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Bipolar Disorder in Children and Adolescents

Though bipolar disorder is a lifelong condition, there are certain approaches that mental health professionals can use to treat it in both adolescents and adults.

Bipolar Disorder in Children and Adolescents

Estimated watch time: 55 mins

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Presentation Materials:

About Michael Pipich LMFT :

Michael Pipich holds a Master of Science degree in clinical/community psychology from California State University, Fullerton, and a Bachelor of Science degree in psychology from Loyola Marymount University. He is a licensed marriage and family therapist (Colorado license MFT744), and he has treated a wide range of mental disorders and relationship problems in adults and adolescents for more than 30 years, both in-office and via online teletherapy.

Michael is also a national speaker on bipolar disorder. His book, Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder (Citadel Press, 2018) is widely regarded as an important work in the field of bipolar treatment. Michael is also known as an expert in many legal cases involving psychological treatment and the law, and has taught several graduate-level psychology courses. He was selected as a collaborating investigator by the American Psychiatric Association, performing clinical field trials for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). He’s been featured on television, radio and in print media on a variety of topics, and he is the host of Breakthrough with Michael Pipich on the VoiceAmerica Network.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Hi, everybody. Welcome to our community education event. My name is Valerie, and I am part of our community outreach team here at The Recovery Village in Palmer Lake, Colorado. For those of you who don’t know about our organization, The Recovery Village is a part of Advanced Recovery Systems, which is an integrated behavioral health care company that treats addiction, substance use disorders, eating disorders and co-occurring mental health issues. We have a network of nine facilities across the country, including an adolescent program for ages 13 to 17. After the event, we will stay on the Zoom for anybody who has further questions about our services, and you can also put those in the chat. 

Moving on to our guest speaker, I’m excited to introduce you to Michael Pipich. Michael is a psychotherapist with more than 30 years of experience diagnosing and treating bipolar disorder. He holds a Master of Science and Clinical Psychology from California State University Fullerton, and a Bachelor of Science in Psychology from Loyola Marymount University. He currently practices at the Colorado Center for Clinical Excellence in Denver, and he is the author of “Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder.” Michael is also known as an expert in many legal cases involving psychological treatment, and he has taught several graduate-level psychology courses. He’s been featured on television, radio and print media on a variety of topics, and he is the host of “Breakthrough With Michael Pipich” on the VoiceAmerica Network. Lastly, Michael was selected as a collaborating investigator by the American Psychiatric Association, performing clinical field trials for the DSM-5. He is a clinical fellow of the American Association of Marriage and Family Therapists. So, thank you for being part of our event today, Michael, and the floor is yours.

Michael:
Thank you very much, Val, and thank you to Ashley and to everybody at Advanced Recovery Systems for the invitation, and thank you all for joining from wherever you are. Obviously, there’s so much going on in the world. I was just kind of reflecting this morning on how important it is for us to kind of take a moment to get away from Twitter and the news and everything else. And by the way, I hope everybody on the Gulf Coast is going to be doing okay. There’s so much going on, and for us to be able to gather here together and share what I believe is a very important clinical topic, it helps us, I think, to really stay on track in terms of the work that we’re all charged to do, even under these really, really difficult circumstances. So, thanks again for being here and sharing this moment with me.

I have a real passion when it comes to treating bipolar disorder for a lot of reasons, and very happy to have the book out, “Owning Bipolar,” available for patients and families and for our clinicians as well. I think to really delve into not just the clinical aspects for a better understanding of the disorder itself, but the very experiences that people have with respect to bipolar in their lives, be it the individual with the condition but also family loved ones — people around that person where bipolar is in their life as well. And as I have been doing trainings and speaking not just to professionals but in the community as well, one of the hottest of the subtopics, so to speak, has to do with children and adolescents with bipolar disorder. The other kind of hot subtopic is substance abuse with bipolar disorder. So, those are the things I think, for a lot of people, really stand out as necessary. And so I think, again, it’s important for us to share some of this information today. 

I hope it’s helpful. I do have a lot of slides and information to share with you within an hour. It’s a bit compressed from my usual larger, all-day training and stuff like that, where I really delve into various subtopics in the realm of bipolar. But hopefully, this provides some insight And with regard to whatever questions you might have or issues that you want to share, certainly if we don’t get to those today, I would welcome your questions at my website, which is MichaelPipich.com. You can go there; there’s a link to send me an email. Also, if you’re interested in the notes that I have in front of me that I’m looking at for today’s presentation, you can also download it. There’s a tab there that says “events.” So, MichaelPipich.com/events, and you’re free to download the notes from this presentation. And also, there’s references available to you there as well if you want to check out some of the research that I’ve used to formulate this presentation.

Moving forward, let’s see if we can do that. We’ll start with some general facts about bipolar disorder, and then we’ll go to the more specific issues as they relate to kids, children and adolescents in particular. I call these the not-so-fun facts about bipolar disorder, but I think they’re really important to understand and use as a springboard. The DRAM court 2012 study looked into the duration of untreated bipolar disorder, and there’s the statistics for you on your screen. Basically, what they found is that between the first identifiable bipolar mood event and a treatment provided specifically for bipolar disorder — in the average person with bipolar disorder — is about 10 years. You can see the mean, 9.6 years. I called that the 10-year gap in treatment. And along with that, about an average of four mental health professionals are consulted before a person with bipolar disorder is actually diagnosed with the condition. So, we already know from this study — and it certainly aligns with much of my experience — that people wait years and years before they’re actually diagnosed,

Especially in outpatient settings, the most undiagnosed bipolar disorder individual would present with major depression. In other words, if somebody comes to treatment, including a young person, usually what we see presented is something that is more identifiable as major depression. With kids, that might be other behavioral problems, academic problems, attention deficits, relational interpersonal issues and so forth. Along with the diagnostic problems, substance abuse — because it is particularly common with bipolar disorder — is what very often treatment professionals sort of see as the most salient problem and drives a lot of people, including young people with bipolar disorder, to treatment initially. But we also know that about half of all people with bipolar disorder — kids and adults — will have had some type of substance use disorder in their life. When we see that as the obvious of the salient problems, it’s always important, I believe, to delve into the history of that individual the best that we can as clinicians, along with whatever corroborating data we can get from other professionals or for family and so forth that might lead us down the road to the underlying possibility of mood swings. And having substance abuse problems often masks those symptoms as well, so after a period of time of sobriety, it’s especially important to delve into that history and to observe that individual to see if mood swings are readily available to assess. 

But here is my No. 1 reason why I think it’s so important to understand what it means to have an underlying bipolar disorder that would otherwise go on identified or untreated. In bipolar disorder, the suicide potential is 20 to 30 times higher than what we see in the general population. Lifetime risk for suicide and bipolar disorder is 20%, and it’s one in five people with bipolar disorder. And this next bullet point — the third one down there — that’s right from the DSM. I promise you the first time that I saw that, I must have read that another dozen times to make sure I really was reading that correctly. One-fourth of all deaths by suicide may be bipolar-related, and there is an increasing risk with age. So, people with bipolar disorder who aren’t treated don’t mellow with age, as we would like to think most of us would otherwise, but in fact become an increasing risk for suicide. So, when you think about that with young people and know how dangerous suicide is among our youth and how prevalent that is, it’s sort of like the No. 1 or No. 2 leading cause of death among young people. In people with bipolar disorder — young people especially — the risk is very, very high.

Along with untreated bipolar disorder is greater incidents of violence, substance abuse and relapse, hospital admissions of all kinds. And a very important one for anyone — but again, when it comes to kids, I think this is very revealing — mania induced by psychotropic medication. In other words, the wrong psychotropic medication, with respect to bipolar disorder. And in that, we would see primarily with antidepressant medications — SSRIs, SNRIs — that can induce mania, particularly when there is not a mood-stabilizing agent along with that medication. But also, very often, we have young people diagnosed as ADHD, which may or may not be an appropriate diagnosis. They may have bipolar disorder co-occurring or it may be mistaken for bipolar disorder, in which case they would be given psychostimulant medication, and as a result of that, that can increase irritability, agitation and possibly a manic episode. By the way, I happen to think there’s some research to suggest that this may, in fact, be the case when we see warnings of the increase of suicide potential as a result of antidepressant medication. 

