Apps, Winkler and Jandrisevits (2008) warn that the attention recently paid by mental health professionals and the media to juvenile bipolar disorder, while beneficial to the patients themselves, can lead to misdiagnosis and faulty therapeutic approaches. Hence, they prepared this primer of sorts to help nurses find their way through a thicket of symptoms that overlap with other disorders. As well, the many possibilities for behavioral and cognitive support therapies mean nurses confront the opportunity to help locate suitable resources in the locality.
Three Key Points
The three critical themes in the article consist of: a) ensuring that the symptoms are not confused with simple mania on one hand or the various depressive symptoms on the other; b) discriminating juvenile bipolar disorder from attention deficit-hyperactive disorder (ADHD), especially because the two disorders are all too frequently co-occurring; and, c) carefully distinguishing juvenile bipolar disorder from the familiar excesses of adolescent behavior.
The distinctive characteristic of juvenile bipolar disorder is alternating major depression and manic episodes lasting two weeks and one week, respectively. Depressed mood may present as withdrawal or intense irritability. As well, appetite (and weight) may erode, sleeping patterns disturbed, psychomotor agitation is observable, subjective fatigue constant, and self-worth diminished to the point of suicidal ideation. On the other hand, it is the occurrence of mania that signals bipolar disorder. Elevated mood may be accompanied by the characteristic flight of ideas, the rapid speech this triggers, sleeplessness, grandiosity, and hedonistic overindulgence.
The confusion with ADHD that may be co-occurring or not is understandable because the two syndromes share distractibility and hyperactivity. Enabling differential diagnosis of bipolar disorder, however, is the aforementioned mania, elation, decreased need for sleep, and delusions of grandeur. In addition, the disruptive behavior that marks ADHD is absent when bipolar disorder alone afflicts the child. In any case, the authors recommend that when there is co-occurrence – more likely than not – the goal of treatment should be to stabilize bipolar disorder first.
Thirdly, the task is to differentiate juvenile bipolar disorder from extremes of adolescent mood swings and behavior. After all, every nurse and parent is familiar with the labile moods of older children and teenagers. By themselves, these extremes are stressful for families and school mentors. The distinguishing characteristic of bipolar disorder in the young is that mania and depression are already so advanced as to cause functional impairment and delayed development.
Benefit and Practical Application to Nursing
Clearly, differential diagnosis of juvenile bipolar disorder is a tricky process. Though the authors concede prevalence among children and adolescents is so low as to be minuscule, nurses in primary care, occupational and school settings are obviously well-placed to ask the pointed questions that will differentiate dysfunction in the young person. This is not just an academic prospect that holds for any class of systemic or mental health complaint. After all, the authors point out, the psychotropic drugs that stabilize those with juvenile bipolar disorder can aggravate the situation if the patient is truly afflicted with ADHD alone, for example. There is also a recommended sequence for stabilizing the two major syndromes that characterize juvenile bipolar disorder. Thirdly, nurses can probe patients, parents and guardians about the length of episodes or for signals that a course of treatment is beginning to take hold. Fourth and just as helpful is the assistance pediatric nurses can give for referrals to alternatives and adjuncts such as child psychiatry, other categories of therapy, psycho-education or support groups in the community. All these are characteristic of the wide-ranging knowledge and care nurses must have to engage with this rare but complex disability.
Apps, J., Winkler, J. & Jandrisevits, M. D. (2008). Bipolar disorders: Symptoms and Treatment in Children and Adolescents. Pediatric Nursing, 34 (1) 84-88.