Bipolar Disorder in Children:Neglected Health Problem or Trendy Diagnosis?

Bipolar disorder is being diagnosed with increasing frequency in children. Some psychiatrists claim that the symptoms of early onset in children differ from the symptoms in adults. But other medical experts hesitate to acknowledge a diagnosis of bipolar disorder in children. And both sides worry about the unintended consequences of medication on children with an improper diagnosis.

Learn to recognize the symptoms of bipolar disorder in children.

By Sara Solovitch

Michael Klein, a San Francisco boy a couple months shy of his 12th birthday, had a very disturbing day at school. When his mother, Valerie (whose name, along with Michael's, has been changed at her request), arrived to pick him up, the teachers at his therapeutic day school reported that he had been uncontrollable all day, kicking, yelling and screaming.

At their insistence, Michael was taken to the emergency room at Stanford Hospital where it took five adults and an injection of Depakote, a mood stabilizer, to restrain him. Five days later, he returned to his mother's house in Mountain View. But that weekend, he again lost control. He threatened his mother with a baseball bat, kicked her and pushed her out of his bedroom, nearly breaking her hand when he slammed the door.

For the first time since her son was diagnosed with bipolar disorder at age 6, Valerie was scared of him. This time, he was taken to the acute adult psychiatric unit at Valley Medical Center in San Jose, where the examining psychiatrist informed her of the obvious: her son's behavior was "not age-appropriate."

"I said, of course not. He's been diagnosed with bipolar disorder. And the doctor said, `No, we're not going to call this bipolar.' He refused to accept the diagnosis." In fact, there are many medical personnel who hesitate to diagnose or even acknowledge the existence of bipolar disorder in children. They say that the hallmarks of the disease (periods of depression followed by bursts of energy, prolonged wakefulness, and sharp, focused thinking) are nonexistent in childhood. The cynics among them disdain it as the diagnosis du jour.

And yet in other circles, bipolar disorder is being diagnosed with increasing frequency in children. Researchers and clinicians at Stanford University and other teaching hospitals are seeing a dramatic rise in the diagnosis of mood disorders in children and adolescents, including bipolar disorder. They say that the increase is not yet fully understood, but can be attributed to more media attention and perhaps an actual increase in the prevalence of the disorder.

Dr. Kiki Chang, director of the Pediatric Mood Disorders Clinic at the Stanford University School of Medicine, explains that children present with symptoms which are complex and different from the typical pattern of symptoms seen in adults. "It can be difficult to diagnose if you don't specialize in the disorder," Chang says. For example, while a bipolar adult cycles back and forth between mania and depression every few months, a child may cycle back and forth several times a day. He estimates that it may affect up to 1 percent or more of children and adolescents.

An Overlapping Disorder
In their much-cited 1999 book, The Bipolar Child, psychiatrist Demitri Papolos, director of research of the Juvenile Bipolar Research Foundation, and his wife, Janice, call bipolar disorder in children a neglected health problem. The Papoloses claim that one-third of all children who are diagnosed with attention deficit disorder with hyperactivity (ADHD) actually suffer from early symptoms of bipolar disorder. They say that half of the 3.4 million children currently diagnosed with depression later turn bipolar. And, they add, it overlaps with many other childhood disorders, including obsessive-compulsive disorder and Tourette's syndrome.

"It was almost a relief to me when I read the Papolos book," says Valerie Klein. "It was like, `My God, have they been in my house?'"

"We hear that all the time," says Dr. Papolos, talking by phone from his office at Albert Einstein College of Medicine in New York. "Parents say, `It was like there was a videocamera in my house.' If you read it - and you know your child - the symptoms are pretty recognizable."

Chief among the symptoms are long, raging temper tantrums; inflexibility; destructiveness; excruciating sensitivity to stimuli; an excessive fear of death, and poor sleep patterns.

Family history is one of the strongest keys. According to Dr. Chang, children of parents with mood disorders are at high risk for developing such disorders. Children with only one parent with bipolar disorder appear to have a 14 to 25 percent chance of developing the illness themselves.

Critics Disagree
But while the disorder has been getting more and more media attention, there are the critics.

