Like many other mental health terms, the word “bipolar” has entered the popular lexicon; particularly when we think of “teens with bipolar disorder,” the phrase is frequently misused to describe everything from a moody and unpredictable adolescent to rapidly changing weather conditions. This contributes to a lack of understanding and empathy for individuals who struggle with bipolar disorder, causing both heartache and sometimes shame for them and their families. Our understanding of bipolar disorder has increased in recent years as has the availability of effective treatment options. In spite of this, it is estimated that individuals “with bipolar disorder face up to ten years of coping with symptoms before getting an accurate diagnosis, with only one in four receiving an accurate diagnosis in less than three years”. In children and teens with bipolar disorder a diagnosis can be even harder, and frequently cannot be differentiated from other childhood mental health conditions when symptoms first appear. ESS offers this article as a brief overview for school professionals seeking to understand how to ask the right questions and seek appropriate resources when certain behaviors are noted in their students.
What is Bipolar Disorder?
Previously known as manic depression or manic-depressive disorder, bipolar disorder is characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a mood disorder that is distinct from the various subtypes of major depression and persistent depressive disorder (previously known as dysthymia). Its primary feature is recurrent shifts back and forth from a depressed state and varying states of elevated mood that fall outside the range of typical positive emotions/behaviors.
As with many mental health disorders, there is not one single cause of bipolar disorder. Researchers believe that a combination of genetic, environmental, and biological factors are involved, and those at higher risk typically have a family history of bipolar disorder, have experienced a traumatic event, and/or have a substance use disorder. And, as with all mental health conditions, neuroscientists are working to identify what differences in brain structure and function may contribute to its development.
There are three major subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic Disorder. All three subtypes include both manic and depressive episodes with periods of reduced symptoms and relative stability in between. The major difference among the subtypes is how extreme the mood states are and how long they last.
Bipolar I most closely resembles the classic description of manic-depression, with manic episodes that can be quite extreme and can at times develop into a full psychotic state. To meet the DSM-5 criteria for a Bipolar I diagnosis an individual must have a history of at least one lifetime manic episode. A manic episode is described as “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy” that lasts for at least a week and is present most of the day, nearly every day. Full blown manic episodes can be preceded and followed by periods of hypomania (a less extreme expression of elevated mood) or major depression. To qualify as a manic episode, the person must experience a marked impairment in occupational or social functioning, and exhibit at least 3 of the following symptoms:
- Intense feelings of euphoria, excitement, or happiness
- Grandiosity or inflated sense of self-esteem
- Decreased sleep (3 or fewer hours per night)
- More talkative than usual and pressured speech
- Flight of ideas, racing thoughts
- Increased goal-directed activity (e.g., house cleaning, work projects, social commitments, etc.) or psychomotor agitation (i. e., activity not in service of a goal or purpose)
- Increase in risky behaviors with potential long-term consequences (e.g., buying sprees, risky sexual activities, gambling, etc.)
Depressive episodes for individuals with Bipolar I must include at least 5 of the following features:
- Depressed mood most of the day, nearly every day
- Decreased interest and pleasure in most activities
- Sleep disturbance, either too much or too little sleep
- Weight loss
- Psychomotor agitation/restlessness or feelings of being slowed down
- Fatigue, loss of energy
- Feelings of worthlessness and/or guilt
- Reduced ability to concentrate or think clearly
- Recurrent thoughts of death
A person diagnosed with Bipolar II exhibits mood states that vary from even to high to low, with highs that are less extreme and are called “hypomania” (“hypo” means beneath or below). Depressive episodes experienced by these individuals, however, can be just as severe as those with major depressive disorder (MDD) or bipolar I disorder. The more subtle “highs” and the deep “lows” often contribute to misdiagnosis, with many individuals initially being diagnosed with depression or some other mental health disorder and being treated accordingly.
To meet the DSM-5 criteria for a bipolar II diagnosis an individual must have a history of or currently be experiencing a hypomanic episode that lasts for at least 4 consecutive days, and must have experienced at least one depressive episode and no manic episodes in their lifetime. Although the impairment is less severe and the symptoms are potentially less extreme, the individual must exhibit (or have exhibited) at least 3 of the features described above for mania, and 5 or more of the symptoms listed above for depression.
The third type of mood disorder in this category is known as Cyclothymic Disorder. This diagnosis is used to describe individuals who do not meet the DSM criteria for bipolar I, bipolar II or for MDD, but who for at least 2 years (1 year for children and adolescents) have experienced chronic, fluctuating mood disturbance with numerous periods of hypomania and numerous periods of depression that are noticeably distinct from one another.
Diagnosing Children and Teens with Bipolar Disorder
Although bipolar disorder was identified by mental health professionals as early as 1851, until recently it was believed that mood disorders did not develop until adulthood. (Mason, B.L., et al., Behavioral Sciences , Vol. 6, No. 3, 2016) It was not until the 1990s that bipolar disorder was acknowledged as a legitimate diagnosis for children and adolescents.
