by James Chandler, MD, FRCPC
Prevalence of Bipolar illness
Causes of Bipolar illness
Diagnosising Mania in Children
Co-morbidity
Course and Prognosis
How bipolar disorders screw up your life
Treatment
Medications
Non- medical treatments
The bipolar disorders are mood disorders. That means that amongst other things, there is a major change in mood. In bipolar disorders, this change in mood can be down, as in depression, or the opposite, mania. That is, a person can be inappropriately up. Some types of bipolar disorder have a lot of depression and only a little mania. Others have half and half. Still others seem to be both manic and depressed at the same time. Some people with bipolar disorders only have a few cycles of depression and mania. Others have many cycles a year. When bipolar illness is present in children and adolescents, it is more severe and harder to treat than when it occurs in adults. Pediatric Bipolar illness is one of the most severe conditions in pediatrics. In the milder forms, it can be disabiling. In the severe forms, it can be lethal. The prognosis cancers in pediatrics is better than many forms of bipolar illness.
All bipolar disorders are a combination of mania with or without depression. So what is mania? Here are the official criteria:
An elevated, expansive, or irritable mood, lasting at least 1 week. This mood is also accompanied by at least three (four if mood is only irritable) of the following:
1. Inflated self -esteem or grandosity
2. Decreased need for sleep
3. Increased talkativeness or pressure to keep talking
4. Racing thoughts or flight of ideas
5. Distractibility
6. Increased Activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences.
The disturbance should be so severe that hospitalization is required to avoid harming themselves or others.
In pediatric mania and hypomania, the mood is more likely irritability. these features come and go throughout the day and are not as persistent as in adults.
Here are some examples:
Justin is 11 years old. He is usually a hyperactive boy who does okay in school, but not without a lot of help from teachers and his family. His mother, Christine, first wondered what was going on on April 3. The teacher called saying she had to send Justin to the Principal's office twice that day. When Justin came home he zoomed inside threw his book bag in the door, and shouted something about a great idea. She came outside to watch as her son leaped from the top of the house to a bush with his arms holding a big piece of plywood. By the grace of God, he was not hurt. When she asked what was he doing, she got some answer about space shuttles and landing pads. She took the board and told him to go inside. He punched her in the stomach and said, "no way, bitch" and went off on his bike. She had never seen her son like this. Over the next three days, life became unbearable. He was thrown off the bus, wrecked his bike, nearly burned down the house making pancakes at three am, and called his friends in the middle of the night when his parents were sleeping. He shaved pieces of his hair off, drank four cans of beer out of the refrigerator, and finally ended up jumping up and down on top of an RCMP car before he was brought to hospital.
Sarah is 12 years old. She has been depressed for about 6 months. She isn't suicidal, but she just lays around, is more irritable, and does worse at school than before. She has let a lot of her friendships go and the only thing that still gets her excited is when her cousin down the road visits. Over the last few days Sarah started to finally come out of her slump or depression. She started calling old friends, went back to playing the piano, and seemed more interested in her school work. It was last Friday that they noticed the giggling was more than usual. She called about ten friends to see if they could come over and most did. They started playing a game, and then Sarah started to giggle and come up with new rules and make all sorts of jokes, only a few of which were funny. Sarah thought they were all funny. She put her socks on her ears and started dancing around the room. Her friends didn't think it was funny, and then Sarah got mad and told them to all go home. The weekend was rough. Her parents were awakened to piano playing throughout the night and every hour or so she would zoom in to tell them something she forgot. Except it was so mixed up with giggling, you couldn't tell. Discipline made no difference. On the next day of school, Monday, the principal called her Dad at the garage to have him pick her up. She was disrupting the whole class and acting like a two year old. She was laughing, but no one else was. They brought Sarah home and basically watched her 24 hours a day for 2 weeks. Her mom had to take a leave from work. Eventually she slowed down and returned to her usual depressed self. It took months before her old friends would have anything to do with her.
