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Article
Childhood Bipolar Update: What You May Not
Know
Introduction
Ongoing
research and investigation into early onset mood disturbance and mood
dysregulation are increasingly conclusive that Bipolar Disorder in
childhood is a viable and appropriate diagnosis. While there are still
those who refuse to entertain the idea that children can have this
illness, these same individuals are probably the ones who refused to
believe that children could even be depressed. Indeed, it was not until
as recently as the 1980’s that children
could be officially diagnosed
with depression. Since that time, the psychiatric and behavioral
healthcare fields have gone a step further to reach the understanding
that Bipolar Disorder can have a childhood onset.
Research
Current
treatment approaches are showing dramatic effects when the proper
protocol is used along with a thorough history to document the genetic
transmission found in a majority of mood disorder cases. Dr. J.
Biederman of Massachusetts General Hospital has found in his research
that there is an increased number of relatives with Bipolar Disorder in
those children diagnosed with early onset childhood mania. Furthermore,
Dr. Biederman cites a high incidence of irritable presentation with a
chronic course in these children. Mood stabilizers were found to be an
effective treatment, while stimulants were not effective, especially
when the child’s disorder was
misdiagnosed as Attention
Deficit/Hyperactivity Disorder (ADHD).
Dr. A. Nierenberg, also of
Massachusetts General Hospital, has found
in his research that of 500 adult patients with a history of Bipolar
Disorder, 50% reported having the onset of their illness prior to age
18. Of those adult patients, 13% had a lifetime diagnosis of ADHD. What
was most interesting about this study is that Dr. Nierenberg found that
those adults with a history of ADHD had an earlier age of onset and a
more difficult course of the illness, with more depressions, manias,
violence and suicide attempts. They also had more incidences of panic,
anxiety, agoraphobia (e.g., fear of going outside or to school), social
phobia, Generalized Anxiety Disorder, and substance abuse. The
combination of mood dysregulation with coexisting anxiety is what leads
so many with these types of presentations to abuse substances, in an
attempt to lower their difficult to manage anxiety and confusion.
Research has shown that this group of children, with difficult to
manage anxiety, also had relatives with anxiety disorders, pointing out
again how important the complete history (e.g., genetic family history)
is to gain a proper understanding of that child. A correct diagnosis
will then lead to proper treatment, and stabilization, which is the
ultimate goal.
Another researcher from the National
Institute of Mental Health
(NIMH) found that children with Bipolar Disorder had problems with
delayed spatial memory rather than immediate spatial memory, and that
they also had problems with response inhibition on attentional tasks.
Another interesting fact that was discovered with bipolar children is
that while they had little difficulty recognizing facial emotions in
adults, they had increased errors in recognizing facial emotions in
other children. In particular, those children with Bipolar Disorder
mistook neutral and other facial expressions for anger in other
children.
Assuming
ADHD Can Be Dangerous
When
the preconceived notion that a child has ADHD and is evaluated with
simple diagnostic measures and rating scales, such as the TOVA (Test of
Variables of Attention), in order to validate the diagnosis, the
results can be correct and incorrect at the same time. The child will
present with deficits of attention, but not with classic Attention
Deficit Disorder because the clinician has not done their homework to
understand that symptoms of Bipolar Disorder can look like ADHD. The
harm here is that if the diagnosis is not correct and the medications
are either stimulants or something like Straterra (which is an NRI-
Norepinephrine Reuptake Inhibitor- very closely related to
drugs
like Prozac and Paxil), you can very much worsen
the child’s
behavior. These behaviors may manifest in worsening tantrums, or
suicidal thinking/acting. Those clinics that tend to just specialize in
ADHD tend to find ADHD wherever they look, and may easily overlook the
possibility of Bipolar Disorder in children.
Complete
Research-0riented Service
The
importance of a complete research-oriented service with a
multidisciplinary overview is what sets Diablo Behavioral Healthcare
apart. Here at Diablo Behavioral Healthcare, we have seen cases where
not only was the diagnosis incorrect, but that the previous clinician
had increased the stimulant dose in attempt to gain behavioral control,
believing all along that they were treating the child for ADHD, even
though the patient had a history of relatives with Bipolar Disorder.
This is indeed the "tail wagging the dog". Not understanding what
genetic transmission is, nor taking a complete family history, is one
of the main sources of improper diagnosis today.
Prevalence
of Pediatric Bipolar Disorder
Ongoing
studies continue to point out the increase in the diagnosis of
pediatric Bipolar Disorder. The prevalence is noted by one study to be
in the area of 7.2% of the population, with the mean age around 9.6
years. The high rate of a family history of bipolar is around 42%. The
children presented with 42% having only irritable mood, 8% with only
elated mood, and 50% with both moods. The most common coexisting
condition was ADHD, detected in 58.3% of all subjects (Juvenile Bipolar
Disorder in Brazil: Clinical and Treatment findings, pp. 1043-1049).
Current
Treatment
Current
treatment is demonstrating that often children and adolescents with
bipolar illness will often require one or more mood stabilizers, and
sometimes the use of the newer antipsychotics, such as Abilify or
Risperdal. Once the child or adolescent
has had their
mood stabilized, then and only then should the use of a stimulant be
considered to deal with any residual ADHD symptoms. This treatment
process can be very effective to allow the child to do well in school
and at home, as long as care and very frequent contact is maintained
between the clinician and the child and their family. The role of
family/parent education cannot be understated here. For these patients,
it does indeed "take a village". These are not the cases to be seen by
the clinician only every three months, as managed care would like us to
do. The availability of child-oriented mood charts and the use of
medication rating forms all add to the ability to properly understand
and treat these children correctly.
Evaluation
Protocol
There
is growing agreement that when a child presents with symptoms of what
looks like ADHD or substance abuse, they should be evaluated using a
protocol that takes into consideration the possibility of Bipolar
Disorder. It is also important to recognize that often the first
symptoms children in the 3- to 5-year-old range present with are
irritability and mood dysregulation. This will often be prior to any
development of the more typical manic and depressive symptoms seen
around age 8 or 9 years. Those children with severe and extreme
irritability and significant temper tantrums are among the first signs
that you are not dealing with the uncomplicated ADHD diagnosis,
according to the Child and Adolescent Bipolar Research Foundation.
Importance
of Early Intervention
Children
with ADHD rarely, if ever, present with suicidal thinking, pressured
speech, grandiose thinking, and auditory or visual hallucinations. They
do not generally have periods of prolonged tearfulness and withdrawal,
as seen with the level of emotional unbalance in mood-disordered
children. For us here at Diablo Behavioral Healthcare, it is somewhat
of a mystery how some of these misdiagnoses occur; but they do, and we
in turn do our best to get these children onto the correct track and to
return them to the highest level of functioning they are capable of.
The most promising news here is that research indicates that aggressive
treatment at a very young age may prevent the downward spiral that so
many patients experience who have Bipolar Disorder. Early intervention
appears to be a protective factor in preventing ongoing bipolar
upheaval.
Summary
What
this means to parents is, if treatment is accurate and appropriate,
there is a real possibility that the correct approach can better
insulate children from a lifelong course of ongoing difficulties. The
sad truth is that in the U.S. today, for the majority of patients with
Bipolar Disorder, especially children, there is a 10-year span between
the first onset of symptoms and the correct diagnoses and treatment.
How much growth and development is interfered with while waiting this
long to do the right thing?
Author
William Shryer, DCSW, LCSW
Clinical Director
Diablo Behavioral Healthcare
Danville, CA
