What's Wrong with my Child? ADHD or Bipolar? -- Full-Length Doctor's Interview
In this full-length interview, Demitri Papolos, M.D., explains the symptoms of bipolar disorder in children.
Ivanhoe Broadcast News Transcript with
Demitri Papolos, M.D., Psychiatrist,
Associate Professor of Psychology, Albert Einstein College of Medicine,
Director of Research, Juvenile Bipolar Research Foundation,
TOPIC: What's Wrong with my Child? ADHD or Bipolar?
After watching these children, what is the difference between bipolar disorder in children and bipolar disorder in adults?
Dr. Papolos: In adults, the presentation of the illness is one where you see rather long durations of cycles of mood, so the mania with the hypomania will last for a week or sometimes months. The presentation, the picture of the mood state, is one of, in adults, typically elation or irritability. There’s usually a tremendous amount of energy, a great deal of anxiety, often agitation, the speech is pressured, it brooks not interruption. The pattern of the cycling, usually for the most part, is mania or hypomania, followed by a period of depression and the depressive episodes are, typically for adults, a depressed mood, sadness, melancholia, and sometimes irritability. They have problems concentrating. They feel worthless. There’s a change in sleep cycle. Often, there’s a sleeping too long and there’s a change in appetite or cravings for carbohydrates or sweets. Suicidal ideation is also not unusual. There’s a withdrawal from the world and an isolation. Often, one of the principle symptoms is a loss of interest in things that would ordinarily give them interest. In children on the other hand, while many of the symptoms and behaviors are similar, the mood swings are typically much more rapid. They will cycle within the day, often multiple times, and apparently for about 80 percent of them, there is a very regular 24-hour cycle that is noticeable. In the morning, they wake up as if they are waking up out of some hibernated state. They are very hard to get going. The parents will describe them as needing to put them on roller skates to get them moving. There’s a difficulty initiating movement. They’re irritable, and if you ask them to do anything, they’ll bite your head off. As the day goes on, they get more energy, they’re more active, and often they’ll get through the school day and then around four o’clock in the afternoon, the rocket thrusters go off. There is a tremendous amount of energy. The moods become either incredibly irritable or elated, silly, goofy, and regressed.
Those are the typical ways in children that the manic or hypomanic state presents. It’s not that way in adults. Then, as the evening goes on, there is more intense activity -- jumping up on beds, provoking their siblings, and then difficulty settling at night and getting to sleep. So, in terms of the mood a swing, that is a common presentation for children whereas in adults, the mood swings are, from one pole to another, are usually much more longer lasting.
That’s a big problem currently in terms of diagnosis and recognition of early onset bipolar disorder because the current manual that psychiatrists, psychologists, mental health professionals use around the country to make the diagnosis is the DSM-IV. The DSM-IV does not distinguish between adult- and childhood-onset bipolar disorder. So, there is a duration requirement typically for making the diagnosis, and of course, most of these kids don’t meet that criteria. They don’t have cycles of longer than a week, so a very, very large percentage of children who are held to that standard and who do have bipolar disorder are not diagnosed. They’re often diagnosed with other conditions that are much more commonly recognized like obsessive/compulsive disorder, major depression, certain anxiety disorders, separation anxiety disorder, because those conditions go hand in hand with bipolar disorder. The problem with that is that most of the, and also attention deficit disorder is another common set of symptoms that overlap with bipolar disorder, and so many, many of these children are originally diagnosed with that condition. The significant problem with that is that most of these conditions are treated with medications that make the course of bipolar disorder worse. So, typically children, parents, who bring their children to me have had their children exposed to multiple trials of stimulants and anti-depressants and the course of their illness has worsened over time. That’s a big, big problem. In many ways, it’s a national mental health problem because so many of these children are being diagnosed with these other conditions where the symptoms are really part of the disorder but not necessarily independent of the bipolar disorder.
I have parents telling me the doctor said it's ADD or ADHD and put them on Ritalin. Then the child ended up hospitalized. How common is it that something like that happens?
