Typical Teen Behavior or Something More?

From The Quarterly, September 2016

Advice on Caring for Children and Adolescents with Bipolar Disorder

David Miklowitz, Ph.D. is Professor of Psychiatry in the Division of Child and Adolescent Psychiatry at the UCLA Semel Institute, and a Senior Clinical Research Fellow in the Department of Psychiatry at Oxford University. His research focuses on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder.

Among his many honors, he is a NARSAD Young Investigator (1987); Distinguished Investigator (2001); and in 2011 was the Foundation’s Colvin Prizewinner for Outstanding Achievement in Mood Disorder Research. He has published over 250 research articles and eight books, including The Bipolar Teen: What You Can Do to Help Your Child and Family (with Elizabeth George) and The Bipolar Disorder Survival Guide.

Symptoms of bipolar disorder aren’t the same in adults and children. Can you start by describing the disorder in adults?

In adults, bipolar disorder is characterized by swings from severe states of depression to states of either mania or hypomania (a less intense form of mania). A full manic episode usually lasts at least a week, although for some people it can last several weeks. The person becomes elevated in mood or extremely irritable, and they feel grandiose—they have all sorts of ideas about things they’re going to accomplish or powers that they have acquired. They sleep very little or not at all, and don’t feel tired the next day. They are loaded with energy, and they speak fast. They often do very impulsive things—like spend a lot of money, or have sex with a lot of partners. And then these episodes swing to the other extreme, depression. They lose interest in everything. They become very fatigued, and they’re often suicidal.

What about in adolescents or younger children?

About 1.8 percent of children under age 18 have some form of bipolar disorder. The majority of cases emerge between ages 15 and 19, but there’s quite a bit of variability, anywhere from childhood up to later adulthood. Adolescents have longer periods with “subthreshold” symptoms than adults, or more frequent switches between depression and mania. Children and adolescents also develop more of what we call mixed episodes, or combinations of mania and depression. Here’s a scenario: The child comes in irritable and says, “There’s no point in the world and my life is terrible,” but they’re also talking rapidly and moving a mile a minute. Some people describe it as a “tired but wired” feeling. When adolescents have depression and anxiety, we also worry about suicide, because adolescents can be impulsive.

With younger children—four, five and six years old—the disorder is not very common, but there are enough cases on record that we know it can occur. The children usually have a family history of bipolar disorder. In addition to problems with sleep, increased activity, and impulsiveness, they may go from explosive and aggressive to hyper-sexual— even five-year-old children have been known to say and do inappropriate things. And once in awhile we see delusional thinking, things like, “I have 100 brothers and they live on the moon.” When we have a child who shows those signs, we often don’t know whether it’s bipolar or some other disorder, or even a developmental transition. Mania is often confused with attention deficit disorder, and both poles can have a significant anxiety component.

Bipolar disorder has a strong genetic component. What do you tell parents who blame themselves for their child’s disorder? Among women who have bipolar disorder, the rate of the disorder in their children is around 10 to 15 percent. But there’s no clear agreement on what exactly is inherited. It’s probably not bipolar illness per se but something like vulnerability to mood swings when under stress. After all, the majority of people whose parents have bipolar disorder don’t actually develop it themselves. This is what I tell parents: “There are many genes and they are inherited in complex ways. We don’t know the actual mechanisms, but we suspect it’s a combination of genes, environmental factors, and changes in cells and circuits in our brains. It’s not like blue eyes or blonde hair. None of us can control what genes we bring into this world, or how those genes get translated into illness in our children.”

Some typical teen behavior—such as unstable moods and risky behavior with drugs or sex—can also be expressions of bipolar disorder. How can a parent tell the difference?

This is one of the toughest problems for parents. The key is the clustering of unstable moods with other symptoms. Let’s use the example of a child who goes snowboarding, jumps off a cliff, and breaks his leg. Is that a manic symptom? Well, does he also have a decreased need for sleep? Is he saying grandiose things like, “I’m the best snowboarder in the world?” Is he staying up late at night and talking faster? Does his behavior stand out, even among his friends?

