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                  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

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