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Bipolar Disorder Hits the Youngest the Hardest

Bipolar Disorder Hits the Youngest the Hardest

Number of children affected may be 'vastly' underestimated, experts contend

By Linda Searing
HealthScoutNews Reporter
FRIDAY, Nov. 23 (HealthScoutNews) -- People may think small kids don't generally get as sick as grown-ups. But new research shows that when bipolar disorder, or manic
depression, is involved, the exact opposite is true.

"The little children that we see have the most severe form of the illness," says Dr. Barbara Geller, one of the nation's acknowledged pioneers in research on bipolar children.

By contrast, she says, only 20 percent of adults with the disorder have the severest form.

A typical bipolar adult has high or low periods that last for a few months, she explains, but can feel and behave normally in between, free of the disorder's telltale mood swings.

"But the children do not have well periods," Geller, a psychiatry professor at Washington University School of Medicine in St. Louis, says. Rather, they have manic and depressive episodes almost simultaneously, her research shows.

"A child can be absolutely manic and amusing and, just a few minutes later, can be suicidal and talk about stabbing themselves in the heart," Geller says.

Since 1995, Geller and her colleagues have been following 93 bipolar children, comparing them to 81 hyperactive children and 94 healthy children. The children were all around 7 years old when the study began, she says.

The idea was "to characterize systematically what this illness looks like in prepubertal children," Geller says.

Bipolar disorder is a serious brain disease that causes extreme changes in a person's mood, energy and ability to function. It afflicts about 2.3 million adults in the United States, according to the National Institute of Mental Health. About 1 million children are bipolar, reports the Child & Adolescent Bipolar Foundation, based in Wilmette, Ill.

Some experts, however, suspect that far more children have the disorder than many doctors believe.

"We think that it's vastly underdiagnosed," says Ruth Field, president of the foundation's board of directors. "Vastly."

That's because, experts say, children with bipolar disorder may appear instead to be hyperactive or have attention deficit hyperactivity disorder, commonly known as ADHD.

Or doctors may think some of them have conduct disorder, oppositional defiant disorder or even attachment disorder, which is the inability to bond with other people, Field says.

"It would be a real shame to diagnose young people with a condition for which there is no treatment and let them suffer when, if they had the correct medical diagnosis, there's adequate treatment," she adds. "Bipolar disorder is a medical illness that responds to treatment," usually medications that control sufferers' mood swings.

Recent research also has shown that almost half the children who doctors first believe are depressed are eventually diagnosed as bipolar, Field says.

But researchers like Geller say they're making progress in identifying the extent and severity of the disease in children.

"We now can tell who's [hyperactive] and who isn't," Geller says.

"Hyperactivity, irritability, distractibility, aggression -- those symptoms don't tell you anything because they're so common," she says. Children who are hyperactive, autistic or manic, for instance, all could have these symptoms.

"But elation and grandiose behavior occur only in the manic kids," Geller says. "[They're] the cardinal symptoms of mania. They're unique to [bipolar disorder], and don't occur in ADHD."

To understand the world of the bipolar child, picture this:

"A normal child is told they're going to Disneyland and goes absolutely bananas. And that's completely appropriate," Geller says.

But a bipolar child "will be just that happy and excited for no reason at all in the middle of the classroom every day," she explains. That's what she calls inappropriate elation.

As for the grandiose behavior, again imagine a child in school, but this time the child "tells the teacher how to teach, tells other students what to learn, generally takes over the classroom," Geller says.

That's like an adult "who calls the president, calls the mayor and advises them on what to do," she says, something a bipolar adult might do.

Finding these "childhood equivalents of adult symptoms of mania" has been groundbreaking and critical, Geller says.

"This was important because many of the [warning signs] in adults could not possibly occur in children," she says. "They aren't going to max out credit cards, have four marriages [or] call the president and tell him how to run the country."

But now, she says, we know that children with this disorder behave much the same as bipolar adults, just in a more childlike way.