Dr. Papolos: Well, we just finished a retrospective study on about almost 200 children looking at both the effect of antidepressants and stimulants on the course of illness. In the study we did, about 70 percent of the kids had significant adverse responses. Many of them became violent, extremely aggressive, and oppositional. A certain percentage become psychotic and require hospitalization. Others can become suicidal. In many, many of these kids, it throws them into what’s called a mixed state. A mixed state is basically where you have symptoms of both poles at the same time, and it is incredibly agitating. It is the period of time when most people, adults with bipolar disorder, actually do have the energy to kill themselves and the motivation to do that. So, it’s a very, very important message to get across to clinicians, many of whom are pediatricians who are prescribing for these children because there are way too few child psychiatrists around the country to really see and treat all of them. So, that is something that is of real significance.
When you say they are experiencing both poles at the same time, what does that mean?
Dr. Papolos: They’ll have symptoms of mania or hypomania and they’ll have symptoms of depression at the same time. So, for example, they may feel that they’re worthless and that everybody hates them, and they’ll have no interest in doing anything and feel isolated. At the same time, they’ll have this tremendous energy that comes with mania or hypomania. But, typically when you’re depressed, you don’t have much energy. You’re slowed down. There’s a fatigue, so there’s no capacity really to act on an impulse that you might have that is to hurt yourself, whereas in a mixed state, you have a combination of the sense of worthlessness and sense of isolation and a sense that there’s no future pleasure that’s going to come into your life and you have this agitation and energy.
You mentioned pediatricians need to be aware of it, but what about parents? What is a parent who might have a bipolar child need to know when they do get this diagnosis of ADD or OCD or Oppositional Defiance?
Dr. Papolos: You’re right. All too often, parents go into a situation and expect that the professional is going to be able to make the right diagnosis and prescribe the right medication. I think it’s important for parents to realize that until around 1995, there was very, very little that was written about this condition in childhood. There were a handful of anecdotal reports, no real clinical studies, and the prevailing view in psychiatry was that bipolar disorder did not occur before puberty. The same thing is true of depression 15 years ago. Children were not thought to be able to have a major depression until they reached puberty, and even then, it was considered to be a rare phenomenon. So, the training of most child psychiatrists who are practicing today excluded the training in the diagnosis and treatment of this condition, and it is still controversial. So, parents need to know that before they go seeking professional help. One of the things we advise parents to do, if there’s a family history and they see their child is manifesting some of the symptoms like the ones that I talked about, is that they go to our Website and take a look at the inventory that we’ve developed that will help them to determine whether it's reasonable to go ahead and get a consultation, looking to see if their child has bipolar disorder. If they suspect that, then they need to carefully interview the physician who they are going to for consultation and begin with the question, "Do you believe that bipolar disorder exists in childhood?" If the answer is yes, then, "How many children have you diagnosed, and how have you treated it?" We have a section in the book that actually gives parents an idea of the questions they could ask of a physician that they go to to help them determine whether that’s the right direction to go in. So, that’s something that I think would be worthwhile to take a look at before you went about that kind of inquiry.
Clearly it is happening in children before puberty, so how young are you seeing it develop now?
Dr. Papolos: Based on retrospective accounts from parents, typically the earliest that I’ve actually seen and diagnosed a child is about age 4 or 5. That’s only where you really see the primary manifestations of the condition and where there’s a strong family history, but retrospectively, what we find is there are a lot of early antecedent symptoms that are rather typical and that precede the onset of the full picture. So, you may diagnose a child and they may sort of fully declare themselves at age 6, but when you’ve got a history of going back, you’ll hear about very, very specific symptoms that are characteristic, not of all of them, but commonly observed. We’ve had one mother who described her child in utero as a ninja baby, so much movement and an inhibition of the motor system that she knew there was something different about this child from the very beginning. And, the temperamental features that children have even as early as infancy, often there are the bright-eyed babies of the nursery, oversensitive, overreactive to sensory stimuli, easily aroused, crying, whining, irritable, hard to settle. They often don’t settle into a regular sleep pattern, until long after it would be expected. So, there is some problem clearly with the arousal system. They are unable to modulate sensory input as it’s coming in, and they also have difficulty regulating their own moods and emotions.
