/dp/B005HROKHU/ 

[3] Pavuluri, Mani (2008). What Works for Bipolar Kids.

Amazon: https://www.amazon.com/dp/1593854072/ref=rdr_ext_tmb

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