Mania Can Be Triggered in Children by Depression Meds
Summary:
Paragraph three reads: ""A very common scenario is a teenager who’s depressed and has a family history of bipolar," says Chang. 'They are at high risk of eventually developing mania. We foundantidepressants can trigger mania in some of these kids.' "
Is it a phase? Friday, April 1, 2011 BY KATHRYN DAVIS The Parent Paper
When she’s not texting or listening to her iPod, Jennifer (not her real name) enjoys Facebook, shopping and writing poetry. Like most teenagers, she argues with her parents. However, Jennifer’s conflicts are so intense and so frequent lately that family activities and trips are adversely effected, and often even cancelled. When she was diagnosed with ADHD in middle school and put on a stimulant medication, it seemed to help for a while, but lately her behavior has been getting worse. Lately, she seems angry most of the time, accusing others of being mean and unfair. She doesn’t seem to enjoy favorite activities, and is having sleep problems. Recently Jennifer’s parents took her to see a new doctor who made a different diagnosis: bipolar.
For many years, doctors believed bipolar was an adult disorder. However, that belief has changed recently. Kiki Chang, director of the Pediatric Bipolar Disorders Program at Stanford University, says the number of children under 18 diagnosed with bipolar disorder has risen 4,000 percent in the U.S. in the last decade. According to the Bipolar Research Foundation, juvenile bipolar disorder, also called early-onset bipolar, includes characteristics that are often seen with a number of other disorders. This overlap of symptoms is one reason bipolar in children and adolescents is so difficult to diagnose. Even worse, treatments that are used for one disorder can sometimes trigger bipolar in someone with a susceptibility, such as a family history.
"A very common scenario is a teenager who’s depressed and has a family history of bipolar," says Chang. "They are at high risk of eventually developing mania. We found antidepressants can trigger mania in some of these kids."
Diagnosing
Diagnosing bipolar disorder in children and adolescents is complex and not done on the basis of symptoms alone. Experts only consider the diagnosis in cases where the behaviors are extreme, and of a very long duration. When bipolar symptoms are seen after treatment for a different disorder, or treatment for another disorder does not improve symptoms or worsens them, doctors may then consider bipolar. The increase in the number of diagnoses, Chang points out, could be the result of factors such as a growing awareness of the high rate of inheritability of the disorder, the inclusion of irritability as a primary symptom of mania and improved research in child development. There is still potential for over diagnosis, however, which is why it is so important for physicians to make careful and detailed evaluations, including such factors as family history and behaviors both at school and at home.
In her book, Bipolar Kids, author Rosalie Greenberg, M.D. offers advice for parents and includes reassuring facts and real-life examples from her many years in practice. The book contains easy-to-read charts that help in understanding how common symptoms of disorders like ADHD and bipolar can overlap and how they differ.
"Studies indicate that the majority of youngsters with bipolar disorder meet the criteria for ADHD, especially when in the manic state," notes Greenberg. "And there are as many kids with both disorders." She points out that up to 20 percent of children with ADHD are estimated to also have bipolar disorder.
"Irritable behavior is one of the most frequent reasons why parents bring their child to a mental-health professional," says Greenberg. "But irritability and temper outbursts are diagnostically nonspecific, and can be seen in children without any serious psychiatric problems."
Mood disorders such as bipolar can include mania, where there may be increased energy levels. Children and adolescents may exhibit extreme irritability in this mood, and may also feel an exaggerated sense of their own abilities or knowledge. "A manic child is always right," notes Greenberg. "When the parent says the toy store is closed, it’s Sunday night, and they will open tomorrow, the child gets into a rage. He tells his mother that she is wrong. He knows better. He calls her a liar, and tells her she’s just mean and he hates her. The more she tries to reason with him, the angrier he gets."