What you may have very often — not always, but very often — is a young person with an underlying, undiagnosed bipolar disorder. And because it can immediately increase agitation and mania, it could heighten any existing feelings of suicide. So, the issue of diagnosis and early treatment becomes, I think, not only important from a typical clinical and therapeutic standpoint, but just in terms of early detection that will save lives. That’s why I believe, in this particular instance, it’s very, very important. Moving on a little bit, I think the facts surrounding this particular issue — clinicians often tend towards evaluating presenting symptoms and can miss historical data about mania or hypomania. Again, this is in general — most of the research about bipolar disorder is in adults. And it’s true, I think, with any kind of psychopathology — except for those that are very, very specifically about kids. And because bipolar disorder is generally thought of in terms of adolescents to early adulthood, there’s not a ton of research that I can find current about what it is, what that experience is and how to detect it in children.

We’re going to look at some things today that I hope will be kind of illuminating. And when I present this to you, please understand I present it humbly because the more that I’ve learned in my research in bipolar disorder has trained me better. Particularly when I was writing the book and researching for the book itself, it really caused me to think back to patients that I’ve taken care of in the past. Certain individuals kind of popped into my mind where, you know, that person might’ve had bipolar disorder instead of whatever I thought we were dealing with at the time. So, I humbly share with you that we can all, I think, do a better job. And whatever questions and insights that you can provide likewise, I think, would be very, very helpful in our therapeutic community as we build an improved knowledge base and awareness of how to deal with this problem.

So, moving on a little bit in terms of causation, that image on your screen — I want to say what, really, that is. That’s a microscopic image of stem cells. And the reason that I put that up there along with the bullet point next to them is that the team at the University of Michigan found that the stem cells in people with bipolar disorder develop differently than those who do not have bipolar disorder. So, I think the way that I read that is that bipolar disorder starts in the beginning of life, and I think we all know that stem cells are those basic building blocks that eventually differentiate into other kinds of cells and tissues and organs and so forth. But think for a moment that in the basic building block of somebody that has bipolar disorder, they’re going to develop differently. And specifically for our purposes, they develop differently neurologically, compared to people who do not have the genetic predisposition for bipolar disorder. I think that that’s so important for so many different reasons when it comes to helping young people and, in particular, helping their families — their parents in particular — to understand the nature of bipolar disorder. It’s important to understand it has been with them since the very beginning of their lifespan and not something they necessarily acquire later in life.

Now, having said that, there are other internal or endogenous factors, including endocrine and metabolic changes, and the big one for all of us would be puberty. That’s, in fact, where we begin to see anyway, typically, the kind of recognizable symptoms and episodes in bipolar disorder that we are familiar with. I think, classically and with respect to DSM criteria, we know that the average age of onset is right around 18 to 20, depending on bipolar I or bipolar II. Nonetheless, we often think of bipolar, again, as being an adult disorder. I like to think of it as a disorder that starts early in life, and through changes based on that predispositional makeup genetically. And then with factors that are catalytic to it — or triggers, if you will — we start to see those symptoms manifest in ways behaviorally that we can look at and observe and measure in a sense. But I don’t think we should ever forget that there’s an internal experience when it comes to bipolar disorder that can start very, very early in life in terms of how the individual may see himself or herself in these extreme sort of positions, right? 

So, you can see on the screen, exogenous or external factors include developmental challenges, stressors, traumatic events, but they tend, again, to be more catalytic than predisposition. The bottom line as far as that is concerned, again, is that it starts early in life. Maybe what we see and identify comes later. Sometimes, it really is quite stealthy in the beginning part of life. So, you don’t always see it at the — in terms of prepubescents — maybe not even until late adolescence or into adult life. In the case of women who have their first manic episode as a result of postpartum, it could be even later into the 20s or 30s. But generally speaking, again, it’s something that an individual has carried through his or her life. The earlier that we can sort of identify some of these things as they’re presented to us, the better. The picture on your screen — I’ve just put on the big seven, which represents what a manic or hypomanic episode is all about.

In my larger presentation, we really break these down individually, but I just wanted to make sure that we were all on the same page in terms of what an episode like this would be all about. Hypomania is, along with depression, the characteristic features of bipolar II. Mania by itself is characteristic of bipolar I. You only need one manic episode; you don’t even have to have an episode of depression to be diagnosed with bipolar I in your life. Usually, what we see with kids are a combination of some of these, if not all of these symptoms, but they don’t always manifest in a very lengthy period of time. According to the DSM, that’s what we’re supposed to look for, but I would suggest that any of these sorts of symptoms — not necessarily exclusively by themselves — but as they build sort of upon themselves and develop a constellation of symptoms, they would suggest the strong possibility of an emerging bipolar disorder. 

And then now, as we go into more specifically about kids, let me take a moment to suggest that there is a certain controversy about childhood onset of bipolar disorder in general, but specifically prepubescent, which is roughly — before the age of 12 is usually the cutoff we would typically think about between preadolescence and adolescence. But I do believe that there’s an emerging body of research to suggest, again, that there can be a childhood onset prior to adolescence and prior to that hormone switch, which often is very catalytic for that underlying bipolar predisposition. So, we know there’s controversy about whether — a lot of people like to argue about whether or not it’s possible — but hopefully, based on the understanding of genetics, we can see that that sort of underlies what a lot of kids may be going through.

The mania itself can resemble other disorders or maladaptive patterns. Those are the more typical ones, and we’ll talk a little bit more about that as we go forward. And then adolescent onset is more commonly recognized than prepubescent onset, but even then, the length of manic or hypomanic episodes may not correspond to what we typically think about and what is typical for us to have a clear diagnosis. Lots of times, kids — particularly when they have that emerging symptom profile — will have very intense but brief episodes, more maybe like a cycle or something of that nature or what we would maybe think about as rapid cycling kinds of things. I’ve seen instances where kids, within a day or within hours, can really switch from what we would say, “Oh, that’s a manic episode,” to something that looks depressive that looks in between, as if they’re in a baseline mood. Again, I think we have to sort of take this in a context that may not always correspond to some of the more traditional ways that we think of bipolar episodes. I don’t know if you know either of these children; I don’t know them personally, but they do remind me of certain ones that I have met along the way. 

We will now get into childhood markers for bipolar disorder in particular. First one is a big one. Any family history of mental illness, especially if it is bipolar disorder. So, it’s not unusual to have a bipolar parent or a grandparent, or even in extended families, such as aunts, uncles, or even a sibling that might have bipolar disorder. It is pretty highly hereditary. You don’t necessarily have to dig too far back into the family tree. So, any immediate information with regard to family history of mental illness, especially bipolar, is important now. If we know that there is a close family relative, let’s say, that has had a history of schizophrenia, does that preclude bipolar disorder? And the answer to that is no, because there is more research to show that, genetically, there’s a lot of crossover. So, when we talked about the genetics of bipolar disorder, it’s not as if there’s a bipolar gene.

I think there’s one study that I remember reading recently that showed there’s about 30 genes that are associated with bipolar disorder in the sense of how, neurologically, emotions are regulated in an individual. And if you took — I don’t have my Venn diagram — there it is, if you can see the screen. You know, the Venn diagram circles. So, there’s so many that would be identified in schizophrenia, so many in bipolar I, so many in bipolar II, so many in major depression, and some of those cross over in some key areas. And the more that we understand what those particular genes do — I think among other things — we have opportunity for better treatments down the line. But for now, if you have somebody with a family history — very, very important. And if you don’t know much about the family history, to gather data in that situation could be very important in this case. You probably want to talk to the kids, parents or any appropriate adult individual in their lives.

Depressive episodes earlier in life — they tend to be more severe, more recurrent rather than single episodes. And if there’s a history of suicidality, one level or another — from ideation to planning it to actually making an attempt or gestures or whatever the parlance is that we’re using these days to kind of scale that danger zone. There is the repetitive nature of these episodes that I think start to lead us down that possible path. Along with those items, substance abuse, self-medication, co-occurrence is very frequent, a history of impulsivity, aggression and self-harm. In other words, just high levels of impulsivity that are out of control. I believe there’s, when it comes to kids, more cycling than distinct episodes. As they get older, those episodes tend to lengthen in terms of their course over time with respect to mania and hypomania, mania being at least a week, hypomania being at least four days or so. And then the differences in terms of the level of consequences. Certainly, if there is any indication of psychosis, that also has to be added and publicly brought to the forefront in terms of those particular markers that would suggest possible bipolar disorder. As we mentioned, manic response to antidepressant or psychostimulant medications, and then the last bullet point is something that is really interesting and important. Higher levels of emotional reactivity and longer periods compared to what we would expect developmentally for that individual child.

