Mania in children?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Do children really have mania?

Parents bring children into the emergency rooms and the psychiatric facilities because their child “flips out” and begins damaging property. Say the child begins breaking out all the windows in a row of buildings. They are angry and out of control. Efforts to get them to stop are unsuccessful and they may continue even when threatened with violence. Is this an early sign that the child has Bipolar disorder?

Diagnosing Bipolar Disorder in children is highly controversial. To make that diagnosis we need to know if children really have episodes of mania or hypomania. No mania and there should be no Bipolar Diagnosis. Anger and mania are related; they may overlap but are they part of the same thing? The researchers in this area are clearly not in agreement. I will save my opinion for the end.

Children have temper outbursts. If we reduce the level of symptoms needed to include those outbursts as a mental illness all children would get the label and the diagnoses would become meaningless.

To be considered Mania it should last 7 days, for Hypomania an episode needs to last for at least four days. This rules out all those brief temper outbursts from consideration.  It also excludes those times when any and all of us might have a time period of excitement when we sleep less or are excited to pursue a new activity, like a new love interest.

Recently there has been an increase in the use of the Bipolar NOS diagnoses in children because this allows for some judgment calls as to the length of episode needed to make the diagnosis. One study (Stringaris et al. 2010) looked at children who had been diagnosed with Bipolar and concluded there was no evidence of mania in children under the age of thirteen, meaning no child that young should be getting the diagnosis of Bipolar. Other researchers disagree.

Stringaris did find that of those children who had brief episodes, too brief to meet criteria for a hypomanic episode, fully 25% did go on to develop all the symptoms needed to diagnose Bipolar Disorder within two years. His conclusion is that we should wait until the teen years and the full criterion is met before diagnosing Bipolar Disorder.

This is a problem for me. Why would we begin treating a child if they do not have an illness? No diagnosis no treatment. So to get the family the help they need, we need the diagnosis. If not Bipolar Disorder then what would we call this child’s problem? Also, the study tells us that 25% of these brief episodes will develop symptoms in 2 years. What about 10 years or 20?  I have not yet found research that answers those questions.

Early onset researchers come up with a different answer. Telling us that – Mania, Bipolar one, mostly starts in the adolescent period (McNamara, 2010.) This study goes on to cite 6 factors that may constitute risk factors for the early development of Bipolar Disorder.

One significant risk factor is a history of being the victim of abuse and neglect. We know that early childhood experiences can induce changes in the wiring of the brain. So can later life traumas. Psycho-social stressors are also listed as risk factors. These are also risk factors for personality disorders and other mental illnesses.

This tells us that experience and learning can be risk factors for developing Bipolar Disorder.

A family history of Bipolar is also a risk factor. Not just family members living in the home, but first-degree family members who have any mood disorder, whether in the home or not, appear to increase the risk of developing Bipolar.

That says that heredity is a risk factor for Bipolar Disorder.

A history of substance abuse, prescribed antidepressants and stimulants and dietary deficiencies all have been implicated as having a connection to Bipolar disorder.

See: Do medications and drugs cause Mania or Bipolar Disorder and other Co-occurring blog posts

Lastly, McNamara sums up the argument for diagnosing Bipolar Disorder in children by saying that most people who go on to get the diagnosis had “prodromal” or early symptoms 10 full years before they were diagnosed.

We know from other mental health research that the sooner an illness is recognized and treated the better the chance of a full recovery.

My opinion

Children who have a brief – one day temper or behavioral outburst are unlikely to be having Bipolar disorder. This is anger or bad behavior and you should try treating them for anger and behavior first. But the pattern needs monitoring.

There are dangers from over treating psychiatric illnesses in children and there are dangers of under-treating. Pick a provider you trust and listen to their advice and judgment. I especially recommend a consultation with a child psychiatrist whenever possible.

Don’t adopt a wait and attitude, even if you decide to skip the medication for now, if your child has these kinds of symptoms get the child counseling or therapy.

Care to share or comment?

Has your child had outbursts that looked like mania or hypomania and have you considered the possibility they may have Bipolar disorder?

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

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Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

How is Hypomania different from Mania or a Manic Episode?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Hypomanic Episodes.

In a post on Manic Episodes we talked about how episodes, according to the DSM are not diagnoses, they are “building blocks” out of which diagnosis are created. Someone could have either a manic episode or a hypomanic episode. The primary significance is the decision on labeling the condition as Bipolar one or Bipolar two. No Manic or Hypomanic Episode and you will not get the Bipolar label.

The Bipolar Disorder spectrum currently is very confused and confusing. It includes Bipolar I, Bipolar II, proposals for Bipolar III, IV and so on, as well as hypomania, mania, Cyclothymic Disorder, Hyperthymia, Hyperthymic personality disorder and so on. This spectrum is a very divergent group. Disorders involving an elevated mood may be the most Heterogeneous group there is (Van O’s et al. 2007.)

Lumping all these variety’s together may be overlooking the possibility that there are “Types of Bipolar Disorders.”

