Helping a Young Child with Pediatric Bipolar Disorder

Currently, a debate rages among doctors and academics about whether the symptoms of bipolar disorder can even emerge when a child is under 10. In fact, the current Diagnostic Manual of Mental Disorders (and bible to all psychiatrists, doctors and other healthcare providers), doesn’t recognize pediatric bipolar disorder. In other words, looking under “p” for Pediatric Bipolar Disorder in the Manual (also known as DSM IV) won’t get you anywhere. 

Doctors have yet to devise official symptom criteria and treatment protocols for pediatric bipolar disorder. But that doesn’t mean children aren’t being treated with bipolar medications and talk therapies. In fact, they are in increasing numbers and sometimes with very positive results.

Keeping in mind that some medical staff will not agree with us, we will continue with the article, assuming that pediatric bipolar disorder can be diagnosed ethically and accurately and that certain treatments should be applied based on that diagnosis. Perhaps we will be proven wrong down the road. The best information we have so far from the National Institutes of Mental Health assures us that: “there is a growing body of evidence that suggests that bipolar disorder can exist in children.”

A troublesome outcome of the lack of agreement in the medical and scientific communities about pediatric bipolar disorder has lead to an unfortunate consequence. When a child comes in to the psychiatrist’s office with extreme irritability and hyperactivity, professionals have been known to diagnose the child with attention deficit disorder. If, on the other hand, the child is lethargic and taking no interest in playing, professionals may suggest treatment for depression. The medications prescribed for those two issues most likely will not alleviate the symptoms of pediatric bipolar disorder. When the prescribed treatments fail, parents and doctors alike throw up their hands.

Children with bipolar disorder exhibit their symptoms slightly differently than adults with the disorder. This can make pediatric bipolar disorder difficult to diagnose. Nevertheless, after scanning the list below, you can see how adult bipolar symptoms translate into their childhood forms.

Quirky Behavior or Something More?

It can be difficult for parents to know which behaviors doctors view as normal, developmental changes in a child and which behaviors indicate evidence of a mood disorder. Often, parents commiserate with each other, dismissing concerns—sometimes too easily. Raising children is difficult—“the hardest job in the world,” as the politicians like to say. Parents who are not experts in child development or psychiatric issues (most of us) struggle with knowing just when to let a behavior go and when to “overreact.”
Parents of first born or only children can get the most confused. Particularly if they have little previous experience with children, they may not see the dividing line between normal and abnormal behavior. Is the energy charging the child reasonable high energy or something more serious? Is the child’s constant talking and curiosity a sign of high intelligence or mania? Use the list below as well as the explanation that follows to determine whether your child should be examined by doctors or other healthcare professionals.

Children suspected of having pediatric bipolar disorder typically display:

• explosive and frequent tantrums
• chronic irritability—more irritability than peace or joy
• cravings for carbohydrates and sweets
• lack of interest in playing, either with friends or alone
• rapidly changing moods lasting a few hours to a few days (a few days up and a few days down)
• rapid jumps from project to project
• excited speech patterns and chronic talking
• chronic defiance
• hyperactivity, agitation
• inability to focus
• nightmares, even night terrors
• aggression above and beyond that typical for age-level
• impulsivity and reckless behaviors (such as jumping from the top of the stairs or trying to fly)
• exaggerated beliefs about their own importance or skills

Many of these behaviors, when looked at individually, occur in adolescents without bipolar disorder all the time. The real test for bipolar disorder lies in the symptom frequency and severity, but most importantly, the presence of at least four behaviors, occurring at the same time.

Further, these symptoms must also create great stress or upset for the child, emerge in several venues (e.g., at school and at home), and last for at least 2 weeks.

Your Family’s Health Insurance and Bipolar Disorder

Unfortunately, without the stamp of approval from the DSM IV and because of the uncertainty over the very classification of pediatric bipolar disorder, many insurance companies do not reimburse families for medication or therapy. In some cases, doctors may get approval to apply a treatment “off-label” (used for a condition the medication wasn’t initially designed for), particularly if the depression or ADHD medications don’t work. At that point, a child could be diagnosed as having either “treatment-resistant depression” or even “treatment-resistant ADHD.”

To win the “treatment-resistant” label, someone has to have tried four medications and shown no improvement in symptoms and mood. It may be a long, aggravating road to get an insurance company to allow your doctor to prescribe a bipolar medication, but there are some bipolar medications that have had very positive results in some children.

First Steps to Helping a Child with Bipolar Disorder

When your child is diagnosed with bipolar disorder, you as the parent will have to assume responsibility. Luckily, support groups and healthcare providers stand ready to help you with information, education, and even counseling for yourself.