In particular, I would cite this study. It’s Luby and others — I think Luby, Tandon and Belden. This is a 2009 study in preschoolers for toddlers that were identified to have bipolar disorder. They had a family history of bipolar disorder. They had other indications. Is that a pretty elegant study? You could question the methodology all you want, and I think that would be something worth discussing in itself. But nonetheless, I thought it was a pretty cool study in terms of how they separated these particular preschoolers and identified them as having some sort of bipolar involvement. And they noticed that those that were basically assessed to have bipolar disorder had longer and more intense episodes of joy, sadness and anger compared to non-bipolar preschoolers and what we would expect developmentally. So, if they were happy about something — maybe they got a toy or something — they would be happier and for longer periods of time. If the toy was withdrawn, they would be angrier for a longer period of time — beyond, again, what their peers would do in those typical situations. And I think that point right there in terms of emotional reactivity is very key, particularly when you’re talking about kids prior to age 12, and I think more evidence to suggest the importance of genetics as well. 

We also want to look for — and this is particularly true for adolescents — extreme or abrupt changes in appearance, interests, goals, affiliation, like peer affiliation. If they’re a basketball player and that’s how they identify themselves or whatever that would all be — you know, social affiliations and athletic affiliations, artistic affiliations, religious or cultural affiliations and overall self-image. And we know that adolescents like to change their appearance, like to experiment with other things. That’s obviously not unusual, but we’re talking about extreme and abrupt changes beyond what we would expect from that particular developmental level.

So, when you meet with the child and you’re maybe looking in the direction of bipolar disorder, some elucidating questions you might want to share could include: What is life like when you’re not feeling depressed? I think that’s an important one because sometimes, the answer to that question could be something mild or mundane as well. “It’s okay. It’s not bad,” but it’s an opportunity to talk about maybe the other side of that mood swing. “What’s that really like? Do you ever feel better than okay? Do you ever feel better than average or better than normal,” you know? Whatever sort of language you think could help that individual to say, “Yeah, you know, there’s times when I’m really, really excited. I’m really happier.” “Well, tell me about that a little bit more,” and start to kind of dig into those specific examples of what life is like beyond depression itself. Another question could be: “What do others in your life think about you in your different moods?” Remember that bipolar disorder — for everybody — is about moods that don’t reflect the basic character of the individual as we would know that individual in their baseline mood zone. 

Their mania doesn’t define them, their depression doesn’t define them — at least, that’s what we would expect. They may think otherwise; they may think that’s more of who they are, but we’re trying to discern whether or not this is a mood disorder or, among other things, maybe something more characterological, as we would see in late adolescence or into adult life. But begin a dialogue in terms of what others think about them or how they see others, seeing them in their different mood states, and then maybe also have them draw. I know when you work with kids, creative exercises and activities can be very, very helpful. Maybe help them draw pictures of themselves and their different mood states, or for older kids, maybe chart their moods, kind of give them a graph or something. Whatever you think, creatively, can help them to begin to share information and increase their own insight and awareness along the way in terms of how this is about their emotional states and how their emotional states may change along the way.

Just briefly about differential diagnosis, which we could spend a lot of time with when it comes to bipolar disorder, but these are kind of the main ones when it comes to kids. At least when people ask me questions, they’re most interested — I think, above all — about ADHD. And then to some extent, these others, as you see on your screen. For the sake of time, we’ll just kind of simplify them. I believe that the key differential diagnostic concept for anything — for kids, for adults, for any possible axis one or axis two diagnosis — is that when it comes to bipolar disorder, its features are episodic. They come and go in episodes. What you see on your screen — and very typically other disorders as well — are considered more pervasive. So, somebody with ADHD or OCD or even borderline personality disorder, they can have good days and bad days, but they’re not swinging wildly away from one set of symptoms or one set of experiences to the other. When we look at bipolar disorder, even in children, we’re going to see moments in their life — maybe it’s brief, maybe very long — where their real, characteristic self is more available to us and symptoms are typically less available. They may feel bad about their symptoms. They still may be struggling as a consequence of those symptoms, but in these other disorders, particularly when it comes to ADHD, it’s more pervasive. You can have a good day with ADHD, but chances are tomorrow is going to be another struggle for you. Whereas in bipolar disorder, again, it’s episodic and not pervasive. And then about borderline, in particular, that is really a diagnosis that is for adults, and very often, we talked about kids and adolescents.

I said if they’re having borderline traits — which may coalesce into a borderline personality disorder later in life, and that’s not always inaccurate — that that could be very well true. But personally, I think it’s important to know that any kind of personality disorder — particularly borderline — is about a long-standing interpersonal dysfunction well into adult life. So, if you have a late adolescent or young adults, let’s say, anywhere from 16 to 22, 23, and they look really borderline — so to speak, ‘cause we talk that way, “borderline” — they could certainly be. But also, I think it’s important to look at it from a mood perspective and see if it’s more about mood swings. Because you can have co-occurrence of bipolar and borderline, but again, borderline tends to reflect a more long-standing pattern into adulthood. I would imagine there might be a ton of questions about differential diagnosis. So, feel free to hold onto those questions either for today or anytime you can let me know.

Going to this slide. So, some words about treatment and interventions right now. Several years ago, kind of frustrated with how to approach bipolar disorder from a therapeutic perspective. I developed a three-phase approach to bipolar disorder in terms of bipolar therapy, which I think is useful, no matter what your theoretical orientation happens to be. And we talk a little bit about it here further on the next slide, but one of my personal frustrations when it comes to bipolar disorder is sort of a long-standing concept that the way to treat bipolar disorder is to get them on meds. Medication, I believe, is very, very important, and I think the research is off the charts in terms of the necessity for that in many, many people. I think that coming out of the 1970s and 1980s, the use of lithium and then later, other mood stabilizers and so forth, were so revolutionary that even psychoanalysts and other therapists kind of saw this is almost curative and that there wasn’t really anything else you needed to do for bipolar disorder. Well, that’s not true. I think a combination of medication — appropriate medication — and an appropriate approach to therapy for individuals and families is the best and comprehensive approach available.

So along those lines, a collaborative approach to medication adherence — not about getting them on that. It’s about helping them, ultimately, to accept the reality of bipolar in their lives and what’s necessary in order to achieve mood stabilization — working through the denial that is so often present in individuals and in families accepting a chronic mental illness or a chronic condition and associated identity issues. How people perceive themselves and other people around them. It really changes because, again, they’ve been bipolar their whole life and they see themselves and others in these extreme mood experiences. So, helping them through education and support — as well as therapy, I think — together is the best and comprehensive roadmap. 

The three phases of bipolar therapy are basically centered around the medical stabilization of mood swings. So, what I’ve identified as the three phases of bipolar therapy: the pre-stabilization, which is about breaking down symptoms. More often than not, people don’t want to let go of their perceived beneficial aspects of mania or hypomania, even when it comes to kids. So sometimes, what you have to do is instead of saying, “You have bipolar disorder needing treatment,” it’s about, “Well, you’re having problems sleeping. Are you having problems with concentration or you’re having problems controlling your impulses?” We want to break those things down into understandable parts and increase the conversation for patients. And for their parents and family members to understand that the symptoms are problematic — not the individual. And then discuss all the issues around stigma, denial, fears about medications and real concerns about medications to help them move into that stabilization phase, which is marked by the trials of medication — and sometimes trial-and-error medication — as well as helping the family stabilize around those prior consequences that they’ve suffered as well.

So, now you’re kind of bringing together the symptoms and the pieces and treating the disorder. And then beyond that, once medications are set, that’s the post-stabilization phase, and that’s about treating the whole person — and very often when it comes to kids, the whole family, where that’s appropriate and where that may be indicated — so that that person can thrive beyond bipolar in his or her life. There’s some brief psychotherapy issues to discuss. Bipolar disorder is a lifelong but manageable condition. The symptoms are acute. The disease process, if you will, from a medical standpoint — neurological standpoint — is chronic. It’s not going to go away. Parents like to think that their kids can outgrow anything, and being a parent myself, I totally get that. That’s one of the first things I think a parent will say when they have news about a condition that has been diagnosed in their child: Will he or she outgrow this? You don’t outgrow bipolar disorder; it’s with you, but it doesn’t have to define your life. It can be a part of your life that needs attention from time to time, but once it’s manageable through that post-stabilization phase, then you can really focus on success. 

