The Bipolar Child - A New Emergence The bipolar child is a relatively neglected childhood diagnosis that is the subject of great controversy in the fields of clinical and child psychiatry and psychology. Diagnosis and treatment of such a devastating disorder is very difficult due to several different factors, including, Childhood-onset Bipolar Disorder (COBPD) does not have its own criteria in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), published by the American Psychiatric Association, Washington D. C. , 1994, the main diagnostic reference of Mental Health professionals in the United States of America, a child shares the same criteria standards as an adult, plus there are several similarities in COBPD and Attention Deficit Hyperactivity Disorder (ADHD), causing some misdiagnosis, and the simple fact that there is little reference to the disorder in a medical and psychiatric field afraid to step into the world of childhood mood disorders. (Papolos NARSAD 2003, Popper 1989, NIMH 2000) Only until recently has more research and development been conducted on CO PBD.

According to the DSM-IV diagnostic criteria, a person must have at least five of the following symptoms during the same two week period to qualify as a major depressive episode: a depressed mood lasting most of the day for several days, a significant weight gain or weight loss, a loss of interest in activities, difficulty sleeping or an increased need for sleep, restlessness or slowed pace observable by others, daily fatigue, feelings of guilt or worthlessness, inability to concentrate, or recurrent thoughts of death. For a mixed episode, a person must display symptoms of depression and mania every day during at least a one-week period. A manic episode is described as elevated or abnormally irritable for at least one week, with a least three of the following: personal greatness, decreased need for sleep, extreme talkativeness, "racing" thoughts, or hyper sexuality (excessive sexual activity, or sexual desire). The DSM-IV states that these symptoms must interfere with daily functioning and not be a result of the effects of drugs, medical condition, or temporary results from a traumatic event for all of these; depression, mixed state, and mania.

The Child and Adolescent Bipolar Foundation lists four types of mood disorders in the bipolar window; Bipolar I, Bipolar II, Cyclothymia, and Bipolar NOS (Not Otherwise Specified). Bipolar I can be described as alternating episodes of intense and sometimes psychotic mania and depression. In Bipolar II, episodes of hypomania a markedly elevated or irritable mood accompanied by increased mental and physical energy is experienced between recurrent periods of depression. Periods of less severe, but definite mood swings is defined as Cyclothymia. And finally, Bipolar NOS is used when doctors are not clear of which type of bipolar disorder is emerging (CABF 2002) Symptoms of Childhood-onset Bipolar Disorder can be found in children as young as two-years old. Parents have been reported as noticing something was different about their child even during infancy, describing their child as having been unusually fidgety, difficult to soothe, extraordinarily clingy, and sleeping erratically (CABF 2002, Kluger & Song 2002).

One of the definitive differences in the Childhood and Adult-Onset forms of bipolar is what is known as ultra-ultra rapid or ultra dian cycles, (rapid swings of mood and energy multiple times in one day). Parents describe children as alternating between several different mood states, including: unpredictable belligerence, nastiness, hostility, silliness, goofiness, and giddiness. Severe, prolonged temper tantrums with an enormous amount of energy exuded including aggression, violence, and rage can also be described by parents of these children. This is not included in the DSM-IV, and thus it is likely that not more than 25% of children with COBPD are properly diagnosed. New criteria should be developed for children with the inclusion of the ultra-ultra rapid cycling and the tendency towards temper tantrums and extended rages (NARSAD 2003).

It can be very difficult to identify episodes of mania or depression in children because of the waxing and waning course they follow (Weller and colleagues 1995). Dimitri Papolos, M. D. , research director of the Juvenile Bipolar Research Foundation and co-author of The Bipolar Child, believes he has spotted a pattern in these children through a study of three hundred bipolar children ages four to eighteen years old. Characteristically, in the morning, they are more difficult to wake up, don't want to get dressed or go to school. They are irritable, and can snap and complain or be withdrawn and somber.