Alex is 13. He has been a tough child to raise from infancy. He has always been aggressive and very active. By the time he got to school, he had already been seen by a pediatric psychiatrist and diagnosed with ADHD. Except for 5th grade, he passed every year with the help of a flexible program, medications, and a devoted family. Lucily, he hadn't been in much big trouble, until now. A week ago Alex took off. He was mad at his Dad about some trivial matter, threw a plate at him and headed into town on foot. A week later the RCMP called saying they had, after a major search, found the child. Acccording to their reports, he had broken into two houses, and stolen about 3 quarts of rum in each home. He had drank that and smoked all the cigarettes he had stolen, too. Another boy who was also involved went to the police as he thought Alex was going crazy. Alex was running around the camp they were staying in all night long shouting and screaming songs from a CD he had. When the RCMP arrived, Alex was overly friendly, talking a mile a minute, and wanted them to listen to this CD. He then said, "Catch me Pigs" and took off into the woods. It took them another hour to catch him. After staying at home for a couple of days, he slowly came back to his old self, except he was depressed. He couldn't understand why he had done these things. No one else could either. He is still on probation a year later and some of his old friend's parents still won't let their children hang out with Alex.
Mania or hypomania can also come with psychosis. Psychosis is the word to describe hallucinations, paranoia, and bizzare thoughts. Here is an example of that.
Neal is 13. Neal had an episode of depression a year ago where he did not want to do any sports at all and just sat around at home. He gained 10 lbs and spent most of his time in his room playing video games. He barely was passing in school and was a hard guy to live with. this was totally out of character. Neal was not an inside guy. He was usually outside building something, snaring rabbits, playing ball in the summer, soccer in the fall, and playing hockey in the winter, when he and his parents could afford it. He was turning out to be a real asset on his Dad's boat this lobster season and the other fisherman at the wharf often commented on what a fine young man Neal was becoming. Until a month ago. It started with not sleeping and racing their four wheeler. He smashed it and didn't seem to worried at all. When his father approached him about this, he told his father off and walked off. He got in fights at school for the first time in his life. He started wearing only purple clothes. Why? Because, he was "King". At first it was like a joke the way he treated everyone like subjects. Then it wasn't. Especially when he would not eat for two days because he had heard, through the TV, that the food was being poisoned. He then locked himself in his Dad's truck and talked to his "Judos" (his made up word) for half the evening. When the RCMP came, he finally came out, telling his parents how all this was foretold in the Bible. They brought him to the hospital.
The type of Bipolar illness is determined by the combination of mania or hypomania ith either mild or severe depression. It is also determined by how fast the cycling is. That is, how often do they have an episode in a year?
Bipolar I Disorder - Children with this disorder have episodes of mania and episodes of depression. Sometimes there are fairly longer periods of normality between the episodes. Usually people spend much more time depressed than Manic. However, some children will have Chronic Mania and rarely get depressed.
Bipolar II Disorder - Here people mostly have depression and occasionally have an episode of hypomania, but not mania. Most people with this have long episodes of depression and virtually no time of wellness.
Cyclothymia - this variant is characterized by many episodes of hypomania and occasional episodes of mild depression only. A child may have quite a few episodes of hypomania over the span of a year.
Mixed states - In these conditions, a child will show signs of depression and mania at the same time. Most often, the mood is depressed and there are thoughts of suicide and hopelessness. The rest of the picture is however mania.
Rapid cycling Bipolar illness - This means there are many cycles of mania and depression each year.
About 1 % of Adults have a type of bipolar illness. As a person's age goes down, the smaller the chance of bipolar illness. It is currently very unclear how common it is in children. Perhaps .5% is a good guess. In adults, Bipolar illness is more common in females. In chldren and adolescents, it is more common in males.
Genetic - This is a strongly genetic condition. If a child has two parents who have had mood disorders, nearly every child will have a mood disorder (either a type of depression or a type of mania). If one parent has a mood disorder, about a quarter of the children will get a mood disorder.
Drugs - a number of drugs can make a person manic or look like mania. Steroids (by mouth, not just inhalers) are the most common perscription cause. Street drugs can mimic mania. A few other rarely used medications can, too.
