What Works for Bipolar Kids
Help and Hope for Parents
By Mani Pavuluri
The Guilford Press Copyright © 2008 The Guilford Press
All rights reserved.
Yes, Bipolar Disorder Does Occur in Children
Jeremy walks in, wearing a broad smile. He chats garrulously with my staff. He is extremely hyper and starts playing with all the other patients in the waiting area, making rules and bossing them around. Seeing me, he runs up and twists my arm hard as we shake hands. He bursts into laughter as I pull my hand away. His mom, who looks tired and helpless, tells us Jeremy hardly slept the night before. He is chirpy and giggly, talking like a super-express train. He agrees to be videotaped, and my staff goes to get the equipment, but as soon as the camera is set up, his mood changes completely. He starts to direct the filming, then suddenly gets irritable and goes out of control, knocking over the equipment and swearing nonstop.
This is a real example from my clinic. Although somewhat dramatic, stories like these are hardly isolated incidents among bipolar children. Here are a few more examples of things that our patients said or did while in our clinic:
John (age 10) lifted my research assistants up in his arms; he even attempted to pick up men twice his size and hug strangers, although he would startle and yell if anyone touched him.
Cindy (age 6) threw herself onto the floor in the hospital corridor and refused to move or get up. She screamed incessantly and turned red in a rage for a half hour before getting blood drawn.
Jared (age 11) touched everything in sight, talking constantly about things that seemed to have nothing to do with what he was exploring and ricocheting from one topic to the next. "I was thinking that there was this hamster that looked into a mirror and thought there was another hamster and he ran into the mirror!" he said, then laughed hysterically before darting off to another part of my office and telling a story about the time he had "saved" his brother from a dog with "teeth at least a foot long."
Sylvia (age 9) hid testing materials in our lab in the bottom of a Kleenex box, locked my staff out of the office, threw testing materials away, and jumped up and down in the garbage can.
Andy (age 7) saw a bird fly against the window of his third-floor playroom and land dazed on the roof below. He climbed out the window and onto the roof in an attempt to help the bird. When his mother retrieved him safely and asked him what he was doing, he responded, "I can fly." His mother reminded him that people can't fly, and he said, "Then God would save me."
Hannah (age 8) declared, "I'm going to marry you and make you my pretty, pretty princess." She was provocative and overfriendly for a first meeting.
In the course of 15 minutes during the diagnostic evaluation, Asaad (age 5) went from laughter to yelling and turning red, then broke down crying, unable to articulate his problems given his very young age.
Joe (age 12) let out a torrent of taunts and criticisms, talking so fast that he was almost incoherent, yelling constantly, rationalizing his anger, and calling his mother a "moron" who had "no brains" as if he were a viciously angry ex-husband.
If your child has received a bipolar diagnosis, or you just suspect that he has the disorder, you may have one of two reactions to these examples. These glimpses of rapid mood swings, irritability, sensitivity to criticism, rapid speech, and difficulty focusing may seem so instantly familiar that you might wonder if someone came into your home and videotaped your child. Maybe your child has behaved in all of these ways at some point. Or you may feel that some of the symptoms match and some don't, that your child is never "that bad," but secretly fear he could get that way. You're not at all sure whether the behaviors depicted above that you are seeing in your son or daughter are indicators of bipolar disorder instead of something else entirely.
Even medical professionals have varying reactions to these types of cameos. Either they think these are accurate depictions of childhood bipolar disorder, or they believe that these are difficult behaviors not specific to bipolar disorder, or they dismiss them all as not really bipolar disorder. One parent was often told there was no such "animal" as early-onset or childhood bipolar disorder, and because she was in the mental health field she was accused of "looking for a problem that simply isn't there."
Let me take a minute to clarify how you should view the behaviors portrayed in these very brief stories. The complex emotional turbulence and havoc caused by these children is obvious and dramatic, but parents and professionals should realize that one size does not fit all—in other words, no one description captures all the typical bipolar diagnostic symptoms. Your child might have the "classic symptoms," which easily lead to diagnosis, and/or some difficult behaviors, like those described above, which occur more rarely but are definitely associated with the disorder. Because at our clinic we treat hundreds of bipolar children and research their brains and cognitive function, we recognize the wide range of symptoms that can lead to a diagnosis of pediatric bipolar disorder. We think in terms of treating a spectrum of problems related to wiring in the brain that cause dysfunction, rather than just hanging a label on a child based on a diagnosis.