By the afternoon, the "darkness lifts" and they enjoy a few "clear" hours. Then by mid-afternoon, what is described as "rocket thrusters going off" begins, and wild, giddy, euphoric play begins, stories are made up and they may insist that they have super powers. Efforts to calm them down are resisted and the wild behavior can continue late into the night (Kluger & Song 2002) Just one description that was outlined in the TIME article, Young and Bipolar, published August 19, 2002, can paint a picture of what living with a bipolar child can be like. Lynn Brom an, 37, of Los Angeles, is raising 3 children, two of whom- Kyle, 5, and Mary Emily, 2, are bipolar. Kyle has been expelled from six preschools and two day-care centers and has destroyed a once tidy home. He had been hospitalized for violent outbursts at age four and still has periods where he goes almost completely feral.

He has even thrown a butcher knife at his mother. What a scary picture this paints. Unfortunately, Childhood-onset Bipolar Disorder can include ADHD-like symptoms but they are more severe, and ADHD may actually be a forerunner for full-blown mania (NIMH 2000). In a study listed on the National Alliance for Research on Schizophrenia and Depression (NARSAD 2003) website, in a group of 120 children and adolescents (ages 3-18) diagnosed with bipolar disorder, 93% met the DSM-IV criteria for ADHD. A child may even have ADHD and bipolar disorder simultaneously.

There in lies another difficulty in the diagnosis. Charles Popper, M. D. outlines several similarities and differences in ADHD and COBPD. These similarities include; impulsivity, inattention, hyperactivity, increased physical energy, behavior and emotions change often, frequent coexistence of conduct disorder and oppositional-defiant disorder, and learning problems, family histories of mood disorders, treatment with psycho stimulants or antidepressants can help in both depending on which phase the bipolar is in. Differences are seen in destructiveness, duration and intensity, regression, triggers, moods, and sleep.

An ADHD child may break things carelessly or accidentally when playing, a bipolar child usually will be destructive through anger, like temper tantrums accompanied by violence and property destruction. An adult would be unable to imitate a bipolar child's anger and outburst without reaching exhaustion quickly, they can continue for over 30 minutes and up to 2-4 hours, an ADHD child usually calms down within 20-30 minutes. After the "tantrum" is over the ADHD child may experience some disorganized thinking and confusion, a bipolar child may even have no memory of the tantrum at all. Sensory or affective over stimulation like quick transitions or an insult can set an ADHD child off, whereas a in a bipolar child limit-setting like an parental "NO" can easily be a trigger. Bipolar children may even actively seek conflict with an authority figure. There is generally little depression in an ADHD child.

An ADHD child my have difficulty going to sleep but an bipolar child may experience multiple awakening each night and have fears of going to sleep, which can be linked to severe nightmares that can often involve explicit gore or bodily mutation. ADHD is a chronic and continuous, but tends to improve with age. Bipolar can become more severe and dramatic as the child becomes older (Popper 1989). The differences are there but without clear definitions in the DSM-IV there is surely several children suffering with a misdiagnosed or under diagnosed mental disorder.

There have been progressively higher rates of early onset bipolar disorder in children and adolescents in successive generations since 1940 (NARSAD). Hence, in every generation since World War II, bipolar disorder and depression has begun at an earlier age (CABF 2002). The average age of onset has fallen in a single generation from the early 30's to the late teens, and this number doesn't even include children under the age of 18 (Kluger & Song 2002). Part of the increase could be that bipolar is being tracked genetically; genes may express themselves more aggressively in each generation. For the general population the chance of developing full blown bipolar disorder is about 1%, in the bipolar spectrum 4-6%. If one parent is bipolar the risk is 15-30%, if both parents have bipolar the risk increases to 50-75%.

The risk among siblings is 15-25% and among identical twins 70% (CABF 2002). Two more ideas for the increase are family and school stress and recreational drug use or that the diagnoses have just gotten better. Fortunately there are several different treatments for the disorder but it can take several years of a trial and error method to develop the correct plan for a specific child. Mood stabilizers, antidepressants, and ant psychotics are the three most commonly used types of medications used. Some people may need a combination of two or three drugs to become stable and some may take a very long time to stabilize. Mood stabilizers are the primary treatment.