I probably should say something that I’d neglected when you asked me the question about the difference between adult and child bipolar and I didn’t talk about the aggression. Another major difference between adults and children with bipolar disorder is that children typically have very, very oppositional, domineering, overbearing, and aggressive behaviors. Now, it's not unusual to see the overbearing, willful, stubborn, persistent behaviors, but it's not as common to see four-hour rages and tantrums that occur over the drop of a hat or particularly when a parent says no or deprives them of something that they want, whether it’s a toy or something that they want to do. If a routine is interrupted, something that’s expectable, that could be one trigger and provoke a rage. This is something that seems to be characteristic of many of these children.
It used to be that children were not diagnosed with this, and now clearly they are. Is it becoming an increasing problem or diagnosis in children? What do you attribute that to?
Dr. Papolos: It’s hard to know because there really have yet to be any general population studies of bipolar disorders. All of the studies that have been sponsored by the National Institutes of Mental Health over the years and for childhood psychiatric disorders pretty much excluded the diagnosis of bipolar disorder. There’s only one study in adolescence that was done and they looked at a group of about 1,700 high school students. In the children who would be diagnosed, let’s say, according to the way they actually do present, which are these shorter cycles, upwards to 9 percent of the population might be considered to have the illness, whereas if you look at the brief duration criteria, it's more like 1 percent of the population. So, that’s been shown in adult studies more recently that depending on the criteria you use to make the diagnosis, you’ll increase the size or decrease it, which makes sense. So, that’s in adolescence.
We really have no such studies in children, so there’s no way really of objectively answering the question. Clearly, because of the fact that there has been much more attention, national attention, that’s been brought to this diagnosis over the last two or three years, it's becoming more acceptable to make the diagnosis, whereas before, most of these children were diagnosed as having oppositional defiant disorder or attention deficit disorder or some of the psychiatric diagnosis. So the rates, because of that, are obviously becoming higher simply because it's more recognized. Whether there’s been an increase, an actual increase, in children of this diagnosis is a matter of debate at this point. There is evidence from studies that have been done by the National Institute of Mental Health or sponsored by the National Institute of Mental Health, in the general population, looking at the onset of mood disorders that includes bipolar disorder and depression since 1949. What’s been reported, is that within the generations, beginning in 1949 through the present, there are higher rates of mood disorders in the general population and the onsets are earlier and earlier with each generation. So, this may be some phenomenon that’s going on that has some potential genetic or environmental factors may be involved that are leading to earlier and earlier onset of these conditions.
We talked about children who are bipolar and are treated as if they’re ADD or ADHD have obviously been treated wrong and have been given the stimulants or antidepressants. How do you treat a child with bipolar disorder? What kinds of medications do they need to be taking?
Dr. Papolos: Let me start by saying there really are only a handful of studies, double-blind, controlled studies, that would allow us to conclude objectively what medications would be best used to treat the condition. So, in the interim, clinicians who are faced with having to choose some way of treating these kids rely primarily on adult studies, and so the same medications that are being used on adults to treat bipolar disorder are being used in children. Those include lithium, which is the gold standard, and also medications that were primarily first developed and used to treat seizure disorders. In fact, most of the mood stabilizers that are used to treat bipolar disorder in adults and children are anti-convulsants, anti-seizure medications. The other class of medication that’s most commonly used are major tranquilizers or anti-psychotic medications, and often, children need to be on more than one mood stabilizer and often major tranquilizers as well to achieve some kind of stability through the illness.
What are some of the triggers that you see in children that set off these various episodes, whether it be mania, depression or whatever?
Dr. Papolos: There are a number of triggers that can increase the cycling and also increase the frequency of rages. There are a number of factors for both the cycling and for the rages. Certainly, seasonal change in a major precipitant. Studies in adults have shown that the spring and fall are peak times for both mania and depression; usually in the spring, there’s a rather significant increase in hospitalizations for mania primarily, but also depression, and the reverse in the fall. Very large peaks for depression and hypomania or mania, there’s a lower peak at that point. Also, at both times, the rates of suicide and suicide attempts are sky-high, so there’s a definite seasonal variation in the condition. Other triggers that you see are sleep deprivation. Sleep appears to be a primary modulator of cycling and typically, if a child gets less than six hours of sleep, often the next day paradoxically, they’re not less tired, but they’re more active and the reverse is true for depression. The longer they sleep, the more likely they are to be in a depressed mood and have low energy following that. So, it's quite different than you might imagine. In terms of the rages, the typical triggers are a parent saying no, depriving the child of something, whether it's telling them they can’t have a toy they want can set off an enormous burst of anger that can last for sometimes half an hour or even four hours, and thwarting some agenda that some child has. If he has in his mind that he wants to go and do something and you get in his way, it’s kind of like waving a red flag in front of a bull. So, those are the kinds of things we often advise parents to try to avoid, particularly the word no. There are other ways of telling a child they can’t do something and that definitely is a provocation. It's almost like you’re turning on something very primitive that gets reflexively expressed by the tone of voice in the statement.
