bipolar in kids

Pediatric bipolar disorder has been coming up more frequently over the last few years, and the current flap is about Joseph Biederman, who is an advocate of the view that bipolar can exist as early as birth. There’s also scandal (from back in December) over a four-year-old who died from being given too much medication by her parents, and that’s being brought up in this as well.

Those are the extreme cases. I’m going to write about the typical stuff.

(But first: At birth? Why at birth? I’m pretty sure our emotional regulation systems neither suddenly turn on nor suddenly break then. I know he’s using it for dramatic effect, but it bugs me.)

The news coverage I’ve seen tends to have one of two themes:

1. “Kids will be kids”: You can’t diagnose bipolar in children because that’s just what children are like – they change by nature. (This is similar to the incorrect argument that AD/HD doesn’t really exist, because to be bored by school is to be a normal child.)
2. We’re overprescribing antipsychotics to children. They should only be prescribed for their intended purpose. (Meaning, to treat psychosis, or, even more restrictedly, to treat schizophrenics.)

I’m going to talk about the “kids will be kids” aspect, and then talk about why it actually is hard to diagnose bipolar disorder in children, and will talk about antipsychotics later in the week. I’m pulling heavily from Goodwin & Jamison’s “Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression”, second edition. The first edition is considered the classic work in the field; the second edition is just out as of a couple months ago and I heart it down to my research-loving bones.

Okay:

Bipolar disorder occurs in young children.

There are debates over how common it is, what it looks like when it happens, and whether we can diagnose it and when, but it’s not at all like being a normal child.

Here are a couple parallel normal and pathological examples from the Goodwin and Jamison book (originally from Geller et al, 2002a and if anyone really wants cite that I’ll get it for you):

Happiness: Child was extremely happy on days family went to Disneyland, on Christmas morning, during grandparents’ visits (joy appropriate to context, not impairing).

Elated mood: 9-year-old continually danced around at home, stating, “I’m high, over the mountain high” after suspension from school.

Sexuality: 7-year-old child played doctor with a friend of the same age.

Hypersexuality: Girl faxed a note to the local police station asking police to ____ her [underlines in the original]

And you can find all kinds of examples on websites for parents of bipolar children – kids trying to spontaneously jump out of cars, that kinds of thing.

It’s hard to diagnose because kids with bipolar frequently meet criteria for other disorders too

Like ADHD, conduct disorder, and oppositional defiant disorder. Some kids have a *lot* of problems, and it’s not clear whether they have one disorder that’s causing other disorders (for example, bipolar disorder can cause anxiety) or whether they have multiple disorders (bipolar disorder can coexist with a separate anxiety disorder). This happens with adults as well, but it’s particularly common for kids with bipolar-ish symptoms.

This leads to a disturbing situation that I would like to see get more press: although the popular controversy is about whether bipolar exists in kids, it should really be about what is going on with these kids who are badly impaired and difficult to diagnose and treat. It’s not about whether they’re bipolar or not, with “not bipolar” meaning “normal”, because they’re not normal. It’s about what should we be doing to help them.

Children with bipolar disorder also tend to look different from adults with bipolar disorder. They are more likely to rapid-cycle (go through many mood shifts throughout the day); to be irritably instead of happily manic; and to not have well periods between mood episodes. So they’re less likely to be recognized by practitioners whose mental picture of bipolar disorder is based on an average adult.

Another interesting question is whether the kids we’re identifying with bipolar disorder are going to grow up to look like most adults with bipolar disorder – do they have an early version of the disorder that changes as they mature? Do they have a more severe version of it that doesn’t? Or do they have something that’s just different?

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3 Responses to bipolar in kids

  1. L.RabbitGirl says:

    “(But first: At birth? Why at birth? I’m pretty sure our emotional regulation systems neither suddenly turn on nor suddenly break then. I know he’s using it for dramatic effect, but it bugs me.)”

    Well, I could see this. I don’t think you “catch” bipolar like a virus and I do think it does exist from birth. Whether it is apparent or not is likely dependent on the child’s maturation, intelligence, personality and environment. As well as the severity of the disorder already inherent in the child. So from birth? Yes. Absolutely. Though the disorder only becomes more evident as the child grows. Also, there are the situations where a first true episode isn’t triggered until later in life. But there are still symptoms that can be present long before the bipolar is diagnosed.

  2. Michael Cohn says:

    An unspoken part of any controversy of this nature is, “if we diagnose children with disorders like bipolar and schizophrenia, what then?” Do we want to put them on meds for the rest of their lives? If so, what’s going to happen to their brains? We rightly warn teenagers that abusing drugs is especially dangerous for them, because while your brain is still forming, disruptions to neurotransmitter levels can have long-term effects. We see the same thing in children who are exposed to excessive stress levels and show hyper- or hypo-reactivity to stress as adults (depending on the age range of the exposure).

    Of course, untreated bipolar disorder is also an abnormal brain state, and as you constantly point out, it continues to get worse if it is not treated. But that doesn’t mean medication is innocuous, either… drugs that simply produce a natural, well-regulated brain state only exist in TV commercials. Giving drugs to kids with bipolar is probably the safest course of action, but you have to acknowledge that it goes against the grain of both parents and scientists to recommend a long-term treatment without knowing what it’s actually going to do.

    So, do we have any idea what the long-term effects are for kids who take lithium or antipsychotics? Or any psych meds? I’m pretty sure the answer is no, because we never do, but I keep hoping…

  3. resonance says:

    LR – I explained the emotional regulation / birth thing kind of poorly, I think. I agree that bipolar can be present from birth. Birth may not be a mile marker for emotional regulation systems, though. (For example, babies often already cry at birth or shortly thereafter, so there has to be something in place already.) So if it’s something that’s present in the very early development of an emotional regulation system, then it might be there before birth. Not, you know, always before birth, but showing up at some point along the way.

    M – will try to address your comments when I post later.

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