Unfortunately, not everyone recognizes the diagnosis, and there is still a lot of controversy over the label. In this chapter, I hope to clear that up. Make no mistake about it; bipolar disorder does exist in children. The answers to the questions you have about your child's condition aren't always simple or definitive, but they are becoming clearer as brain imaging and clinical research continue to reveal new and useful insights about childhood bipolar disorder each year.
HOW IS CHILDHOOD BIPOLAR DISORDER DEFINED?
Bipolar disorder is a mood disorder characterized by swings between the opposite and extreme emotional states of mania and depression. The simplest way to put it would be to say that people who have bipolar disorder are sometimes much more "up"—excited, energetic, optimistic, and so forth—than the rest of us and other times much more "down"—that is, sad, dejected, lethargic, and hopeless. But this condition is actually much more complex than that definition implies, and that's why the term "bipolar" is more commonly used today than the older "manic depression"—because it is thought more accurately to reflect the disorder's cyclical nature and the wide variety of symptoms that accompany its two poles (the "bi") of ups and downs. A person suffering from bipolar disorder will not necessarily appear to be energized and happy at one time and visibly sorrowful at another. A person experiencing either mania or depression can seem mainly highly irritable, and the line between the two mood poles isn't always very clear, especially in children.
Differences in the way children manifest bipolar disorder, in fact, are one reason some people doubt that the illness occurs in children at all. Yet we know that it does. Bipolar disorder is said to affect 1–2% of adults worldwide. In one community school survey of older adolescents (aged 14–18 years), some form of bipolar disorder occurred in 1% of them over the course of their lives. It's harder to pin down the incidence of bipolar disorder in children because it is so often misdiagnosed, but, in my opinion, even the rate in teenagers may have been underestimated in the school survey as it was based on interviewing teenagers only, who in most instances deny that anything is ever wrong with them.
When I started my medical training 25 years ago, the idea of bipolar disorder in children was nonexistent. Only adults showing clear signs of mania or elated mood followed by severe depression were recognized as having bipolar disorder. When children with these symptoms came to us for help, we cobbled together several diagnoses to explain their problems and then struggled to understand why they did not respond well to treatment.
The current idea or definition of bipolar disorder in children really started to take shape in the mid-1990s, when new research opened the door to our present understanding. Various researchers looked at the disorder from different angles, each one focusing on a different symptom or dimension as the hallmark of the disease: one focused on irritability, which is a common reason for families to seek treatment for their children; another focused on grandiosity and elated mood; and another stuck to the classic symptoms of mood states that fluctuated from mania to depression similarly to late-adolescent-onset/adult bipolar disorder.
In order to come to a consensus, in 2001, the National Institute of Mental Health (NIMH) convened two Research Roundtables with experts in the field, which produced a general agreement about the main types of bipolar disorder, one based on a narrow definition consisting of the classic symptoms described above and the other a broader definition that encompasses a wide range of symptoms, including severe irritability, "affective storms," mood lability, and severe temper outbursts, falling short of the full set of symptoms or without clearly defined mood cycles. Debate continues between various schools of thought, with some believing that the criteria are being applied too broadly and others feeling that a narrow definition, "the middle cut," leaves out too many children who should be helped.
I, too, erred on the side of caution in diagnosis when I came from Australia to the United States in late 1990s. I used to diagnose what we now think of as childhood bipolar disorder as attention-deficit/hyperactivity disorder (ADHD) (as children with bipolar disorder are hyperactive and distractible) + oppositional defiant disorder (ODD) (as they are irritable and difficult but short of conduct problems) + major depression (as they had mixed depressive symptoms). This diagnosis still did not address these children's elated mood, grandiosity, excitability and exuberance, creative and excessive productivity, flights of ideas and pressured speech, sleep difficulties, or hypersexuality. We could not control their emotional dysregulation. Like most of my colleagues, I treated these children with stimulants or antidepressants, with poor results. It was like the fable of the blind men trying to describe an elephant—we defined the problem based on the part we were touching at the time.
I spent significant amounts of time investigating the syndrome to understand it better. I began to attract patients from all over the country and abroad, and in the course of treating them, a pattern emerged. I saw that the mood fluctuations weren't just a matter of temperament. They worsened with age. In addition, the symptoms and cycles didn't behave exactly like bipolar disorder in adults (see the box below). Two big things convinced me that this was a distinct disorder that manifested itself in children uniquely: (1) treating it as simply ADHD, depression, or a combination of the two did not do the trick; it was much more complicated than any of these other conditions; and (2) treating it like adult bipolar disorder seemed to help these children, although there were some important differences owing to brain development and their youth when symptoms began.