Now, let’s move to family therapy and support. There’s your typical American family right there together — that looks lovely. Going back to the genetic aspect of bipolar, I said that this was an important idea for a number of reasons. One of the most important things is that because it’s a condition that a person has genetically and neurologically, it’s nobody’s fault. And I think parents really need to understand that, as well as individuals, but treating and managing the illness takes commitment first by the patient and next by the family members. And certainly in very young patients, they don’t have as much autonomy and say in terms of what’s going to happen. For kids and certainly for adolescents, there has to be their buy-in. If they don’t buy in, it’s really not gonna matter a whole lot when everybody else does around.

So, helping them to achieve that sense of acceptance first makes everything else, I think, a lot easier for everybody involved. It’s difficult to accept when a loved one has been victimized by those consequences. Very often, those loved ones — when it comes to kids — are parents, but it also can be siblings, it can be friends, it could be girlfriends, boyfriends that have suffered as well. And then one of the key things in family therapy and support is that bipolar disorder is not an excuse — it’s an explanation of what’s been going on, and you hear that a lot. I hear it in adult couples where the spouse will say, “Well, I don’t know about this bipolar. I think that just would let them off the hook.” Like it’s just an excuse that he’s applied, and I always go back to the idea that it’s not an excuse. It’s an explanation which informs us and lets us all know what we can do — and particularly that patient, what he or she can do. That’s their responsibility. 

And by the way, that’s why I named the book “Owning Bipolar,” because it’s ultimately about owning that in that person’s life, and then also in the loved one’s lives, as well for parents that have bipolar disorder — a child or adolescent living with that. There’s often an inverse level of acceptance. In other words — and you see this a lot with kids in general. You work with kids, you’re probably familiar with this. It’s like if the kid is accepting it, very often, the parents don’t as much. Or if the parents say, “Hey, you know what? This is a problem. You’ve got to deal with it.” They are less invested, and so there’s kind of this inverse or teeter-totter kind of thing between kids and parents all the time, but you see it a lot when it comes to the issue of bipolar disorder, and we’re trying to get them on that same level together. Parents often are looking for information and the answers; initially, they’re looking for support for their parenting from we, the therapists. And then, with regard to that sort of inverse relationship, they can often view the child’s denial as opposition to authority — this case, the professionals. But they can also see that if the child is really all-in as sort of an overidentification with bipolar — now, they’re part of the bipolar crowd and they’re associating with that. 

There may be some truth to that in a sense, but it’s also something, I think, important to check — because if they are buying in, that’s certainly the preferred position to be in. And very often, kids find support — either friends they know personally or online in other groups where it may be appropriate — to know that they’re not alone and that it’s okay. They’re going to be okay. Also with parents, the acceptance and treatment participation levels may differ between the parents, and that’s particularly true in blended families as well. There can be all kinds of competing opinions. It’s really good to be able to try to get everybody on page. I usually start with somebody that I can ally with and build upon that. Not necessarily put everybody in a room — in this case, virtually in a room — and everybody’s sort of verbally duking it out in terms of what’s going on with the kid. But increase that level of therapy support, listen to fears and listen to concerns.

You see that bullet point I mentioned earlier about outgrowing the condition. Very important thing to understand and deal with therapeutically and firmly but, you know, with obvious finesse. Because that’s a very critical thing for a lot of parents, and then fears about medications. Medication is a big issue for anybody and it is a big issue with children, but it can be a very confusing one. Typically, adolescents — because they have like these awesome metabolic systems where things just kind of go through them — sometimes, their medication levels need to be at or even higher than the kind of typical adult levels. And that’s one of the things that parents can get a little bit upset about or worried about, understandably. But also, concerned about — does the medication do damage to the individual. 

While side effects are very important things that we talk about frequently, one of the things that research has shown is that, with respect to bipolar disorder and mood-stabilizing medications, they have what’s described as neuroprotective effects. That is to say that mood swings are actually damaging to the brain; mania and psychosis can be damaging to the brain. We have a lot of evidence to demonstrate that, both in bipolar disorder and also schizophrenia. So, medications that prevent that can actually maintain healthy brain functioning for the long-term. And there are always issues down the line — 20, 30 years down the line — that need to be recognized and dealt with through the lifespan. But I think it’s really important to have that honest conversation about their concerns, but also the benefits of what it is to treat mood swings, both medically and psychotherapeutically. And that kind of leads that conversation for parents —that it’s important to see treatment as the best defense against substance abuse.

Self-harm, suicide — probably should’ve put that first — but also educational, occupational failures. You know, we’re trying to prevent that sexual acting out, et cetera. Also, in terms of the older child — let’s say the college-age child — these so-called adult children, 18 and above, that may be still dependent on the parents. Very often, that conversation has to include what it feels like to not have control over your child and working together from that point of view and when to intervene and when to let go, though that’s always an ongoing kind of issue where parents are concerned in the therapy process in general. Since I put sexual acting out there, it just reminds me that we talked earlier about how kids have, very often, more intense and maybe shorter duration of episodes, but a more intense presentation of symptoms. One thing that you typically don’t see in prepubescent children as you would in adolescents and adult mania is hypersexuality, and I just wanted to make sure that that was clear. Typically, we see hypersexuality in the constellation of other symptoms of bipolar disorder in adolescence and adulthood — we typically think in terms of that’s part of that sort of manic expression. But if you see that with kids, it almost certainly has something to do with trauma at one level or another. So, I just think that’s an important thing to note. 

Then finally, with regard to family therapy and support, in the post-stabilization phase, I always try to teach patients and their families and their loved ones what I call “the grand bargain.” So, as they go into treatment and they get through that stabilization phase and they’re starting to do well and they’ve accepted what’s going on and what their needs are — people with bipolar disorder don’t want their loved ones to always think that that’s who they are and what they’re constantly having to deal with. And it’s understandable from the family point of view because of everything they might’ve gone through and the fears that they may still have. But what happens very often is that if the individual child or adult with bipolar disorder in that post-stabilization phase gets angry about something or is really happy about something or really anxious about something, what they don’t want to hear from their loved one is, “Are you off your meds now? You’re kind of looking manic to me now.” Maybe they’re really experiencing an authentic emotional experience. Maybe a kid is really angry at her mom for something, you know what I mean? Those things really do happen. And one of the challenges through post-stabilization is recognizing the difference from those authentic emotions and separating from what was driven by bipolar mania or bipolar depression for that matter. For the loved one, to have a conversation about those real emotions and whatever their concerns may be. 

So, the grand bargain is basically this from the family perspective: “If you always keep me apprised of how you’re doing with your bipolar disorder, I won’t think everything about you is bipolar disorder.” And from the sort of patient perspective, if you will, “I will keep you apprised of how I’m doing with my bipolar disorder if you don’t think everything about me and what I’m experiencing at the moment has to do with bipolar disorder,” so that both individuals and families learn what an authentic emotional experience is really all about. So critical in the long-term health and well-being of that person who is managing bipolar disorder. And then the other thing too — and is so important for parents accepting all the changes in that person — but also knowing that not everything will change. Bipolar treatment doesn’t take somebody and make them the ideal child or, for that matter, the ideal spouse or sibling or anybody else.

It allows them to be who they are and all their wonderful flaws, but it doesn’t ever define that person or necessarily that relationship — provided the treatment is set for long-term benefit. And that kind of brings us about five minutes to the top of the hour. That’s the information that I have to share with you today. I know that it’s kind of rapid-fire, so I’m happy to entertain some questions, but before we do that, here are the references. Quickly write them down, or you can look them up or send me an email and I’ll send them to you. And then an opportunity to take a look at the cover of my book; if you’d like to look into that, it’s available in all the online retailers and elsewhere. It’s also available on Audible for those who like their books read to them. So, enjoy. And again, there’s my website as well — MichaelPipich.com — if you have any questions or you want more information. Thank you for your attention. I appreciate it very much. 

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

Many children and adolescents with bipolar disorder go undiagnosed and poorly treated. This can result in devastating life consequences, including substance abuse and suicide. In this webinar presentation, Michael Pipich, MS, LMFT, shares a variety of diagnostic techniques and treatment approaches for young people with bipolar disorder and their families.

