Populations

The Bipolar Child - What to Look For

No, it's not normal kid behavior.

Julie writes:

"It is very difficult to be a parent of a child with bipolar. I have a six-year-old son who is diagnosed with ADHD. Doctors will not officially diagnosis a child this young with bipolar. With all the articles I have read and the medicine I have recommended to the doctors, I know he is bipolar. He is currently in a class for behavior disorder. I get called at least once or even twice a week to pick him up because he has hit another child or spit on the teacher. I am very close to losing my job and I feel like my world is tumbling down around me. I’m afraid to let other people watch him because they do not understand his illness and I am afraid they may hurt him. Most people believe children with bipolar are spoiled and just need some discipline. I am afraid that someone may unintentionally cause harm to him through their anger.

"I feel responsible for him and must leave work to care for him. I feel so alone. No one can possible relate to the problems a mother must endure for a child like this. I ask God several times a day why couldn't I have just had a normal child. Why must I fight to get his medicine right? Why must I miss work to care for him? Why can't we go out to eat without an episode?

"I also have two girls (ages two and 12 )that must watch his behavior escalate to the point where he knocks holes in the walls, pees in the closet and tears up his and their favorite toys. I feel so alone and drained. I have nowhere else to turn."

The Bipolar Child

Demitri Papolos MD and Janice Papolos, authors of "The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder," advise that parents with a hyperactive child consider the possibility of bipolar disorder first, rather than ADHD or other disorders. This is especially important in light of the fact that a misdiagnosis with the wrong medications can have a bad impact on a bipolar child. According to the book's authors, 93 percent of bipolar children meet DSM-IV criteria for ADHD. Fortunately, they list a number of key differences between child bipolar and ADHD behavior, including:

ADHD kids break things carelessly while bipolar kids tend to do so in anger.
ADHD kids calm down in 20 to 30 minutes while bipolar kids tend to rage for hours.
Children with ADHD are triggered by overstimulation while bipolar children typically react to limit-setting, such as a parental "no".
ADHD children are often unaware of the danger of their behavior, while bipolar children tend to be risk-seeking.

In 2001, Dr Papolos, along with parents, researchers, and clinicians, and Janice Papolos set up the Juvenile Bipolar Research Foundation,. Dr Papolos is Director of Research for the Foundation. The foundation brings together an international consortium of collaborating research groups and individual investigators in a setting free from the usual institutional red tape.

The JBRF is also aiming to produce an expert consensus on the diagnostic criteria for early onset bipolar disorder. The DSM-IV, which is based on our knowledge of the illness in adults, takes no account for how the illness manifests in kids, particularly in prepuberty. The DSM’s requirement that a manic episode last at least a week, according to Dr Papolos, belies the reality of kids being whiplashed from mania to depression and back again several times a day. "Right now," Dr Papolos told a 2004 JBRF conference, "there is really no consensus in the field of psychiatry about what this illness looks like."

Dr Papolos, who did part of his training at New York State Psychiatric Institute of Columbia University under Robert Spitzer MD and Jean Endicott PhD, co-authors of the ground-breaking DSM-III of 1980, pointed out that the DSM was never meant to be written in stone, and that it was intended to be revised as new evidence came in. Unfortunately, there has not been a revision since 1995 and there won’t be a new edition until 2010 at the earliest.

Symptoms and Behaviors of Early Onset Bipolar Disorder

So far 2,800 families have completed symptom inventories on the JBRF website. The site also features an interactive diagnostic workshop for clinicians and researchers. This kind of dialogue, plus his own clinical experience, has guided Dr Papolos toward a "core phenotype," a set of symptoms and behaviors that is being tested and further refined. At present, this core phenotype breaks down into three main areas:

Episodic and abrupt transitions in mood accompanied by rapid alternations in levels of arousal, emotional excitability, sensory sensitivity, and motor activity. Four mood states are identified as mania/hypomania, anger, depression, and anxiety. Mixed episodes "are associated with overlapping features of the primary mood states." (Present most days over 12 months, causing fundamental impairment in one or more settings.)
Poor modulation of drives. This includes aggressive, sexual, appetitive, and acquisitive, resulting in behaviors that are excessive for age or context. (Present most days over 12 months, causing fundamental impairment in one or more settings).
At least four of the following disturbances (present over 12 months): Excessive anger and oppositional/aggressive responses. (These kids have trouble responding to "no," waiting their turn, or adopting to changes in plans or routines, among other things); Poor self-esteem regulation (These kids can go from a sense of being the most powerful person in the world to being the worst person in the world.); Sleep/wake cycle disturbances; Low threshold for anxiety; Low threshold for arousal (These kids can go from zero to sixty in a nanosecond and back again into a state of complete boredom); executive function deficits (including mental, emotional, and motor activity inflexibility).

"All of these are basic human behaviors," Dr Papolos explained to this writer, "but they’re writ large." Rages typically go on for hours, leaving families mentally whipped in their wake, but unable to let down their guard for fear of yet another Vesuvius erupting without provocation. But outsiders rarely find out because moms and dads - in the words of the Papolos' book - "like battered wives present a brighter face to the world and refuse to have themselves picture their child or them that way."

Anonymous writes of her eight-year-old daughter:

"I am physically abused by her, biting, pinching, kicking, punching, tearing my clothes trashing the house and calling the police on me. ... It has been an emotional and physical journey with searching for the right counselor and doctors because a counselor thought I was abusing her when I would actually be defending myself. The adrenaline of a child in a rage, I feel, is comparable to an adults'."

As for acquisitive behavior, they want to have it and have it now. They get into "mission mode" and relentlessly pursue whatever need comes to the fore. And when it comes to appetite, roll over Dr Atkins - these kids experience carbohydrate binges that would make Cookie Monster jealous (with resulting glucose level spikes and crashes that feed into their wild roller coaster rides).

Much More than Mood

If only mood disorders were just about mood. When I put that observation to Dr Papolos in a phone interview, I literally felt the receiver resonate in a palpable wave of agreement.

To examine two key characteristics of Dr Papolos’ core phenotype in more detail ...

Sleep in Early Onset Bipolar Disorder

Kids with bipolar often find themselves caught in a deadly cycle of being unable to arouse themselves in the morning and being too revved up to go down for the night. According to Dr Papolos, bipolar kids tend to experience sleep inertia, where they feel literally chained to their beds in the morning. They generally come alert at about 11 o’clock, and as the day goes on they get more and more energy, until about four in the afternoon when, as one parent told Dr Papolos, "the rocket thrusters go off." Over the course of the evening, the kid is still accelerating, making re-entry and bedtime a virtual impossibility.

"The child is more of a night owl," Dr Papolos explained. When these kids don’t have to get up for school the next day they sleep, later and later in the day.

But sleep is generally far from a relief. Bipolar kids tend to experience a range of sleep disturbances that include night terrors and nightmares - often with images of gore and mutilation and themes of bodily threat and parental abandonment - sleep-walking, teeth-grinding, and bed-wetting. At the JBRF conference, Janice Papolos graphically described these frightening experiences, where kids in their dreams are frequently chased by sharks and the jaws literally sever their arms and legs. Most of us wake up before capture. These children don’t. "And we want them to get up and go to school the next morning," she observed.

Problems in the Hard Drive for Kids with Bipolar Disorder

"Executive functions are probably one of the least studied and most often overlooked contributors to academic and behavioral problems in children," Dr Papolos told the JBRF conference. These are the central processes that are most intimately involved in getting organization and order to our action and behavior, he explained. The frontal and prefrontal lobes are the seat of these activities, the very last part of the brain to evolve, and the evidence suggests that the circuitry here may not be fully intact for kids with bipolar.

