Speaker: Dr. Dimitri Papolos, May 2004 Health Care Leadership Forum

Dr. Papolos' presentation focused on the emerging public health issue of children with bipolar disorder. Following are some of the highlights from his presentation.

Bipolar disorder (manic-depressive illness) affects close to 1 million children and adolescents in the United States at any given time. Abrupt swings of mood and energy that occur multiple times within a day, intense outbursts of temper, poor frustration tolerance, and oppositional defiant behaviors are commonplace in juvenile-onset bipolar disorder. These children veer from irritable, easily annoyed, angry mood states to silly, goofy, giddy elation, and then just as easily descend into low energy periods of intense boredom, depression and social withdrawal, fraught with self-recriminations and suicidal thoughts. Recent studies have found that from the time of initial manifestation of symptoms, it takes an average of ten years before a diagnosis is made.

Bipolar disorder--manic-depression--was once thought to be rare in children. Now researchers are discovering that not only can bipolar disorder begin very early in life, it is much more common than ever imagined. Yet the illness is often misdiagnosed or overlooked. Why? Bipolar disorder manifests itself differently in children than in adults, and in children there is an overlap of symptoms with other childhood psychiatric disorder. As a result, these children may be given any number of psychiatric labels: "ADHD," "Depressed," "Oppositional Defiant Disorder," "Obsessive Compulsive Disorder," or "Separation Anxiety Disorder." Too often they are treated with stimulants or antidepressants--medications which can actually worsen the bipolar condition.

Bipolar disorder is different in children and adults
Adults seem to experience abnormally intense moods for weeks or months at a time, but children appear to experience such rapid shifts of mood that they commonly cycle many times within the day. This cycling pattern is called ultra-ultra rapid or ultradian cycling and it is most often associated with low arousal states in the mornings (these children find it almost impossible to get up in the morning) followed by afternoons and evenings of increased energy.

It is not uncommon for the first episode of early-onset disorder to be a depressive one. But as clinical investigators have followed the course of the disorder in children, they have reported a significant rate of transition from depression into bipolar mood states.

Childhood symptoms and when they begin
We have interviewed many parents who report that their children seemed different from birth, or that they noticed that something was wrong as early as 18 months. Their babies were often extremely difficult to settle, rarely slept, experienced separation anxiety, and seemed overly responsive to sensory stimulation.

In early childhood, the youngster may appear hyperactive, inattentive, fidgety, easily frustrated and prone to terrible temper tantrums (especially if the word "no" appears in the parental vocabulary). These explosions can go on for prolonged periods of time and the child can become quite aggressive or even violent. (Rarely does the child show this side to the outside world.)

A child with bipolar disorder may be bossy, overbearing, extremely oppositional, and have difficulty making transitions. His or her mood can veer from morbid and hopeless to silly, giddy and goofy within very short periods of time. Some children experience social phobia, while others are extremely charismatic and risk-taking.

Misdiagnosis and Mistreatment
Several studies have reported that over 80 percent of children who have early-onset bipolar disorder will meet full criteria for ADHD. It is possible that the disorders are co-morbid--appearing together--or that ADHD-like symptoms are a part of the bipolar picture. Also, the ADHD symptoms may simply appear first on the continuum of a developing disorder.

Children with bipolar disorder exhibit much more irritability, labile mood, grandiose behavior, and sleep disturbances-- often accompanied by night terrors (nightmares filled with gore and life-threatening content)--than do children with ADHD.

Because stimulant medications may exacerbate a bipolar disorder and induce an episode or negatively influence the cycling pattern of a bipolar disorder, bipolar disorder should be ruled out first, before a stimulant is prescribed.
Almost all the children in our study of 120 boys and girls diagnosed with bipolar disorder met criteria for oppositional defiant disorder (ODD). Again, the child should be evaluated for a possible bipolar disorder.

Diagnosis of early-onset bipolar disorder
The family history is an important clue in the diagnostic process. If the family history reveals mood disorders or alcoholism coming down one or both sides of the family tree, red flags should appear in the mind of the diagnostician. The illness has a strong genetic component, although it can skip a generation.

Many parents are told that the diagnosis cannot be made until the child grows into the upper edges of adolescence--between 16 and 19 years old. The Diagnostic and Statistical Manual of Psychiatry--the DSM-IV--uses the same criteria to diagnose bipolar disorder in children as it does to diagnose the condition in adults, and requires that the manic and depressive episodes last a certain number of days or weeks. But as we already mentioned, the majority of bipolar children experience a much more chronic, irritable course, with many shifts of mood in a day, and often they will not meet the duration criteria of the DSM-IV. The DSM needs to be updated to reflect what the illness looks like in childhood.

Treatments
The first line of treatment is to stabilize the child's mood and to treat sleep disturbances and psychotic symptoms if present. Once the child is stable, a therapy that helps him or her understand the nature of the illness and how it affects his or her emotions and behaviors is a critical component of a comprehensive treatment plan.

Mood stabilizers are the mainstay of treatment for a bipolar disorder, but many of these medications have only recently begun to be used in children with the condition, so not a lot of data about their use in childhood bipolar disorder exists. Many psychiatrists are simply adapting what they know about the treatment of adults to the pediatric and adolescent population. (However, the anticonvulsant mood stabilizers such as Depakote and Tegretol, etc. have been used to treat young children with epilepsy for quite some time, so there is a literature about these drugs in the pediatric population.)

Commonly prescribed mood stabilizers include lithium carbonate (Lithobid, Lithane, Eskalith), divalproex sodium (Depakote, Depakene), carbamazapine (Tegretol), and Oxcarbazapine (Trilepta). Newer agents such as gabapentin (Neurontin), lamotrigine (Lamictal), topirimate (Topomax), and tiagabine (Gabitril) are currently under clinical investigation for the treatment of bipolar disorder and are being used in children. (Lamictal is Black Label for those under the age of 16.)

If a child is experiencing psychotic symptoms and/or aggressive behavior, the newer antipsychotic drugs, risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and Aripiprazole (Abilify) are commonly prescribed. Older antipsychotics such as thioridazine (Mellaril), haloperidol (Haldol), and molindone (Moban) are old standbys. Clonazepam (Klonopin) and lorezapam (Ativan) are also used to treat anxiety states, induce sleep, and put a break on rapid-cycling swings in activity and energy.

It's very risky to use antidepressants with these children. Several studies have reported high rates of the induction of mania or hypomania and rapid-cycling in children with bipolar disorder who are exposed to antidepressant drugs of all classes. In addition, the child may experience a marked increase in irritability and aggression. Many parents on the BPParents listserv (an on-line community of parents who communicate with each other from all over the world via E-mail) reported that their children experienced psychosis and were hospitalized subsequent to their treatment with antidepressants. Some children did well for weeks or even for three months before a switch into mania and ultra-rapid mood shifts began.

For more information on bipolar disorder in children, log on to www.jbrf.org or read The Bipolar Child by Dr. Papolos. It is available at bookstores and the libraries of Battle Creek, Marshall and Albion.

Dr. Dimitri Papolos spoke with physicians, nurses, hospital and healthcare administrators, and board members at the Health Care Leadership Forum.