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David Baxter PhD

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The storm of a bipolar child: Experts still have much to learn about the juvenile form of the illness

Jan. 2, 2007--At age 4, Jesse was explosive and inconsolable when things didn't go his way. By the time he entered kindergarten in Manhattan, a paranoia had taken over, and he felt the other kids were looking at him strangely.

By the time he entered kindergarten in Manhattan, a paranoia had taken over, and he felt the other kids were looking at him strangely. He wanted to lash out at them because he feared they would hurt him.

Jesse's parents knew such behavior was not normal. His manic energy forced them to play with him sometimes round the clock; he'd rage at the slightest provocation. The family barely slept -- the boy's night terrors triggered piercing screams.

After taking him to various doctors, some of whom recommended hospitalization, Jesse's mother found Dr. Gianni Faedda, a Manhattan psychiatrist who specializes in treating pediatric bipolar illness. Faedda was the first to diagnose Jesse with the disease. It took almost 18 months of mixing and testing many medicines that are used traditionally in adults with bipolar illness to get the right one for him. The medicine and weekly play therapy with a child psychologist to work on controlling his emotions and behavior have gone a long way toward steadying Jesse's mood and behavior.

"We're thrilled," said his mother, who lives in Manhattan and asked to remain anonymous because of what she fears is lingering stigma about the illness afflicting her son, who is now 7. "It's about finding the right fit," said the mother, who was grateful that someone finally understood her son's condition.

"The illness comes out in the child's behavior. It's not the child's choice or his fault," said Faedda, who, along with therapist Nancy Austin wrote a book released last month titled Parenting a Bipolar Child: What to do and why.

In an interview, Faedda likened life with a bipolar child to living in a war zone -- from struggles over getting up in the morning to afternoon agitation and aggression to difficulty getting to sleep at night. "Home life for a kid with bipolar is a minefield," he said.

Indeed, psychiatrists now believe that the thunder clouds that follow these children around darken virtually every aspect of their young lives. "They can't think straight. They lose control, and it is very scary -- for the child and for his or her family," Faedda explained.

Bipolar puzzle
Experts are still trying to figure out whether bipolar children experience the same kinds of symptoms as bipolar adults. Clearly, the young brain is a work in progress, but studies have shown that even young children can experience mood swings, impulsivity, aggression, depression and suicidal thoughts -- just like bipolar adults.

Bipolar illness affects two in every 100 people and usually begins in adolescence. Childhood forms are much more unusual and harder to diagnose.

One mother from Newton, N.J., whose daughter was diagnosed with bipolar illness in preschool said she had gone from doctor to doctor since the girl was born, in search of an explanation for her daughter's moods. The child slept only six hours when newborns were sleeping 16. And when she was awake, hour upon hour was spent screaming. Nothing could console the girl. By the age of 3, she was seeing things that were not there. Her fears were palpable, and her behavior was manic. If she was offered one doll as a gift, she "would not stop screaming at the top of her lungs until she got 10 dolls," her mother said.

She has spent her mothering years fearing that Child Protective Services would come after her because her child would kick and scream and rant in stores, buses and just about anywhere. Finally, a preschool principal mentioned something about bipolar disorder, and that sent the girl's mother searching for information online.

And there it was: symptom after terrifying symptom that described her little girl. She had lived with the disease for years because her husband had been diagnosed with it and was receiving treatment. But she just didn't expect it in a child so young.

Now 8, the girl has been on a combination of medicines, but they seem to work only for a week or two, maybe a month, and then she's back to the same raging behavior. The mother now has two other children and feels they are in constant danger from their sister.

The girl's first hospitalization was in October. A second admission came in December. Her mother is exhausted; the house is the battleground that Faedda talked about.

The daughter has hallucinated much of her young life. "I am afraid that she is as much a threat to herself as she is to others," her mother said. "We can't go for a drive, or pick pumpkins, or buy a Christmas tree. My only peace of mind is when she's at school."

While the daughter's behavior improves in school, like that of many bipolar kids, she deteriorates as the day goes on. Her mother is trying to get her into a therapeutic program and acknowledges she sometimes wonders about whether the girl should be in a residential program. "Do I keep her home because she is my child?" the mother asks. "She is always screaming and threatening my other children. She has beaten my son out of a deep sleep. She's not a bad girl. She's a sick girl," said the mother.

10 common traits

Bipolar disorder in children is a difficult diagnosis that is hotly debated in the pediatric medical community. Can a young child suffer from a severe mental illness that can cause uncontrollable irritability, mood swings, sadness, psychosis and problem thinking?

The answer, said Albert Einstein College of Medicine's Dr. Demitri Papolos, is a resounding yes. Papolos is co-director of the Bronx hospital's program for behavioral genetics and is also director of research at the Juvenile Bipolar Research Foundation in Maplewood, N.J.. Papolos and his wife, Janice, wrote a bestselling book in 1999, now in its third edition, called The Bipolar Child. His team of scientists has one of the largest collections of information in the world on bipolar kids -- more than 6,500 individual cases and an additional 650 sibling pairs where one child has the illness and the other doesn't.