By watching this presentation, the viewer will:

  • Learn about bipolar disorder and how it affects individuals who live with the condition
  • Understand the lifelong effects that can occur when bipolar disorder remains undiagnosed and untreated
  • Be aware of ways that clinicians can better diagnose and treat bipolar disorder

Presentation Materials:

About Michael Pipich LMFT :

Michael Pipich holds a Master of Science degree in clinical/community psychology from California State University, Fullerton, and a Bachelor of Science degree in psychology from Loyola Marymount University. He is a licensed marriage and family therapist (Colorado license MFT744), and he has treated a wide range of mental disorders and relationship problems in adults and adolescents for more than 30 years, both in-office and via online teletherapy.

Michael is also a national speaker on bipolar disorder. His book, Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder (Citadel Press, 2018) is widely regarded as an important work in the field of bipolar treatment. Michael is also known as an expert in many legal cases involving psychological treatment and the law, and has taught several graduate-level psychology courses. He was selected as a collaborating investigator by the American Psychiatric Association, performing clinical field trials for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). He’s been featured on television, radio and in print media on a variety of topics, and he is the host of Breakthrough with Michael Pipich on the VoiceAmerica Network.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. 

Hi, everybody. Welcome to our community education event. My name is Valerie, and I am part of our community outreach team here at The Recovery Village in Palmer Lake, Colorado. For those of you who don’t know about our organization, The Recovery Village is a part of Advanced Recovery Systems, which is an integrated behavioral health care company that treats addiction, substance use disorders, eating disorders and co-occurring mental health issues. We have a network of nine facilities across the country, including an adolescent program for ages 13 to 17. After the event, we will stay on the Zoom for anybody who has further questions about our services, and you can also put those in the chat. 

Moving on to our guest speaker, I’m excited to introduce you to Michael Pipich. Michael is a psychotherapist with more than 30 years of experience diagnosing and treating bipolar disorder. He holds a Master of Science and Clinical Psychology from California State University Fullerton, and a Bachelor of Science in Psychology from Loyola Marymount University. He currently practices at the Colorado Center for Clinical Excellence in Denver, and he is the author of “Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder.” Michael is also known as an expert in many legal cases involving psychological treatment, and he has taught several graduate-level psychology courses. He’s been featured on television, radio and print media on a variety of topics, and he is the host of “Breakthrough With Michael Pipich” on the VoiceAmerica Network. Lastly, Michael was selected as a collaborating investigator by the American Psychiatric Association, performing clinical field trials for the DSM-5. He is a clinical fellow of the American Association of Marriage and Family Therapists. So, thank you for being part of our event today, Michael, and the floor is yours.

Michael:
Thank you very much, Val, and thank you to Ashley and to everybody at Advanced Recovery Systems for the invitation, and thank you all for joining from wherever you are. Obviously, there’s so much going on in the world. I was just kind of reflecting this morning on how important it is for us to kind of take a moment to get away from Twitter and the news and everything else. And by the way, I hope everybody on the Gulf Coast is going to be doing okay. There’s so much going on, and for us to be able to gather here together and share what I believe is a very important clinical topic, it helps us, I think, to really stay on track in terms of the work that we’re all charged to do, even under these really, really difficult circumstances. So, thanks again for being here and sharing this moment with me.

I have a real passion when it comes to treating bipolar disorder for a lot of reasons, and very happy to have the book out, “Owning Bipolar,” available for patients and families and for our clinicians as well. I think to really delve into not just the clinical aspects for a better understanding of the disorder itself, but the very experiences that people have with respect to bipolar in their lives, be it the individual with the condition but also family loved ones — people around that person where bipolar is in their life as well. And as I have been doing trainings and speaking not just to professionals but in the community as well, one of the hottest of the subtopics, so to speak, has to do with children and adolescents with bipolar disorder. The other kind of hot subtopic is substance abuse with bipolar disorder. So, those are the things I think, for a lot of people, really stand out as necessary. And so I think, again, it’s important for us to share some of this information today. 

I hope it’s helpful. I do have a lot of slides and information to share with you within an hour. It’s a bit compressed from my usual larger, all-day training and stuff like that, where I really delve into various subtopics in the realm of bipolar. But hopefully, this provides some insight And with regard to whatever questions you might have or issues that you want to share, certainly if we don’t get to those today, I would welcome your questions at my website, which is MichaelPipich.com. You can go there; there’s a link to send me an email. Also, if you’re interested in the notes that I have in front of me that I’m looking at for today’s presentation, you can also download it. There’s a tab there that says “events.” So, MichaelPipich.com/events, and you’re free to download the notes from this presentation. And also, there’s references available to you there as well if you want to check out some of the research that I’ve used to formulate this presentation.

Moving forward, let’s see if we can do that. We’ll start with some general facts about bipolar disorder, and then we’ll go to the more specific issues as they relate to kids, children and adolescents in particular. I call these the not-so-fun facts about bipolar disorder, but I think they’re really important to understand and use as a springboard. The DRAM court 2012 study looked into the duration of untreated bipolar disorder, and there’s the statistics for you on your screen. Basically, what they found is that between the first identifiable bipolar mood event and a treatment provided specifically for bipolar disorder — in the average person with bipolar disorder — is about 10 years. You can see the mean, 9.6 years. I called that the 10-year gap in treatment. And along with that, about an average of four mental health professionals are consulted before a person with bipolar disorder is actually diagnosed with the condition. So, we already know from this study — and it certainly aligns with much of my experience — that people wait years and years before they’re actually diagnosed,

Especially in outpatient settings, the most undiagnosed bipolar disorder individual would present with major depression. In other words, if somebody comes to treatment, including a young person, usually what we see presented is something that is more identifiable as major depression. With kids, that might be other behavioral problems, academic problems, attention deficits, relational interpersonal issues and so forth. Along with the diagnostic problems, substance abuse — because it is particularly common with bipolar disorder — is what very often treatment professionals sort of see as the most salient problem and drives a lot of people, including young people with bipolar disorder, to treatment initially. But we also know that about half of all people with bipolar disorder — kids and adults — will have had some type of substance use disorder in their life. When we see that as the obvious of the salient problems, it’s always important, I believe, to delve into the history of that individual the best that we can as clinicians, along with whatever corroborating data we can get from other professionals or for family and so forth that might lead us down the road to the underlying possibility of mood swings. And having substance abuse problems often masks those symptoms as well, so after a period of time of sobriety, it’s especially important to delve into that history and to observe that individual to see if mood swings are readily available to assess. 

But here is my No. 1 reason why I think it’s so important to understand what it means to have an underlying bipolar disorder that would otherwise go on identified or untreated. In bipolar disorder, the suicide potential is 20 to 30 times higher than what we see in the general population. Lifetime risk for suicide and bipolar disorder is 20%, and it’s one in five people with bipolar disorder. And this next bullet point — the third one down there — that’s right from the DSM. I promise you the first time that I saw that, I must have read that another dozen times to make sure I really was reading that correctly. One-fourth of all deaths by suicide may be bipolar-related, and there is an increasing risk with age. So, people with bipolar disorder who aren’t treated don’t mellow with age, as we would like to think most of us would otherwise, but in fact become an increasing risk for suicide. So, when you think about that with young people and know how dangerous suicide is among our youth and how prevalent that is, it’s sort of like the No. 1 or No. 2 leading cause of death among young people. In people with bipolar disorder — young people especially — the risk is very, very high.

Along with untreated bipolar disorder is greater incidents of violence, substance abuse and relapse, hospital admissions of all kinds. And a very important one for anyone — but again, when it comes to kids, I think this is very revealing — mania induced by psychotropic medication. In other words, the wrong psychotropic medication, with respect to bipolar disorder. And in that, we would see primarily with antidepressant medications — SSRIs, SNRIs — that can induce mania, particularly when there is not a mood-stabilizing agent along with that medication. But also, very often, we have young people diagnosed as ADHD, which may or may not be an appropriate diagnosis. They may have bipolar disorder co-occurring or it may be mistaken for bipolar disorder, in which case they would be given psychostimulant medication, and as a result of that, that can increase irritability, agitation and possibly a manic episode. By the way, I happen to think there’s some research to suggest that this may, in fact, be the case when we see warnings of the increase of suicide potential as a result of antidepressant medication. 