However, the most important one to be aware of are the antidepressant medications. The drugs used for depression can make some people manic or hypomanic. In a recent study of Prozac in children for depression, about 5-10 % switched to mania. These were children who had not had mania before.
Infections - in rare cases infections of the brain, AIDS, and a few other rare diseases can cause mania. This is very rare in otherwise well children.
Hormones - Too much thyroid hormone can make you manic. This is also very, very rare in children.
Other rare neurologic conditions - Strokes, Multiple Sclerosis, tumors, epilepsy, and a few other rare causes can cause mania in children.
There are two types of mistakes you can make in diagnosising any disease. You can think something is mania when it really is something else, for example, street drugs. Or you can think a disorder is something else when it is really mania. In children, the mistakes are almost always the second kind.
Besides a complete history and physical and talking to everyone involved, it is often times necessary to do other tests. Urine drug screens, CAT scans of the head, and blood tests are often used. If there is no family history of a mood disorder, then I am more aggresive in finding other causes.
This is the hard part. Mania can look a lot like a few other psychiatric disorders. It can look like a Oppositional Defiant Disorder or Conduct disorder (personality characterized by persistent violation of the rights of other and their property). It can look like ADHD. Almost 90 % of children who get mania will also have ADHD. (See accompanying handouts for details on these) It can look like "stress". Mania can also look like schizophrenia. Pediatric mania is more often accompanied by psychosis than in adults. Also mixed states and a rapid cycling picture are more common. These atypical features (for adults) can remind people of adult schizophrenia.
Usually by keeping two things in mind you can keep from missing mania. First, Conduct Disorders usually do not get suddenly ten times worse. Nor do they appear out of the blue over age 7. Second, mania is usually genetic. A strong family history of mood disorders, especially mania, makes me wonder about mania in any episode of wild and out of character behavior.
Co-morbid conditions are those that tend to run together. Diabeties and heart disease are a common example. In pediatric psychiatry, there is a huge amount of comorbidity. Bipolar disorders have a lot of co-morbidity. In fact, in children and younger adolescents, it is almost always preceded or accompanied by another disorder.
What this means is that a child who is destined to get a bipolar disorder usually will show another psychiatric disorder earlier in his life. By far the most common one is ADHD. Over 90% of children who get manic had ADHD before they got manic or hypomanic. On the other hand, most children with ADHD never get mania. Other problems like oppositional defiant disorder and Conduct disorder are also common in children who get manic. This makes it even harder at times to tell if a person has a bipolar disorder as many of the signs and symptoms are the same as in ADHD. However, in ADHD alone, the symptoms do not dramatically increase for no apparent reason.
Bipolar disorders by their very definition are not one time illnesses. One of the most common questions I am asked about children who have been hypomanic, depressed or manic is, will this happen again? The sad answer is probably yes. Between 20-30% of children who have severe depresssion will become manic later in their lives. This is more likely if the depression came on suddenly, included psychosis, and a family history of bipolar illness was present.
Pediatric bipolar illness is very severe and chronic. Almost all children will have another episode of mood disorder in their lives. Most will have another episode within the next five years. A number of things can be helpful in predicting this, but none is more important than a history of prior mood disorders, especially mania. The longer you have been ill with bipolar disorder and the more episodes you have had, the more likely you are to get it again. In other words, the longer bipolar illness goes on, the harder it is to stop. Here are some slightly less important predictors
No family history, medical causes present for mania (like steroids), no other neuropsychiatric disorders, sudden onset of mania after a stressor, a history of good functioning before illness, and above all, no prior episodes.
A strong family history of pediatric onset mania, numerous other co-morbid psychiatric disorders, poor functioning before illness, rapid cycling, mixed mania and depression, and above all, a long history of bipolar illness.
Most of these factors can not be changed by doctors, families, or patients. However, keeping a bipolar disorder from recurring can be affected. That is why identification and treatment of bipolar illnesses is critical. The longer a child has bipolar illness, the more likely it is to go on and on.
