Watching For Signs of Bipolar in Children

Children and a diagnosis of bipolar disorder is an increasingly controversial topic. We take a hard look at this hot issue.

Donna S. often catches herself watching and waiting for something she hopes will never happen. Ever since she learned that bipolar disorder has a strong genetic component, Donna has been angst-ridden that her child, John, will inherit her illness.

John was only 7 when Donna took him to a psychiatrist for an evaluation.

“I was afraid we would become one of the statistics people were telling me about,” says Donna, executive director and founder of the Ohio, branch of the Depression and Bipolar Support Alliance. “My family tried to tell me to relax.”

Although John did well in school, he was a highly sensitive child.

“He could be really happy and having fun, and then be sad the next minute,” says Donna, a single parent. “Because I was looking for something, I thought there was something.”

The psychiatrist agreed that John was anxious, but said it was understandable given that his grandmother, to whom he was extremely close, had been diagnosed with cancer and that his mother was periodically hospitalized for bipolar episodes.

Today, John is a healthy 16-year-old. He is a member of his high school football team, participates in school musicals and shows more than a passing interest in girls. Still, Donna admits that the possibility of John developing a mood disorder “is always in the back of my mind.”

Child rearing can be a challenging, emotional process for anyone. But the stress can be amplified in families with a history of bipolar disorder, who must worry about distinguishing normal, childhood upheavals from signs of an emerging illness.

If a grade-schooler has trouble controlling his temper at school, is it a phase or something more ominous?

Is the pre-teen flitting around her bedroom late at night showing normal girlhood energy or the beginnings of mania?

How is a parent to know?

Rise in bp diagnoses sparks continued controversy

Those worries have been aggravated by a dramatic increase in the diagnosis of bipolar disorder in children and the resulting attention in the mainstream media. An issue once discussed primarily in medical journals is now a frequent topic on everything from the evening news to The Oprah Winfrey Show.

But how can parents sort through the often-conflicting reports?

Doctors at New York’s Stony Brook University recently analyzed data from patients discharged from U.S. psychiatric hospitals from 1996 to 2004. They found that while the number of adults with a bipolar diagnosis rose slightly, the number of children discharged with that diagnosis increased from one in 10 in 1996 to four in 10 by 2004.

The exact reason behind those numbers is unclear. Some mental health experts point to the 1994 update of the Diagnostic & Statistical Manual of Mental Disorders (also known as the DSM-IV). That year, psychiatry’s official manual widened the definition of bipolar disorder.

Mental health advocates cite improved diagnosis and awareness of the illness. Still others believe publicity generated by the pharmaceutical industry may be driving the increase.

Adding to the confusion, leaders in the field of child psychiatry have yet to reach an agreement on how to best diagnose pediatric bipolar disorder. Is extreme irritability enough of a marker? Some say yes. Others, however, contend children must clearly exhibit bipolar symptoms, as classified in the DSM-IV, including elation, grandiosity and decreased need for sleep. Yet a third group says children must fit the DSM-IV guidelines, but also may have rapid cycling, rather than discrete episodes of mania and depression.

“The controversy is over how narrowly or broadly to define childhood bipolar disorder,” said Joan Luby, MD, an associate professor of child psychiatry at Washington University School of Medicine in St. Louis, Missouri.

Clearer guidelines and more education are necessary to improve the accuracy of diagnosing childhood bipolar, Dr. Luby says. “I think there is a general consensus that the diagnosis is being used too broadly by too many, but also is perhaps being missed in some affected children,” she says.

Pass-on risk unclear

Experts agree on one crucial issue. The chance a child of a bipolar parent will inherit the illness appears relatively small. But there are reasons to be concerned.

More than two-thirds of people with bipolar say they have at least one close relative with the disorder or with unipolar major depression, suggesting a genetic component, according to a study published in the May 2003issue of Archives of General Psychiatry.

A 1997 analysis of 17 prior studies also suggests there are reasons to be vigilant. The 10-year-old, but still cited, research study found that bipolar offspring had only a 2.7 percent chance of being diagnosed with bipolar. But they did have a 50 percent chance of suffering from some type of psychiatric disorder, such as ADHD, anxiety disorder or depression, compared to29 percent in the general population.

If you have a family history of bipolar disorder and your child begins to exhibit signs of depression, extreme irritability or ADHD, but no classical signs of mania, diagnosis can be tricky. Is the child demonstrating early manifestations of bipolar disorder—or other mood disorders?