What you may have very often — not always, but very often — is a young person with an underlying, undiagnosed bipolar disorder. And because it can immediately increase agitation and mania, it could heighten any existing feelings of suicide. So, the issue of diagnosis and early treatment becomes, I think, not only important from a typical clinical and therapeutic standpoint, but just in terms of early detection that will save lives. That’s why I believe, in this particular instance, it’s very, very important. Moving on a little bit, I think the facts surrounding this particular issue — clinicians often tend towards evaluating presenting symptoms and can miss historical data about mania or hypomania. Again, this is in general — most of the research about bipolar disorder is in adults. And it’s true, I think, with any kind of psychopathology — except for those that are very, very specifically about kids. And because bipolar disorder is generally thought of in terms of adolescents to early adulthood, there’s not a ton of research that I can find current about what it is, what that experience is and how to detect it in children.

We’re going to look at some things today that I hope will be kind of illuminating. And when I present this to you, please understand I present it humbly because the more that I’ve learned in my research in bipolar disorder has trained me better. Particularly when I was writing the book and researching for the book itself, it really caused me to think back to patients that I’ve taken care of in the past. Certain individuals kind of popped into my mind where, you know, that person might’ve had bipolar disorder instead of whatever I thought we were dealing with at the time. So, I humbly share with you that we can all, I think, do a better job. And whatever questions and insights that you can provide likewise, I think, would be very, very helpful in our therapeutic community as we build an improved knowledge base and awareness of how to deal with this problem.

So, moving on a little bit in terms of causation, that image on your screen — I want to say what, really, that is. That’s a microscopic image of stem cells. And the reason that I put that up there along with the bullet point next to them is that the team at the University of Michigan found that the stem cells in people with bipolar disorder develop differently than those who do not have bipolar disorder. So, I think the way that I read that is that bipolar disorder starts in the beginning of life, and I think we all know that stem cells are those basic building blocks that eventually differentiate into other kinds of cells and tissues and organs and so forth. But think for a moment that in the basic building block of somebody that has bipolar disorder, they’re going to develop differently. And specifically for our purposes, they develop differently neurologically, compared to people who do not have the genetic predisposition for bipolar disorder. I think that that’s so important for so many different reasons when it comes to helping young people and, in particular, helping their families — their parents in particular — to understand the nature of bipolar disorder. It’s important to understand it has been with them since the very beginning of their lifespan and not something they necessarily acquire later in life.

Now, having said that, there are other internal or endogenous factors, including endocrine and metabolic changes, and the big one for all of us would be puberty. That’s, in fact, where we begin to see anyway, typically, the kind of recognizable symptoms and episodes in bipolar disorder that we are familiar with. I think, classically and with respect to DSM criteria, we know that the average age of onset is right around 18 to 20, depending on bipolar I or bipolar II. Nonetheless, we often think of bipolar, again, as being an adult disorder. I like to think of it as a disorder that starts early in life, and through changes based on that predispositional makeup genetically. And then with factors that are catalytic to it — or triggers, if you will — we start to see those symptoms manifest in ways behaviorally that we can look at and observe and measure in a sense. But I don’t think we should ever forget that there’s an internal experience when it comes to bipolar disorder that can start very, very early in life in terms of how the individual may see himself or herself in these extreme sort of positions, right? 

So, you can see on the screen, exogenous or external factors include developmental challenges, stressors, traumatic events, but they tend, again, to be more catalytic than predisposition. The bottom line as far as that is concerned, again, is that it starts early in life. Maybe what we see and identify comes later. Sometimes, it really is quite stealthy in the beginning part of life. So, you don’t always see it at the — in terms of prepubescents — maybe not even until late adolescence or into adult life. In the case of women who have their first manic episode as a result of postpartum, it could be even later into the 20s or 30s. But generally speaking, again, it’s something that an individual has carried through his or her life. The earlier that we can sort of identify some of these things as they’re presented to us, the better. The picture on your screen — I’ve just put on the big seven, which represents what a manic or hypomanic episode is all about.

In my larger presentation, we really break these down individually, but I just wanted to make sure that we were all on the same page in terms of what an episode like this would be all about. Hypomania is, along with depression, the characteristic features of bipolar II. Mania by itself is characteristic of bipolar I. You only need one manic episode; you don’t even have to have an episode of depression to be diagnosed with bipolar I in your life. Usually, what we see with kids are a combination of some of these, if not all of these symptoms, but they don’t always manifest in a very lengthy period of time. According to the DSM, that’s what we’re supposed to look for, but I would suggest that any of these sorts of symptoms — not necessarily exclusively by themselves — but as they build sort of upon themselves and develop a constellation of symptoms, they would suggest the strong possibility of an emerging bipolar disorder. 

And then now, as we go into more specifically about kids, let me take a moment to suggest that there is a certain controversy about childhood onset of bipolar disorder in general, but specifically prepubescent, which is roughly — before the age of 12 is usually the cutoff we would typically think about between preadolescence and adolescence. But I do believe that there’s an emerging body of research to suggest, again, that there can be a childhood onset prior to adolescence and prior to that hormone switch, which often is very catalytic for that underlying bipolar predisposition. So, we know there’s controversy about whether — a lot of people like to argue about whether or not it’s possible — but hopefully, based on the understanding of genetics, we can see that that sort of underlies what a lot of kids may be going through.

The mania itself can resemble other disorders or maladaptive patterns. Those are the more typical ones, and we’ll talk a little bit more about that as we go forward. And then adolescent onset is more commonly recognized than prepubescent onset, but even then, the length of manic or hypomanic episodes may not correspond to what we typically think about and what is typical for us to have a clear diagnosis. Lots of times, kids — particularly when they have that emerging symptom profile — will have very intense but brief episodes, more maybe like a cycle or something of that nature or what we would maybe think about as rapid cycling kinds of things. I’ve seen instances where kids, within a day or within hours, can really switch from what we would say, “Oh, that’s a manic episode,” to something that looks depressive that looks in between, as if they’re in a baseline mood. Again, I think we have to sort of take this in a context that may not always correspond to some of the more traditional ways that we think of bipolar episodes. I don’t know if you know either of these children; I don’t know them personally, but they do remind me of certain ones that I have met along the way. 

We will now get into childhood markers for bipolar disorder in particular. First one is a big one. Any family history of mental illness, especially if it is bipolar disorder. So, it’s not unusual to have a bipolar parent or a grandparent, or even in extended families, such as aunts, uncles, or even a sibling that might have bipolar disorder. It is pretty highly hereditary. You don’t necessarily have to dig too far back into the family tree. So, any immediate information with regard to family history of mental illness, especially bipolar, is important now. If we know that there is a close family relative, let’s say, that has had a history of schizophrenia, does that preclude bipolar disorder? And the answer to that is no, because there is more research to show that, genetically, there’s a lot of crossover. So, when we talked about the genetics of bipolar disorder, it’s not as if there’s a bipolar gene.

I think there’s one study that I remember reading recently that showed there’s about 30 genes that are associated with bipolar disorder in the sense of how, neurologically, emotions are regulated in an individual. And if you took — I don’t have my Venn diagram — there it is, if you can see the screen. You know, the Venn diagram circles. So, there’s so many that would be identified in schizophrenia, so many in bipolar I, so many in bipolar II, so many in major depression, and some of those cross over in some key areas. And the more that we understand what those particular genes do — I think among other things — we have opportunity for better treatments down the line. But for now, if you have somebody with a family history — very, very important. And if you don’t know much about the family history, to gather data in that situation could be very important in this case. You probably want to talk to the kids, parents or any appropriate adult individual in their lives.

Depressive episodes earlier in life — they tend to be more severe, more recurrent rather than single episodes. And if there’s a history of suicidality, one level or another — from ideation to planning it to actually making an attempt or gestures or whatever the parlance is that we’re using these days to kind of scale that danger zone. There is the repetitive nature of these episodes that I think start to lead us down that possible path. Along with those items, substance abuse, self-medication, co-occurrence is very frequent, a history of impulsivity, aggression and self-harm. In other words, just high levels of impulsivity that are out of control. I believe there’s, when it comes to kids, more cycling than distinct episodes. As they get older, those episodes tend to lengthen in terms of their course over time with respect to mania and hypomania, mania being at least a week, hypomania being at least four days or so. And then the differences in terms of the level of consequences. Certainly, if there is any indication of psychosis, that also has to be added and publicly brought to the forefront in terms of those particular markers that would suggest possible bipolar disorder. As we mentioned, manic response to antidepressant or psychostimulant medications, and then the last bullet point is something that is really interesting and important. Higher levels of emotional reactivity and longer periods compared to what we would expect developmentally for that individual child.