This 14 year old would have a bout of depression followed by hypomania for a week, and then more depression for another 6-12 months, then another bout of hypomania. This girl appeared to have chronic depression that never responded to treatment until someone finally saw her during an episode of mild hypomania. Then she was finally treated for bipolar disorder.
Now 11, Christin had a mild episode of depression after his parents seperated at age 7, and then was well until age 11, when he became very depressed, then manic. He has spent about 2 years of his 11, or about 20% ill.
The most common pattern which is missed is ADHD followed by mania and depression. this child had marked ADHD for his first 7 years of life. Then every year or so he has an episode of hypomania which lasts a week and is hard to distinguish from his baseline hyperactivity. Finally at age 12 he becomes depressed and is treated with antidepressants alone. This unfortunately leads to full blown mania and finally the correct diagnosis.
Ashely started having an episode of depression lasting a few months followed by an episode of hypomania lasting a few weeks. She had this cycle every two years, then every year, then every 6 months and is no constantly either manic or depressed. Luckily, medications worked wonders for her.
Jonathan never received any treatment until he was in a youth prison. Starting with ADHD, he developed chronic mania for two years, followed by an episode of depression with a life threatening suicide attempt.
Disablity during episodes - if you are more than a little depressed or have any degree of mania, you just can't do much of what you should be doing at a certain age. A child will not get along with his family. His friends will be fewer and not exactly the best kind of kids. It will make other family members have trouble themselves as this is so hard to live with. It can split up parents. In older children, serious crimes or accidents can occur during mania. School is very difficult to continue.
Disability between episodes - When other children see a child who is manic or hypomanic, they don't forget it for a long time. These children are shunned once they are well and are not easily accepted back by their peers. Depression is less of a problem. The irritability which often accompanies pediatric depression can burn out friendships for a long time, even after it is gone.
Self esteem and development- having multiple episodes of bipolar illness interupts a child's normal psychological development. They end up in many ways immature for their age and in other ways older than their age because of all the suffering they have gone through. From the child's perspective, it is as if there is tornado going through their lives on a random basis. The child is willing to pick up the pieces and start over a couple of times, but after that, many will just give up and think or say, "what is the use of trying? It is all going to get wrecked before I get going by the next episode"
Suicide - Obviously the worst outcome is this. It is not uncommon. In pediatric bipolar illness, 20% will make a serious suicide attempt. There are no quality studies of pediatric completed suicides in bipolar illness. In adults, about 19% of those with bipolar illness committ suicide.
The aims of treatment are fourfold.
1. treating acute symptoms
2. prevention of relapse
3. reduction of long-term morbidity
4. promotion of long-term development and growth.
Each of these goals is achieved with a combination of different treatments. Here are the different types of treatments. Nearly every person with bipolar illness will need a number of different types of treatments.
The medicines for bipolar illness fall into four categories, anti-manic agents, anti-depressants, sedatives, and neuroleptics.
- These drugs change the chemical balance in the brain. When they are effective, hypomania or mania goes away. When they are effective, they also will reduce cycling and make a person less likely to become manic again. In some people they are also effective for depression. However, they are much more effective for mania than depression. So, you could easily see the cycling stop and see the mania end, and have a child end up depressed.
We know these agents are effective in many adults with bipolar illness. They are less effective in pediatric bipolar illness, mostly because it is a more severe form of bipolar illness. For example, adolescents who have bipolar illness and and are prescribed lithium (and take it) will have a 37% chance of relapsing over the next 18 months. If they don't take the lithium, they have a 90% chance of relapsing. In severe cases of rapid cycling bipolar illness, these drugs are often used in combination.
Although we refer to lithium as a drug, it is actually a naturally occuring element. In some places in the world it is present to a significant degree in the drinking water. It has been used in adults for bipolar illness for almost 40 years. Approximately 80% of adults with bipolar illness will respond. The response is less when there is a mixed picture or rapid cycling. In some children and adults, it can make a normal life possible again. This drug will often stop or reduce cycling, get rid of mania and hypomania, and sometimes get rid of depression, too. It is not clear exactly how it affects the different parts of the brain to accomplish this. However, it is not an easy to use drug. It has numerous side effects.