Hypomania requires a specific time period in which someone has had the symptoms of “elevated, expansive or irritable mood.” The difference is that for full mania the period needs to last for a full week, hypomania need only last for four days.

This creates some problems. What if you have manic-like symptoms for only three days? Do you get left out of the Bipolar spectrum? If someone has serious mania but it only lasts 6 days do they get Bipolar II not Bipolar I?

The effort to separate out conditions by the length of symptom duration may help psychiatrists decide what medication to prescribe but it does not make much difference to the client who has short but intense episodes of manic-like symptoms.

Since some of the changes in Hypomania may be subtle we take the word of others who know you or live with you to make this decision.

Most of the symptoms used to define hypomania are the same as those used to define a manic episode. The primary difference is the duration, four days to six is hypomania and a week or more is mania.

The exception here is that since hypomania is supposed to be a milder or different from mania.

If you have ever had hallucinations or delusions (not caused by drugs) then we skip the hypomania label and go directly to mania.

Here are the hypomania symptoms, then the exclusions. This narrative parallels the DSM but is my less technical, more colorful explanation.

The symptoms list is a lot like the list for Mania. I have italicized some of the differences.

A. For at least 4 days the person has an episode of “elevated, expansive or irritable mood.” Elevated does not mean happy. There are lots of descriptions of these elevated moods and they vary from person to person but the key factor is that these episodes are not like other people and that there are times when this person is not like this. If this episode is really bad we may waive the 4-day rule.

B. Pick 3 or four symptoms from a list of seven.

Each of these symptoms can vary in intensity and it is a judgment call. The result is that diagnosis can vary from clinician to clinician and even from time to time for the same person and the same clinician.

Here are the 7 symptoms needed to make a manic episode.

1. Grandiosity and excessive self-esteem. They can make no mistakes and can’t understand why people question them.

2. Sleep changes. You don’t need to sleep. Someone with Bipolar I can stay up for days and is full of energy. They may only sleep three or four hours a night. And in the morning they are not tired.

This reduced need for sleep may be a little less than in mania but the result is the same. People who are going manic or hypomanic get accused of drug use but if tested they have no drugs in the system or at least no drugs that explain the excess energy.

This is a troubling part of the diagnosis. Research studies (Carver & Johnson 2008) say that a lack of sleep can “induce” mania. So the lack of sleep is both a cause and a symptom of Mania? This sleep mania question needs more research. If the definitive study of this connection has been done so far I have not found it.

Not sleeping and not feeling tired does not mean that the person is rested. The longer this below normal sleep episode goes on the more irritable and delusional the person is likely to get. They may even begin to hallucinate. Only they don’t know they are delusional. They are convinced they are right and other people are dumb to not see how smart they are. If the hallucinations or delusions are noticeable to others we call it mania, not hypomania.

3. They talk a lot.

In hypomania, you may be able to interrupt them but not for long. They have a lot to say. Sometimes they talk too loudly and too emphatically. This is not the same as the way we old people talk when wound up, but that might give you a picture.

4. They feel their thoughts are “racing.”

Too many things to think about. In kids, this looks a lot like ADHD.

5. Lack of focus and easily distracted.

They are in such a hurry they move from topic to topic, project to project and can’t figure out what to do next. Lots of things left half-finished and on to the next one.

6. Increased goal-directed activity.

In mania it is excessive, in hypomania, those around them notice an increase but can’t explain why.

This can be trying to do too much at work, socially, sexually or in most any area of life. This over goal-directed activity can lead to excessive physical motion like a person whose engine is always running.

7. Overdoing pleasurable activities.

Hard to believe that someone could have too much fun but what we are looking for here is not that they have a lot of fun but that they continue to do pleasurable things despite negative consequences. This could also be affected by the assessor’s values judgments.

Examples of excesses are overspending, reckless or dangerous activities, “sexual indiscretions” and so forth. This needs to be more than someone who just likes to do something, like collect something. There is an episodic nature to these activities and most everyone will agree that this person has binges of overdoing things despite them getting in trouble.

This characteristic is highly related to the continued use despite negative consequences we see in substance abuse. As a matter of fact, people with a Bipolar diagnosis are much more likely to also have addiction and alcoholism issues than the general population.

The result?

To be diagnosed with a hypomanic episode you need to have three of the seven symptoms. We want four if you are just irritable but not expansive or elevated in mood. But with hypomania, the symptoms can be milder, more of a judgment call and can be briefer in time duration.

If you or someone you know has symptoms of hypomania please see a professional. This article is not meant to be enough for you to do “do it yourself diagnosis.” There are many effective treatments for Mania, Bipolar Disorder, and related conditions.

BIG QUESTION: What about people who have these symptoms for less than four days? Or those that move in and out of Hypomania very quickly? Are we missing some other type of Bipolar Disorder? Or is that moodiness something else?

Stay tuned for more on Mania, Hypomania, Cyclothymia and Bipolar Disorder and Types of Bipolar Disorder and the things we know and don’t know about all these topics.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.