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The Bipolar Child
Broadcast starting week of September 20, 2005

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The program begins with comments from host Dr. Fred Goodwin. He observes that bipolar disorder, also called manic depressive illness, is under diagnosed and under treated among adults. For children with this disorder, the problem is even more daunting.

These vulnerable kids and their parents are up against a powerful and persistent belief among most mental health professionals that bipolar disorder rarely occurs before adolescence.

As a result, when symptoms of bipolar disorder do appear, they're often misdiagnosed as something else. The tantrums, mood swings and irritability are often seen as symptoms of attention deficit hyperactivity disorder, or some other disorder. On average, more than 10 years elapse between the first symptoms of bipolar disorder and its correct diagnosis and treatment.

The problem is that mental health professionals have not yet acknowledged that bipolar disorder does not express itself in the same way in children as it does in adults. The consequences of misdiagnosis can be disastrous for the child and for the entire family.

Next we hear from a mother and her 14-year-old son, who has bipolar disorder. His problems began in first grade, and worsened considerably when he was misdiagnosed as having Attention Deficit Hyperactivity Disorder and placed on Prozac. He's been stable for two years now on a combination of Depakote, a mood stabilizer, and Ritalin. Doctors failed to consider early-onset bipolar disorder as a diagnosis despite a clear family history of mood disorders and alcoholism.

Dr. Goodwin then welcomes his guests for the hour, Janice and Dr. Demitri Papolos, authors of a new book, The Bipolar Child. The book, subtitled "the definitive and reassuring guide to childhood's most misunderstood disorder" is published by Broadway Books.

Dr. Papolos is a psychiatrist and associate professor of psychiatry at Albert Einstein College of Medicine in New York City and co-director of the Program in Behavioral Genetics. Janice, his wife and writing partner, is an established author, who co-authored Overcoming Depression with her husband in 1987. Also joining them is Martha Hellander, executive director of the Child and Adolescent Bipolar Foundation, and herself the mother of a child with bipolar disorder. The foundation, based on the web at www.bpkids.org, is a virtual community of support and information for parents raising children with bipolar disorder.

Dr. Papolos explains that early-onset bipolar disorder is often characterized in infancy by difficulty in settling the child for sleep, and sleep disruptions. By the time the child is in school, parents and teachers often start to notice hyperactivity, fidgetiness, and difficulty in paying attention. As time goes on, more than 90 percent of bipolar kids will also show oppositional behavior, at times reacting with tremendous rage when a parent is even slightly critical or says "no."

Janice Papolos explains that the cases described in their study and their book came through an Internet list-serv, bpparents.org. In additional to reviewing medical records, the Papoloses had access to more than 175 e-mails a day describing the children's behavior through each day and through the seasons.

Dr. Papolos talks about the difference between bipolar disorder in children versus adults. More than 70 percent of children will show a typical pattern of change during the course of the day, he says, often appearing almost coma-like in the morning and showing giddiness and goofiness at night. Parents often describe a "Dr. Jekyl and Mr. Hyde" type of changeability in which a particular mood may last only an hour or even minutes.

In response to a question from a child psychologist in Kansas, received by e-mail, Dr. Papolos explains some of the ways that a mental health professional can differentiate between bipolar disorder and Attention Deficity Hyperactivity Disorder. Among them, he says, are the rapid fluctuations in mood mentioned above, as well as rages that last more than a half an hour (and can last up to seven hours). Particularly telling in their study, he says, was a clear family history of mood disorders and/or alcoholism, pointing to the importance of taking a careful family history before arriving at a diagnosis.

Misdiagnosis carries a tremendous risk, Dr. Papolos noted, as the stimulants and anti-depressants often administered for ADHD and depression can have terrible consequences for bipolar kids. In the Papolos' study, 65 percent of kids exposed to stimulants had serious adverse effects. They can become manic, violent and psychotic enough to require hospitalization on stimulants, and react even worse when placed on antidepressants.

Since the stakes are so high, says Janice Papolos, the standard should be to rule out bipolar disorder before writing any prescriptions. She points out that 94 percent of bipolar kids will meet the criteria for ADHD. In addition, while suicide is always a risk with bipolar disorder, Dr. Papolos says, it's even a higher risk when kids are exposed to stimulants and antidepressants. Kids will sometimes become grandiose in their mania and think they can fly, and try to jump out of a window or out of a moving car.

So what gets in the way of a correct diagnosis? Dr. Papolos says he believes the largest single obstacle to treatment are the current diagnostic manuals used by clinicians. The American Psychiatric Association's DSM-IV, for example, requires that childhood bipolar disorder fulfill the same criteria as adult bipolar. This is reinforced by a pervasive myth that's been drilled into mental health professionals that bipolar disorder does not occur before adolescence, he says. It would be more useful and accurate, he says, to urge professionals to inquire about rapid mood swings within the course of a day, as opposed to whether there manic symptoms last more than a week.

Dr. Goodwin takes a call from Kathy, from Virginia, whose husband is diagnosed as bipolar and whose eight-year-old daughter has both bipolar and obsessive-compulsive disorder. She describes the symptoms, which change dramatically -- from irritable to goofy -- during the course of a single day. Kathy wants to know whether she can expect a normal life for her daughter. Responding, Martha Hellander says that while it takes a while to get the right medication mix, many parents report that their children, once stabilized, continue with a perfectly normal childhood and adolescence.