- Occasionally this drug can cause nausea, vomitting, diarrhea, shakiness, and balance problems. Overall, these are less than in adults.
Psychologically serious but medically non serious side effects
- This drug can cause or worsen acne. It can cause weight gain. It can, in some cases cause bedwetting.
Lithium can damage the kidneys. The most common problem is that it makes a person make lots of weak urine, so they need to urinate all the time. Other changes can also occur more rarely. To be used safely, blood tests for the kidneys and urine tests are done on a regular basis. With regular monitoring, these changes can be detected before they become serious.
Lithium can affect the thyroid glands. It can make the thyroid gland reduce the amount of hormone it puts out. This is another thing that can be managed by monitoring blood tests. If it is severe, and the drug is helping a lot, then a person can be given thryoid pills.
Lithium, at high levels, can affect the brain. If a person has high levels of this drug in them, it can make them confused, cause coordination to be poor, and make thinking slower. For this reason, the level of the drug needs to be monitored regularly.
If you become dehydrated from the flu, diarrhea, or other causes, and you keep taking your lithium, your body will save it up and the level will go higher and higher. This is the main danger of this drug. Anyone who is taking this drug needs to talk to the prescribing physician if they are getting dehydrated so they can figure out what to do. Usually, the drug is stopped temporarilly.
You should not take Lithium if you are planning on getting pregnant. It has been reported to cause certain defects in the heart of the fetus.
Because what you are treating is a lot worse than the above. You don't treat mild conditions with Lithium. Bipolar illlness is not mild.
Because most people do not have any of these major side effects.
Because if people know what can go wrong, and the doctor knows, and things are carefully monitored, you can pick up any problems before they get serious.
Lithium comes in a couple of forms and sizes. The dose is determined by the blood level. So you have to take it for a few days, then check the blood level, adjust the dose, and check the blood level again. Once the level is in the proper range, then it is usually only checked every few months.
When the drug works, it is usually within 2 weeks for mania or 4-6 weeks for depression. It is very cheap.
Annette is 14. She has been admitted for depression following a week of hypomania. She has had one previous admission for depression. Her pediatric psychiatirst wants to treat her depression without risking her switching into mania. So he feels Lithium is a good choice. Before he starts the drug, blood tests for kidney function and thyroid function are checked. She starts taking 150mg twice a day and after a few days of this it is increased to 300 mg twice a day. Four days later a blood level is checked. It is .4 . The level should be .8-1.0. The doctor increasing the dose to 450mg twice a day and checks a level in another five days. It is .9. Annette has a little nausea and a tiny bit of tremor, but otherwise has no side effects. After a few weeks, she is still very depressed. An antidepressant, Paxil, is added. Over the next two weeks she recovers from her depression. For the first month, she gets her lithium level checked weekly. Then it is twice a month for a few months, then every month. After she has been on the drug 3 months, other lab tests are checked. Annette takes the drug for 6 months, but at that point feels that she no longer needs it and think it is causing her acne. Against everyone's advice, she stops it. One month later she is again hypomanic, but her acne is better.
This example points out the reality of Lithium use in pediatrics. The medical side effects are a breeze to manage compared to compliance issues. Many children with bipolar illness do not have a lot of insight into their illness. Frequently after a few months they become non-compliant. Usually it is for trivial reasons from an adult's perspective. The biggest problem with lithium is that people don't like to take it long term. In fact, a big part of the counseling for this disorder is devoted to just this issue.
This mood stabilizer has been used for years to treat epilepsy. Over the last five years it has been found to be very effective in bipolar illness in adults, especially in mixed bipolar illness and rapid cycling bipolar illness. It is not clear how this, or other anticonvulsant drugs work for bipolar illness. It has been tested some, but not a whole lot, in pediatric bipolar illness.
