Gwen writes…

My son was diagnosed with bipolar disorder in the 5th grade. He is now about to turn 21. He cuts and he cannot hold a job or finish a class at the local community college.

His bipolar disorder seems to be more depression-based than manic, or maybe the lithium and Abilify he takes helps the mania but doesn’t treat the depression.

Are there any medications recently developed which can help the depression? I know there is a study underway looking at this problem, but I can’t find out much about it. Sam took the initial test and they said that he qualified, but is no longer interested in participating in the research.

Cathi asks…

My friend’s 9 year old has had severe behavioral problems and several alternating diagnoses. The Dr. has prescribed Focalin, Trileptal, Lamictal, and Seroquel. She has no concentration, violent outbursts, hallucinations, etc. She has been diagnosed, at present, with ADHD, Bipolar, ODD, and PDD. She will not do work at school; instead, she sits and picks at her skin. She has been violent and tried to choke other individuals. Mam says she can’t even leave the house with her.

My friend has no money. The state has removed an older child due to DMH reasons. She is afraid of the state agencies, but has nowhere to turn. Court appointed attorney said to call if she won the lottery. What happens to these children? These medications seem excessive and risky considering her age, the possibility of adverse interaction, and off label usage. Any advice or help. We are desperate. Thank you.

Dr. Fink answers…

This is an all too common situation in children with multiple levels of developmental, emotional , and behavioral symptoms, especially when the family’s resources are limited. The first place to start is with the current doctor to get a clearer picture of the reasons for the current medications and to express clearly the ongoing symptoms that are not being addressed.

According the NPR health blog “Shots,” three psychiatrists at Harvard University who were leaders in research on bipolar disorder in children were punished over not disclosing payments from drug companies for research and other activities totaling more than $4.2 million dollars. (See “Harvard Punishes 3 Psychiatrists Over Undisclosed Industry Pay,” by Richard Knox.) The psychiatrists cannot accept any payments from industry for one year and must seek approval for any such payments after that period. Additionally they will suffer a “delay of consideration” for promotions and advancements in their institutions.

The doctors’ public response to this suggests that they felt that they operated in good faith and that they now realize they should have paid more attention to the details regarding disclosure.

In a recent study entitled “Postural Control in Bipolar Disorder: Increased Sway Area and Decreased Dynamical Complexity,” Indiana University researchers measured and compared the magnitude of postural sway between study participants with and without bipolar disorder. The study involved 32 participants, 16 of whom carried the bipolar diagnosis. The control group was made up of 16 age-matched non-psychiatric healthy participants. Participants were asked to stand as still as possible on a force platform for 2 minutes under 4 conditions: (1) eyes open-open base (feet apart); (2) eyes closed-open base; (3) eyes open-closed base (feet together); and (4) eyes closed-closed base.

The researchers postulated that because many of the structural, neurochemical, and functional abnormalities identified in the brains of those with bipolar disorder are also implicated in postural control, people with bipolar disorder would have less postural control and hence a greater magnitude of sway than those without a brain disorder. In other words, there’s a connection between motor and mood disorders. The results supported their hypothesis:

A big challenge in diagnosing bipolar disorder or attention deficit hyperactivity disorder (ADHD), especially in children, is that the two disorders share behavioral symptoms, including impulsivity, irritability, and attention problems.

Unfortunately, they don’t share treatment protocols; if the diagnosis is wrong, treatment may be counterproductive. Stimulants, like Ritalin, which are effective in treating ADHD can make a child with bipolar disorder more manic. Giving a mood stabilizer, like Tegretol, to a child with ADHD may result in little or no improvement or severe side effects. Getting the diagnosis right is the key to effective treatment.

We often discuss the stressors that play a role in triggering bipolar disorder in adults who have a genetic susceptibility to it, but what about stressors in childhood?

Results of a study published in the January 2011 edition of the American Journal of Psychiatry entitled “Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study,” claim to show that childhood trauma from maltreatment and bullying is associated with children’s reports of psychotic symptoms.

While the report serves an important role in calling attention to the serious psychological and psychiatric damage that intentional abuse and bullying can cause, it also raises the question of what is and is not psychosis, especially in children.

On Tuesday, November 30, NIMH posted a Science Update entitled “Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder.” The update references an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010.

Based on results from the study, researchers concluded that “Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders.”

I first wrote about my concerns surrounding this issue in 2007 in a post on my Bipolar Blog entitled “Bipolar Disorder Overdiagnosed in Children?” Back then, Benedict Carey of The New York Times wrote a piece calling attention to the 40-fold increase in the diagnoses of bipolar disorder in children between 1994 and 2003, climbing from 20,000 cases in 1994 to 800,000 cases in 2003.

The Child and Adolescent Bipolar Foundation (CABF) has asked us to spread the word about its campaign for votes to win the Pepsi Refresh Project and a $250,000 grant to aid families and children living with bipolar disorder and depression. CABF has been chosen to compete for the top grant in November, 2010. Winners are decided by total votes cast via Internet and text messages throughout the month.

If selected by popular vote, CABF will use an innovative social media awareness effort to:

On August 4, 2010, the American Academy of Child and Adolescent Psychiatry (AACAP) released its new Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.

“Medication decisions for children with bipolar disorder are complex and difficult for many parents. AACAP’s Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents compiles the very best information and helps parents decipher the daunting decision-making process. I consider it required reading for any parent of a child with bipolar disorder.”
— Susan Resko, Executive Director Child & Adolescent Bipolar Foundation

This is another resource that parents of children and adolescents who have been diagnosed as having bipolar disorder may want to investigate.

A Science Update published by the National Institute of Mental Health (NIMH) entitled “Imaging Studies Help Pinpoint Child Bipolar Circuitry” reports the results of recent brain imaging studies that reveal that “…the brain works differently in youth with bipolar disorder (BD) than in chronically irritable children who are often diagnosed with pediatric BD.”

According to Ellen Leibenluft, M.D., chief of NIMH’s Section on Bipolar Spectrum Disorders, which is conducting the studies, “This suggests that chronically irritable children may suffer from a syndrome distinct from BD and may require different treatments.”

This particular article draws some very useful distinctions among the following three diagnoses: