An overview of the symptoms and definition of bipolar disorder will be performed in order to clearly define the disorder to use for linkage of the symptoms found in children and adolescents. This paper will examine the diagnosis, prognosis and course of early onset bipolar disorder. An assessment will be conducted of the treatments for early onset bipolar disorder and its effectiveness in the course of the disorder.
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Until about ten years ago, clinicians assumed that the onset of bipolar disorder transpired in early adulthood. Now researchers recognize that children and teenagers may suffer from the disease. This illness can cause turbulent mood swings and even episodes of rage. Within these episodes of rage a child or adolescent can end up causing harm to themselves, causing harm to others and committing criminal acts. The early onset of bipolar disorder is believed to be very volatile if not treated properly. This paper will explore the effects, diagnosis and prognosis of bipolar disorder in children and adolescents.
Before examining the diagnosis of bipolar in children and adolescent it is necessary to get a clear understand of the criteria and symptoms found in the general population. In general, bipolar disorder also known as manic-depressive disorder, bipolar affective disorder or manic depression, is a mood disorders defined by the occurrence of one or more episodes of uncharacteristically elevated energy levels, cognition, and mood with or without one or more depressive episodes (American Psychiatric Association, 1994). The elevated moods are clinically denoted as mania or, in milder forms as hypomania. The disorder has been subdivided into bipolar I, bipolar II, cyclothymia, and not otherwise specified types which are divided based on the nature and severity of mood episodes experienced (American Psychiatric Association, 1994).
Bipolar I is regarded as the classic form of the illness. Individuals diagnosed with Bipolar I experience recurrent episodes of mania and depression. This episode of depression is similar to clinical depression, with depressed mood, loss of pleasure, low energy and activity, feelings of guilt or worthlessness, and thoughts of suicide (American Psychiatric Association, 1994). Depressive symptoms of bipolar disorder can last weeks or months. An individual may begin to feel normal for some time, or may go straight into a manic episode. Generally, during a manic episode of Bipolar I the elevated mood can manifest itself as either jubilation or as irritability. In severe manic episodes, psychotic symptoms may occur or in other words the person may lose touch with reality. Without treatment, an episode of mania can last a few days to a few years. On average symptoms continue for a few weeks to a few months. Depression may follow shortly after, or not appear for weeks or months (American Psychiatric Association, 1994). A small percentage of patients diagnosis with bipolar I have rapid-cycling symptoms of mania and depression. This rapid-cycling can even alternate between mania and depression in the same day.
If an individual is diagnosed with Bipolar II he or she will experience depression just as in bipolar I. However, the episodes of mania in Bipolar II are not as acute which as mentioned before is clinically known as hypomania (American Psychiatric Association, 1994). People experiencing hypomanic episodes often seem very stimulating and intriguing. Some may think of them as being the “life of the party” because the individual experiencing hypomania may be making jokes, taking an intense interest in other people and activities, and infecting others with their positive mood. However, hypomania can also lead to erratic and unhealthy behavior such as over spending money, making risky sexual decisions, and engaging in other spontaneous behaviors. Typically, a bipolar II diagnosis exhibits more depressive episodes than hypomanic episodes (American Psychiatric Association, 1994). The depressive episodes can occur soon after hypomania subsides, or much later. Some people cycle back and forth between hypomania and depression, while others have long periods of normal mood in between episodes. Without treatment an episode of hypomania can last anywhere from a few days to several years. However for the most part, symptoms continue for a few weeks to a few months.
A milder form of bipolar disorder known as cyclothymia includes fewer severe mood swings with interchanging periods of hypomania and mild depression (American Psychiatric Association, 1994). The low and high mood swings never reach the severity of major depression or mania (American Psychiatric Association, 1994). In most people, the pattern is irregular and unpredictable. Hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month — or may cycle continuously from hypomanic to depressed, with no normal period in between (American Psychiatric Association, 1994). A differentiating characteristic of this type of Bipolar Disorder is that symptoms are usually never absent for more than two months.
