The Manic Child
The following is an interview I found off the 20/20 site. I found it very
suprising as well as informative. Even if you are not a victim
of bipolar disorder, or have a loved one who is, you'll find this
interview very interesting.
An associate professor of psychiatry at Albert Einstein
College of Medicine and the medical advisor for Parents of Bipolar
Children, Papolos has just published The Bipolar Child,
which he co-authored his wife, Janice.
On 20/20, Deborah Roberts spoke to Papolos and the parents of
children with bipolar disorder as they reveal the struggles of dealing with
mentally ill children. Demitri and Janice Papolos joined ABCNEWS.com in
an online chat.
Welcome to ABCNEWS.com's live chat with Demitri and Janice Papolos. Demitri and Janice, thank you for joining us at this late hour. Dr. Papolos, what are the major symptoms in children with bipolar disorder?
Well, bipolar disorder in childhood has a number a different symptoms. Some of the cardinal symptoms include extreme temper tantrums, out of control behavior that is related to difficulty modulating aggression. That's not the only symptom. Rapid fluctuating mood swings that may occur many times within a day. Problems with the sleep/wake cycle, carbohydrate cravings, disregulation of appetite. Problems with concentration such as distractibility, racing thoughts, and often oppositional behavior are some of the other features of the condition.
Is it common to find other disorders paired with bipolar such as ADHD?
Yes. In the study Janice and I completed in over 140 individual cases, greater than 80 percent of children with bipolar disorder also met criteria for Attention Deficit Disorder.
In a nature vs.nurture debate, can the environment that the parents provide influence (for the better) if not prevent this behavior in a child?
I think that when that you get inside the home of a family dealing with a bipolar child, you see a child who, if you place a limit on the child -- i.e. "you can't go to McDonald's" -- he/she can begin a rage that can go on for three hours. These children rail against structure. Mostly what we've found is that star charts and reward systems don't work with these children. So you learn to pick your battles and you try to endure the extreme irritability and volatile emotional reactions of these children, and until they are stabilized on medication there doesn't seem to be any sort of parenting that would stop this irritability. They're feeling such terrible things inside and their moods are shifting so rapidly that once they are stable medically you could parent in the way you expect to parent in this country.
One of the major underlying problems of the condition is that the circadian system is easily disregulated. And this has major implications in terms of sleep/wake cycle which is often easily perturbed in children who have bipolar disorder. Parents can help by trying to set regular limits to the sleep/wake cycle -- meaning having their children try to sleep at a reasonable time at night and getting them up in the morning -- preventing the tendency that exists with the condition to have a sleep/wake reversal. This can help to prevent the development of symptoms. In this way, the environment can alter a predisposition that is there on a genetic basis.
My wife is bi-polar and my 3-year old son shows strange signs of aggression at times. Is bi-polar disorder hereditary? And if so, is my son too young to be tested if some form of testing exists?
Yes, this condition is hereditary and in fact many studies of adult bipolar disorder have demonstrated convincingly the genetic basis of this condition. Our study of children and parents with children who have the disorder found that over 80% had some form of bipolar disorder and/or alcoholism meaning that both these conditions seem to predispose to early onset of bipolar disorder. There is currently no genetic test to determine if one has a bipolar disorder.
In our study we found the mood disorders and/or alcoholism were coming down both the mother's and father's sides. This is called bilineal transmission. These are spectrum disorders. This child may have some sort of problem at a certain point but that doesn't mean that he may be like Robbie in the tape (in the ABC segment).
Demitri and Janice - Please take a few minutes to comment on the extreme range of symptoms found in bipolar youngsters, from the very young to the adolescent and older teens. And also, what do you believe the chances are for any of these children with proper treatment to experience a relatively normal life?
The tendency for when the condition manifests itself in early childhood is that the mood and energy cycles are extremely rapid and also there is a tendency for the mood to be often irritable and for there to be relatively few periods of normal mood. When the condition begins in adolescence and adulthood the tendency is for the mood and energy cycles be longer and for there to be intervals of well-functioning.
I think that people should know that there are new medications that are just starting to be used, and are in the pipeline, and when someone is properly medicated and takes care of him/herself, such as taking care of sleep hygiene, not taking drugs and alcohol, we know quite a few people living full, creative and meaningful lives. As attention is coming to this disorder in child and adulthood, there is every reason to hope there will be better medication.
What meds do you recommend for bipolar disorder?
Initially, the condition should be treated with mood stabilizers and the examples of mood stabilizers include lithium, Tegretol, and Depakote.
Are there any natural herbs or vitamins that can help this disorder?
There have been studies in adults, one study that was done at Harvard, that showed that Omega-3 and Omega-6 free-fatty acids can influence positively the course of treatment. They haven't been used as mono-therapy in any study yet, but as an adjunctive agents they have been found to positively affect the condition in adults.
There are now more studies gearing up on the Omega-3's because the results were so remarkable that they broke the double-blind of the study, and the ethics committee wouldn't let the study continue with others taking the placebo because those on the Omega-3 were having such a positive response.
I am a School Psychologist at a small school district in Wisconsin. I work with several bi-polar children on a daily basis. I have read numerous books on behavior modification and classroom management, and I was curious to hear what basic principles you would suggest. I would appreciate your feedback. Thank you.
We have an IEP in the book -- it's the first published Individual Education Plan for children with bipolar disorders that takes into account their seasonal mood swings, shifts in energy and attention, and would help a school-system structure. It is very detailed and would help a school-system structure and educational and social plan for a child with this disorder. Because it's so difficult for these children to wake up in the morning, to schedule their most academic classes later in the day would be helpful.