Nuisance side effects - occasionally this drug will cause nausea, vomiting, or diareha.
Medically serious side effects - this drug can cause substantial weight gain in some persons. In rare cases it can affect the ovaries and change a girl's periods. This appears to be reversible. It may cause poly cystic ovaries in rare cases, but this is still controversial. When combined with other siezure drugs in very young children, it can affect the liver. It can cause serious birth defects if it is taken during pregnancy.
The drug comes in 250mg and 500 mg pills called epival. You can start taking nearly the full dose right away. The dose in milligrams is usually ten times the weight in pounds each day. Blood levels are checked at regular intervals.
Overall, this drug is much, much easier to use than Lithium. The side effects, outside of weight gain, are usually mild. If there are mixed features, signs of epilepsy or brain damage, it is my first choice.
Pediatric bipolar illness can be very hard to treat. Other drugs for siezures are sometimes used, even though there is not as much information regarding their use for pediatric bipolar illness. Tegretol and Lamictal are two that occasionally are used. Sometimes, these drugs are used in combination.
These are drugs used to quiet down people. This is very important in mania. In the days before medical treatment, mania was a lethal illness. Approximately 10% of adults with mania died of exhaustion. Sleep deprivation worsens mania and depression. That is another reason for using sedatives. The type of sedative that is used depends on two things. First, is the person psychotic? Secondly, will they take medications by mouth?
If a person is not psychotic, the first choice drug is Lorazepam (Ativan). It has been found to be very safe in mania, can be given by mouth, liquid, or needle, and has few side effects except sedation. It can make a person's gait off balance or make their speech slurred. It is not addictive when used in the short term to quiet a person down. The dose is variable. It usually ranges from 4-20 mg a day. When it is used for anxiety, the dose is much less.
If a person is psychotic, usually a neuroleptic is added. If a person won't take medications by mouth, then the drugs below aren't used. Then we have to use the older drugs like Haldol, as the new drugs don't come in an injectable form.
When mania or depression is present with hallucinations, bizzare thinking, or unusual movements, these drugs are used. Occasionally they are used for mania which does not respond to anything else. At the moment, there are two reasonable choices, resperidone and olazepine. These are two of the new drugs for schizophrenia which have much fewer side effects. I use them when mania with psychosis is present. Both of these drugs are expensive. Both can cause weight gain, but that is about it. In the past other drugs were used for psychosis which caused tons of side effects. I do not usually use them in pediatric bipolar illness.
Name of drug use of drug dosage side effects comments
(brand name)
Lithium mood 300-900 mg a day can be many. cheap. safe if
stabilizer requires lots monitored
of monitoring carefully
Valproic acid mood 1000-3000 mg a weight gain, used for mixed and
(Epival) stabilizer day very safe rapid cyclers.
expensive
carbamazepine mood 400-1200 mg a wiehgt gain, not a first choice
(tegretol) stabilizer day nausea
lamictal mood 400-1000 mg a weight gain very new. little
(lamotrigine) stabilizer day experience
resperidone neuroleptic 1-6 mg a day weight gain very expensive
(resperidal)
Lorazepam sedative 4-20mg a day slurred very safe
(Ativan) speech
Olazepine neuroleptic 1-10 mg a day weight gain new, very
(zyprexa) expensive
The drugs for depression are shown in the MDD handout.
There is unfortunately no specific treatment of this type for biploar illness. There are a few types of counseling used in bipolar children.
If you have bipolar illness, it is a terrifying experience. Children need to learn all about it from Doctors, nurses, families, and other people with bipolar illness.
This involves teaching families and children about the impact of noncompliance, how to tell if you are relapsing, and what to do to avoid getting sick. In this category are things like avoiding substance abuse and not getting sleep deprived.
If a child has been ill with bipolar illness, it has, by definition, been rough on some of the other people in the family. Other sibs have often been ignored. Some members are scared of being alone with the person. Others might think it is someone's fault (or theirs). Often pediatric psychiatrists and other professionals need to meet with families to work this out.
