Bipolar disorder in childhood and adolescence

BIPOLAR DISORDER IN CHILDHOOD AND ADOLESCENCE

-Guide for parents-

 

Joaquín Díaz Atienza and Pilar Blánquez Rodríguez

Introduction

There are a number of child psychiatric illnesses¹  These conditions, which until a few years ago were not recognized in childhood, have now been accepted by specialists thanks to more sophisticated studies, especially those involving the genome and neuroimaging, and with more sound methodological approaches. In fact, their diagnosis and treatment should be carried out by a child psychiatrist or another professional with extensive experience in this disorder. We would not be surprised if, before this guide was available, your child had been diagnosed with another psychological or child psychiatric problem.

With this guide we aim to help family members and teachers of children and adolescents with bipolar disorder to understand the mood swings and behaviors characteristic of this medical problem, which are so disconcerting for those who live with the child, whether parents, teachers or classmates.

Throughout this booklet we will explain what it consists of, what its symptoms are and how to treat it, both medically and psychosocially, including the essential family and school readjustments.

Definition

We understand bipolar disorder to mean²   A significant, serious, and treatable disease, due to cerebral causes, possibly genetic, whose fundamental characteristic is abrupt changes in mood, although with alterations, equally, in the child's general behavior.

The important thing is that today, a correct and early diagnosis of this serious medical problem leads to the prescription of a treatment that will almost certainly minimize the serious consequences of not intervening. This is not only because we have a range of increasingly effective medications with fewer side effects, but also because it allows us to develop specific psychosocial intervention strategies, thereby preventing risky behaviors for other disorders, especially in adolescence. Similarly, the negative consequences within the family, at school, and in relationships with peers can be minimized.

Therefore, a first piece of advice: read this guide carefully and if you have any further questions about the disease or how to deal with your son or daughter, do not hesitate to consult your doctor.

Does my child really have bipolar disorder?

Unfortunately, parents often ask themselves this question more frequently than they should. There are several reasons for this. First, while the frequency in adults is approximately 1-2%, it is a relatively uncommon disorder in childhood and adolescence and is most often diagnosed late. In fact, its prevalence in children and adolescents is increasing daily, with the sole reason being the greater ability of professionals to differentiate it from other psychopathological conditions.

There are some claims about the International Scientific Societies which alerts us: It is thought that quite a few children diagnosed with Attention Deficit Hyperactivity Disorder, Conduct Disorders and Other Disruptive Conditions These are more or less insidious manifestations of a future bipolar disorder. Similarly, according to the American Academy of Child and Adolescent PsychiatryApproximately one-third of children and adolescents diagnosed with depression may be experiencing early symptoms of future depression. tbipolar disorder.

These data indicate how important experience and knowledge of this disease are for the clinician in order to reach a diagnosis as early as possible, since it involves specific and more decisive treatments.

A second piece of advice: abandon the uncertainty about your child's diagnosis and follow the advice you are given.

What are the symptoms of Bipolar Disorder?

We doctors are guided by criteria that are accepted by almost everyone: The DSM-5 of the American Psychiatric Association or the ICD-11, which is published by the World Health OrganizationHowever, while these criteria are clearly applicable in adulthood, they are less efficient and valid in children and adolescents, as they barely consider the developmental aspects of child and adolescent behavior. Thus, some clinical characteristics typical of children and adolescents would serve to rule out the diagnosis in adults.

For this reason, we will differentiate between the symptoms that typically appear in children and those more characteristic of adolescence. It's important to keep in mind that there isn't a clear distinction between the two; rather, it's a continuum.

But before discussing the symptoms themselves, we want to describe the different types included in the classifications mentioned above.