Detective work
Researchers are looking at ways to both diagnose the disorder as well as to predict susceptibility. One way is through brain imaging using an MRI (Magnetic Resonance Imaging). This kind of testing has led experts at the National Institute of Mental Health (NIMH) to discover that the part of the brain that processes emotions, the amygdala, is smaller in kids with bipolar disorder and also somewhat hyperactive. It is uncertain whether this is a cause of the disorder or a result of it. However, researchers like Dr. Mani Pavuluri from the University of Illinois at Chicago's Pediatric Bipolar Research Program are hoping to use this kind of information to further an understanding of the disorder. "Imaging will give you a map of the networks of the brain," she explains. This kind of technology, she adds, "allows us to find ways to map the brain circuits in ADHD that look different from bipolar disorder."
Pavuluri and her colleagues have been using functional MRIs to examine the brain operations of children with bipolar disorder. She sees misdiagnosis as the primary issue. "By doing this research, we can tell the thumbprint of brain function of bipolar disorder that looks different from ADHD. We are hoping this will help prevent misdiagnosis in the future."
Another avenue, says Chang, involves finding biological markers that predict the risk a child has for developing the disorder. "By understanding the neurobiology and the genetics, we hope to understand how it develops in the brain. If we achieve these two goals, we can figure out who needs early intervention and also what types of early interventions to prevent or delay the onset of bipolar."
Because misdiagnosing bipolar disorder can mean prescribing the wrong treatment, making a distinction is vital. "Once we learn the basics, we can recognize it early and treat it with the right medications. If you give the wrong medications, symptoms can get worse," Pavuluri warns. "If you give mood stabilizers to someone with ADHD, it dulls the thinking. If you give stimulants to someone with bipolar disorder, mania gets worse."
"There are a variety of behaviors that are often observed in bipolar children, but each one by itself is not necessarily unique to this diagnosis," notes Greenberg. She points to an increased craving for certain foods. "Typically when one thinks of a depressed individual, they associate lack of appetite. But bipolar kids exhibit signs of what we call an atypical depression and actually show cravings, typically carbohydrates like pizza, pasta, cheese, ice cream, French fries, etc. Interestingly, they can also show an increase in carbohydrate craving when they are manic."
Another behavior seen with bipolar, says Greenberg, is a thermoregulatory difference. "They are typically warm, or even hot, when other people feel cold. This will result in the child not wanting to wear a coat in very cold weather, or wanting to go to school in shorts and a t-shirt when it’s 35 degrees outside. They can feel very uncomfortable when the weather is very warm. They may prefer to sleep in the nude or with little clothing, or want the fan or air conditioner on even in the middle of winter."
Another behavior often seen in someone experiencing mania is hyper sexuality. "In an adult this can mean being very flirtatious, dressing in a sexually, overly seductive way, having multiple affairs, etc.," explains Greenberg. "In a child, it will, to some degree, manifest differently, depending on the youngster’s age. Young children may use a lot of ‘potty talk’ or ‘bathroom words’ or try to see their parents naked, or get out of their shower and do a dance while naked for others to see." She notes that, as children with bipolar age, the behaviors may resemble adult hypersexual behaviors. Teens may become somewhat promiscuous or seek sexual activities on the Internet. Of course, warns Greenberg, "A child that exhibits hypersexual behavior cannot be automatically assumed to be bipolar. It is extremely important to rule out other potential causes of this behavior, such as child sexual abuse, or maybe the child witnessed inappropriate sexual behavior at home, etc."
One other behavior Greenberg notes is sleeping problems. "For many bipolar children, nighttime is when they experience an increase in fears, especially separation type fears like fear a neighbor’s dog will die, even though it’s not been ill. When the bipolar child is in the manic state, he’s too full of energy to fall asleep and wakes up early, as there is a lot on his mind that he wants to do now."
Another clue is to look at differences in behavior at home and at school. If there is no behavior problem at school, but the child is out of control at home, he may have bipolar. "Many of these kids have co-morbid (additional) anxiety disorders that actually serve to inhibit behavior that may call attention to them in the classroom." In addition, children with bipolar may be expending a tremendous amount of effort controlling themselves at school. "After using a great deal of effort to not have problems in school," Greenberg says, "when the child gets home, he relaxes his controls and lets his feelings out. To some degree I think this is because these children have learned what appropriate behavior is. They know if they get out of control at school, they will be rejected by teachers and peers. At home, you’re with your family, the people you feel the safest with to be yourself."