How can a parent know the proper steps to pursue to rule in or out bipolar disorder for a child when so many professionals are unwilling to diagnosis bipolar at such a young age?
Well, I think the first step is to find someone who is willing to accept the idea that bipolar disorder can manifest itself in childhood. Unfortunately, you may have to go to a research center where the condition is being studied, but that is the first imperative. Knowing your family history and whether there are individuals in your family or whether you yourself have a bipolar disorder or mood disorder or alcoholism would be helpful bits of information to convey to the evaluating psychiatrist. Since there are no biological markers that are measurable, the clinical information, meaning the symptoms and behaviors and the family history, are the only ways that someone can make a diagnosis.
I think parents must be very very brave, and they need to have so much information at their fingertips that if they meet a doctor who is starting to blame them without analyzing the family history or the early symptoms of childhood, if the doctor does not know that or that he cannot make the diagnosis because the DSM-4 doesn't allow you to make the diagnosis in childhood, if the doctor says that to you, then you have to find another doctor and another and another until you find one that will. A doctor should rule out bipolar before making an ADHD diagnosis. Stimulants and anti-depressants can wreak havoc with a bipolar child.
Are there certain diets that can enhance or diminish these symptoms? Are there any food preservatives or additives that should be avoided?
Not that we know of.
Regarding the new drugs, my son is on a somewhat new drug, Risperdal. It seems to be working for him at this time. What do you think of this drug?
Risperdal is a major tranquilizer and anti-psychotic medication that is used in conjunction with mood stabilizers such as lithium, Tegretol, and Depakote and often used as treatment for aggressive and agitated behaviors and psychotic symptoms such as delusions and hallucinations. For many children with this condition, it has proved to be an effective adjunct.
Julie writes: What would you recommend as an extra activity that we could involve my nephew in to get him more active? The meds he's on make him so groggy he doesn't want to do anything. He has gained at least 45 lbs from the meds.
A number of medications that are used to treat this condition do in fact have the unfortunate side effect of causing weight gain. Among them, Depakote, Zyprexa and Risperdal are common offenders. Maintaining an active exercise schedule and reducing the dietary intake of carbohydrates and fats may help to curb the weight gain that may occur with these drugs. Another mood stabilizer called Topomax is often used as an adjunctive agent because it has an effect to decrease appetite and can balance the effects of some of these other drugs while at the same time providing help with mood stabilization.
What do you have to say to people who would say 'bipolar' disease is a cop-out for teens who have been involved in acts of violence? Medication can not be the answer for everything. Couldn't there be some societal influence such as family, friends, etc., that could be causing children and teens, violent in nature, to act the way they do?
If they are bipolar they are bipolar and they need treatment. Not all violent children are bipolar. Unfortunately, the piece that was aired focused on the violent behaviors of people with bipolar disorder. There are a wide spectrum. Many do not exhibit this type of violent behavior. Some of the most creative and gifted minds in human history have had childhood onset of bipolar disorder including Sir Isaac Newton, Charles Dickens, Beethoven, and Vincent van Gogh. All managed to contribute great gifts to our world.
Is there evidence of a higher divorce or separation rate in families with bipolar children?
It's totally devastating to a family. All the hopes and dreams of what we hope family life will be - you know, "Leave it to Beaver" - have to be modified and mourned for a period of time until the child gets stabilized. Many families feel that they are the only ones suffering with this. They feel totally alone and isolated. They feel shame and guilt. They feel blamed by everyone including family members, misunderstood and angry, and very concerned that they can't provide "normal" life for the other siblings.
And the siblings suffer terribly because not only are they afraid of the child, it's so disruptive, but they feel they have to be weller than well to the parents. I would urge mental health professionals and parents not to overlook the deep, deep feelings that the siblings are experiencing and to get them psychological help. The stresses on the marital union are enormous and need tremendous support or they will wake up one day and find themselves, as one woman in our book put it, like roommates trying to survive a crisis together. They need tremendous support systems.
Does stress or lack of sleep or other events of trauma precipitate the onset of Bipolar Disorder at any age i.e., with careful management of these external factors, can a genetically predisposed individual actually avoid manifesting the disorder all together?
Well, I don't think there is anyway we can answer that with real objective data. It is clear that stress and particularly stress that involves the sleep/wake cycle, that of seasonal change, are all contributors to unleashing a predisposition that is genetically based.
Is there an average number of times per day that a young child will have these tantrums?
While they are part of the condition, the cycling is not necessarily tantrums, but the cycling really should be seen as cycling of dramatic changes in mood and energy levels that can occur multiple times a day, can occur weekly, monthly, or several times a year. These cycles of mood tend to switch between moods of irritability to moods of elation that could be described as silly, goofy, and giddy, and alternatively to moods of depression, sadness, melancholia, and withdrawal. At the same time the energy levels also shift from low levels of energy to high levels of energy. This is a characteristic of the condition. Common in early onset, children tend to have very low energy in the morning which increases as the day goes on, and escalates in the evening and at night.
Parents describe the cycles as Dr. Jekyll and Mr. Hyde - a child can go upstairs in a stormy mood and come down 20 minutes later in a giddy silly mood. That's how fast the cycling can take place.
Demitri and Janice, thank you for your time this evening. Any final thoughts?
We're at the frontier of understanding this disorder of childhood. There is a new Child and Adolescent Bipolar Foundation. Or parents can join NAMI (National Alliance for the Mentally Ill). As everyone comes together and demands more research and more attention paid to this disorder, as well as parity in insurance, we can stabilize these children better so they can have a brighter future.
I think it's important to underscore that many of these children have difficulty modulating a number of emotions. Many are extremely gifted and have much to offer to our country and the early recognition of this condition and early treatment is an exceedingly important goal to reach.
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