Diagnosing bipolar disorder in adulthood has its challenges, however, diagnosing bipolar in children and adolescent pose an even greater challenge. The presentation of bipolar in children and adolescents has a striking difference than in adulthood. The most noteworthy feature of children with a bipolar disorder is chronic irritability, which is often shown by anger and aggression during a manic episode (Haugaard, 2004). Children experiencing a manic episode may be more irritable and prone to temper tantrums than manic adults, who are more likely to be elated or have high energy during these episodes (Haugaard, 2004). A child might scream at parents or friends even if the anger is not warranted. He or she may say harmful things or may even strike others for no obvious motive (Haugaard, 2004). The temper upsurges during manic episodes often include high levels of spontaneous belligerence or threatening behavior toward others and are often the primary reasons for hospitalizing children with bipolar disorder (Haugaard, 2004).
Children and some adolescents may not have the cognitive skills to express feelings of sadness and depression during a depressive episode. Instead children may complain of headaches, muscle aches, or stomach aches or being tired. Children often miss school or talk about running away from home throughout a depression episode. The child may become socially isolated and sensitive to any kind of rejection or criticism. Early onset bipolar disorder is difficult to differentiate from other common medical and mental disorders found in children and adolescent such as attention deficient disorder, conduct disorder, depression and substance use disorders. However, it is not uncommon for bipolar disorder to be diagnosed with other coexisting mental disorders.
Another challenge with diagnosing adolescents and children with bipolar disorder is the phenomena that they often do not present with classic model symptoms of mania alternating with precise episodes of depression and normal. More often, mixed episodes of depression and mania occur simultaneously and rapid cycling may be more customary among adolescents. Juveniles with mania may have a complicated diagnostic depiction, sometimes appearing with psychotic symptoms such as hallucinations and paranoid delusions, extremely labile moods with depressive and manic features, and severe abrupt and deteriorations in behavior.
Irritability, aggression, and impulsivity are major features of bipolar disorder among early onset which can lead to behavior that result in contact with the legal system. Due to this display of aggression and risky behavior this disease may contribute to or intensify delinquent and disruptive behavior in a variety of ways. For instance, mania may lead to thrill-seeking and sensation-seeking behavior such as vandalism, shoplifting and arson. The hopelessness and lack of future orientation that can accompany depression may cause a juvenile engaging in these activities to disregard future penalties or consequences. Furthermore, juveniles, particularly boys, are more prone to act out their depression through disruptive and aggressive behaviors.
It is important to explore the possible causes of early onset Bipolar in order to improve diagnosis and treatment. While the precise origin of early onset bipolar disorder is not currently known, substantial evidence proposes a biological basis. If there is a family history of bipolar disorder, depression, and substance abuse many genetic reports show the risk of having bipolar disorder increases. There is also evidence that a disproportion of neurotransmitters, which are chemicals responsible for sending messages within the brain, have been implicated in bipolar disorder. Also, various areas of the brain responsible for controlling thoughts, behaviors, and emotions are also showing differences in individuals diagnosed with bipolar disorder.
Adolescents are at greater risk of developing bipolar or other mood disorders if they have poor relationships with their parents, have poor peer relations, or have been victims of abuse, all of which increase the risk of contact with the juvenile justice system (Ryan and Redding, 2004). This fact may explain why bipolar disorder appears to be more common in the juvenile offender population than in the general adolescent population. However, a more precise frequency rate of bipolar disorder among juvenile offenders is unknown, partly because of the lack of easily administered, valid, reliable instruments for diagnosing bipolar disorder in this group (Ryan and Redding, 2004).
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It appears that early onset bipolar disorder has biological origins and environmental impact, thus when looking for the cause of bipolar disorder, the most suitable explanation at this time is what is coined the Diathesis-Stress Model. The word diathesis means, in basic terms, a physical condition that fashions a person more than usually susceptible to certain diseases (Merriam-Webster’s online dictionary, n.d.). Thus, the Diathesis-Stress Model says that each person inherits certain physical weaknesses to problems that may or may not surface contingent on what stresses occur in his or her life. The diathesis-stress model relates to explain the cause of bipolar disorder in that a person may have innate features that predispose them to the disease and thus surface due to some life inflicted stressor. A life inflicted stressor could be abuse, neglect or simply disappointment.
As with all serious disorders, early onset bipolar disorder requires treatment because treatment can help control symptoms. Medication and psychotherapy are often used together to greater the chance of success and increase quality of life. In addition, assistance and guidance for the entire family is essential, and consultation with school personnel and others who have regular contact with the child may be necessary.