Let's first understand what we mean by the term Bipolar Disorders

As you can see in Figure 1, several terms appear that we wish to clarify. term depression It indicates the presentation of a sad mood, low energy, apathy, lack of interest, a tendency to cry, and, in children, irritability, sleep disturbances, and changes in appetite. Sometimes, age-dependent, it can include loss of bowel and bladder control and problem behaviors such as increased disobedience, social withdrawal, and suicidal ideation. term hypomania It refers to the presence of an expansive mood, excessive joy, restlessness, oppositional behavior, irritability in the face of minor frustrations, sleep disturbances (insomnia), changes in appetite (eating excessively or, sometimes, the opposite), and talkativeness. It is less intense than the maniaIn this stage, we can sometimes find psychotic symptoms such as delirium and/or hallucinations, although these are rarer in childhood than in late adolescence and adulthood. Cyclothymia It is characterized by abrupt but less intense mood swings.

Once these terminological aspects have been clarified, we will now describe the symptoms of bipolar disorder, paying special attention to how they usually present in children and adolescents.

Figure – 1

How does bipolar disorder manifest in children?

The younger the child, the greater the difficulty in arriving at a correct diagnosis, and therefore the greater the likelihood of making a mistake. There is a tendency to confuse bipolar disorders with... Attention Deficit Hyperactivity Disorder or Conduct Disorder with the significant negative consequences this entails for proper treatment.

In childhood, unlike in adults, mood swings fluctuate rapidly. Children often exhibit a mixture of manic and depressive symptoms, along with significant and more or less persistent irritability (dysthymia).

Symptoms that may occur include:

• Mood alterations:
  1. Euphoric mood, irritability, or both.
  1. Depression: sadness, crying.

These mood swings are usually rapid, lasting from hours to a few days, can appear explosively, and are difficult to control at home.

• Symptoms of anxiety:
  • Tension, increased level of vigilance (expectant).
  •  If the child is young (approximately 5-7 years old), episodes of separation anxiety may occur, especially in a depressive mood.
  • Fewer hours of sleep. If depression is the predominant symptom, it's not uncommon to sleep too much.

• Behavioral and cognitive symptoms:
  • Hyperactivity to episodes of agitation.
  • Oppositionism, negativism.
  • Defiance of authority and disobedience.
  • Attention problems: distractibility.
  • Very fast thinking
  • You can undertake multiple activities that you never finish.
  •  Risky behaviors, as if he sensed danger and, sometimes, the belief that he had "magical" powers such as being able to fly or others.
  • Uninhibited sexual behavior.
• Psychophysiological alterations:
  • Sleep disturbances: insomnia or drowsiness, night terrors and nightmares.
  • Capricious changes in eating habits.
  • Enuresis.

These symptoms are not constant and do not all have to occur in the same child.

Third piece of advice: if your son or daughter, more or less suddenly, begins to be more irritable, more oppositional, negativistic or defiant, presents problems with sleep and reckless behaviors, with moments of excessive joy or inexplicable withdrawal, consult with a child psychiatrist.

How does bipolar disorder manifest in adolescents?

Although bipolar disorder typically presents in any of its clinical forms with few differences from how it usually appears in adults, this is not always so clear. There are situations where the presentation of symptoms can mimic other child and adolescent psychiatric disorders and are frequently mistaken for conversion disorders, until the condition becomes definitively established. The most frequent problems that lend themselves to diagnostic error are:

In children:

Behavioral disorders

Oppositional defiant disorder

Attention deficit hyperactivity disorder Panic disorder

Intermittent explosive disorder

In adolescents:

Borderline personality disorder

Post-traumatic stress disorder

Acute psychosis or schizophrenia

Let's look at the most characteristic symptoms depending on the type of disorder, as reflected in the figure –1..

Bipolar I:

Alternating episodes of depression and mania of varying intensity are common in the same child.

The symptoms of depression can manifest as:

• Sadness, frequent crying, or emotional lability.
• Depressive stupor³which can be confused with hysterical symptoms due to its clinical and evolutionary characteristics.
• Suicidal ideation or recurring thoughts about death.
• Sleep disturbances (insomnia or excessive sleepiness)
• Changes in appetite, usually anorexia.
• Irritability.
• Generalized psychophysical decline.
• When it is not excessively acute, it can manifest itself through poor school performance or changes in social relationships.