In an article on their Bipolar Child website, Demitri and Janice Papolos elaborate the many complex cognitive and motor functions that come into play putting together a simple shopping list. Then they ask you to walk in the child’s shoes:

"Think of a child who has graphomotor problems so that he or she writes letters in a laborious, illegible manner; who has sequencing problems so that spelling is greatly below par; and who has memory challenges so that the missing items or ingredients aren’t summoned easily to mind (or kept in working memory long enough to write them down). A shopping list becomes a whole new order of accomplishment, demanding effort even at this rudimentary level."

They go on to say that it is estimated by some psychiatrists and neuropsychologists that many bipolar children have disorders of written expression. In verbal communication, Janice Papolos explained, there is forgiveness for going off on tangents while in writing there isn’t. Dr Papolos pointed out that starting in the sixth and seventh grades, kids are graded on how to write essays, a highly difficult and stressful task for these kids. The schools don’t pick up the problem, the kids become oppositional, and are viewed as having behavior problems.

At the same time these kids lack the ability to organize things. Their rooms become landfills, their backpacks black holes. As Janice Papolos explained, parents have to act as their child’s frontal lobes. But while other kids are becoming autonomous in their journey to adulthood, parents of bipolar adolescents continue to organize their lives. This protracted dependency predictability results in acrimony in an already strained relationship.

When We Were Young

Bipolar disorder seems to be feeding on our young, but the phenomena didn't simply erupt overnight. Many of us diagnosed as adults can rewind the tape back to our childhoods, like watching a broken teacup on the floor jumping back onto the table and putting itself back together - a handle that flew off at age 15, a bottom that cracked open at age 12 ...

Many of my Website readers report a sense of being different as a child. Writes Nassim:

My childhood peak experiences involved making pipe bombs. There was just something about lighting one on a summer evening then sprinting to safety to then experience a flash of light and a shock wave pulsing through my body that transported me out of myself. ... I also have the ability to knock things off the counter with the back of my hand and grab them with the same. This is an unconscious act and works out well if it is an orange or a glass but I have speared myself a couple of times by grabbing knives.

Windy reports:

I was told I broke figurines and dishes climbing in the pantry. The stories about living in the two-family flat with me climbing on the outside edge of the porch and going into the attic and climbing out the window . I could not get along with the girls next door I was not allowed in their yard? But could get along with the girl downstairs.

Geena recalls:

I knew that I was different at a very early age. In Catholic school, I questioned religious theories. My questions were met with the "we have a heretic here" response. Childhood was pretty painful. I was an outsider who was bored constantly. My parents tried to keep me involved in activities, but nothing really kept me interested. My room and books provided my safe haven.

High school was the worst time for me. People singled me out for ridicule, and I just took it on the chin. Fortunately, I excelled at academics without paying much attention. I got drunk on graduation day so that I could survive the commencement ceremony.

Says Serendipity:

My earliest childhood memory is of primary school and the assassination of JFK and wondering why the tears were flowing for someone I had never met. At least then I was "normal" or at least my reactions were. From then on, oh how I wished the aliens would pick me up and place me on the right planet - a place where mood swings are common, ECT and deep sleep were never heard of, medical retirement was not in the dictionary, and "tar and cement" had never been invented.

Controversy About Diagnosing Bipolar Disorder in Kids

Soon after the publication of The Bipolar Child, an article appeared on t WebMD article that began:

"A dangerous new trend is on the rise, noted child psychiatrists tell WebMD. Egged on by a batch of popular self-help books, more and more parents are becoming convinced that their children have bipolar disorder - and even scarier, their doctors are agreeing."

The article used the word, fad, in the title and the contents mentioned hysteria.

At the 2001 Depression and Bipolar Support Alliance annual conference, Dr Papolos noted the myth that children can’t have bipolar disorder is a fairly modern one, stemming from the 1930s when standard textbooks began purging their pages. In 1960, a seminal textbook was published that established criteria so stringent that it guaranteed a diagnosis would be rare (such as the child requiring heavy sedation or ECT).

