Bipolar Disorder in Children Divides Professionals Disorder Not Formally Recognized in Children
Albuquerque Journal
By Jackie Jadrnak
January 29, 2001
The Albuquerque woman's son, James, was diagnosed with the disorder when he was 9, following an earlier diagnosis of ADHD.
Even as an infant, he acted colicky, cried a lot and didn't sleep well, she said. As he got older, he had temper tantrums that would last an hour, sometimes all day.
"He was kicked out of every day-care program," she said, explaining that his infractions included aggression, throwing chairs, hitting and kicking.
When he had screaming tantrums at home, she often would open the door so passers-by could look in and see she wasn't hurting him.
Anything would set James off, Roach said. The sensory stimulation of a grocery store would trigger a tantrum. He became uncomfortable if people sat too close to him, even as close as classmates often sit in school. "In the car, the sun would hit him the wrong way, and it was enough for a full-blown temper tantrum," she said.
Bipolar disorder and ADHD can look similar in children, with both producing impulsive behavior, hyperactivity, difficulty concentrating and distractibility. But the intensity of anger and aggression in bipolar kids is more extreme and longer-lasting than in kids with ADHD, said George Shute, an Albuquerque neuropsychologist.
Setting limits -- saying "no" to the child -- often triggers a tantrum that lasts well beyond the five or 10 minutes you might see in other children, he said. Also, a family history often shows a history of mood disorders or alcoholism, he said.
Another key in diagnosis is seeing how the child responds to medications that attempt to balance brain chemicals that are off-kilter in mental illnesses, he said. Antidepressants can trigger a manic episode in bipolar kids, he said. Stimulants used for ADHD can make all their symptoms worse, he added.
One 15-year-old, for example, couldn't concentrate, got into fights and was impulsive, Shute said. Diagnosed with ADHD and treated with a stimulant, the youth said he had an easier time concentrating, but still wanted to hit people, according to Shute.
When James was diagnosed as having ADHD and was treated with a stimulant, he had some of his worst tantrums ever, Roach said.
The best treatment for children with bipolar disorder is with a mood regulator such as Depakote, an old anti-seizure drug that recently was approved for mood regulation, according to Tengco.
But treatment isn't always easy.
Roach said James, 18, has been reasonably stable in his high school years with a mixture of a mild antidepressant, a stimulant and an anti-anxiety drug. That's not a mixture you normally would give someone with bipolar disorder, but the side effects of the preferred medications were too severe for James, she said.
Lithium, a traditional treatment for bipolar disorder in adults, worked well, but caused his weight to balloon, leading to swelling in his brain, Roach said. Some anti-seizure medications made him so lethargic, he was almost unresponsive, she said. And anti-psychotic medications made him hyper-sensitive, jittery and jumpy.
"You've got to find a doctor who listens," Roach said.
Shute and Tengco have been speaking around the state, often to school nurses and other education personnel, to get more recognition for childhood-onset bipolar disorder. "A lot of cases are underdiagnosed," Tengco said.
The failure to treat children early enough can affect them the rest of their lives, according to Papolos. Extreme mood swings through their formative years could make it difficult for them to develop a healthy sense of self-esteem, learn how to get along well with others or simply figure out how to behave appropriately in the world, he said.
And untreated children often end up running afoul of the law or becoming addicted to drugs or alcohol, he said.
Some studies suggest bipolar disorder has been showing up in progressively younger ages since about 1950, Papolos said. The reason isn't known, he added.
No one is sure if these kids diagnosed with bipolar disorder in childhood will grow up to develop the more classical disease, with longer, distinct periods of depression and mania and stable periods in between. One small study looking at 25 adults with an unusual form of rapid-cycling moods in bipolar disorder showed they had symptoms in early childhood, Papolos said.
That raises suspicion that the children diagnosed today may continue with rapid mood changes into adulthood, but more research needs to be done to answer that question, he said.
Sometimes, he said, he gets so frustrated that he throws things and hits the wall. He displayed small scratches on his fists, explaining that when one hand gets sore, he switches to the other. "I have little control over my moods," Roach said.
Clayton said she doesn't have big mood swings but seems to have a mixture of moods. "I laugh and cry at the same time. It's the most ridiculous thing. It's horrible, because I can't stop," she said.
She rarely gets depressed, she said. But when she does, she gets very quiet, goes home, sleeps and doesn't want to deal with anything.
Imhoff-Kerr said she sometimes switches from mania to depression. "It's like you're going a million miles an hour and like hitting a brick wall," she said. "One time I got so depressed, I went under my teacher's desk in class the whole time. My friends would bring me tissues and sodas."
Clayton and Imhoff-Kerr both admitted to feeling suicidal at times.