In the months and years ahead, Geller says, she and her researchers "want to see if the children stay the way they are, having the most severe form [of bipolar disorder], or if, later on, they'll look like the more typical [bipolar] adult."

What To Do

Field says, "What organizations like ours need to do is get the word out to the medical profession, especially pediatricians, who are on the front lines of medical care for children and adolescents, that bipolar disorder can occur in all age ranges."

"So don't rule it out," she advises doctors. "Consider it along with all the other things you're considering, so you don't accidentally make a mistake."

To better understand bipolar disorder, check out information from the National Institute of Mental Health. Or visit the Web site of the Child & Adolescent Bipolar Foundation.

"A child can be absolutely manic and amusing and, just a few minutes later, can be suicidal and talk about stabbing themselves in the heart."

-- Dr. Barbara Geller,Washington University School of Medicine

Perhaps, instead, they coud have said: Does your child have bipolar disorder ?

www.ncbi.nlm.nih.gov/entr...t=Abstract

J Child Adolesc Psychopharmacol. 2003 Summer;13(2):123-36.

Response to methylphenidate in children with attention deficit hyperactivity disorder and manic symptoms in the multimodal treatment study of children with attention deficit hyperactivity disorder titration trial.

Galanter CA, Carlson GA, Jensen PS, Greenhill LL, Davies M, Li W, Chuang SZ, Elliott GR, Arnold LE, March JS, Hechtman L, Pelham WE, Swanson JM.

OBJECTIVE: Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children.

METHODS: Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two "mania proxies" were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies.

RESULTS: Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects.

CONCLUSION: Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms.

The purpose of this particular report was to determine if a proxy could be developed to help determine which children may have short-term adverse reactions to stimulants. They were unable to do that, but since the original study sample was not designed to address this question, the study limitations are quite significant, and the conclusions must be viewed in context of the limitations:

1. Some bipolar subjects screened out of the study to begin with.

2. Low number of participants with manic symptoms, suggesting limited power of the study conclusions. (Significantly lower numbers than any other research has suggested -- this is the most serious limitation -- that most bipolar was probably screened out of the study "because subjects were excluded if they had been treated with antipsychotic medication in the last 6 months, were currently hospitalized, had missed one fourth of school days in the past 2 months, or were suicidal.") Where most studies of ADHD subjects from a variety of settings find about an 11% rate of bipolar, this study found only 1.4%, which is so low that it casts doubt on the results.

3. Results not generalizable to other ADHD treatment settings because of volunteer subjects.

4. Lack of valid instruments to assess manic symptoms.

5. Only a 1-month trial -- unable to draw conclusions about real-world practice over the long-term. "The analysis does not address the concern that children with subsyndromal symptoms of bipolar disorder or children with ADHD and manic symptoms might respond well to stimulants initially but develop an adverse reaction over time."

6. Nature of the titration trial, with random daily dose switching and intermittent placebo.

A helpful post from RedGiantStar

p082.ezboard.com/ftourett...1824.topic


redgiantstar
10/11/05 3:57 pm)
Re: Just returned from bi-polar links Hi ltb,

I don't come here often but your post caught my attention. TSNW was one of the first message boards I came to when my son started having tics and OCD sx suddenly. I still refer people here for help with tic/TS issues. Anyway, my son has subsequently been diagnosed with Bipolar Disorder and Aspergers Syndrome (along with episodic tics and OCD related to PANDAS). He is doing really well at this time. Actually, he has been doing well for about 2+ yrs now.

I think I can help you with some of the mood and med questions. Hand tremors on Depakote are not uncommon. Beta blockers can sometimes help with this side effect, as well as possibly lowering the dose. Regarding the extrapyramidal symptoms you were seeing, I would be much more likely to suspect the atypical antipsychotics. Did you know that once EPS are present as a result of an AP that the rule of thumb is usually to avoid all meds in that class? EPS are much more likely to occur again in a person who has already developed them on a med in the same class.