Papolos wants to hunt for bipolar genes which would then be matched with specific behaviors. The team has found 22 traits shared by many of these children -- from a very low tolerance for situations that frustrate them to over-sensitivity to stimuli such as light and sound. But the scientists have determined that 10 in particular, including aggressive obsessions and the fear of being hurt by others, seem to best describe the child with bipolar illness.

In a recent study, Papolos and Michael Lipton of the Nathan Kline Institute, a psychiatric research center upstate, brought in a dozen of these children for brain scanning. "In every one," Papolos said, "there were specific structural changes in the hippocampus and the amygdala", sub-cortical brain regions that regulate memory, learning and emotion.

Five years ago, there was a lot of debate about whether the childhood version of the illness existed at all. That debate has subsided somewhat, but there are still many questions about the proper way to diagnose and treat a child with the disease.

"The condition in children is still controversial," said Dr. Vivian Kafantaris, a psychiatrist at Zucker Hillside Hospital, part of Long Island Jewish Medical Center. She and her colleagues are studying whether the juvenile form is distinct from the adult form and are trying to develop treatments.

"Treatment is sub-optimal for these kids," she said. More than one medicine usually is needed to tackle the complex range of symptoms. They are now testing mood stabilizers, including the adult bipolar drug lithium, in combination with anti-psychotic drugs in 100 children ages 10 to 18. And they are just starting to enroll children for an outpatient drug treatment study. (For more information on the studies, call 718-470- 8362.)

Much of the early work on the disease in children took place at Harvard University under Dr. Joseph Biederman and his colleagues. His research lab helped to put the disorder on the map, and it is continuing to follow a large group of bipolar children to see how the disease progresses.

Frequent misdiagnoses
Two years ago, Faedda and his colleagues published a paper in the Journal of Affective Disorders about the growing number of children diagnosed with bipolar after being treated earlier for other disorders, such as depression or attention deficit hyperactivity disorder.

Faedda and others agree that doctors who miss the correct diagnosis can inadvertently trigger symptoms of the underlying bipolar disorder by giving medicines for other conditions. Many of those initially diagnosed with major depression in childhood are subsequently diagnosed with bipolar disorder, Papolos said.

To help zero in on the right diagnosis, he has developed a bipolar questionnaire for families that was launched in September on the Juvenile Bipolar Research Foundation's Web site. It can be scored online for a $25 fee and then should be submitted to the treating professional. The foundation also has created an illustrated interview for parents and clinicians to use to assess children, as well as a clinical guide that doctors and therapists can download to help make them make a diagnosis.

But most important is the need to consult with a psychiatrist familiar with bipolar disorder in children, Faedda said.

Dr. Robert Kowatch, a psychiatrist at the University of Cincinnati, cautions parents that a diagnosis of bipolar disorder could be over-used to describe "kids who are just irritable and moody." A good rule of thumb, and most parents would know, he said, is that in bipolar cases "there are no good days ... these kids can have severe mood swings many times a day for hours on end."

The good news, he said, is that "kids can do well with good treatment and careful management."

Kafantaris described a recent case of a 10-year-old boy with mania who was admitted to the hospital after a suicide attempt. On the ward, he became convinced he could build an airplane and take his friends for a joyride.

He hardly slept, talked ultra-fast and continued with his grandiose plane-building idea. As the medicines kicked in -- a mix of lithium and an anti-psychotic -- his symptoms disappeared. "He went from wanting to build a real plane to talking about a model plane to drawing a plane on paper," she said.

Meanwhile, the mother of Jesse, the once-manic 7-year-old from Manhattan, is finally getting to see the other side of the impulsive aggression that drove her child for years. He can play with his sister and the family cat. He works on projects and comes up with creative ideas. The medicines are finally working, she said. "He still needs round-the-clock structure, and he still gets frustrated. But he is learning how to deal with it."

Here is an excerpt from Demitri Papolos' 65-item checklist of behaviors and symptoms to help doctors diagnose bipolar illness in children. A parent or clinician is asked to rate the frequency of each behavior on a scale from "never or hardly ever" to "very often or almost constant." It can be scored online for $25 at

  • has auditory processing or short-term memory deficit
  • is extremely sensitive to textures of clothes, labels and tightness of fit of socks or shoes
  • exhibits extreme sensitivity to sound and noise
  • complains of body temperature extremes or feeling hot despite neutral ambient temperature
  • has periods of high, frenetic energy and motor activation
  • has many ideas at once
  • has periods of excessive and rapid speech
  • has exaggerated ideas about self or abilities
  • displays abrupt, rapid mood swings
  • displays precocious sexual curiosity

NB: Children are often imaginative and energetic and by nature young children are typically egocentric by adult standards - this is normal. Thus, the presence of one or more of these symptoms does NOT mean that your child has bipolar disorder. As with anything else, it's often a matter of degree rather than the presence or absence of a specific symptom. Childhood biploar disorder can only be accurately diagnosed by a child psychiatrist or child psychologist. ~ David Baxter
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