The symptoms of mania can be caused by:

• High mood, excessive and unjustified euphoria.
• Excessive irritability, or sudden changes.
• Verbosity or excessive talkativeness (sometimes jumps from one topic to another in a rushed manner).
• Sleep disturbance (insomnia).
• Psychomotor restlessness that can progress to agitation.
• Delusions of grandeur and omnipotence.
• Superficial thinking.
• In the most severe cases, hallucinations may occur.
• Loss of appetite or, on the contrary, an increase in appetite.
• Sexual disinhibition with significant risks.

There may be periods of absolute normality between the two episodes, or, more frequently, periods of relative normality.

Bipolar II:

In this clinical form, the characteristic feature is the presentation of hypomanic episodes interspersed with recurrent depressive episodes. This presentation is the most relevant aspect of this modality, along with the lesser intensity of the expansive episodes (see hypomania).

Cyclothymia:

Adolescents with cyclothymia experience mood swings, as described above, but with much less intensity. It is important to be careful not to confuse this with borderline personality disorder in late adolescence.

Fourth piece of advice: If your son or daughter exhibits three or more of the symptoms we've mentioned, lasting longer than two weeks, you should consult a child psychiatrist or, if this isn't available in your area, a specialist in child and adolescent mental health issues. Remember that timely intervention is crucial.

What are the causes of Bipolar Disorder?

Family background:

Today it is accepted that there is a significant genetic component to the presentation of this disease, although this is not well established, and considerable variability among affected individuals (polygenic) is the norm. Furthermore, the psychosocial circumstances surrounding the onset of the disease are also important for proper treatment, as they have a significant influence on its course. The estimated risk varies from one study to another. However, several epidemiological findings support its genetic etiology: A surprising fact has been observed: the higher incidence of this disorder today in childhood and adolescence, with onset occurring approximately ten years earlier than in their parents. It is estimated that the incidence is 1-6% of the prevalence seen in healthcare settings, including both classic and mild forms.

When one of the parents suffers from Bipolar Disorder, the risk in one of their children is 15 to 30%, if both parents suffer from it, the risk rises to 50-75%.

Studies in monozygotic twins have shown a risk of 70%, while among siblings and in dizygotic twins it is 15-25%.

Therefore, although the role of genetics in the presentation of bipolar disorder has been highlighted, it does not fully explain the presentation of the disorder.

Drug Use and Bipolar Disorder

There is a tendency to hastily link drug and alcohol use as triggers for bipolar disorder. This popular opinion persists because it is not difficult to find an association between substance use and the disorder. However, what might actually be happening is that the onset of the disorder during ages such as puberty is the real risk factor for drug use.

Therefore, when substance use appears in a pre-adolescent or when risky behaviors related to it are present, a child psychiatric evaluation would be highly advisable to rule out not only the onset of bipolar disorder, but also a range of other disorders that may underlie the substance use. This is especially true when this behavior appears in a pre-adolescent who has previously exhibited normal behavior.

Advantages of early diagnosis

It is quite common for diagnosis to be excessively delayed, with the resulting negative consequences for the child and their family. Likewise, it is also common for the child to have consulted with professionals with limited experience in diagnosing this disorder, with the same consequences, as the disorder worsens.

It is not uncommon for the reason for seeking specialized help to be primarily due to the consequences: expulsion from school, problems with the law, side effects from medication or incorrect psychotherapeutic interventions, suicide attempts, drug abuse, accidents, pregnancies, or sexual activity inappropriate for the age.

It is important to remember that some professionals do not accept a diagnosis of Bipolar Disorder due to the child's age.However, if we take into account the scientific data, information from the family and, above all, the positive, even spectacular, response to the correct treatment and the follow-up studies that have been carried out, TODAY IT IS NOT DISPUTED by the majority of the scientific community.

How to find the most suitable place and professional?

Your child should be diagnosed and treated by a child psychiatrist. These days, it's not difficult to find specialists in this field in your area. They can be found in the Child and Adolescent Mental Health Units or Services of his province.

At the end of this document, a list of the different Child and Adolescent Mental Health units in each of the Andalusian provinces is given.