When does it cross the line that a parent should be concerned that maybe there is something else going on when they say no and their child gets upset? When is it possible mania, as opposed to a child being a child and not wanting to have something taken away from them?
Dr. Papolos: I think the best way of understanding this is that the responses, the mood states, the anger, the aggression, the increase in sexual behavior, which we didn’t mention, all of these things are normal, human behaviors. Children will get silly, goofy and giddy. Children will get angry. Children will explode. It’s the intensity of these responses and the fact that they are poorly modulated, that they go on and on and on. That’s really the characteristic. It’s the lack of the capacity to modulate emotion, drives, and the expression of feeling.
Do you have any research showing whether it is more prevalent in males or females?
Dr. Papolos: As I said, there aren’t any epidemiological studies so we can’t really say, but from the clinical reports and the studies that have been done, the small-scale studies that are being reported in the literature, if you look at the male/female ratio, it is heavily weighted towards males. On the other hand, most childhood psychiatric disorders apparently are heavily weighted towards males. The same could be said about attention deficit disorder. Now, why that is is a different question. I don’t think we have the answer for that, but it may very well be that particularly with bipolar disorder, that boys may have a greater capacity to express aggression and that is often the primary symptom that brings a child to the attention of a mental health professional. It gets them kicked out of school, suspended, and poses a lot of behavioral problems.
I just want to elaborate because this is the third time the hypersexuality has been sort of referenced but then kind of stopped. I was just wondering if you could sort of give me the laundry list of what other symptoms go along with bipolar disorder in children that parents might not be aware of, the more unique ones.
Dr. Papolos: I’m not sure. I would say that hypersexuality is unique. I think it's probably less discussed, and I think that’s really in general, in terms of psychiatric interviews, I think it’s an area for whatever reason that isn’t one that’s of direct inquiry. Particularly for children, where the expectation is that children are really not sexually mature and there’s not that kind of curiosity and interest. With kids with bipolar disorder, it’s as if the program that was intended to be released in adolescence and puberty is manifest much early. Not in all children with bipolar disorder, but certainly in a fairly sizable percentage. Typically, what you see when you see hypersexuality is there’s a much greater interest in genitalia. They will often be touching, either directly or surreptitiously, their mother’s breasts. They’re very interested in if they see it in pornography and essentially public displays, running around naked in the house, often when they’re in a silly, giddy, hypomanic state. So yes, that is a symptom. Again, it's aggression and sexuality are both primary drives in human beings and just like aggression, sexuality is poorly regulated in these kids.
Going back to what’s normal, what’s not normal, and this may be reiterating what we’ve already talked about, for example, separation anxiety. At what point does a parent need to be concerned that this isn’t just separation anxiety and the child misses his mother?
Dr. Papolos: I think again children with bipolar disorder, for those who experience separation anxiety, it is usually extreme. I can site some examples that might give you a better idea. We had one child who was so anxious when the mother would leave the room, it wasn’t just at school, but he demanded that mother carry a walkie-talkie around and he would of course have one in the household so that he had immediate access to her and knew where she was at any time. So, it’s the extreme. It’s normal for children going off to school for the first time to have separation anxiety, and there’s a spectrum of degree. Sometimes it takes two or three weeks; sometimes it takes a couple of days for a child to be able to separate from a mother and that’s normal, but this is a kind of separation anxiety that is prolonged, consistent, and continues for months. Many, many children with bipolar disorder persist in having some form of separation anxiety, and it is in fact also an issue with adults, so it continues as a persistent feature of the personality, well beyond the time that you would expect that it wouldn’t be an issue.
When does aggression go beyond just normal childhood frustration?