If parents suspect a problem, they should first talk to the child and say, “Here’s what I’m seeing. Do you think you need to talk to somebody?” The child will probably say no. Then you go a little further and say, “Why do you think you’re more irritable? It must be hard to get through the day with such little sleep.” If you suspect that he or she does have a mood disorder, get an evaluation with a psychiatrist or a psychologist—a diagnostic evaluation that includes a full medical history. Ask for recommendations on next steps— knowing that no one doctor has all the answers.

If there are questions about whether your son or daughter’s behavior is healthy or not, it may be best to just do “watchful waiting” for a while, before insisting on medications or therapy. If your child has expressed any suicidal ideation and depression, get rid of any weapons in the house and make sure alcohol or prescription medication are not easily available.

You emphasize the importance of monitoring moods. What are the best ways to do that?

Keeping a record is often the first step in knowing whether a child needs treatment. There are all sorts of mood charts you can download as apps (for example Mood Reporter or IMoods). They let you record what time you woke up, and when you went to bed. You record your mood at various times during the day on a scale, say from negative five— depressed—to plus five, which is hyper-activated or overly happy. Ideally the child keeps the chart, but if they won’t this is something the parents can monitor as well.

When you take a look at the end of the week, you will find patterns. For instance, the child’s parents are divorced, and over three weeks you notice that her mood goes down right before she’s about to go to the other parent’s house. You can also use a chart to track whether a new medication is working or causing agitation and sleep loss.

What are some common triggers for mood episodes?

One common trigger is a change in sleep-wake cycles. You’d be amazed by the number of phone calls we get at our clinic in the first couple weeks of the high school semester. Suddenly children have gone from sleeping until 10 or 11 a.m. to getting up at 6 a.m., and it’s counter to their natural biological rhythm. Sleep is so important in teens that we tell parents it’s important to have family rituals around bedtime—certain times when you start getting ready for bed, when all electronics are shut off, and when the lights go out.

Interestingly, both positive and negative life events can be triggers for mood episodes. Breaking up with a girlfriend, loss of a grandparent, high levels of criticism from a parent— those can all trigger depression. In addition to changes in sleep, positive events can trigger mania, such as getting a date to the prom or getting elected class officer. Look for evidence that the teen is “revving up” after these events or sleeping less and less.

Anything that’s a stimulant—cocaine and amphetamines— can trigger mania. Alcohol is more associated with depression. We have no evidence that marijuana causes manic or depressive episodes, but smoking marijuana regularly will interfere with the effectiveness of mood stabilizers. Another problem with marijuana is that people tend to go off their mood stabilizers, thinking marijuana will work as a substitute. But it doesn’t, and it can interfere with sleep. We ask parents to be aware of possible early warning signs of mania or depression, and they might be very subtle things. For example, the child may be hiding food under their bed, watching TV to see if their name is called, or calling relatives they haven’t spoken to in years. When parents notice, that’s a time to call the physician, and maybe get a change in medications to stave off the need for hospitalization. They may not be able to prevent their child from having a mood swing, but they may be able to prevent her from having a full manic or depressive episode. If we can reduce the severity, their lives are going to be easier.

How can parents find the right doctor?

Try to find a psychologist or psychiatrist who knows about childhood mood disorders. If all they tell you is that they look for unacknowledged childhood traumas, then you’re not in the right place. And you probably don’t want to see a psychiatrist who just has a general practice. It’s best to go to a child psychiatrist who has some experience with mood disorders. Beyond that, I think it’s a question of finding a doctor you can communicate with, one you’d be comfortable calling in an emergency, and most importantly, one your child wants to talk to.

What role should parents have in the child’s medications?