Janice Papolos also mentions a study that shows that children with early onset bipolar actually do better later in life than people who develop the disease as adults. In response to Kathy's concern about her child's lack of response to medications, Dr. Papolos observes that he's hearing many reports that many doctors, even when they do prescribe mood stabilizers, often prescribe them at doses too low to have a therapeutic effect.

Dr. Goodwin's next call is Diane from California, who asks about the genetic transmission of bipolar disorder, and the disease's impact on families affected. Dr. Goodwin says that studies show that 80 percent of the causal factors for bipolar disorder are genetic. Regarding the impact on families, Martha Hellander says that many mothers become clinically depressed, and that it's hard on marriages because fathers often don't see the full extent of the child's difficult behavior at home. Siblings are also strongly affected, and it's important to get the entire family into counseling, the guests agree.

Next, Dr. Goodwin asks Dr. Papolos how early the disorder can be diagnosed.Dr. Papolos describes the case of a 6-year-old that he followed for six months before prescribing a mood stabilizer, and observed that within a week, the child's mood, behavior and sleep all stabilized.

Janice Papolos observes that bipolar children are often unusually creativeand intelligent, and sometimes capable of presenting quite a normal front to the outside world. But when they come home to their parents, the picture can change dramatically. Parents have reported broken collar-bones, broken fingers, black eyes and cuts and bruises. Parents say that raging bipolar children will get a "feral" look, like a cornered wild animal. Afterward, they are terribly remorseful if they remember the episode, and often do not remember it at all.

Are these kids dangerous? Martha Hellander says they are more likely to hurt themselves than anyone else, but that the mother is most at risk. With proper treatment, she says, the raging and violent behavior generally disappears completely. She reiterates the importance of early diagnosis and treatment, pointing out that when the child becomes a teen, parents have less opportunity to intervene. Parents need to teach bipolar kids to manage their illness, just as if it were diabetes or any other chronic disease.

Dr. Papolos goes on to discuss what we know about what's going on in the brain of a bipolar child, and says he believes that researchers will eventually confirm that the problem lies with a kind of seizure in the emotional part of the brain.

The next caller, Ann, from Minnesota, says it's hard to get doctors to pay attention to her bipolar daughter's depressed symptoms, observing that they seem more interested in rages and mania. Dr. Papolos reports that because of the risk of inducing mania with antidepressants, he's using bright light treatment and Omega-3 fatty acids to treat depressed bipolar children, with some success.

Dr. Goodwin mentions that The Infinite Mind before this broadcast received three separate questions by e-mail regarding links between bipolar disorder and the autistic spectrum disorders, such as Asperger's and Pervasive Developmental Disorder. Dr. Papolos mentions a study recently published in the Journal of Neurology that looked at large number of families with autism and found high levels of bipolar disorder in first-degree relatives.

The next caller, Jennifer from Georgia, has a 6-year-old daughter with bipolar disorder who was misdiagnoses as ADHD at age 4. Jennifer asks about the advantages and disadvantages of treating a child that young with mood stabilizers.

This is a question often asked by parents, Dr. Papolos says. He asks: If your child was diagnosed early with a motor seizure disorder, such as epilepsy, would you want to wait to begin treatment? Both Dr. Papolos and Dr. Goodwin note that most mood stabilizers are anti-convulsants, which are commonly and safely used to treat seizure disorders in children. On the other side, Dr. Goodwin says, parents and doctors need to weigh new research indicating that continued bipolar episodes can damage the brain. And Martha Hellandar suggests that concerned parents might wish to visit the website of the Child and Adolescent Bipolar Foundation, at www.bpkids.org , to read comments from parents who waited to treat their children.

The medications do have side-effects, Dr. Papolos says. Many kids on the common medications, including Depakote (valproic acid), lithium and Risperidal (risperidone) experience a tremendous hunger, and gain weight.

The last caller is Bette, from California, who wants to know what can happen when a child with bipolar disorder reaches adolescence.

Dr. Papolos notes that adolescence, and normal hormonal changes during puberty, can bring on the illness in kids with a genetic susceptibility. Janice Papolos points out that sleep is essential to maintaining health, and that maintaining healthy sleep habits is often problem for teen-agers. In addition, 60 percent or more of those with untreated bipolar disorder will end up abusing alcohol or drugs, and can get in trouble with the law.

Next, the panel discusses problems at school. Bipolar children are often bright and creative, but can annoy their teachers and classmates with their grandiosity and inability to pay attention. Like other children with disabilities, bipolar children are entitled under federal law to an Individual Educational Plan. But while school authorities know how to draw it up an IEP for dyslexics, they are generally at a loss about how to proceed with bipolar disorder. Some parents have used the Papoloses' book to help inform schools about the disorder, Janice says. Click here for a sample Individual Education Plan excerpted from the Papoloses' book.

Another on-line resource for parents of bipolar kids is http://www.bpso.org/, a community for the significant others of people with bipolar disorder. That website includes extensive links to other related sites. Finally, interested listeners may wish to consider Dr. Goodwin's own book, Manic-Depressive Illness, co-authored by Dr. Kay Jamison, a definitive clinical and historical guide for understanding and treating the disorder.

 

 

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