We recommend that parents follow these guidelines when looking for a doctor to treat their child's problem:

• That they have extensive experience in mood disorders in children and adolescents.
• That has extensive knowledge of pediatric psychopharmacology.
• That they are willing to develop a bio-psycho-social treatment approach and not limit themselves to pharmacological prescription. In other words, that they know how to organize interventions in the school setting.
• That he/she is able to establish a positive relationship with the child.

TREATMENT

The paper of the parents

When parents notice a problem and decide to consult a doctor, they should bring with them as much detailed information as possible about the changes they have observed. This information is crucial for diagnosis, especially since some children don't present with symptoms pronounced enough to make a definitive diagnosis. In fact, a diagnostic evaluation typically involves at least two or three appointments.

Parents need to work closely with their child's doctor. This is a chronic illness with relapses and periods of recovery. Therefore, it is essential that parents are fully involved in the treatment. The more involved they are, the less frequent and severe the episodes can be, and the less severe the negative impact on the child's social and academic life can be.

The best way to help is to have as thorough an understanding of the disease as possible. Read everything you can find. You should also participate in parent support groups in your area. It's very helpful to learn about the difficulties other parents face in living with their children and how other families have overcome them.

Figure 2 shows the factors that favor a good prognosis and those that can negatively affect it.

 

All of us—parents, educators, and healthcare professionals—should work together to implement a comprehensive treatment plan that minimizes the adverse effects of bipolar disorder.

Medication

Unfortunately, due to incomprehensible prejudices, clinical trials in children and adolescents are almost nonexistent. Fortunately, in recent years some trials have been conducted, and thousands of children are now benefiting from their results. Regarding bipolar disorder and pharmacological treatment, to the author's knowledge, there are no controlled clinical trials in children. Therefore, child psychiatrists are forced to adapt prescriptions that have proven effective in adults to children and adolescents.

All of this means we have to prescribe with a degree of uncertainty, always basing our decisions on the results we obtain to maintain, adjust, or change the medication. This is despite the fact that clinical practice has demonstrated the primary importance of medication in the treatment of bipolar disorder. Furthermore, other treatments are often contingent on the improvements achieved with medication.

It is very important for family members to know this, as it often takes weeks or even months to find the best treatment for each patient, with the resulting anxiety this delay causes for parents. If you have any doubts, you should discuss them with your doctor and ask them to clarify all your questions about the medication, as your consent is essential.

Don't be swayed by the prevailing prejudices about the undesirable or dangerous effects of the medication. Find a doctor you trust and follow their advice. Remember that there is a high suicide rate associated with this child and adolescent psychiatric disorder (around 18-20% in untreated patients).

What medications are used?

The primary treatment involves prescribing mood stabilizers. Some are classic and have demonstrated their effectiveness in clinical studies, while newer medications, although their efficacy is not as well-established, have fewer side effects.

1. The most studied is the LITHIUM (Plenur)Its effectiveness in preventing relapses in mania and depression is widely demonstrated. Its effectiveness in suicide prevention has also been observed. Although this is a personal opinion, I believe it is best to begin treatment with other mood stabilizers and switch to lithium based on the quality of the therapeutic response.
2.   El SODIUM VALPROATE (Depakine). It is one of the most commonly used antiepileptic drugs for bipolar disorder, having proven effective as a mood stabilizer. In childhood and adolescence, it is preferred over lithium. It is also a well-tolerated medication.
3. La CARBAMAZEPINE (Tegretol). It has the same uses as the previous one. It has also proven effective. Carbamazepine is usually chosen when there are episodes of self-harm or aggression towards others associated with bipolar disorder.
4. They are also being used CALCIUM CHANNEL BLOCKERSThey seem to act as mood stabilizers.

However, at certain times during bipolar disorder, we must also prescribe OTHER MEDICATIONSWhen symptoms of excitability, irritability, and significant psychomotor restlessness appear, the following are usually prescribed: NEUROLEPTICS (Risperdal, Zyprexa, and others). Parents should be aware that these medications are necessary at certain stages of the disease and that they also have some side effects such as sedation and weight gain.

Depending on the patient's anxiety level, anxiolytics are usually used, normally benzodiazepines, as they produce improvement in psychomotor restlessness and usually regulate sleep.

