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Child Adolescent Bipolar Disorder, Glaser MD Bipolar disorder's diagnostic criteria is entirely based on the study of adults older than 18 years. The long term outcomes of the illness treated or untreated is also based on the study of adults. There are limited studies utilizing bipolar medications in children (including teenagers) that do give us information as towards their safety, side effects, and efficacy. BUT, making the diagnosis of Bipolar disorder and trying to predict the long term outcome of the child's condition is more of art than science. This is particularly important when weighing the pros and cons of medication for your child. Bipolar disorder typically begins in late teens to early twenties. (Schizophrenia, an illness with similar symptoms as bipolar also begins at this time.) In addition, there are usually prodromal symptoms. Prodromal means characteristics of the illness that occur before the full fledged illness presents itself. These are subtle and do not meet the criteria for a positive diagnosis yet. But they are early signs of the condition. The symptoms of Bipolar disorder are fully explained on another page. The diagnostic criteria, are based on adults. Child psychiatrists therefore do their best to extrapolate the data from adult studies to children. I have reviewed the data on bipolar disorder in children (and teenagers) and spoken personally to the leaders in research and treatment of pediatric bipolar disorder. I have also evaluated thousands of children for this diagnosis as well as prescribed medication for over 15 years. I have thus had the opportunity to see the long term effects. I will start by describing how I make the diagnosis of bipolar disorder and what differentiates it from other conditions. Then I will discuss the prognosis of the condition. Followed by a discussion of the various medications for bipolar disorder. HOW DO YOU MAKE THE DIAGNOSIS? Bipolar disorder has periods of mania (high energy) and depression (low energy) or mixed phases (high energy plus depression). Mania is characterized by extreme sillyness, hyperactivity, rapid speech, intense mood swings, anger, euphoria, grandiosity (feeling like superman), extreme intense desires, constantly looking for excitement, disorganization, forgetfullness. This sounds a lot like normal childhood or even ADHD (attention deficit hyperactivity disorder). So this is how I differentiate Bipolar disorder from normal childhood or other conditions. First, bipolar disorder sometimes is periodic. It can come and go in phases. However, in children this does not usually seem to be the case. Bipolar disorder causes severe problems at home and in school. Next, some symptoms are specific for bipolar disorder. Hallucinations, usually auditory, are very specific for this condition or a related condition called Psychotic disorder N.O.S. (Psychotic disorder N.O.S. means psychotic symptoms due to any number of things). Both bipolar and psychotic disorder are treated with the same medications pretty much. Determining if a young child is hearing voices versus normal childhood imagination is very tricky and not for the novice examiner. A child who is delayed is even more difficult. Next, is a decreased need for sleep, such as a child who can stay awake for several days in a row. Some people have trouble falling or staying asleep at night but they feel tired the next day, or they nap in the daytime, or they want to sleep late in the morning. That is not decreased need for sleep. Decreased need means they do not sleep and they do not feel tired the following day nor make up for the lost sleep the next night. Time spent at a slumber party or while under the influence of drugs does not count. This occurring for several days in a row or on more than one occasion is a tell tale sign of bipolar. Other symptoms of bipolar disorder such as feeling grandiose can too easily be normal childhood development. ADHD (ADHD used to be called ADD)is all too common now a days in our youth. ADHD means the patient has trouble with paying attention to boring tasks such as school work or household chores. And/or the child is hyperactive-can't sit still, has an engine that won't shut off. This does not apply to playing video games or watching television. These symptoms of extra energy, easy distractibility, and disorganization, are very similar to the manic phase of bipolar disorder. It is very important to make the correct diagnosis because the medication treatments are entirely different. If the wrong medication is taken, a negative outcome could result. Therefore, every child being evaluated for ADHD (ADD) must also be evaluated for bipolar. Furthermore, some scientific evidence indicates that the prodromal symptoms of bipolar disorder and schizophrenia look like ADHD symptoms. ADHD, bipolar, and schizophrenia are highly genetic. Identical twin studies and studies of families with these disorders indicate genes account for up to 75% of the condition. Therefore, a positive family history of one of these conditions is a good source of information when making a diagnosis in a person. Another sign of bipolar disorder is failed treatment for either depression or ADHD. If a child receives a medication for either depression or ADHD and gets more rageful, or more hyper, or stays awake for days, then that is a sign of bipolar. WHAT IS THE LONG TERM OUTCOME FOR PEDIATRIC BIPOLAR DISORDER? Bipolar disorder is a chronic condition that requires lifelong medication. However, most diagnosis of bipolar disorder in children are based on softer evidence than in adults. Therefore I am not as confident at predicting the long term nature of the condition. In adults, UNTREATED patients with bipolar disorder will eventually, over many years, loose their minds and become completely insane. TREATED patients who always take their medications, do not use any drugs or alcohol, live healthy lifestyles, and stay in counseling, do very very well. They live normal lives. Symptoms can change over time. Also, as the child gets older and more mature, their own description of their thoughts, feelings, and experiences change. Thus, statements by children and teenagers such as hearing voices must be taken with a grain of salt. However, if your child is in fact hearing voices, or is having manic episodes, he or she must receive medication treatment or severe, permanent brain damage will occur. MY CHILD HAS SEVERE TEMPER TANTRUMS, IS THAT BIPOLAR DISORDER? Anger and rage is a symptom of bipolar disorder but by itself, it is not enough to make the diagnosis of bipolar. Other conditions can have anger problems also. ADHD (ADD) causes a child to be impatient so they can get very angry if they don't get what they want. The common diagnosis for people with rage problems but no other symptoms is Intermittent Explosive Disorder. However, if there is a strong family history of Bipolar disorder then the rage problems may be the early signs of a potentially much more serious condition. Early intervention can lesson its severity significantly. SHOULD I MEDICATE MY CHILD? Untreated bipolar disorder, over many years, causes brain atrophy. This means that nerves die and the brain shrinks. The longer a person has symptoms of bipolar present, the more outbreaks that occur, the more brain damage results. The brain can heal minor injuries but not severe injuries. Therefore, the longer you wait to treat, the more damage occurs. Think of it like the head of a man in the boxing ring. Each time the child hears voices, or has excessive manic energy, imagine the man in the boxing ring getting punched in the head. The boxer can take a few blows to the head, but too many blows, the brain gets knocked out. The great news is that modern medications for bipolar likely prevent further damage, and help the brain heal from past damage. A recent study examined patients treated with second generation antipsychotics (abilify, seroquel, risperdal, zyprexa, geodon). It found that in schizophrenia patients treated with medication as soon as the illness presented itself had good outcomes and had minimal brain damage. Patients who got medication later had worse outcomes and had clear evidence of brain atrophy (damage). It appears that the medication may even minimize or prevent the full blown illness from even occurring. In my own practice, I have seen a clear difference in outcomes between patients treated within a few months of symptom onset versus those treated after a few years. Schizophrenia and bipolar share many similarities on the microscopic lever. The medications that treat schizophrenia are also FDA approved to treat bipolar. The long term outcomes of untreated bipolar are the same as schizophrenia. It is likely the same benefit with medications will occur with bipolar disorder. Studies have shown similar nerve cell destruction in untreated depression versus treated depression. This is important particularly if your child is being treated for ADHD but he/she may actually have Bipolar disorder. Since the prodromal signs of Bipolar are likely the same as ADHD, this error commonly occurs even with the most experienced psychiatrists. However, the medications for ADHD do not help prevent the damage to the brain that bipolar causes and may in fact worsen the condition over time. You may refer to the page labeled Bipolar Disorder Treatment to review the medication treatments. Mitchell L. Glaser, MD. Chicago Illinois |
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