'School is a nightmare! Isabelle* can't wake up in the morning, often falling asleep three times after being woken – even after eating breakfast. She has been late for school more than 110 days this year. She doesn't write her homework down and is constantly in detention for not having brought her books or done her homework. She struggles to make friends and currently has only one.
"She also tends to be bullied a lot. One afternoon last week she had two episodes spurred on by her being in trouble at school and having to spend breaks outside the office. When she got home things quickly escalated – from her telling me that she had a bad day at school and her teacher hates her to her saying I make her life terrible at home and accusing me of not wanting her."
Jessica's* daughter, Isabelle, is 11 and has been diagnosed with childhood bipolar disorder.
Also known as paediatric or early onset bipolar disorder, this illness has been found to affect children as young as six. According to the National Alliance on Mental Illness in the United States, about 7% of American children seeking treatment at psychiatric facilities fit the criteria for this condition.
Although no local statistics are available, Johannesburg child psychiatrist Dr Linda Kelly said this diagnosis was rare but legitimate. Agreeing on the rarity of the condition, Tara Hospital consulting child psychiatrist Dr Sonja Vermaak said: "I've seen typical presentations of bipolar disorder in young adolescents, but it is extremely rare in the pre-adolescent group."
The topic of childhood bipolar disorder is quite controversial. Some experts believe the adult diagnostic criteria cannot be accurately applied to children and are therefore excited about the possible addition of a new diagnostic category for children in the latest edition of the diagnostic manual the psychiatric profession uses. The new edition is due to be released next year.
Others specialise in this condition and have a completely different perspective, as do the parents of children who show heightened emotional reactivity and a difficulty in regulating moods and behaviour.
Bipolar disorder is a brain illness characterised by extreme changes in mood, energy, thinking and behaviour. The mood changes that occur are referred to as episodes and these can be depressive episodes, manic episodes or a mix of both, which is more common in children.
A growing body of evidence suggests that childhood bipolar disorder involves more rapid and severe cycles of moods than adults with this condition experience. This may result in chronic irritability.
"Children may shift between moods more frequently and may experience symptoms more often," Kelly said. "Making a diagnosis is complicated by this rapid cycle, which may make it seem as if a child is simply being difficult. Many of the symptoms of this condition also overlap with those of other mental illnesses."
Differentiating children with bipolar from those with attention deficit hyperactivity disorder or even depression, for that matter, has proven to be a challenge owing to the similarity of the symptoms.
In diagnosing bipolar disorder, the psychiatrist does not use brain scans or blood tests, but asks the parents detailed questions related to their child's mood and sleep patterns, energy and behaviour and family medical history. The causes of bipolar disorder include genetics.
"I find that children with this condition usually have a parent living with the same illness, if not both of them," said Kelly. Other contributing factors include abnormal brain function and structure as well as a stressful environment, which can trigger the disorder.
The National Alliance on Mental Illness reports that children living with bipolar disorder seem to be affected more severely than adults with this condition. These children are more at risk of school difficulties, substance abuse and suicide, and anxiety and attention deficit hyperactivity disorders often coexist. The illness severely affects children's school performance and social relationships. They also have low self-esteem and anything that threatens their comfort and self-confidence negatively affects them.
Because of the educational challenges in teaching children with extreme mood shifts, a thorough understanding of the condition and the unique needs of these children in a classroom environment is needed. Lee Rodrigues, co-founder of Bipolar Kids SA, a South African organisation offering support to parents of children living with bipolar disorder, said: "Because of the fear of being ridiculed or humiliated in class, together with their own poor self-image, the bipolar child will not tell anyone at school how they are feeling inside. Instead, they bottle this up and once they arrive home the pressure just explodes into tantrums, crying, threats of suicide, banging doors and even violent attacks on the parents."
On the important topic of suicide, particular attention should be paid to signs of suicidal thoughts. After experiencing an episode, children with bipolar disorder often feel terrible about it and some say they would rather be dead or wish they were never born.
Lilly* had this to say about her daughter: "Anna* once asked her psychiatrist to please give her enough tablets to make her go to sleep and die so she'd never have to wake up again. When asked if she didn't think the people who loved her would miss her, she replied that we'd soon get over it and live a far better life without her."
Laura*, a six-year-old diagnosed with bipolar disorder, asked: "Mum, do we have a gun in this house? I want to shoot myself. I'd rather be dead than angry. Wouldn't you rather be dead than angry?"
Caring for a child with bipolar disorder is extremely emotionally demanding and incredibly stressful for parents and places great strain on their relationship. Quality time alone is essential, especially because many children living with bipolar experience anxiety and separation issues and become very attached to one of their parents, generally the mother. A lot of them describe sleep problems and difficulties with getting their children to sleep in their own beds, which puts even more strain on the parents' relationship.
"Support is needed not only for the child affected, but for the entire family," said Cassey Chambers from the South African Depression and Anxiety Group.
Having a support system in place, such as a grandparent, aunt or even a babysitter who can allow the parents some time away together, can help to alleviate this stress. Alone time with siblings is just as vital – these children often do not receive the same amount of attention as the child affected by the disorder and may feel anger or resentment towards that child. They also need to learn how best to handle their brother's or sister's emotions and behaviour.
Treatment for childhood bipolar disorder is continual and focuses on managing the symptoms. It can include medication, which requires the monitoring of side effects and continual consultation with your doctor.
"What's most important to consider is the child's quality of life. Improving this is one of the major goals of treatment," said Kelly.
It is also vital that parents never suddenly stop giving the child their medication without the doctor's guidance. It can be dangerous and worsen their symptoms. It is possible that it may take a while to get the combination of medication right and that it may need to be adjusted during the course of the child's treatment. To support the treatment, use a mood chart and track the child's moods, behaviour and sleep patterns. This will enable parents to monitor the illness and show the doctor the treatment's efficacy.
Often, a child psychologist will also be involved in the process, working with teachers and patients as a team.
Vermaak said: "Medication should always be prescribed in conjunction with ongoing parental support and, very often, therapy for the child."
She advises parents to learn as much as possible about their child's diagnosis and ask questions of the professional managing their child's condition.
"Parenting needs to be understanding and sensitive to the fact that children with this illness struggle at times to control their behaviour. A firm but kind approach is best," said Vermaak.
Lee Rodrigues warned: "Be sure that you can distinguish between bipolar episodes and simply bad behaviour. Just because your child is diagnosed with bipolar disorder does not mean they are allowed to disobey rules and disrespect others."
Echoing her sentiments, Vermaak is concerned that childhood bipolar disorder may be an "easy" diagnosis for children with behavioural problems: "It may seem easier to label and medicate this behaviour than to manage it through other techniques. That's why an accurate diagnosis is so important. In some instances, a second opinion may be valuable."
One of the biggest challenges in managing this condition is that the symptoms and presentation of the disorder often change as a child grows and caregivers find they need to be creative and flexible in adjusting treatment to ensure it is as effective as possible.
To support this, parents should form a close relationship with the child. Help them by explaining that the treatment will make them feel better, by listening to them and handling their mood episodes with patience and ensuring they take the time just to be children and have fun.
Dessy Tzoneva works for the South African Depression and Anxiety Group
*Names have been changed.