Q: An adult family member was recently diagnosed with manic-depressive illness. I am concerned that one of my pre-teen boys may be at risk. Do children suffer from manic-depressive problems?
A: Recent trends in pediatric mental health show that more and more doctors are noticing bipolar disease – known in lay terms as manic-depressive illness - in children and adolescents. Experts in the field estimate that the incidence in adolescents is close to 1%; in preschoolers, the true incidence remains a mystery.
One feature that stands out is an almost ever-present family history of the illness. When this is the case, most parents’ concerns for their children are justified - psychological or psychiatric help must be sought.
Given the complexity of bipolar disease in children and adolescents, many child psychiatrists consider themselves to be the best clinicians to diagnose this challenging disorder. The problem is that most child psychiatrists in North America have an extremely long waiting list, in some cases as long as one year.
This condition is a serious mental health issue. If the onset of bipolar disease occurs prior to 18 years, a child is 10 times more likely over his or her lifetime to commit suicide. In addition, a diagnosis is particularly challenging given frequently associated psychiatric conditions, such as anxiety and ADHD (Attention Deficit Hyperactivity Disorder).
Most family members and teachers would agree that dealing with bipolar children could be compared to walking on eggshells. It is not an easy situation to deal with day after day, and creates plenty of stress for the rest of the family. These patients create chaos in the home and at school by:
- Requiring less sleep, yet are bubbling over with energy.
- Repeatedly being expelled from day care or school because peers and teachers cannot control or tolerate the mood swings, aggression and rapid switching of behavior.
- Showing grandiose behavior, such as insisting they are so important that the whole world should change to accommodate their own amazing skills, talents and abilities.
- Being extremely irritable.
- Creating major safety concerns, such as climbing out of a window at night and sitting on the top of the roof.
- Behaving aggressively, such as punching holes in walls or wrecking cars.
Given bipolar disease is frequently misdiagnosed or under recognized, family doctors and pediatricians may actually make the symptoms worse by prescribing antidepressants or stimulants. In fact, the first step before using stimulant medications, particularly in patients who have both bipolar disease and ADHD, is to treat the mood of the child with mood stabilizing medications. The draw back is that many of these medications have side effects and a narrow therapeutic window, while the effects of some are only fully understood by child psychiatrists.
A product used for ADHD, Strattera, can exacerbate mood liability and mood cycling. There is also speculation that some patients, who show an increase in suicidal thoughts while being treated with an antidepressant, may actually be previously unrecognized bipolar patients.
Risperidone, a mood stabilizer, works for many bipolar patients. But recent data indicates that not only does it cause rapid weight gain, it also puts patients at risk for pituitary tumors. For this reason, some clinicians will check a patient’s prolactin levels (a hormone produced by the pituitary gland) as well as order an annual MRI.
Some child psychiatrists use lithium in their pediatric patients, a medication used in the past in adults with bipolar disease. The downside is that blood tests are required on a regular basis in order to monitor the therapeutic levels.
Compliance with medications becomes particularly problematic with adolescents. Many adolescents want to be independent and will abruptly stop their medication. This tends to occur when they notice side effects, such as acne or sexual dysfunction (Some bipolar teenagers exhibit hypersexuality and will engage in unprotected sex, often with partners ten years older than themselves).
Given the controversies related to diagnosing bipolar disease, and the challenges in finding the correct medications, some families opt for psychotherapy and psychoeducational group therapy as complimentary treatments.
At this point, the information is too insufficient for most clinicians to feel comfortable in managing bipolar problems all on their own. Knowing the importance of preventing suicide, many child psychiatrists will allow their peers to do consultations over the telephone, given the issue is urgent enough.
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