Boris Birmaher, MD, a professor of psychiatry at the University of Pittsburgh School of Medicine, conducted a five-year study comparing more than 400 children of bipolar parents, ages 2 to 18, to 300 children randomly selected from the community.

Preliminary data indicates that the children of bipolar parents were roughly eight times more likely to have a bipolar spectrum disorder during the course of their life. This spectrum includes symptoms ranging from very mild to severe, Dr. Birmaher says.

It is important to note, however, that bipolar disorder affects only about 3 percent of the total U.S. population in a given year, according to the National Institute of Mental Health. So even if a child has aparent with bipolar, the chance he or she will develop the illness remains statistically small.

“Don’t worry too much,” Dr. Birmaher advises parents. “If you compare children of parents with bipolar disorder with children in the general population, they are at high risk, but that does not necessarily mean they will be bipolar. You can have lots of diabetes in the family, but not necessarily have diabetes.”

Children of bipolar parents are also at higher risk for other mood disorders: They are three times more likely to suffer from episodes of depression and twice as likely to suffer from anxiety disorders than the control group, Dr. Birmaher found.

Ellen Leibenluft, MD, an investigator with the National Institute of Mental Health (NIMH), the lead federal agency for research on mental and behavioral disorders, cautions parents and health care providers against leaping to conclusions.

“It is often viewed that if the child of a bipolar parent is having any kind of difficulty, the child must have bipolar, but the statistics don’t bear that out,” she says. “They do have an increased risk, but most won’t be bipolar.”

And other experts fear that many children are being misdiagnosed.

Gabrielle A. Carlson, MD, director of child and adolescent psychiatry at Stony Brook University Medical Center, for example, says that many children who have problems regulating their emotions or who suffer from ADHD are now being labeled bipolar.

“There are a million different reasons” children have trouble regulating their mood, she says. “My major objection is that when people give you a conditioned response that it’s bipolar, it shuts off minds as to what else might be causing the behavior and I don’t think that’s in anyone’s best interest.”

The potential dangers of misdiagnosis are clear: prescribing the wrong medications unnecessarily exposes a child to powerful medications that carry side effects. And, if bipolar disorder is mistaken for unipolar depression or ADHD, antidepressants or stimulants could trigger a manic episode.

The fact that bipolar is a multi-gene disorder further complicates diagnosis, says Dr. Leibenluft of the NIMH.

“For argument’s sake, let’s say bipolar disorder is made up of 15 different genes,” she says. “If someone has two of these genes, are they bipolar? It’s not a yes or no question. They may have a little bipolar and a bunch of other stuff.”

Susan Resko is executive director of the Children and Adolescent Bipolar Foundation (CABF), a parent-led non-profit, based in Illinois, which offers support, information and advocacy to families raising children diagnosed with, or at risk for, pediatric bipolar disorder. She is also the mother of a bipolar child.

Resko questions whether pediatric bipolar is currently over-diagnosed.

“My attitude is that before it was completely unrecognized. Now, is the pendulum in the middle, or swung the other way? I don’t know.”

Watch, but don’t worry

All parents want to keep their children safe.

The trick, say experts, is to be watchful, without being overly wary. Dr. Leibenluft urges parents to treat each child as an individual and assume all is well until you have reason to believe otherwise.

“Obviously, you want to let them have as typical a development as possible,” she says. “You wouldn’t want to start out with the notion of treating them differently.”

Instead, “put them in situations where they are likely to achieve success and get the support they need. You can have a child of someone who is bipolar who is doing perfectly great.”

But separating the normal rebelliousness and moodiness of childhood and adolescence from more troubling behaviors is not always easy.

“Children can sometimes be grandiose and impulsive. Teens can be very loud, easily irritated and love staying up late. Since these are signs of normative development, we shouldn’t assume bipolar disorder,” says Helena Verdeli, PhD, an assistant professor of clinical psychology at Columbia University who studies genetic linkage.

The possibility… is always in the back of my mind.

“However, parents need to be concerned if they see a pattern of severe fluctuations in mood, energy and daily routines that lead to difficulty in functioning in school, with friends, or at home.”

And should a troubling pattern emerge, experts recommend having your child evaluated by a mental health professional who specializes in children.

To determine what role therapy can play in delaying, reducing or even eliminating mood disorders, Dr. Verdeli and her Columbia University colleagues are studying 60 children of bipolar parents. So far, each child, aged 12 to 18, has experienced mild depression or mania, but not a full-blown mood disorder.

The control group receives monthly counseling sessions and some information about mood disorders and how to cope with their parents’ illness. A second group is undergoing both weekly individual therapy sessions and family therapy, with the goal of teaching the teenagers coping skills and ways to improve their home life.