In particular, I would cite this study. It’s Luby and others — I think Luby, Tandon and Belden. This is a 2009 study in preschoolers for toddlers that were identified to have bipolar disorder. They had a family history of bipolar disorder. They had other indications. Is that a pretty elegant study? You could question the methodology all you want, and I think that would be something worth discussing in itself. But nonetheless, I thought it was a pretty cool study in terms of how they separated these particular preschoolers and identified them as having some sort of bipolar involvement. And they noticed that those that were basically assessed to have bipolar disorder had longer and more intense episodes of joy, sadness and anger compared to non-bipolar preschoolers and what we would expect developmentally. So, if they were happy about something — maybe they got a toy or something — they would be happier and for longer periods of time. If the toy was withdrawn, they would be angrier for a longer period of time — beyond, again, what their peers would do in those typical situations. And I think that point right there in terms of emotional reactivity is very key, particularly when you’re talking about kids prior to age 12, and I think more evidence to suggest the importance of genetics as well. 

We also want to look for — and this is particularly true for adolescents — extreme or abrupt changes in appearance, interests, goals, affiliation, like peer affiliation. If they’re a basketball player and that’s how they identify themselves or whatever that would all be — you know, social affiliations and athletic affiliations, artistic affiliations, religious or cultural affiliations and overall self-image. And we know that adolescents like to change their appearance, like to experiment with other things. That’s obviously not unusual, but we’re talking about extreme and abrupt changes beyond what we would expect from that particular developmental level.

So, when you meet with the child and you’re maybe looking in the direction of bipolar disorder, some elucidating questions you might want to share could include: What is life like when you’re not feeling depressed? I think that’s an important one because sometimes, the answer to that question could be something mild or mundane as well. “It’s okay. It’s not bad,” but it’s an opportunity to talk about maybe the other side of that mood swing. “What’s that really like? Do you ever feel better than okay? Do you ever feel better than average or better than normal,” you know? Whatever sort of language you think could help that individual to say, “Yeah, you know, there’s times when I’m really, really excited. I’m really happier.” “Well, tell me about that a little bit more,” and start to kind of dig into those specific examples of what life is like beyond depression itself. Another question could be: “What do others in your life think about you in your different moods?” Remember that bipolar disorder — for everybody — is about moods that don’t reflect the basic character of the individual as we would know that individual in their baseline mood zone. 

Their mania doesn’t define them, their depression doesn’t define them — at least, that’s what we would expect. They may think otherwise; they may think that’s more of who they are, but we’re trying to discern whether or not this is a mood disorder or, among other things, maybe something more characterological, as we would see in late adolescence or into adult life. But begin a dialogue in terms of what others think about them or how they see others, seeing them in their different mood states, and then maybe also have them draw. I know when you work with kids, creative exercises and activities can be very, very helpful. Maybe help them draw pictures of themselves and their different mood states, or for older kids, maybe chart their moods, kind of give them a graph or something. Whatever you think, creatively, can help them to begin to share information and increase their own insight and awareness along the way in terms of how this is about their emotional states and how their emotional states may change along the way.

Just briefly about differential diagnosis, which we could spend a lot of time with when it comes to bipolar disorder, but these are kind of the main ones when it comes to kids. At least when people ask me questions, they’re most interested — I think, above all — about ADHD. And then to some extent, these others, as you see on your screen. For the sake of time, we’ll just kind of simplify them. I believe that the key differential diagnostic concept for anything — for kids, for adults, for any possible axis one or axis two diagnosis — is that when it comes to bipolar disorder, its features are episodic. They come and go in episodes. What you see on your screen — and very typically other disorders as well — are considered more pervasive. So, somebody with ADHD or OCD or even borderline personality disorder, they can have good days and bad days, but they’re not swinging wildly away from one set of symptoms or one set of experiences to the other. When we look at bipolar disorder, even in children, we’re going to see moments in their life — maybe it’s brief, maybe very long — where their real, characteristic self is more available to us and symptoms are typically less available. They may feel bad about their symptoms. They still may be struggling as a consequence of those symptoms, but in these other disorders, particularly when it comes to ADHD, it’s more pervasive. You can have a good day with ADHD, but chances are tomorrow is going to be another struggle for you. Whereas in bipolar disorder, again, it’s episodic and not pervasive. And then about borderline, in particular, that is really a diagnosis that is for adults, and very often, we talked about kids and adolescents.

I said if they’re having borderline traits — which may coalesce into a borderline personality disorder later in life, and that’s not always inaccurate — that that could be very well true. But personally, I think it’s important to know that any kind of personality disorder — particularly borderline — is about a long-standing interpersonal dysfunction well into adult life. So, if you have a late adolescent or young adults, let’s say, anywhere from 16 to 22, 23, and they look really borderline — so to speak, ‘cause we talk that way, “borderline” — they could certainly be. But also, I think it’s important to look at it from a mood perspective and see if it’s more about mood swings. Because you can have co-occurrence of bipolar and borderline, but again, borderline tends to reflect a more long-standing pattern into adulthood. I would imagine there might be a ton of questions about differential diagnosis. So, feel free to hold onto those questions either for today or anytime you can let me know.

Going to this slide. So, some words about treatment and interventions right now. Several years ago, kind of frustrated with how to approach bipolar disorder from a therapeutic perspective. I developed a three-phase approach to bipolar disorder in terms of bipolar therapy, which I think is useful, no matter what your theoretical orientation happens to be. And we talk a little bit about it here further on the next slide, but one of my personal frustrations when it comes to bipolar disorder is sort of a long-standing concept that the way to treat bipolar disorder is to get them on meds. Medication, I believe, is very, very important, and I think the research is off the charts in terms of the necessity for that in many, many people. I think that coming out of the 1970s and 1980s, the use of lithium and then later, other mood stabilizers and so forth, were so revolutionary that even psychoanalysts and other therapists kind of saw this is almost curative and that there wasn’t really anything else you needed to do for bipolar disorder. Well, that’s not true. I think a combination of medication — appropriate medication — and an appropriate approach to therapy for individuals and families is the best and comprehensive approach available.

So along those lines, a collaborative approach to medication adherence — not about getting them on that. It’s about helping them, ultimately, to accept the reality of bipolar in their lives and what’s necessary in order to achieve mood stabilization — working through the denial that is so often present in individuals and in families accepting a chronic mental illness or a chronic condition and associated identity issues. How people perceive themselves and other people around them. It really changes because, again, they’ve been bipolar their whole life and they see themselves and others in these extreme mood experiences. So, helping them through education and support — as well as therapy, I think — together is the best and comprehensive roadmap. 

The three phases of bipolar therapy are basically centered around the medical stabilization of mood swings. So, what I’ve identified as the three phases of bipolar therapy: the pre-stabilization, which is about breaking down symptoms. More often than not, people don’t want to let go of their perceived beneficial aspects of mania or hypomania, even when it comes to kids. So sometimes, what you have to do is instead of saying, “You have bipolar disorder needing treatment,” it’s about, “Well, you’re having problems sleeping. Are you having problems with concentration or you’re having problems controlling your impulses?” We want to break those things down into understandable parts and increase the conversation for patients. And for their parents and family members to understand that the symptoms are problematic — not the individual. And then discuss all the issues around stigma, denial, fears about medications and real concerns about medications to help them move into that stabilization phase, which is marked by the trials of medication — and sometimes trial-and-error medication — as well as helping the family stabilize around those prior consequences that they’ve suffered as well.

So, now you’re kind of bringing together the symptoms and the pieces and treating the disorder. And then beyond that, once medications are set, that’s the post-stabilization phase, and that’s about treating the whole person — and very often when it comes to kids, the whole family, where that’s appropriate and where that may be indicated — so that that person can thrive beyond bipolar in his or her life. There’s some brief psychotherapy issues to discuss. Bipolar disorder is a lifelong but manageable condition. The symptoms are acute. The disease process, if you will, from a medical standpoint — neurological standpoint — is chronic. It’s not going to go away. Parents like to think that their kids can outgrow anything, and being a parent myself, I totally get that. That’s one of the first things I think a parent will say when they have news about a condition that has been diagnosed in their child: Will he or she outgrow this? You don’t outgrow bipolar disorder; it’s with you, but it doesn’t have to define your life. It can be a part of your life that needs attention from time to time, but once it’s manageable through that post-stabilization phase, then you can really focus on success. 