As far as ususual responses to medication: I would consider 2D6 genetic testing. This testing will provide information on how your child's body metabolizes medications. A source of general info: www.psychiatrictimes.com/...=164902190

Some additional reading:

www.currentpsychiatry.com...=2054&UID=

www.psych.uic.edu/pmdc/pharmbook.pdf (excellent medication resource from a leading expert)

www.jaacap.com/pt/pt-core...668.30.pdf (2005 Treatment Guidelines for Children and Adolescents with Bipolar Disorder)

Also, depression need not be present for a diagnosis of Bipolar Disorder. If the criteria for a manic episode are met, depression is not necessary. bipolar.stanford.edu/bipolar.html (click on the tan box for DSM-IV criteria for the 3 types of Bipolar Disorder)

Have you read New Hope for Children and Teens with Bipolar Disorder by Birmaher? Has a PDD been ruled out? Sometimes Aspergers/High Functioning Autism can look like Bipolar and visa versa.

Yep, NAMI seems to have taken down the link ... here is the article:

WHEN ADHD IS NOT ADHD

By Gary R. Spivack, MD (From Treatment Today Magazine, Washington DC, Virginia and Maryland, December 1993)

Case A:

Johnny is a 10-year-old boy whose parents brought him to my office because he is no longer responding to the stimulants that once helped so much. Increased dosage helped temporarily but his ill temper continued to break through. Now he is too strong to held when he has tantrums. He has begun to hurt his younger brother and has threatened to his mother. Parents say that school is not such a problem, but crises at home are frequent, increasing and intolerable. Their son yells hateful epithets at them and has said that he would kill them or himself.

Case B:

Mary, a 12-year-old girl who has been having difficulty paying attention at school, daydreams a lot and "can't concentrate." Her grades are C's and D's despite the intelligence to get A's. Parents say she is well-behaved, well-liked, always in a good mood, talks excessively, has a difficult time waiting her turn, blurts out answers in school and is very distractible. She doesn't get along with her younger sister. She has been on a number of different stimulants but they did not help her grades, poor organization, or inability to finish things that she starts. She feel quite badly about herself, but maintains high expectations. The family is intact with no major changes or difficulties.

Both youngsters hat been diagnosed as having an Attention Deficit Hyperactivity Disorder (ADHD) and were treated with a combination of therapy, family work and medication. There was immediate improvement at times but an overall lack of improvement or worsening over time.

Bipolar Disorder or ADHD?

Bipolar Disorder is a well-known and extremely serious psychiatric disorder when it occurs in late adolescence and adulthood, but only in the past decade has its existence in childhood and early adolescence been revealed. Most clinicians are ill-prepared to recognize children with Bipolar Disorder and parents have no information available to them. The disorder most commonly confused with Bipolar Disorder is ADHD. The areas in which the two disorders can overlap and those in which distinctions emerge are noted below. The typical child with ADHD presents with the following:

Difficulties with attention
Distractibility
Impulsivity
Initability

Yet mania also interferes with attention, increases irritability and impulsivity, and distractibility is essentially the same as a manic flight of ideas. It is not widely appreciated how similar these symptoms can be. Children with ADHD often experience secondary depression and yet depression is part and parcel of a Bipolar Disorder. It is not by accident that so many children with Bipolar Disorder have not been properly diagnosed.

Differentiation of the two disorders requires a careful medical psychiatric approach to diagnosis. As in all diagnostic evaluations, a thorough history and mental status examination give 90 percent of the information necessary to make the diagnosis. The following areas are clinically useful to differential diagnosis and treatment:

Family History - A helpful distinction between the two disorders is a family history. Since both have a familial inheritance, a detailed family history looking for symptoms or diagnosis of either disorder among blood relatives can be useful. If Bipolar Disorder is revealed, the childhood history of those family members should be explored looking for similarities and differences. Many parents tell me that these possibilities were never considered.

School versus Home - If the behavioral difficulties are worse at home than in school, this may also lead to children with Bipolar Disorder, because they have the most difficulty under conditions of intense affect which is present in the most intimate relationships, (i.e., at home, a boy's disappointment in his mother is much more intense than with his teacher or friends). At school, the focus is on work, not on feelings which are diffused over many different people, lowering the intensity of the interactions.