Finally, they can also be useful on other occasions. antidepressants. Today, selective serotonin reuptake inhibitors are commonly prescribed (fluoxetine, sertraline, paroxetine, seropran etc...)

Psychosocial treatment

Orientation familiar

Parents should have the most accurate understanding possible of their child's illness. They should be supported in overcoming their fears and actively participating in treatment by understanding the behavioral problems and inexplicable mood swings so characteristic of these illnesses. Generally speaking, they should:

• A firm attitude towards your child's tantrums and other behavioral problems.
  • Be tolerant of problems that aren't truly serious. Try not to create a spiral of coercion that won't lead anywhere positive. Keep in mind that your child has serious difficulties controlling their behavior and emotions.
  • Create a relaxed atmosphere within the family.
  • Learn how to relax your child with a simple technique.
  • Family functioning (activities) should not be excessively rigid, although it should maintain clear limits.
  • Sometimes, listening to relaxing music, especially during moments of heightened anxiety, can be effective.

• Avoid dangerous objects and situations.

School intervention

It is very important to consider the school in the comprehensive treatment of children and adolescents with bipolar disorder. It is common for the patient to have to temporarily leave school when the illness is triggered, until sufficient adjustments are made. Therefore, regular contact should be established with the school counselor, both to raise awareness among teachers and to prepare for the return to school.

All of this is necessary because the patient needs to return to school as soon as possible, and some adjustments are required: such as a gradual return, and changes in teachers' attitudes towards any initial difficulties the patient may experience, since, in addition to emotional and/or behavioral instability, the patient will also experience the side effects of the medication, which will require a... Individualized PlanIt is recommended that in the case of behaviors that, at first glance, may seem inappropriate, the patient's doctor be contacted to determine what is due to the illness and what may be secondary benefits.

In centers that have accumulated experience with these patients, a series of adaptations are made, which we outline below:

• Evaluate the student's psycho-pedagogical potential
  • If the patient previously had difficulties with performance, the school and academic environment will need to be adjusted to this new situation triggered by the disease.
  • Sufficient communication mechanisms must be established between the school and the family. All incidents must be reported. Likewise, these communication/coordination mechanisms must exist between the school doctor and the school counselor.
  • Adapt the inputs and outputs based on the patient's psychopathological situation.
  • Place the patient in a classroom that offers the best possible tranquility. It is not recommended that there be children in the classroom with behavioral disorders or other disruptive behaviors (e.g., hyperactivity).

• Adapt the assessment tests to the patient's capabilities
  • Most of the time, the school schedule must be adapted to the patient's attendance at their stay in the Day Hospital.

In the event of either remaining in the Day Hospital or requiring hospitalization for treatment, the patient must receive educational support during hospitalization (therapeutic school).

Psychotherapies

Typically, when a patient is in the acute phase, psychotherapy is not possible due to a lack of cooperation. However, treatment often focuses on aspects such as adherence to the treatment plan through explanations about the nature of the disorder. Similarly, when the patient is in this situation, environmental adjustments are made to prevent episodes of aggression, agitation, and potential self-harm.

As the patient recovers their mood and, above all, the frequent episodes of negativity and dysphoria subside, a [condition/treatment/treatment/treatment/treatment/treatment/etc.] can be established. Psychotherapeutic Treatment PlanHowever, this approach must consider all aspects of the psychopathological problem: affective, behavioral, familial, and psychosocial. It is very important to create or maintain social support networks, both at the family and personal levels. It is quite common for families to make undesirable intrafamilial adjustments that significantly impact quality of life.

1. Child and adolescent psychiatry is the same as child and adolescent psychiatry and is the medical specialty that diagnoses and treats psychological disorders in childhood and
   adolescence.
2. They can also read about manic-depressive psychosis, cyclothymia, hypomania, hyperthymia, etc.
3. Depressive stupor: very marked motor inhibition. We have seen some
   teenagers remain almost motionless in bed for days, not wanting to eat or
   drinking from which they have suddenly and inexplicably emerged.