“We know from other studies that high levels of disorganization and conflict…are associated with higher severity of mood disorder,” Dr. Verdeli says. “Although (bipolar disorder) is highly inheritable, environment plays a very important role in triggering episodes—and in improving them. Having consistent daily routines such as having regular times when family members eat, go to sleep, etc., and support from family and friends can make a big difference.”

Washington University School of Medicine’s Dr. Luby advises parents to be in tune with their child’s emotional health.

“If you have an intensely emotional child, help them process and recognize their emotions,” she says. “But parents should not think they can prevent childhood bipolar disorder—it’s a severe brain disorder.”

The best gift a parent with bipolar can give to their child, she says, is to take care of themselves.

“It is really important for the bipolar parent to make sure they themselves get treated and are as psychologically stable as possible,” says Dr. Luby. “If they have an acceptance of the disorder and seek medical treatment, it also sets a good model for the child’s attitude about any emotional disorder they might have.”

What the children of bipolar parents need is what all children need.

“A certain level of common sense should prevail,” Dr. Carlson says. “Children need a regular bedtime, good nutrition, someone to supervise what and how much television they watch—whether you have a mental illness in your family or not.”

Catch it early

It’s not uncommon for Susan Resko of the Child and Adolescent Bipolar Foundation to receive a call from parents of a child who has been diagnosed with bipolar disorder, concerned that one of their other children is also showing signs of emotional problems. She encourages them to have the child evaluated to either assuage or confirm their worries.

“Early intervention saves lives,” she says. “A good treatment team can offer an objective evaluation.”

Resko also recommends that parents keep a journal documenting their child’s behavior, so they can provide details and dates should they ultimately seek professional help.

“Watch for signs, but don’t let it cripple you with fear,” Resko advises. “Educate your children how to manage life in such a way that they don’t take on too much and get overstressed.”

And if your child does develop a mental illness, “try to remain as calm as possible and get support for yourself,” says Resko, who keeps grounded by supporting other parents of bipolar children.

Martha S., 46, has reached out to CABF over the years. She has two sons diagnosed with bipolar disorder, ages 11 and 9. Their sister, Annie, 10, is a “normal, average child,” Martha says. All three are adopted; Martha’s sister is their natural mother.

Annie is “very aware that her brothers are different,” Martha says. “She knows about bipolar and she knows she’s not free from it yet.”

Annie is responsible, a good student and has lots of friends. But as Annie nears puberty, Martha, a former pediatric nurse, has begun to watch for “red flags” that may signal negative changes in her daughter’s behavior.

Donna S. can relate. Even though her son excels in school, she still worries.

“As he grows into his teens, he’s becoming more sensitive,” she says. “He’ll have a tendency to stay in his room for hours and hours. I worry that something is wrong.”

But Donna also recognizes that she and her son cope with stress differently: She likes to talk out problems, while John wants some alone time to think things through. She tries not to push him to talk before he’s ready.

Sometimes, Donna has difficulty distinguishing whether John is a “little hypo-manic,” or “just a little excited at what is going on in his life.”

Still, Donna says she is trying to view her son for who he is, rather than as the child of someone with bipolar disorder.

“Something just clicked one day,” Donna says. “Instead of worrying all the time, I was able to step back and look at what a wonderful young man he is. There’s nothing wrong with him right now.

“Down the road he could have something, but I don’t need to worry about that all the time.”

Watching for patterns

It is now generally accepted by the medical community that bipolar disorder can occur in childhood. Yet, researchers are still struggling how best to diagnose and treat the juvenile form of the disease—a difficult task since it tends to present differently in children. For example, a manic child is more likely to display irritability than elation or euphoria, and more likely to experience rapid cycling than discrete episodes of mania and depression, followed by periods of stability, according to the National Institute of Mental Health.

Child psychiatrists must also try to determine whether bursts of volatile behavior or extreme sadness are truly bipolar, or signs of other mental disorders common in childhood, such as attention deficit disorder and anxiety disorder–or a combination of two or more of these illnesses.

In mania, a bipolar child may giggle uncontrollably in class, or wake up at 4 a.m. during summer vacation. The depressed bipolar child may express sadness through physical complaints—such as a stomach ache or a headache. Or, they may refuse to go to school, threaten to run away from home, become extremely sensitive to rejection or failure, or have difficulty maintaining friendships.

Many children exhibit some of these behaviors. What parents need to look for is a pattern.

Code: bphopekids

Printed as “Parents and the waiting game”, Fall 2007