Although recognizing bipolar disorder does mean looking at unusual, inappropriate, or problem behaviors, there are positive aspects to the disorder as well. The broad emotional range has been attributed to creativity and original thinking. It has been suggested that men like Winston Churchill, Charles Dickens and Isaac Newton may have had a mood disorder when they were young. "There are books written about the link between bipolar disorder that go into detail about these individuals’ lives and clearly give information that is consistent with the diagnosis," says Greenberg. "If you read about the history of these famous men, in books and articles that have nothing to do with BPD, you will be surprised how many signs of the disorder were present..."
One of the most important clues is what Greenberg refers to as listening to the words, not just the music. "I really think that adults don’t give children enough credit. Kids are more aware of their feelings and behavior than most grownups realize. They may not use grown-up words, and say, ‘I’m depressed,’ but they will tell you, if asked or listened to carefully, that nothing is right, nothing pleases them or makes them happy for a prolonged period of time. Most of the kids I see are able to admit they are angry and often more enraged than even they think they should be. They just are unable to explain why."
Down the road
The number one reason for research, says Pavuluri is misdiagnosis, but the research is promising. "We are starting in child psychiatry to think about the dimensions of symptoms, which means that with some symptoms of bipolar and ADHD, like impulsivity, we find ways to see how it differs in the brain, how that leads to impulsivity. Different mechanisms operate in how the end symptoms of behavior are manifested."
Beyond diagnosis, research will offer improved treatment options." We are looking at how medications impact brain function so we know medications are affecting the right section of brain in both disorders," Pavuluri explains.
Through research, answers to these issues are coming.
"Although we’re getting some interesting results," Chang warns, "there are no tests yet specific enough to accurately predict the risk of developing bipolar."
In the meantime, parents can do their own research. Pavuluri offers parents advice in her book, What Works for Bipolar Kids. In addition to Greenberg’s books, she coproduced a DVD entitled Rescuing Childhood.
"In medicine in general, not just psychiatry," Greenberg says, "getting a good history of the problem is key in getting a proper diagnosis. We are not yet at the place where we can get a blood or urine test, X- ray or MRI to diagnosis depression. This is where psychiatry struggles behind general medicine."
"We are incrementally building on our preliminary results," says Pavuluri. "We will, in the next couple of years, be publishing the results of larger studies."
As Greenberg notes, "We live in a very exciting time."
Kathryn Davis is a New Jersey writer and mom and The Parent Paper’s columnist for special-needs issues.
When she’s not texting or listening to her iPod, Jennifer (not her real name) enjoys Facebook, shopping and writing poetry. Like most teenagers, she argues with her parents. However, Jennifer’s conflicts are so intense and so frequent lately that family activities and trips are adversely effected, and often even cancelled. When she was diagnosed with ADHD in middle school and put on a stimulant medication, it seemed to help for a while, but lately her behavior has been getting worse. Lately, she seems angry most of the time, accusing others of being mean and unfair. She doesn’t seem to enjoy favorite activities, and is having sleep problems. Recently Jennifer’s parents took her to see a new doctor who made a different diagnosis: bipolar.
For many years, doctors believed bipolar was an adult disorder. However, that belief has changed recently. Kiki Chang, director of the Pediatric Bipolar Disorders Program at Stanford University, says the number of children under 18 diagnosed with bipolar disorder has risen 4,000 percent in the U.S. in the last decade. According to the Bipolar Research Foundation, juvenile bipolar disorder, also called early-onset bipolar, includes characteristics that are often seen with a number of other disorders. This overlap of symptoms is one reason bipolar in children and adolescents is so difficult to diagnose. Even worse, treatments that are used for one disorder can sometimes trigger bipolar in someone with a susceptibility, such as a family history.