Roach said he likes to take control and exert power. He admitted that he often argues with his teachers. "Teachers try and challenge me, but they never win," he said. "They back down. I don't back down."
But they all said their illness usually doesn't keep them from doing what they want to do. Sometimes, they said, the side effects of their medications worry them more than the illness itself.
Imhoff-Kerr said her medications have caused seizures. "I can go to bed feeling happy and tired and wake up in the emergency room."
Clayton said her medication has affected her thyroid in such a way that she once slept for 36 hours straight. "I literally couldn't wake up," she said.
Roach said he once took a drug that helped control his moods, but it made him perspire a lot and made his heart beat too fast.
In some ways, they said, their illness helps them.
"I enjoy thinking faster than everyone else," Roach said. "I have a lot of thoughts in my head at the same time. I can analyze all 10 at once, pick out the one which I need."
Roach said he wants to go to the University of New Mexico, study drama and become an actor. He rattled off a list of plays in which he already has appeared, both in school and in the community.
Imhoff-Kerr said the manic aspects of her illness help her handle her crowded schedule: a full load of classes at school, six extra-curricular activities, an independent study, driver's education and businesses she runs. She said she hopes to go to college and pursue a double major in psychology and law and a minor in philosophy.
Clayton, who wants to act, sing opera and minor in psychology, said her illness might help her understand what patients are talking about if she becomes a therapist.
"You know what it's like to be on the other side," she said.
The Diagnostic and Statistical Manual -- DSM-IV -- is the bible of psychiatry. If the book doesn't list a diagnosis with particular symptoms, then it doesn't exist.
Or at least it's not formally recognized. And the rapid-cycling bipolar disorder that some mental health experts are diagnosing in children is not listed in the DSM-IV.
"The criteria of DSM-IV requires one mood state or disorder to last for at least a week," said Demitri Papolos, a New York psychiatrist and a leader of the movement to recognize the illness. "We have found rates in 60 to 85 percent of children of very rapid daily (mood) cycles."
The diagnosis is controversial for some people, Papolos said. "Among the people doing the research (on the disorder), it's not controversial," he said. "They recognize the strong family history, the clear group of symptoms. Once you know the condition, it's crystal-clear."
Perhaps the core of the controversy rests not on whether the disorder exists, but whether it should be called bipolar, said Steve Adelsheim, associate professor of psychiatry at the University of New Mexico.
"Is this a childhood version of bipolar disorder with a little different symptom picture -- or is it something else?" he said. "The fight isn't over whether these kids exist, but the battle is what to call it ...
"I think the issue is more that kids with pretty severe behavior need help, and maybe mood stabilizers will work for them," he said.
It would be nice if there were a simple test to diagnose the disorder, but most mental illnesses have to be diagnosed by behavior and family history. "There's not even a definite marker for adult bipolar," said Cynthia King, UNM assistant professor and inpatient attending psychiatrist.
She said she believes in the childhood-onset bipolar diagnosis because she is seeing more and more children who fit the description. She identifies key signs as violent, extended tantrums; extreme irritability and a family history of bipolar or mood disorders (the condition is believed to be genetic).
Other signs include an unusual degree of sexual behavior in young children who have not been exposed to sexual abuse; a disregard of how risky behavior might harm them; and over-inflated self-esteem or attempts to take control, such as telling a teacher how to conduct the class, she said.
George Shute, an Albuquerque neuropsychologist, said some research suggests that one-quarter of children diagnosed with attention deficit/hyperactivity disorder (ADHD) actually may have bipolar disorder instead.
If true, that suggests as many as 1,600 to 2,100 children in the Albuquerque Public Schools system have bipolar disorder, he said.
Bob Bailey, medical director of UNM's Children's Psychiatric Hospital, doesn't believe such estimates. He doesn't even think one out of every 10 children diagnosed with ADHD actually have bipolar disorder.
"I don't think it's that common a childhood disorder," he said. But Bailey added that he does believe it exists. "I know there is childhood bipolar disorder because I've seen it," he said. "It's there. The important thing is to recognize it."
It probably is under-diagnosed in the state, because New Mexico doesn't have enough mental health professionals trained to recognize it, he said.
Bailey said he isn't sure if the diagnosis is showing up more these days because the disorder is occurring more or because people are looking harder for it. But he said research has shown more children are suffering from depression than in the past.
Why?
"I don't think the answer is in on that one," he said.
Copyright 2001 Albuquerque Journal
Click for permission to reprint (PRC# 1.4676.236916)
© 1997 - 2001 Albuquerque Journal
This news story is not produced by the American Psychological Association and does not necessarily represent the opinions of the association.