Fortunately, Dr Papolos said, the myth is being rapidly debunked. Nevertheless, the lack of accurate diagnostic criteria in the DSM-IV helps sow the seeds for controversy and confusion.

According to Martha Hellander, Executive Director (as she then was) of the Child and Adolescent Bipolar Foundation, the problem is not overdiagnosis of bipolar in children. "To the contrary, we receive reports daily of families with children evidencing clear symptoms of being told flat out that 'children can't get bipolar disorder.''"

As to why there is a sudden "epidemic" of childhood bipolar, a 1993 Johns Hopkins study of two generations of bipolar families found that the second generation experienced illness onset 8.9 to 13.5 years earlier and 1.8 to 3.5 times more severe. The authors of the study speculate this may be attributable to a genetic factor known as "anticipation," found to occur in Huntington's, myotonic dystrophy, and fragile X syndrome, all affecting the brain. In these illnesses, genetic mutations are passed from generation to generation in a form of repeat sequences that are enlarged over the generations.

Meanwhile, a mother of a nine-year-old bipolar child had this to say on an internet message board:

"Perhaps we are finally seeing doctors and psychiatrists who are willing to believe it's a real condition, not just a figment of overactive parents' imaginations. Perhaps the professionals are realizing that mothers really DO know their children best."

Thanks to the work of Dr Papolos and others, the tide has turned in favor of recognizing the reality of early onset bipolar disorder. In June 2001, the Fourth International Conference on Bipolar Disorder hosted by the Western Psychiatric Institute in Pittsburgh devoted the better part of an afternoon to the topic. Boris Birmaher MD of the University of Pittsburgh told the Conference that six or seven years ago we would not be talking about bipolar in kids like we are now.

Bipolar Kids Sicker Than Adults

At the 2001 Bipolar Conference, Barbara Geller MD of Washington University presented two-year study findings that showed child-onset mania is not just a milder version of the adult variety. The ongoing study of 268 kids compared 93 kids who experienced mania to those with ADHD and a population of controls.

Nearly 90 percent of bipolar adolescents have co-occurring ADHD, Dr Geller said, but bipolar kids can be distinguished by their elation and grandiosity. Children may not have maxed out their credit cards or have had four marriages, she told the Conference, but there are strong parallels. A grandiose bipolar disorder adult, for example, called the President to tell him how to run the country while a manic child repeatedly called school officials to tell them how to run the school.

It is normal, she went on, for a child to be super happy at Disneyland. An example of pathological elation, on the other hand, involved an eight-year-old girl being super infectiously happy during a clinic visit for failing grades at school.

As well as elation and grandiosity, bipolar kids differ from ADHD kids in flight of ideas. Adults can conceptually understand "racing" thoughts, but kids typically say, "I need a stoplight up there," or "my thoughts broke the speed limit."

What also helps separate the bipolar kids from those with ADHD are lack of sleep, hypersexuality (in 43 percent of her sample, which included examples of an eight-year-old boy who rubbed his crotch in imitation of a rock star and another boy who called 1-900 sex lines) and daredevilry (a three-year-old going into a bar and ordering a drink).

Most of the kids in the study had mixed mania or psychotic episodes, 87 percent rapid-cycled, usually continuously, some for three years, with a poor prognosis over 18 months. The mean age of onset when the study began was seven years, with the kids ill for three years. Surprisingly, less than half had been given an antimania drug. Almost no one had recovered after six months. After 18 months, half had recovered, and after 24 two thirds, but half of these relapsed. In families with high maternal warmth, 42 percent of the kids relapsed vs 100 percent in families with low maternal warmth. "A seven-year-old manic child," she concluded, "is sicker than a 20-year-old manic adult."