Intergration into the community
If a person has or had bipolar illness, they need help getting back into the community. The same concerns that family members have are often found in the community and school. Pediatric Psychiatrists and other professionals often need to work with teachers, community groups, and churches to help vicitms of bipolar illness get back into the mainstream of life.
Remember those initial examples? Here is how the four steps might play out in those cases.
When Justin arrived with the RCMP, he was absolutely wild. Even though he was only 11, it took five adults to bring him in. After quickly obtaining consent from his parents, Justin was given 4mg of Ativan by needle, as he would not stop screaming long enough to take a pill. A half hour later, he was a lot calmer, but still very wound up. The Ativan was repeated a few times that day and he slept 12 hours that night. He was started on Lithium as it had worked very well in his uncle who has bipolar illness. Over the next two weeks, he returned to his old self, but was a little depressed. That was the easy part. Justin's mom and dad blamed Justin for getting ill. His older sister was afraid of him. The school wanted a full time aide to be with him at all times in case he "lost it". Well, between the pediatric psychiatrist, a psychologist, and the uncle, they finally got it all straightened out. Justin returned to most of his previous activities and also started scouts. Six months later he is well, but kids still whisper about him.
After those two weeks of hypomania resolved, Sarah was mostly alone. Her friends thought she was too wierd. She stopped playing basketball, did worse in school, and started smoking. She started writing very dark poems and finally decided she wanted to kill herself and told her ex-boyfriend, who told her parents, who brought her to the hospital. The physician was busy and didn't ask about hypomania. Sarah was put on Zoloft 50mg a day for a week. At that point she was to see the pediatric psychiatrist. After a week she was certainly different, but not exactly better. She couldn't sit still, she was very restless, and had kicked her dog hard enough to break the dg's ribs. After a few days in the hospital taking nothing, she returned to her old depressed self. Sarah didn't care if this was a drug side effect or drug induced hypomania. She was not going to take any more medications. So, the parents worked hard at getting Sarah involved in some new activities. If she didn't go do these things (writing class, drama club, basketball) she would have to go see the pediatric psychiatrist (who she hated) or go to the hospital (which she hated even more). So, with an Aunt acting as counselor, she eventually did pull out of her depression, except in the winter, when she still was a little more irritable than usual.
After Alex was on probation for two months, his parents figured he must be back into drugs or else getting ill again. A few urine tests (for street drugs) later, it was obvious it was a relapse into hypomania. He became more violent at school and at home. Between the pediatric psychiatrist, the parents, probation officer, and the school, they decided to admit him once more to the hospital. He was in the hospital almost two months by the time he was tried on epival, lithium, and finally stabilized on a new mood stabilizer, Lamictal. Unfortunately, his mother had reached her limit of bipolar illness. She would not let him return home, even if he was better. The school basically said the same thing. So Alex ended up in at his Uncle's about 100 Km from home. Luckily, his Uncle was not fishing, because Alex needed a lot of attention to keep his mind off all of what had happened. They spent the winter setting snares, ice fishing, hunting, and playing pool. By spring, after a lot of encouragement from everyone, the mom agreed to take him back for a few months.
Pediatric bipolar illness is rarely mild. It frequently causes major turmoil in the life of the child, community, and family. What is worse, it often hits children who already have a neuropsychiatric problem. Sometimes the medical treatments work great, but often they do not. Even when they do, there can be a lot of problems that remain with families, compliance, and getting people back into their old lives. Since this is a disorder characterized by numerous episodes, the relapses can absolutely destroy patients, familes, and helping professionals.
If you have a child with bipolar illness, you need to take care of yourself. Most likely, this is going to be a long term severe stress on you and your family. See the hints on managing this in the conduct disorder pamphlet.
Perhaps the hardest thing about Bipolar illness is that it is treatable. You can make a difference. As the examples show, there is usually no medical "magic bullet". Dealing with an illness like this takes a lot out of everyone, but there is no alternative. Giving up on a child with bipolar illness, regardless if you are a parent, patient, child, sibling, doctor or other helping professional, is a receipe for suicide.