The primary symptoms of bipolar disorder in young people are the same as those for adults, although when in a manic episode children and adolescents are more likely to be irritable and to exhibit destructive outbursts rather than appearing elated or euphoric. As reported by NIMH, childhood depression is often accompanied by numerous physical complaints such as headaches, stomach aches, or tiredness; poor performance in school; irritability; social isolation; and extreme sensitivity to perceived or real rejections or failure. Also of note is that children may have more rapidly cycling moods and more “mixed” periods during which both manic and depressive symptoms are noted.
Further complicating the diagnosis of children and teens with bipolar disorder is that these symptoms can also be related to other mental health problems including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), oppositional defiant and conduct disorders, anxiety disorders, major depression, substance use disorder, and post-traumatic stress. Add to this the reality that adolescence is often accompanied by changing moods, risk-taking, and unpredictability, and that bipolar disorder can co-occur with other mental health conditions.
Disruptive Mood Dysregulation Disorder (DMDD)
Recognizing the difficulties inherent in parsing out childhood symptoms and wishing to avoid the premature diagnosis of bipolar disorder while ensuring appropriate treatment for troubled youngsters, the professionals who created the fifth edition of the DSM (DSM-5, released in 2013) added a new childhood diagnosis: Disruptive Mood Dysregulation Disorder (DMDD). DMDD is characterized by severe and recurrent temper outbursts that go far beyond occasional temper tantrums. To meet criteria for this diagnosis, a youngster must show symptoms before the age of 10 and be between the ages of 6 and 18. Outbursts must be present for at least 12 months and must occur at least three times per week in more than one setting (e.g., both school and home). In addition, in between outbursts the child must be observed by others to display a persistent angry or irritable mood. Unlike with bipolar disorder, the irritable mood is chronic and severe, not episodic.
The types of medications used for DMDD are different from those used for bipolar disorder. Medications that are typically used to treat irritability associated with ADHD, anxiety, or depression are being used successfully with these youngsters, along with psychotherapy that emphasizes the development of self-regulation skills, and parent consultation to develop behavioral interventions. Much more research is needed to identify the best treatments for DMDD and to understand the course of the disorder. Current research findings suggest, however, that as children with DMDD mature the frequency and intensity of outbursts shift, and it is more likely that they will develop symptoms of anxiety and depression in adulthood rather than bipolar disorder.
What the Statistics Show About Bipolar Disorder
It has been reported that 46 million people around the world have bipolar disorder. According to NIMH, the disorder affects just under 6 million adult Americans, or about 2.8% of the U.S. population age 18 and older. There are similar prevalence rates for adult males (2.9%) and females (2.8%), and approximately 4.4% of U.S. adults experience bipolar disorder at some point in their lifetimes. Individuals who are 18 to 29 years old have the highest rates of bipolar disorder (4.7%), with 1.9% of 13-14 year olds, 3.1% of 15-16 year olds, 4.3% of 17-18 year olds, and 3.5% of 30-44 years olds carrying the diagnosis.
Approximately 2.9% of adolescents have bipolar disorder, and 2.6% are considered to have severe impairment. The prevalence of bipolar disorder among adolescents has been found to be higher for females (3.3%) than for males (2.6%).
Most people are diagnosed with bipolar disorder in their late teens or twenties. Although the median age of onset is 25 years, symptoms can start in early childhood or as late as the 40’s or 50’s. A family history of bipolar disorder is a significant risk factor: when one parent has bipolar disorder, the risk to each child is 15 to 30%, but the risk increases to 50 to 75% when both parents carry a bipolar diagnosis.
As for bipolar’s impact on people’s lives, according to NIMH approximately 82.9% of people with bipolar disorder have serious impairment, the highest impairment level amongst all the various mood disorders. Also of concern is the high risk of suicide among individuals with bipolar disorder: 15 to 17% of diagnosed individuals commit suicide, with a lifetime suicide risk that is 15 times higher than that of the general population.
The Importance of Early Intervention
As is true with other serious conditions like schizophrenia and autism spectrum disorder, early identification and intervention of bipolar disorder can significantly alter the course of a person’s life. As mentioned earlier, the diagnosis of bipolar in youngsters can be quite complicated. Symptoms that manifest in bipolar disorder can appear to be exaggerated versions of normal child and adolescent behaviors, and the more subtle presentation of hypomanic symptoms can be harder to identify. Early signs of the disorder can be overlooked or mistaken for other childhood diagnoses such as ADHD, depression, anxiety, borderline personality disorder, or even schizophrenia. Accurate diagnosis requires a detailed family and personal history, with attention to changes in mood over time and across various settings to discern patterns. The feedback of caregivers and other family members, teachers, and peers, preferably using empirically validated questionnaires, is critical to this process.
Needless to say, both early and ongoing assessments by mental health professionals are essential to promote positive outcomes for young people. Skill building individual therapy along with family psychoeducation and behavioral management techniques can significantly alter the trajectory of the disorder. Medications can also play an important role in reducing the frequency and severity of manic and depressive episodes, thus sparing the child and family from needless suffering, and preventing long periods of disruption from a child’s normal routines that interfere with accomplishing normal developmental tasks. While bipolar disorder cannot be totally eradicated, it is hoped that early intervention can lead to a milder form of the disorder and reduction in suicide risk.