The parent’s job is to get their child in for an evaluation. The doctor is the one who says, “I think you should start taking this medication.” A parent should know what the treatment options are, and then discuss it with the child. If the child is only five years old, obviously they aren’t in a position to decide on their own medications. But when the child is 15 or 16, you don’t want to force it, because if you force them to take medicine they’re just going to refuse them later. You need the child’s buy-in, and the best way to get buy-in is to let the child play a role in the negotiation of medication and dosages.

It’s also very important for both parents to be on the same page, and that’s often the hardest thing. I can’t tell you how many times I’ve seen children or adolescents who just go off their medications one day, and the parents come in for a family session and they tell you, “I don’t know why he went off his medications.” When I explore a little more, I almost always find that at least one parent didn’t believe the medication was a good idea, and the child knew that.

If the child still resists medications, I think it’s the job of the therapist or the psychiatrist to find out what the issue is. It could be side effects—they don’t like what it does to their body—or the stigma of diagnoses like depression or bipolar disorder. They may enjoy the high or manic feelings. Parents also need to acknowledge the side effects and not play them down—side effects like weight gain or acne can be real problems for children.

You recommend “family-focused treatment” for children with bipolar disorder. Can you explain what that involves?

It’s therapy for the family—the parents, the child, and sometimes siblings as well. It has three components: psychoeducation, communication training, and problem-solving skills training, and there is a long history of using therapies with a similar structure to treat other disorders, like schizophrenia. It’s weekly at first and then switches to biweekly. When we combine family-focused treatment with medications, the outcomes are much better than if we use medications alone.

In psychoeducation, we get the child to explain what the episodes are like. We ask the parents the same questions. We get them to have meetings every week to discuss what issues in the family are playing a role in the child’s mood episodes, either positively or negatively. We end psychoeducation with what we call a relapse prevention plan, where we have the family and child list signs that an episode is starting, and plan what to do when this occurs, and what obstacles they foresee. It’s best to make these plans when the child is well and able to look back and see what would have been helpful during the episode buildup.

Then we move on to communication training. We teach people to listen actively, to make requests, to balance positive feedback with negative. That’s done with role playing. For disagreements, I recommend parents use what’s called the “three-volley approach.” If you set some sort of limit, that’s volley one. If the child responds, “That’s not fair,” that’s the second volley. You say, “Let me explain again why I think this is fair,” that’s three volleys. Now, if the child then comes up with another argument, you say, “I explained myself. We can discuss it some other time, but for now, the discussion is over.” And you stop talking.

At the end of treatment we move into a phase where we identify problems that are not getting solved in the family. That might be cleanliness, or money, or taking care of the family pets, or getting back to school. We give the family a structure for solving problems and evaluating solutions, so they feel like they have some control over the things that are happening to them.

How can parents best advocate for their children at school?

First, you have to ask if the child’s at the right school. If there’s a problem at school, is it being driven by the mood disorder, or is it that the school system is not a good fit? It’s good to set up an IEP, which is an individualized educational program. The school does an evaluation, and you sit down with the teachers and the administrators and develop a plan specifying the kind of classroom, the classes, the length of the school day, and more. That’s a legally binding document that the school is obligated to follow. Then the parents meet with the school every couple of months to see how it’s going.

Remember that the child wants to feel normal. My sense is that peers are getting more familiar now with what it means to have psychiatric problems, and there are a lot more children on medications and IEPs now, but nevertheless children feel very stigmatized. Parents should help their child avoid thinking that they’re crazy or are not likable. And that’s where a therapist can be of help too.

Speaking of stigma, do you think children should tell their friends about the diagnosis?

Children have a tendency to tell everybody, and don’t really think through the implications. A child will be heartbroken when a friend’s mom won’t let him play because she’s afraid of the bipolar disorder. It’s OK to tell someone if you have a goal in mind. For instance, a friend can recognize when your son or daughter is getting agitated and call you. A teen might decide to disclose the illness to a new girlfriend or boyfriend. But I also tell them to be aware of the ways that information can be used against you, by peers, teachers or school administrators, and prospective employers. It’s sad, and it’s what we’re fighting against, but it’s also the truth.