"A very common scenario is a teenager who’s depressed and has a family history of bipolar," says Chang. "They are at high risk of eventually developing mania. We found antidepressants can trigger mania in some of these kids."
Diagnosing
Diagnosing bipolar disorder in children and adolescents is complex and not done on the basis of symptoms alone. Experts only consider the diagnosis in cases where the behaviors are extreme, and of a very long duration. When bipolar symptoms are seen after treatment for a different disorder, or treatment for another disorder does not improve symptoms or worsens them, doctors may then consider bipolar. The increase in the number of diagnoses, Chang points out, could be the result of factors such as a growing awareness of the high rate of inheritability of the disorder, the inclusion of irritability as a primary symptom of mania and improved research in child development. There is still potential for over diagnosis, however, which is why it is so important for physicians to make careful and detailed evaluations, including such factors as family history and behaviors both at school and at home.
In her book, Bipolar Kids, author Rosalie Greenberg, M.D. offers advice for parents and includes reassuring facts and real-life examples from her many years in practice. The book contains easy-to-read charts that help in understanding how common symptoms of disorders like ADHD and bipolar can overlap and how they differ.
"Studies indicate that the majority of youngsters with bipolar disorder meet the criteria for ADHD, especially when in the manic state," notes Greenberg. "And there are as many kids with both disorders." She points out that up to 20 percent of children with ADHD are estimated to also have bipolar disorder.
"Irritable behavior is one of the most frequent reasons why parents bring their child to a mental-health professional," says Greenberg. "But irritability and temper outbursts are diagnostically nonspecific, and can be seen in children without any serious psychiatric problems."
Mood disorders such as bipolar can include mania, where there may be increased energy levels. Children and adolescents may exhibit extreme irritability in this mood, and may also feel an exaggerated sense of their own abilities or knowledge. "A manic child is always right," notes Greenberg. "When the parent says the toy store is closed, it’s Sunday night, and they will open tomorrow, the child gets into a rage. He tells his mother that she is wrong. He knows better. He calls her a liar, and tells her she’s just mean and he hates her. The more she tries to reason with him, the angrier he gets."
Detective work
Researchers are looking at ways to both diagnose the disorder as well as to predict susceptibility. One way is through brain imaging using an MRI (Magnetic Resonance Imaging). This kind of testing has led experts at the National Institute of Mental Health (NIMH) to discover that the part of the brain that processes emotions, the amygdala, is smaller in kids with bipolar disorder and also somewhat hyperactive. It is uncertain whether this is a cause of the disorder or a result of it. However, researchers like Dr. Mani Pavuluri from the University of Illinois at Chicago's Pediatric Bipolar Research Program are hoping to use this kind of information to further an understanding of the disorder. "Imaging will give you a map of the networks of the brain," she explains. This kind of technology, she adds, "allows us to find ways to map the brain circuits in ADHD that look different from bipolar disorder."
Pavuluri and her colleagues have been using functional MRIs to examine the brain operations of children with bipolar disorder. She sees misdiagnosis as the primary issue. "By doing this research, we can tell the thumbprint of brain function of bipolar disorder that looks different from ADHD. We are hoping this will help prevent misdiagnosis in the future."
Another avenue, says Chang, involves finding biological markers that predict the risk a child has for developing the disorder. "By understanding the neurobiology and the genetics, we hope to understand how it develops in the brain. If we achieve these two goals, we can figure out who needs early intervention and also what types of early interventions to prevent or delay the onset of bipolar."
Because misdiagnosing bipolar disorder can mean prescribing the wrong treatment, making a distinction is vital. "Once we learn the basics, we can recognize it early and treat it with the right medications. If you give the wrong medications, symptoms can get worse," Pavuluri warns. "If you give mood stabilizers to someone with ADHD, it dulls the thinking. If you give stimulants to someone with bipolar disorder, mania gets worse."