"Bipolar, schmi-polar," scoffs Lawrence Diller, a Walnut Creek behavioral pediatrician and author of Should I Medicate My Child? Sane Solutions for Troubled Kids With and Without Psychiatric Drugs. "In the real world of child psychiatry, these diagnoses are tossed around like bargain basement merchandise…We've become so biologically-oriented, so ready to see disorder, to see any problem in behavior as a manifestation of brain chemistry, that it makes complete sense when Ritalin and Prozac fail before moving on to anticonvulsants and antipsychotics."

Dr. Diller questions whether the change in diagnosis reflects only a change in medication - one whose long-term effects are completely unknown. The short term ones are in themselves problematical: antipsychotic drugs typically induce sedation and can cause huge amounts of weight gain, as well as involuntary movement disorders. "I've got kids who are 6 years old, in the throes of a high-conflict divorce and they're really acting out," he says. "And the child psychiatrist wants to call the child bipolar because he's not responding to Ritalin or some other stimulant. And I'm saying, `Hold on, hold on!'"

Dr. Diller explains that he does not think that medication is never called for. In his own practice, he continues to prescribe psychiatric drugs for children "albeit more methodically, thoughtfully and cautiously" than many of his colleagues. Stanford's Dr. Chang agrees that in some cases, there is a danger of over-diagnosis, "of hopping on the bandwagon," but he sees the positive side of the recent media attention. "This disorder has incredibly severe consequences on a child and the family," he says. "It affects and influences all the domains of life - home, school, play. It can totally wipe out a child. It is important to get it recognized."

The Consequences of the Wrong Medication
Having a clear distinction between bipolar and other disorders is important because antidepressants and stimulants, including Ritalin, "can cause havoc in a child suffering from a bipolar condition, increasing anxiety states, potentially inducing mania…and increases in aggressive outbursts and temper tantrums," write the Popoloses. Indeed, several studies have suggested that children who have been medicated with stimulants, antidepressants and serotonin uptake inhibitors may even be thrown into early and severe onset of bipolar disorder.

"It really is apparent to me that these drugs are not to be prescribed for kids with bipolar disorder," says Dr. Papolos. "When you think that Prozac, Paxil and Zolax are being prescribed very often - and not just by psychiatrists, but by pediatricians - you can see how a public health nightmare is really brewing. The rates of bipolar disorder have been increasing because of the use of these antidepressants in childhood."

As for 12-year-old Michael Klein, both sides may be on the right track. At the time of his hospitalization, his parents were in the process of getting a divorce. His father was disturbed by the idea of medicating his son. During winter break, which they spent together, he weaned Michael off all his medication. That vacation was short-lived since Michael's behavior deteriorated.

Sometimes his mother comforts herself by thinking of the great men and women in history with this disorder, long before it had a name: Sir Isaac Newton, for instance, was said to have written the calculus during an extended two-year period of mania. Charles Dickens, Abraham Lincoln and Winston Churchill were sufferers of bipolar disorder.

"He's a sweet, bright, creative kid who - when things are on an even keel - is very kind," Valerie says of her son. "My hope, like any mother, is that my child can live a full and independent life and go to college. But what I try to do is not think too far down the road. Because it's so uncertain. It's upsetting to me. So I look at the progress he's made and take hope in that."

Books The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder, by Demitri Papolos, M.D., and Janice Papolos, Broadway Books, New York, 1999.

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, by Ross W. Greene. HarperCollins, 2001.

Should I Medicate My Child? Sane Solutions for Troubled Kids With and Without- Psychiatric Drugs, by Lawrence H. Diller, M.D. Basic Books, 2002

Internet Resources - is the Web site of Dr. Demitri Papolos.
Bipolar Significant Others (BPSO) - is an Internet support group for people in relationships with someone who has a bipolar disorder.
The Child and Adolescent Bipolar Foundation - A parent-led, not-for-profit organization providing education, support, and advocacy for children and adolescents, their families, and professionals who serve them.
Juvenile Bipolar Research Foundation - raises and distributes funds for the most promising research into the causes, treatments and prevention of early-onset bipolar disorder.
The National Alliance for the Mentally Ill (NAMI) - 800-950-NAMI - offers support, education, advocacy and research for families with a member living with mental illness.

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Sara Solovitch is associate editor of Bay Area Parent, a Dominion Media publication, and mother of three.