As a general rule, the American Academy of Child and Adolescent Psychiatry recommends a combination of medication and psychotherapy for treating pediatric bipolar disorder. While there is no cure for bipolar per se, ongoing treatment can allow individuals to manage symptoms effectively and to lead productive and healthy lives.
The most common medical treatment for bipolar disorder is a group of drugs known as mood stabilizers. These include lithium (e.g., Depakote and Lamictal) and some drugs that were initially developed as anticonvulsants. These medications are especially effective at controlling manic symptoms and at lowering the frequency and severity of depressive periods. But lingering depression can be much harder to treat, so antidepressants are sometimes added to the medication regime. Antidepressant medications used alone can sometimes trigger manic symptoms in patients, and in these cases, this outcome provides a diagnostic clue that the depression being treated may be part of a bipolar cycle rather than a unipolar depression.
With adolescent patients, atypical antipsychotic medications are also used, and are often more effective than the mood stabilizers that are used so effectively with adults. These medications include Abilify, Vraylar, Latuda, and Zyprexa.
Psychotherapy approaches include cognitive-behavior therapy (CBT) that emphasizes behavioral analysis (understanding triggers, reactions, and outcomes) and behavioral contingencies (rewards and punishments), along with the development of self-regulation and social skills. Dialectical Behavior Therapy (DBT) includes behavioral analysis (known as chain analysis) and the development of self-regulation and social skills, coupled with mindfulness and a focus on emotion regulation by attending to bodily needs and rhythms. Family Focused Therapy (FFT) engages the help of family members to track mood patterns, and to use enhanced communication and problem-solving skills to manage family stress that might contribute to an episode. A newer therapy model, still being researched, is known as Interpersonal and Social Rhythm Therapy (IPSRT). As with CBT and DBT, IPSRT takes an educational and skill building approach, with a special emphasis on establishing and maintaining daily routines to help stabilize moods. This is an especially interesting approach for adolescents who can have very erratic sleep, social, and self-care routines.
How Schools Professionals and Parents Can Help
Diagnosing bipolar disorder in children and adolescents is a complicated endeavor. First and foremost, parents, teachers, and other school professionals who notice mood and/or behavioral irregularities should engage the help of school or community-based mental health professionals as soon as possible.
Some guidelines to keep in mind when supporting children with suspected or confirmed bipolar symptoms include:
- As with all mental health and substance use disorders, adults should sit up and take notice when a child exhibits changes in mood, behavior, sleep/eating, or socialization patterns. While it is not your job to diagnose or treat these disorders, it is parent, teacher, and pediatrician observations that most often get the ball rolling for assessment and intervention. Students with family histories of bipolar disorder should be considered high risk and should be regularly screened in school and/or by a pediatrician and/or by a mental health provider in the community so that emerging symptoms can be recognized early.
- Be aware that perhaps more than other childhood disorders, the diagnosis and effective treatment of bipolar disorder requires parental and teacher involvement to monitor patterns that the youngster may not recognize or may outright deny.
- Keep in mind that even without an understanding of what is happening to them, children and adolescents seek ways to achieve balance and self-control. This may occur by using drugs, alcohol or food to self-medicate mood, by clinging on to “safe” adults, by becoming overly attached to “safe” places (e.g., their rooms), by becoming overly attached to certain hobbies or activities (e.g., online games), etc.
- Remember that once a student is diagnosed and started on medication it is important to monitor medication compliance, typically a significant challenge amongst bipolar patients. One researcher studying interventions for pediatric bipolar found that almost 50% of the time young people were non-compliant with their meds.
- Pay attention to possible seasonal aspects of bipolar disorder. Some bipolar patients, for example, experience a worsening of symptoms in the fall.
- Be a cheerleader for students with bipolar disorder, reminding them that managing the illness is a marathon, not a sprint. Long-term, continuous treatment is critical even when there are long stretches of stability in between episodes.
- Remind children living with bipolar symptoms that while there are many things they can do to manage the illness and function better, they are not to blame for and did not cause the disorder.
- Help youngsters design and follow a daily routine that establishes a consistent sleep schedule, predictable mealtimes and healthy food choices, a consistent exercise routine, and adherence to the prescribed medication regime.
- Parents should work closely with a child’s pediatrician and psychiatrist before administering over-the-counter supplements or medications prescribed by another doctor.
- Encourage youngsters to keep a mood journal to track day-to-day mood levels, to notice triggers, to monitor treatment effects, and to spot changes in eating or sleeping patterns.
- Encourage children to avoid using alcohol and other drugs that can destabilize mood.
- Help children learn how to manage and minimize stress by avoiding triggers and by practicing activities like meditation or yoga that calm the nervous system.
- Maintain a support network – don’t go it alone! Educate people in the child’s sphere about bipolar disorder so that they can provide support and help you recognize the warning signs of manic or depressive episodes.