With ADHD, the controlling variables are information overload and excitability. The child with ADHD often does very well in the home under low stimulation and poorly in school, despite being medicated.

Disassociative Symptoms - Children may feel as though they are outside their bodies watching themselves, may feel that they are not themselves or are fragmented. This may be a response to the intensity of manic emotions. Their drawings reflect this - often of robot-like automatons or aliens rather than real people.

Racing Thoughts - Children are able to describe this very clearly when asked about it directly. This can present as disorganization and an inability to focus on the subject at hand, severely interfering with school work.

Mood - Adults typically experience shifts from normal mood, to depression and mania episodically, while prepubertal children usually experience ongoing continuous mood disturbance that consists of aspects of mania and depression at the same time. This mixed mood is very confusing to the child who can't explain it to his parents, leaving them unaware of his true internal state. The parents view the child through his behavior and are not aware of his subjective distress. Sometimes the depression dominates, resulting in intense suicidal behavior

Energy and Aggression - Hyperactive children have high levels of energy and aggression but their intensity in mania is unmatched by any other disorder. The aggression typically has a "comic book" or "cartoon" quality to it, in which it is apparent that the child relates to his own aggression as though it and its consequences are somehow unreal.

Grandiosity - Manic adults, who are grandiose, see themselves as being of a higher order (i.e., as gods, royalty, or other leaders who are above the common man). Grandiose children also see themselves as a higher order - being an "adult." This puts perspective on their defiance and lack of willingness to follow directions such as when parents ask the question, "Who do you think you are?"

Egocentricity - Manic children expect their inflated desires to be met. Combined with the above grandiosity, one gets an incredibly difficult person to live with and care for.

Hypersexuality - Just as manic geriatric patients can be unusually youthful in their sexual vigor, so can manic children be unusually adult in their sexual interest and behavior. This presents particular problems for parents of early adolescents who pursue sexual behavior as though they were emancipated adults. Provocative postures, gestures, verbalizations and actions are all present.

Loss of Reality Testing - Manic children often say that they hear someone calling their name or have command hallucinations. Other symptoms are worsened when reality does not pose a limit for them. Instead the parents or teachers must impose the limits of reality, i.e., "You can't hit your sister like that because you will hurt her." "You are not in charge here; I am." This bursts their narcissistic bubble and releases rage that is targeted to the bearer of the disappointing news-usually the parent.

Telling Tall Tales - Difficulties with reality testing merge with grandiosity so children exaggerate reality to the point of fantastic, unbelievable, exploits by themselves and others. This is rather different than the more commonplace lying to get oneself out of trouble.

Resistance to Treatment for ADHD - Lack of response is not proof that the child does not have ADHD, but present with other factors, it may warrant changing the working diagnosis to that of a Bipolar Disorder - and a resultant change in medication from stimulants to mood stabilizers, (Lithium, Carbamazepine, and Valproic Acid) antidepressants and antipsychotic medications.

Proper diagnosis cannot be overemphasized since the results of untreated or improperly treated Bipolar Disorder are devastating. Sadly, there is a tremendous overrepresentation of children with Bipolar Disorder in psychiatric hospitals, residential treatment centers and in the Juvenile Justice system. Development of personality disorder-notably Narcissistic, Antisocial and Borderline Personality Disorders-along with Substance Abuse-is almost inevitable without proper treatment.

In this era of managed care, it is also important that the child be properly diagnosed so that the appropriate level of services will be authorized. Medication, intensive personal and family therapy along with environmental interventions, special schooling, hospitalization, and residential treatment all may be necessary for a child and his family to survive the ravages of this disorder.

Parents need to understand this is a biologic, inherited disorder, that they are not at fault by their upbringing of the child, and that with proper treatment, their child can have a productive life.

From RGS (thanks !!)

Practical clues to early recognition of bipolar disorder