by Michael J. Labellarte, M.D.
Almost everyone has a typical reaction to seasonal changes. In springtime, many people feel more energetic, optimistic, and happy. However, the shift into spring can have a counter-intuitive and powerful negative impact on people with mood disorders. Moods do not just perk up in spring and dial down in fall, instead people who suffer with mood disorders are jolted by the change in sunlight intensity during those changes in season. The children, adolescents, and young adults I treat for mood disorders often struggle most around springtime.
Unstable mood describes inconsistent and unpredictable mood changes, for instance excessively happy for no reason, enraged for no reason, unusually sad for no reason, or excessively irritable for no reason. Such unstable moods are problematic when they endure for a discrete period of time (e.g. days, weeks, months) or when they cycle over hours or days during a discrete period. Unstable mood is a buzzword, and the most classic and the most severe disorder of unstable mood is called bipolar disorder.
Two major misconceptions about bipolar disorder exist:
Alternating moments of excessive happiness (euphoria) and excessive sadness (dysphoria) are required to make the diagnosis.
It is a life sentence that does not improve or go away.
What is true is that pediatric bipolar disorder (PBD) can be devastating to children and their families. Children with the disorder have unstable emotions, unstable thinking, and unstable behavior; as a result, these children can be enormously impaired. The children often show up in my office for an evaluation during a crisis when school personnel and other adults in their lives have proclaimed an emergency. The symptoms of pediatric bipolar disorder can be outrageous, ranging among ribald statements, bizarre thoughts, unsafe intentions, and explosive behavior.
The diagnosis of pediatric bipolar disorder is controversial. I have no doubt that bipolar disorder is a valid disorder in children; it exists. I also have no doubt that the medical and psychological community does not always reliably diagnose bipolar disorder in children – we do not often agree when it is present in a child, and when it is not present.
The controversy is driven by the same factors that make PBD difficult to recognize and difficult to treat. Most noteworthy, it is easy to attribute signs and symptom of pediatric bipolar disorder to other clinically important psychiatric conditions that generate their own controversy. The first instinct for a mental health professional is to blame severe mood and behavior problems on competing diagnoses such attention-deficit/hyperactivity disorder (ADHD). Every symptom of ADHD arguably overlaps with every symptom of bipolar disorder, making it very difficult to distinguish the two. The “cardinal symptoms” of PBD are the most convincing qualifiers, but they are also difficult to recognize. The most convincing symptoms of PBD (which are hard to believe once actually seen) focus on mania, such as euphoria (which can appear as silliness, spaced out, confused, or intoxicated), grandiosity (an inflated sense of self-worth that looks like false confidence, self-centeredness, and/or arrogance combined), and rage (an extreme of irritability, much bigger than anger or a tantrum). Excessive “goal-directed behavior or energy” is a required symptom. Racing thoughts (of a non-anxious variety), hypersexuality (at any age), decreased need for sleep, lability (rapid and unpredictable but substantial fluctuations in mood or affect), and tedious argumentativeness (a combination of irritability, grandiosity, and accelerated thinking) are also pretty convincing symptoms of accelerated mood during an episode of bipolar disorder. Severe and treatment resistant depression (with excessive sleep, excessive eating, and negative thoughts) that fluctuates between fair mood and moribund sadness is very suspicious of an episode of bipolar depression even if mania has never surfaced.
Symptoms of PBD can also be mis-attributed to bad behavior, ineffective and “bad” parenting, or “spoiled” temperament/disordered personality. Ironically, unrecognized and untreated PBD is extremely disruptive to adaptive behavior, development of coping strategies, personality formation, parent-child relationships, and other family dynamics.
Unfortunately, there is no psychological test or laboratory test to diagnosis PBD, which is based on a clinical diagnosis. Once diagnosed, PBD requires medication, psychological and other social treatments, and reinforcement of the anchors of a healthy lifestyle (described below). Pediatric bipolar disorder can be managed into remission and your child can then return to their usual personality, their usual behavior, and their usual life. Pediatric bipolar disorder is fixable – once you start the right medication(s) it is only a matter of time, but it can take a long time to stabilize the symptoms. Bipolar disorder at any age tends to reoccur over time, with relapses often measured years apart. The critical thing is to maintain symptom remission. While medication may not be required after a year or so of remission, it is important to maintain the anchors of a healthy lifestyle – productive extracurricular activities, appropriate nutrition and adequate hydration, a routine aerobic exercise regime, and most importantly a consistent sleep cycle.
Should a parent worry if their child is bouncing off the walls, doing cartwheels on the couch, getting into things, arguing over the television/iPad/cell phone, fighting with family members, disobeying, acting unusually absentminded, or wasting time doing routine things like changing out of their pajamas? Maybe or maybe not. On the other hand, it is time to worry if there is a strong family history of mood or behavior problems, if there is a strong seasonal component to serious mood symptoms, if there are cardinal mood symptoms (as above), if a child is out of control, if a child is in jeopardy at school or in extracurriculars, if behavior or attitude becomes intolerable at home, if a child is suffering emotionally, etc. Start the evaluation process by checking with your pediatrician and/or other available experts to guide you on the path to finding a proper explanation for such outsized symptoms.
Dr. Labellarte recommends the following websites to stay informed on pediatric bipolar disorder:
National Institute of Mental Health, www.nimh.org.
American Academy of Child and Adolescent Psychiatry, www.AACAP.org.
National Alliance on Mental Illness, www.NAMI.com.
The Depression and Related Affective Disorders Association, www.DRADA.com).
Read Dr. Labellarte’s interview with Baltimore’s Child on Pediatric BiPolar
Michael Labellarte, M.D. lives with his family in Baltimore. He is an accomplished Child and Adolescent Psychiatrist who practices in Baltimore, Anne Arundel County, and Howard County in Maryland. Please visit www.cpeclinic.com website to see his areas of expertise. He can be reached via email at Dr.Labellarte@cpeclinic.com.