There are even some new ones in development that look very promising. In the Bipolar Child Newsletter Vol. 12, October 2002, Aripiprazole (Ablify) is discussed. Ablify was discovered in Japan by Otsuka Phramaceutical Co. , Ltd. , who working with Bristol-Meyers Squibb to manage Phase III clinical trials in the U.

S. received U. S. FDA approval in November 2002. Child psychiatrists have been testing on the off-label application towards early-onset bipolar disorder finding little side effects claimed by parents and patients. One of the parents writes an email correspondence to the newsletter stating, "Peter started the drug and things have started to get better.

Things "click", he is no longer constantly fighting with his siblings. He is much more compliant and his aggression level has gone way, way down." She also mentioned, "His little brother is still having a hard time understanding why Peter is being nice and not his usual self that he was used to. " Some of the alternative and supplemental treatments that may coincide with medication include; light therapy, electro convulsive therapy, trans cranial magnetic stimulation and nutritional supplements. Along with visits to a child psychiatrist, the treatment plan should include regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist who provides psychotherapy. Another important part of the treatment circle will be knowledgeable parents who have been given the specialized skills and guidance it takes to interact with and control a bipolar child. In response to the TIME article Young and Bipolar, August 19, 2002, one reader writes in Letters, September 9, 2002, "These children experience suffering that no child should know.

Our hope relies in research that is so long overdue. These children are in desperate need of better treatment and medication." This sums up the problem pretty well. There needs to be updates made to the DSM-IV, which is not set to be updated until 2005, to include the symptoms and differences in early-onset childhood bipolar disorder and its adult counterpart. There needs to be an aggressive attempt to stop misdiagnosing children with ADHD, and under diagnosing a disorder that only grows more severe and debilitating without proper treatment. "If you don't catch it early on," says Dr. Papolos, "it gets worse, like a tumor." Works Cited Child and Adolescent Bipolar Disorder: An Update from the National Institute of Mental Health.

National Institute of Mental Health (NIMH). NIH Publication No. 00-4778. August 2000. The Educational Needs of a Child or Adolescent with Bipolar Disorder. Children and Adolescent Bipolar Foundation (CABF).

Reviewed by CABF Professional Advisory Council members and Martha Hollander, Executive Director. Last revised: 10/27/02. Goodman, Robin F. Ph. D. , and Gurion, Anita Ph.

D. About Bipolar Disorder (Manic Depression Illness). Kluger, Jeffrey and Song, Sora. Young and Bipolar Time. com. Time archive.

August 19, 2002. Letters Time. com. Time Archive. September 9, 2002 Moyer, Paula. ADHD Kids May Have Bipolar Disorder, Too -Treating ADHD Alone May Worsen Bipolar Symptoms.

WebMD Medical News. Oct. 29, 2002. Papolos, Dimitri F. M. D.

Childhood-onset Bipolar Disorder: Under-diagnosed, Under-treated and Under Discussion, NARSAD Research. 2003. Papolos, Dimitri F. M.

D. and Papolos, Janice. The Irrepressible Agenda of Children With Bipolar Disorder. The Bipolar Child Newsletter. October 2002. Vol.

12. Popper, Charles M. D. Diagnosing Bipolar vs.

ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, Summer, 1989. Helping Children with Early-Onset Bipolar To Learn "A Guide for Teachers and Administrators" prepared by Parents of Children with Early-Onset Bipolar The BP Parent Listserv. Owner/Founder S.

M. Tomie Burke Weller EB, Weller RA, Frist ad MA. Bipolar diagnosis in children: misdiagnosis, under diagnosis, and future directions. Journal of the American Academy of Child and Adolescent Psychiatry. 1995; 34 (6); 709-714.