Dr. Papolos: When children with bipolar disorder go into rages, it's really unmistakable. One of the things parents will say over and over again is they get this look in their eyes; it’s almost like a feral look, like an animalistic expression where they completely lose control of their impulses. The temper tantrums, or rages as they’re called, can last anywhere from half an hour to four hours, so again, it's an extreme and protracted period of anger and aggression and they can often be profane, violent throwing things, quite abusive often directed mostly at the mother. If you saw one of these rages, it would be unmistakable. You wouldn’t confuse it with an ordinary temper tantrum.
What are some other mental illnesses that perhaps are increasing among today’s youth that we didn’t think affected kids before?
Dr. Papolos: We know that there is some evidence that autistic spectrum disorders are more on the rise. Whether there’s objective epidemiological evidence to support that, I can’t say for sure. I think it’s somewhat controversial, but certainly it would appear that mood disorders, whether they’re more commonly diagnosed because they’re more easily recognized now is a question mark.
Do you think is it because these illnesses are affecting more children or are being better diagnosed?
Dr. Papolos: I think in general, the answer is that it’s hard to tell. I think since there’s no really basis for comparison, we don’t have epidemiological studies that go back with the diagnosis. We really don’t have general population studies that can make those kinds of comparison since a number of the major child psychiatric disorders are the criteria have been rather recently developed, I mean, over the last decade. So I don’t think there’s a long enough perspective looking back to be able to say that with any confidence. I think in terms of the treatment of these conditions, the advent of psychotropic medications, particularly over the last decade, they’re use in children has grown logarithmically. There are certainly recent studies that have been done that have looked at this particular phenomenon. A number of prescriptions for stimulants and for antidepressants have skyrocketed. There is a considerable concern, at least on my part and other clinicians who treat children with bipolar disorder, that because of the adverse effects on the course of illness that particularly antidepressants and stimulants may cause, that we are seeing earlier and earlier onsets in children that are vulnerable to have the condition. That is, to say the children that carry the genetic traits that are vulnerable and that are being induced at ages that are earlier than might be the case, and that’s certainly a concern. Again, there is not sufficient data to support that idea, but from the clinical point of view, it's something that we’re all concerned about.
With all that being said, what in your opinion needs to be done to improve the field of mental illness in children? Where does more focus need to be placed?
Dr. Papolos: I guess there are a couple of areas. First of all, we need to clarify the diagnosis and, I think, recognize that the condition presents quite differently in childhood and to reorganize the way that we define it. The other thing that I think is needed pretty desperately is general population studies that identify the rates of the condition of all of the childhood conditions and right now though, even if we were to have the most accurate diagnostic criteria and clear treatments for the condition, neither of which do we have, we still don’t have anywhere near the number of trained physicians who can diagnose and treat children for a multitude of major psychiatric conditions. There are, I think, only 6,500 child psychiatrists in the country where some states in the union have one or two child psychiatrists. Most of them are concentrated in the metropolitan areas, so it's very clear that it is going to be incumbent on pediatricians who are often the physicians of first contact to begin to learn more and more about behavioral disorders in childhood and become more competent at introducing and treating them with medications.
Is there anything else that you want to add?
Dr. Papolos: If you’re looking for an ADHD statement, I think we’d want to amplify that. It’s very common for children who go on who go on to be diagnosed with bipolar disorder to first be diagnosed with attention deficit disorder. The reason for that is there are at least four or five overlapping symptoms, and because there has been a myth that bipolar disorder does not exist in childhood and attention deficit disorder is so commonly recognized and diagnosed, when a child presents with hyperactivity, pressured speech, problems with attention, distractibility, all of these symptoms are common for both conditions, so typically a clinician will recognize them and diagnose them as attention deficit disorder. In our recent studies, we’ve found that really when you look at specific features of attention deficit, or that is you measure attention and impulsivity, really only about 12 percent to 15 percent of children with bipolar disorder also have attention deficit disorder, so there are co-occurring in a certain percentage of children, but in a very, very large number of children who have bipolar disorder, are first diagnosed with attention deficit disorder and that creates an enormous problem because medications that are typically used to treat attention deficit disorder typically cause adverse effects and often cause an adverse reaction in children that have bipolar disorder.
END OF INTERVIEW
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If you would like more information, please contact:
Juvenile Bipolar Research Foundation