If you suspect your child may have bipolar or another mood disorder, start with the following crucial steps:

1. Help yourself and the doctor understand what’s going on by keeping a journal of the child’s behavior. This journal should document the time and date of the symptom (e.g. temper tantrum, impulsivity, defiance, etc.) and how long it lasted. Jot down where you were and what might have triggered it. Get as detailed as you can: did the child destroy anything? Did he or she act incredibly rudely or anti-social? Did the child spend days with very low energy?
2. Find a pediatrician or child psychiatrist (or pediatric psychiatrist) who specializes in mood disorders. Be persistent in finding someone who has had extensive experience with children manifesting symptoms of all kinds of mood disorders. Ask the doctor or pediatric psychiatrist whether they’ve treated any children with pediatric bipolar disorder before. Ask them their opinion of the debate surrounding this mood disorder.
3. Once you have your child’s diagnosis, read as much as you can about it. Share hopeful information and case studies with your child. Explain that you’ll both be going forward a little differently than perhaps you expected, but you all will still enjoy each other and have happy, fulfilling lives.
4. Explore the possibility of medication. If you doctor recommends one, know that you will “start low, go slow” as they say in the psychiatric communities. In other words, your doctor will first prescribe a very low dose of the medication, increasing it very gradually over several months. You will be instructed to watch for signs of side effects and improvements. It will help you if you write down both of these, so that you can see any progression or change.
5. Explore the possibility of “talk therapy” or even “play therapy” for your child. Therapy in conjunction with medication can be very effective.
6. Research support groups to which you can belong. Discussing your challenges with others will do wonders for your emotional health. Further, you’ll learn from others about treatments, coping skills, routines to have at home and many other ways to handle having a child with bipolar disorder. For support groups in California, do not hesitate to go to www.californiabipolarfoundation.org. If you feel uncomfortable attending one of these meetings, please look at our blog entry, That Uncomfortable First Support Group Meeting . . . Ugh, Just Ugh.

Are There Coping Skills I Can Teach My Child?

Absolutely. Relaxation techniques like meditation, tapes, breathing exercises and other strategies can mean the difference between a potentially humiliating blow-up and containment for your child. Unfortunately, the world is not quite ready to understand the screeching fire alarms you child can emit. While most understand and sympathize when epileptics experience seizures, a manic outburst hasn’t quite attained the same level of understanding in our society. We all hope this acceptance lies in our future.

Should your child use one of the relaxation techniques and succeed, he or she begins to form new neural pathways that could bypass or subdue the anger/panic reaction. Scientists believe brain changes can occur when behavior is modified (hence cognitive behavioral therapy). Your child’s pediatric psychiatrist or pediatrician can help you find effective relaxation techniques and give you tips on teaching them at home.

Arming your child with coping strategies can reduce stress for all family members. They help the child feel in control and even empowered. Another way to empower the child and ward off extreme reactions is to prepare your child for any stressful events or outcomes that may result from a particular situation.

How Can I Change to Help My Bipolar Child?

First and foremost: do not blame yourself. Bipolar disorder is a biochemical event with biochemical solutions. Even if you now realize that relatives had bipolar disorder and you went ahead and had children anyway, you cannot regret your decision.

Keep in mind that some of our greatest artists and thinkers throughout history have exhibited symptoms of bipolar disorder. In more primitive, less driven societies, bipolar disorders are tolerated better. Amazing philosophical, literary and scientific discoveries have come from those with bipolar minds. It is even possible that bipolar “disorder” is really quite planned by nature. 

Rules for Dealing with Bipolar Children

Rule #1: Patience. Acceptance. No: you won’t rear your child in the standard ways. Your child will not react in the same ways that other children react. They will not behave in the same ways. Don’t even try to compare. In fact, coming clean with your friends about your child’s diagnosis is probably the best thing you can do for yourself, your family and, most importantly, your child. Take yourself out of the competition. It’s a huge relief for any parent to stop comparing children, whether their child has bipolar tendencies or not.

Rule #2: Use positive reinforcement and rule structure rather than punishment or blaming. Studies have shown that children with mood disorders respond better in a home environment that is not critical but focused on reasonable problem-solving. These special children appreciate routine where the rules are known in advance and consequences are based on the breach of those rules. Involving children in rule-creation can also serve as a coping strategy. While it’s difficult to always respond to a child suffering from pediatric bipolar disorder in a reasonable, calm way (I’m pretty sure every last parent on the planet has blown up in an “inappropriate” way), providing freedom within a rule structure goes a long way for children with pediatric bipolar disorder. Children with bipolar tendencies rely on consistent, reasonable rules.

Rule #3: Maintain a low-stress, even quiet home. A family communication style that is calm and low-volume reduces the stress the child with bipolar tendencies experiences.

Rule #4: Fight Like a Bear for Your Child’s Individualized Education Plan in the Schools. The squeaky wheel gets the grease, and teachers got into their field because they love kids and they want to do their best for each one. Teachers know that children have individual learning styles. They’ve lived it! In fact, often, teachers are relieved when a child’s behavior is diagnosed. All of society wants those with learning and behavioral differences to have the best shot at contributing and enjoying a fulfilling life.