I felt compelled to do something to help bipolar children who desperately need attention for this poorly understood and ill-treated disorder. Although we don't yet fully understand the disorder or its causes, we must start treating it while our understanding of the brain and nervous system continues to evolve. Rather than being submerged in debate, we must apply these scientific findings to making a difference now for kids in the real world and not keep them waiting! I believe it is better to embrace an imperfect label and do what's right by treating these suffering kids.
Considering how your child is undoubtedly struggling, I'm sure you'll agree. So let's take time right now to clear up a myth that all too often stands in the way of getting help for bipolar children: that you, rather than a biological illness, are to blame for your child's problems. You are a blessing that your child can count on, not a curse that caused the disorder.
IS YOUR CHILD JUST ACTING OUT IN RESPONSE TO POOR PARENTING?
Whether your child is just "acting out" rather than suffering from an illness is a question that can be answered only through a thorough diagnostic evaluation of the sort described in Chapter 2. But if your child does meet the diagnostic criteria, I can tell you without reservation that you are not to blame for your child's behavior or any other aspect of the illness. We know that bipolar disorder is a biologically based illness that tends to run in families; it is not caused by parenting style or any other environmental influences. If you are too reactive and there is emotional friction in the family, it is not healthy for you or anybody, including your bipolar child. It does not mean you are causing the disorder, but you may be fueling the fire inadvertently. So, slowing down, thinking with clarity, and monitoring oneself in the process is a very good thing to do. Unfortunately, the behavior of a bipolar child can be so hard to manage that you may very well feel like a terrible parent, and you may still fall prey to the sorts of fault-finding described in the box on pages 22–23. Education—of yourself and others—is the best antidote. A good place to start is with an understanding of the biological basis of bipolar disorder.
Scientists have yet to identify a specific cause for bipolar disorder, and there is no one test that can be performed to confirm or rule out the disorder; however, studies point to a number of genetic and physiological factors that may play a role in the onset of the disorder and some psychological and social factors that can determine its severity and the child's (and family's) ability to cope. In the future, further studies of these "markers" or risk factors may eventually lead to improvements in the prevention, diagnosis, and treatment of bipolar disorder in children and adults.
Did My Child Inherit This Illness?
There is growing evidence that a predisposition toward bipolar disorder is an inherited trait. Both top-down and bottom-up studies show a strong pattern of family inheritance. In top-down studies, researchers start with members of the older generation with the disorder and track signs of the disorder in these adults' children. Bottom-up studies identify bipolar disorder in children and then look for signs of it in their adult relatives.
One study based on detailed interviews with parents of outpatient children or adolescents with type I bipolar disorder (where children experience full-blown mania and depression versus a "lower grade" of mania known as hypomania in addition to depression; see Chapter 2 for more on the subtypes of bipolar disorder) found that roughly 80% of these children had at least one parent diagnosed with a mood disorder. Several studies have shown a strong link between early age of onset and risk of bipolar disorder among first-degree relatives as compared to relatives of youth with schizophrenia, unipolar major depressive disorder, and normal controls. Further, earlier onset of bipolar disorder is associated with greater odds of having bipolar disorder in the family. Relatives of adolescents with variable symptoms also have increased family history of bipolar disorder, comparable to those with the full syndrome. Relatives of children with ADHD and bipolar disorder are five times more likely to have bipolar disorder than relatives of children who only have ADHD. This statistic makes the scientist in me speculate about whether ADHD and bipolar disorder are somehow related and whether ADHD is symptomatic of bipolar tendencies, as bipolar children often are identified as having ADHD before full-blown bipolar disorder emerges. We don't know if these children get worse because of wrong or harmful stimulant medications or because they are predisposed to develop bipolar disorder anyway.
The genetics of bipolar disorder raises two important issues for families. First, parents frequently feel guilty about "giving" the disorder to their child, even when they might not be affected themselves. Guilt can interfere with effectively parenting a bipolar child and can lead to marital discord and other family conflict. Often, I hear mothers (or occasionally fathers) refer to an undiagnosed partner as having passed along the symptoms. In the heat of the moment, people will say things like "the apple doesn't fall far from the tree." Even when it's true, it is wielded as a negative judgment toward the affected parent, which is particularly common if the parents are divorced. It may, in fact, be true that you passed along the predisposition to bipolar disorder, but it's not as if you did this intentionally or as if there were anything you could have done to prevent it. What's important to know is that there is plenty you can do to make it better for your child. (Continues...)
Excerpted from What Works for Bipolar Kids by Mani Pavuluri. Copyright © 2008 The Guilford Press. Excerpted by permission of The Guilford Press.
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