Medication forms the ground work of the interventions for children with bipolar disorders. Medication is often the most successful way to control their moods. Lithium has been effective in many studies with adults and a variety of case studies, and one placebo-controlled study with adolescents has shown that it can be effective with children (Kowatch et.al., 2004). However, a smaller fraction of pre-pubertal children respond well to lithium. Prolong use of lithium has effects that must be balanced against it benefits. For example, Thyroid supplements are vital with continual lithium usage children (Kowatch et.al., 2004). The long-term effects of lithium when taken by children are being researched. To offset the low success rate of lithium in children a number of anticonvulsants are also used in treating bipolar disorder (Kowatch et.al., 2004). . One of these anticonvulsants includes divalproex sodium, which helps prevent rapid mood cycles (Lofthouse et.al., 2004).
Psychotherapy can help children and adolescents change their behavior and manage their routines. It can also create a more functional relationship with family and others in close contact with the child. One type of therapy for early onset bipolar disorder that is emerging is play therapy. This type of therapy usually has the children placed in hypothetical scenarios that help them to learn how to figure out an emotionally healthy and logical solution. For some children this play therapy is quite successful, but for others it does not work. In cases of bipolar disorder in which the symptoms and mood swings are so severe that the child is unable to control their emotional reaction this therapy may not be useful.
Another type of psychotherapy being used is cognitive behavioral therapy which helps the patient learn what may activate unsuitable behavior and mood swings, the substitute to this inappropriate kind of behavior, and also ascertaining the able to distinguish the symptoms of their disorder (Henson, 2007). With cognitive behavioral therapy, the patient is allowed to see if they can avoid having depressive or manic episodes (Henson, 2007). This type of therapy requires critical thinking and problem solving skills at a level not usually present with younger children. Thus, it is not normally used with children having bipolar disorder who are under a particular maturity or age level. Some clinicians do believe that if the cognitive behavioral therapy techniques were changed to accommodate children, they could be equally effective on children. However, this would be a very difficult objective to achieve.
Family therapy is urged because catering to a child who has bipolar disorder is a family matter that involves parents, the identified child, and siblings. The goal in family therapy would be to reduce family stress, improve family communication, and address unresolved feelings of hurt and confusion. In the family and individual sessions, medication issues and compliance also should be addressed so that optimal care can be attained in the outpatient setting.
Family therapy for bipolar disorder can take more of a psycho-educational approach, aiming at families and patients being able to identify the signals and symptoms of bipolar disorder, develop tactics for interceding timely before new episodes, and assure consistency with medication schedules (Miklowitz, 2007) The clinician involved in the psycho-educational approach will seek to increase the families understanding of the disorder, along with diminishing reservations about the future (Miklowitz, 2007) . If the family is not properly equipped to handle the disorder the patient’s denial of the diagnosis could be stimulated (Miklowitz, 2007). Thus, in addition to providing prescriptive information, clinicians concentrate on the family’s effective response to the illness, its prognosis, and its anticipated treatments and help the family develop managing techniques that are pertinent to their situation (Miklowitz, 2007).
People with bipolar disorder whose symptoms began in childhood have a worse prognosis with their bipolar as adults. The earlier in life a person’s bipolar symptoms appear, and the longer the disorder goes untreated and undiagnosed, the more severe the disorder seems to be throughout their life. In addition, the lengthier the deferment in diagnosis, the more episodes of depression, the more damaging the episodes are, and the more rapid the cycling of episodes.
Unfortunately there is much debate regarding the increase consciousness and diagnosis of bipolar disorder in children. However, the data on early onset bipolar is still very limited and the DSM IV-TR does not specifically address the symptoms found in children and adolescents. Mental health professionals are, for the most part, interpreting the symptom found in early onset bipolar disorder and modifying the criterion for diagnosis. The great debate in the study of bipolar disorder is whether early intervention could change the volatile course of the illness in adulthood, or whether early onset is just an indication of worse course regardless of intervention. Even with new research there are still uncertainties on bipolar disorder presentation, course and accurate diagnosis in young children. While currently researchers and clinicians accept that bipolar disorder exists in young children there is still a lot of research and testing that is needed in order to more clearly understand symptoms and ultimately decrease misdiagnosis. Although early onset bipolar is a chronic disease that frequently imposes confusion on family life, relationships, and school functioning, it is important not to lose hope (Lofthouse et.al., 2004). Several valuable treatments remain and persist to become obtainable at a rapid rate (Lofthouse et.al., 2004).