In the May 2004 Archives of General Psychiatry, Dr Geller reported on the 86 bipolar kids still in the study after four years:

Eighty-one percent originally entered the study with first episode mania, with age of onset at seven years. Manic episodes lasted 79 consecutive weeks, with time to recovery at 60 weeks. Rate of recovery was 87 percent, but 75 percent relapsed after recovery. Only one patient remitted. The kids spent 57 percent of total weeks with mania or hypomania (including mixed) and 39 percent of these weeks were with mania. Major or minor depression (including mixed) occurred during 47 percent of total weeks. Switches from mania or hypomania to major or minor depression occurred once a year, but ultrarapid-cycling was frequent within single episodes. The 51 kids with baseline psychosis were ill significantly longer.

Dr Geller concluded that: "Chronic, severe symptoms have been reported in about twenty percent of adults, but were seen in most" of the kids in the study.

What remains to be answered is whether these children will go on to resemble late teenage/adult onset bipolar or continue to have chronic and mixed cycling.

More Characteristics of Early Onset Bipolar Disorder

An article in the Journal of Clinical Psychiatry by Janet Wozniak MD, Joseph Biederman MD, and Jennifer Richards BA of Harvard reports that childhood onset bipolar disorder made up 16 percent of prepubertal referrals (43 kids) to Massachusetts General Hospital’s pediatric psychiatric outpatient clinic.

Ninety-two percent of the parents interviewed indicated that irritability was the impairing mood state, typically of a hostile, vicious, and attacking quality lasting an hour or more as opposed to the distractibility of ADHD or the crankiness of depression.

Parents report walking on eggshells. Another trait is grandiosity, where parents say children "act too big for their britches." One child began to dig up the backyard to plant a garden to feed the starving people of the world. As opposed to other types of oppositional behavior, "grandiose defiance" is characterized by the child knowing better than the adults around him, a basis for refusing to comply with their "stupid" demands.

Ninety percent of the children meeting criteria for mania also had a depressive episode, and 84 percent had the depressive episode overlap with the manic episode into a mixed state. Children will switch in and out of depression, irritable mania with explosions, and euphoric mania throughout the day, almost every day. Because of this switching, it is very difficult to meet the clinical criteria of a "full week of irritability," or "a full week of euphoria." Oddly enough, "only in a minority of the most severe cases do children demonstrate their most abnormal mood states at school or in the outpatient clinician’s office."

The mean age of onset was 4.55 years, with 75 percent of parents describing their child’s symptoms as beginning under age five. This contrasted with mean age of onset of ADHD at 2.98 years.

Ninety eight percent of the children under age 12 who met criteria for mania also met criteria for ADHD. In contrast, 79 percent of referrals to the clinic met criteria for ADHD without mania. If ADHD rating scales are used, a manic child and a child with ADHD cannot be distinguished from each other. The Mania Rating Scale, on the other hand, can identify manic children. Manic children generally have "greater psychopathology and poorer functioning." The authors note it is also important to look for co-occurring ADHD with mania, and not to mistake these symptoms for residual mania. Other co-occurring conditions include bipolar with conduct disorder and anxiety (52 percent of children with anxiety also have bipolar).

The authors found "very few differences" between child mania and adolescent mania, except that the adolescents had a lower rate of co-occurring ADHD (60 percent).

Last Word

The clinical view of a raging out-of-control monster in diapers is counterpoised by an admittedly unscientific but forcefully accurate observation of reader Cante Jondo, who deserves the last word in Part I:

"There are many extra sensitive people out there, obviously not enough, and they are the ones that from birth on to school days, teen years and adult life suffer the most in a world that has definitely taken away a lot of their energy instead of giving back what they deserve as spiritual people. I think there are people that are simply born with an extra sensitive nerve and it is probable that they do have more capacity than normal people to be in contact with the spiritual world. It is just like the artist, the musician and the mathematician.

"They have certain talents that evolve spirituality through their sensibility. It would be good actually for parents, medics and teachers to become aware of these special children, they are not the same as normal ones and they deserve special attention ... "

Updated Nov 5, 2004, reviewed Feb 15, 2008