Now, let’s move to family therapy and support. There’s your typical American family right there together — that looks lovely. Going back to the genetic aspect of bipolar, I said that this was an important idea for a number of reasons. One of the most important things is that because it’s a condition that a person has genetically and neurologically, it’s nobody’s fault. And I think parents really need to understand that, as well as individuals, but treating and managing the illness takes commitment first by the patient and next by the family members. And certainly in very young patients, they don’t have as much autonomy and say in terms of what’s going to happen. For kids and certainly for adolescents, there has to be their buy-in. If they don’t buy in, it’s really not gonna matter a whole lot when everybody else does around.

So, helping them to achieve that sense of acceptance first makes everything else, I think, a lot easier for everybody involved. It’s difficult to accept when a loved one has been victimized by those consequences. Very often, those loved ones — when it comes to kids — are parents, but it also can be siblings, it can be friends, it could be girlfriends, boyfriends that have suffered as well. And then one of the key things in family therapy and support is that bipolar disorder is not an excuse — it’s an explanation of what’s been going on, and you hear that a lot. I hear it in adult couples where the spouse will say, “Well, I don’t know about this bipolar. I think that just would let them off the hook.” Like it’s just an excuse that he’s applied, and I always go back to the idea that it’s not an excuse. It’s an explanation which informs us and lets us all know what we can do — and particularly that patient, what he or she can do. That’s their responsibility. 

And by the way, that’s why I named the book “Owning Bipolar,” because it’s ultimately about owning that in that person’s life, and then also in the loved one’s lives, as well for parents that have bipolar disorder — a child or adolescent living with that. There’s often an inverse level of acceptance. In other words — and you see this a lot with kids in general. You work with kids, you’re probably familiar with this. It’s like if the kid is accepting it, very often, the parents don’t as much. Or if the parents say, “Hey, you know what? This is a problem. You’ve got to deal with it.” They are less invested, and so there’s kind of this inverse or teeter-totter kind of thing between kids and parents all the time, but you see it a lot when it comes to the issue of bipolar disorder, and we’re trying to get them on that same level together. Parents often are looking for information and the answers; initially, they’re looking for support for their parenting from we, the therapists. And then, with regard to that sort of inverse relationship, they can often view the child’s denial as opposition to authority — this case, the professionals. But they can also see that if the child is really all-in as sort of an overidentification with bipolar — now, they’re part of the bipolar crowd and they’re associating with that. 

There may be some truth to that in a sense, but it’s also something, I think, important to check — because if they are buying in, that’s certainly the preferred position to be in. And very often, kids find support — either friends they know personally or online in other groups where it may be appropriate — to know that they’re not alone and that it’s okay. They’re going to be okay. Also with parents, the acceptance and treatment participation levels may differ between the parents, and that’s particularly true in blended families as well. There can be all kinds of competing opinions. It’s really good to be able to try to get everybody on page. I usually start with somebody that I can ally with and build upon that. Not necessarily put everybody in a room — in this case, virtually in a room — and everybody’s sort of verbally duking it out in terms of what’s going on with the kid. But increase that level of therapy support, listen to fears and listen to concerns.

You see that bullet point I mentioned earlier about outgrowing the condition. Very important thing to understand and deal with therapeutically and firmly but, you know, with obvious finesse. Because that’s a very critical thing for a lot of parents, and then fears about medications. Medication is a big issue for anybody and it is a big issue with children, but it can be a very confusing one. Typically, adolescents — because they have like these awesome metabolic systems where things just kind of go through them — sometimes, their medication levels need to be at or even higher than the kind of typical adult levels. And that’s one of the things that parents can get a little bit upset about or worried about, understandably. But also, concerned about — does the medication do damage to the individual. 

While side effects are very important things that we talk about frequently, one of the things that research has shown is that, with respect to bipolar disorder and mood-stabilizing medications, they have what’s described as neuroprotective effects. That is to say that mood swings are actually damaging to the brain; mania and psychosis can be damaging to the brain. We have a lot of evidence to demonstrate that, both in bipolar disorder and also schizophrenia. So, medications that prevent that can actually maintain healthy brain functioning for the long-term. And there are always issues down the line — 20, 30 years down the line — that need to be recognized and dealt with through the lifespan. But I think it’s really important to have that honest conversation about their concerns, but also the benefits of what it is to treat mood swings, both medically and psychotherapeutically. And that kind of leads that conversation for parents —that it’s important to see treatment as the best defense against substance abuse.

Self-harm, suicide — probably should’ve put that first — but also educational, occupational failures. You know, we’re trying to prevent that sexual acting out, et cetera. Also, in terms of the older child — let’s say the college-age child — these so-called adult children, 18 and above, that may be still dependent on the parents. Very often, that conversation has to include what it feels like to not have control over your child and working together from that point of view and when to intervene and when to let go, though that’s always an ongoing kind of issue where parents are concerned in the therapy process in general. Since I put sexual acting out there, it just reminds me that we talked earlier about how kids have, very often, more intense and maybe shorter duration of episodes, but a more intense presentation of symptoms. One thing that you typically don’t see in prepubescent children as you would in adolescents and adult mania is hypersexuality, and I just wanted to make sure that that was clear. Typically, we see hypersexuality in the constellation of other symptoms of bipolar disorder in adolescence and adulthood — we typically think in terms of that’s part of that sort of manic expression. But if you see that with kids, it almost certainly has something to do with trauma at one level or another. So, I just think that’s an important thing to note. 

Then finally, with regard to family therapy and support, in the post-stabilization phase, I always try to teach patients and their families and their loved ones what I call “the grand bargain.” So, as they go into treatment and they get through that stabilization phase and they’re starting to do well and they’ve accepted what’s going on and what their needs are — people with bipolar disorder don’t want their loved ones to always think that that’s who they are and what they’re constantly having to deal with. And it’s understandable from the family point of view because of everything they might’ve gone through and the fears that they may still have. But what happens very often is that if the individual child or adult with bipolar disorder in that post-stabilization phase gets angry about something or is really happy about something or really anxious about something, what they don’t want to hear from their loved one is, “Are you off your meds now? You’re kind of looking manic to me now.” Maybe they’re really experiencing an authentic emotional experience. Maybe a kid is really angry at her mom for something, you know what I mean? Those things really do happen. And one of the challenges through post-stabilization is recognizing the difference from those authentic emotions and separating from what was driven by bipolar mania or bipolar depression for that matter. For the loved one, to have a conversation about those real emotions and whatever their concerns may be. 

So, the grand bargain is basically this from the family perspective: “If you always keep me apprised of how you’re doing with your bipolar disorder, I won’t think everything about you is bipolar disorder.” And from the sort of patient perspective, if you will, “I will keep you apprised of how I’m doing with my bipolar disorder if you don’t think everything about me and what I’m experiencing at the moment has to do with bipolar disorder,” so that both individuals and families learn what an authentic emotional experience is really all about. So critical in the long-term health and well-being of that person who is managing bipolar disorder. And then the other thing too — and is so important for parents accepting all the changes in that person — but also knowing that not everything will change. Bipolar treatment doesn’t take somebody and make them the ideal child or, for that matter, the ideal spouse or sibling or anybody else.

It allows them to be who they are and all their wonderful flaws, but it doesn’t ever define that person or necessarily that relationship — provided the treatment is set for long-term benefit. And that kind of brings us about five minutes to the top of the hour. That’s the information that I have to share with you today. I know that it’s kind of rapid-fire, so I’m happy to entertain some questions, but before we do that, here are the references. Quickly write them down, or you can look them up or send me an email and I’ll send them to you. And then an opportunity to take a look at the cover of my book; if you’d like to look into that, it’s available in all the online retailers and elsewhere. It’s also available on Audible for those who like their books read to them. So, enjoy. And again, there’s my website as well — MichaelPipich.com — if you have any questions or you want more information. Thank you for your attention. I appreciate it very much. 

Thank you for watching this video. We hope you enjoyed the presentation.

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