That potential cannot be realized unless a good slice of our population receives an “individualized education plan.” The individualized education plan or IEP takes into account the child’s learning style, both his or her limitations and talents. To find out more about how to get an IEP for your child in California, visit http://www.courtinfo.ca.gov/selfhelp/family/speced/iepbasics.htm. It’s a very helpful easy to use site.

You can also get the ball rolling by telling your child’s teacher that you’re having your child evaluated for a mood disorder. It may take a few months for the teacher, the school psychologist, the assistant principal, the learning development specialist and who knows who else to come together in a meeting with you. You may as well schedule an outside opinion while getting the paperwork started at your child’s school.

Rule #5: Explain your child’s disorder to siblings in a positive, accepting way, on a level appropriate to their developmental level. When you do this, you may be surprised at their relief the sibling experiences in finding an explanation for their sibling’s frustrating and even infuriating behavior. Further, the explanation could invoke their sympathy.

At the same time, make it clear to the sibling that, just because his brother or sister has an emotional struggle, it doesn’t mean he or she can abuse ANYONE in the family. Rule transgressions will be punished, no matter the perpetrator. Children are incredibly focused on fairness, and enforcing family rules with the child with bipolar disorder will only help every family member, possibly the child with the illness the most.

Depending on your situation and the temperament of your children, you may consider suggesting concrete and specific ways a sibling can help the child with bipolar disorder. Of course, you cannot put the sibling in a parenting role, but giving the sibling coping strategies will help him deal with the household stress. The coping strategies and even the helping solutions may help the sibling feel a sense of contribution to the welfare of the family (increasing self-esteem) and a sense of control over his or her environment.

Rule #6: Seriously explore family counseling and support groups. Research proves that families containing a child with bipolar disorder experience more stress than families without such individuals. As much as you research your child’s mood disorder, you need outside support and information. You need understanding and commiseration. You need the laughter that comes from sharing completely ridiculous stories that no one else could ever imagine or even be able to endure.

Going to counseling doesn’t mean you are crazy. It is not a sign of weakness. It’s a sign of intelligence. When you find a counselor with experience in the difficulties you’re enduring, you can learn and grow with that person. Consider it education rather than counseling. The counselor is an expert who has dealt with people in similar crises. He or she has seen the coping strategies work the best and the self-talk that lifts one up again. Counseling can make the difference between a completely dysfunctional family and a functional family that appreciates the differences each member has.

Similarly, support groups (like those through www.californiabipolarfoundation.org) helps individuals learn about the best strategies and medications out there. They provide connection to others experiencing the strange and stressful events occurring in your life. Being understood is a human need. By indulging that need, you live a healthier life. At some points, particularly right after your child’s diagnosis, you will need the understanding of a group hat’s been there. Your support group provides that.

Rule #7: Convene a Family Meeting to Discuss Who Will Care for the Child and When.
You cannot meet all of the needs of the affected individual by yourself. You are not that powerful. No one is. Accept your limitations and recruit friends and family members to take on shifts and tasks. Martyr exhausts the caregiver and the ill individual, leading to more dysfunction and mental illness.

Rule #8: Keep in mind or write down that: People with mood disorders can return to stable and productive lives. The crisis you’re experiencing now is most likely short-lived. With appropriate treatment and medication, you may never experience the trauma occurring today. Assuming that, with a diagnosis of bipolar disorder, a “sea change” has occurred and your child is doomed to a life of dependency and sorrow just is not rational. Studies have shown, time and again, that the majority of people with bipolar disorder hold down jobs and create families and a circle of friends. A diagnosis of bipolar disorder does not necessarily mean a drastic shift in the nature and quality of your loved one’s life. Adjustments? Yes. Dependency and hopelessness? No way.

When Your Bipolar Child Is an Adult

Sometimes, diagnoses of bipolar disorder only come when a child is over 18. The diagnosis can be both a relief and a cause for concern. At least you know an explanation to your child’s behavior exists. At least you know you and your child are not the only ones experiencing these intense mood swings and irrational behavior. Now you know a biochemical basis lies behind the trauma you’ve endured.

And yet, keep in mind that, as much as you may want to take care of your child, you must allow him or her to seek treatment independently. You cannot force your adult child to go to a doctor’s appointment. You cannot force them to take appropriate medication. You can only send links to great support groups and other organizations so many times.

Probably the best you can do is offer your support. Offer to drive your adult child to an appointment or accompany him or her to a support group meeting. If you find relevant information, email to ask if your child wants to see the information before sending it.

To help your child and yourself, it’s important to establish boundaries of what you will and will not tolerate. Can your child live with you? Will you commiserate with child self-medicating with drugs and alcohol? Will you lend money to a child in the midst of a manic or hypomanic phase when he or she is acting/spending recklessly? Will you bail this child out of jail should he act in such an anti-social way the police must be called? Determine your reaction to these behaviors before they occur and inform your child of your planned response. Your boundaries could just help your child find the appropriate treatments and medications that usher him or her into a feasible, functional life.