"There are a variety of behaviors that are often observed in bipolar children, but each one by itself is not necessarily unique to this diagnosis," notes Greenberg. She points to an increased craving for certain foods. "Typically when one thinks of a depressed individual, they associate lack of appetite. But bipolar kids exhibit signs of what we call an atypical depression and actually show cravings, typically carbohydrates like pizza, pasta, cheese, ice cream, French fries, etc. Interestingly, they can also show an increase in carbohydrate craving when they are manic."
Another behavior seen with bipolar, says Greenberg, is a thermoregulatory difference. "They are typically warm, or even hot, when other people feel cold. This will result in the child not wanting to wear a coat in very cold weather, or wanting to go to school in shorts and a t-shirt when it’s 35 degrees outside. They can feel very uncomfortable when the weather is very warm. They may prefer to sleep in the nude or with little clothing, or want the fan or air conditioner on even in the middle of winter."
Another behavior often seen in someone experiencing mania is hyper sexuality. "In an adult this can mean being very flirtatious, dressing in a sexually, overly seductive way, having multiple affairs, etc.," explains Greenberg. "In a child, it will, to some degree, manifest differently, depending on the youngster’s age. Young children may use a lot of ‘potty talk’ or ‘bathroom words’ or try to see their parents naked, or get out of their shower and do a dance while naked for others to see." She notes that, as children with bipolar age, the behaviors may resemble adult hypersexual behaviors. Teens may become somewhat promiscuous or seek sexual activities on the Internet. Of course, warns Greenberg, "A child that exhibits hypersexual behavior cannot be automatically assumed to be bipolar. It is extremely important to rule out other potential causes of this behavior, such as child sexual abuse, or maybe the child witnessed inappropriate sexual behavior at home, etc."
One other behavior Greenberg notes is sleeping problems. "For many bipolar children, nighttime is when they experience an increase in fears, especially separation type fears like fear a neighbor’s dog will die, even though it’s not been ill. When the bipolar child is in the manic state, he’s too full of energy to fall asleep and wakes up early, as there is a lot on his mind that he wants to do now."
Another clue is to look at differences in behavior at home and at school. If there is no behavior problem at school, but the child is out of control at home, he may have bipolar. "Many of these kids have co-morbid (additional) anxiety disorders that actually serve to inhibit behavior that may call attention to them in the classroom." In addition, children with bipolar may be expending a tremendous amount of effort controlling themselves at school. "After using a great deal of effort to not have problems in school," Greenberg says, "when the child gets home, he relaxes his controls and lets his feelings out. To some degree I think this is because these children have learned what appropriate behavior is. They know if they get out of control at school, they will be rejected by teachers and peers. At home, you’re with your family, the people you feel the safest with to be yourself."
Although recognizing bipolar disorder does mean looking at unusual, inappropriate, or problem behaviors, there are positive aspects to the disorder as well. The broad emotional range has been attributed to creativity and original thinking. It has been suggested that men like Winston Churchill, Charles Dickens and Isaac Newton may have had a mood disorder when they were young. "There are books written about the link between bipolar disorder that go into detail about these individuals’ lives and clearly give information that is consistent with the diagnosis," says Greenberg. "If you read about the history of these famous men, in books and articles that have nothing to do with BPD, you will be surprised how many signs of the disorder were present..."
One of the most important clues is what Greenberg refers to as listening to the words, not just the music. "I really think that adults don’t give children enough credit. Kids are more aware of their feelings and behavior than most grownups realize. They may not use grown-up words, and say, ‘I’m depressed,’ but they will tell you, if asked or listened to carefully, that nothing is right, nothing pleases them or makes them happy for a prolonged period of time. Most of the kids I see are able to admit they are angry and often more enraged than even they think they should be. They just are unable to explain why."
Down the road
The number one reason for research, says Pavuluri is misdiagnosis, but the research is promising. "We are starting in child psychiatry to think about the dimensions of symptoms, which means that with some symptoms of bipolar and ADHD, like impulsivity, we find ways to see how it differs in the brain, how that leads to impulsivity. Different mechanisms operate in how the end symptoms of behavior are manifested."
Beyond diagnosis, research will offer improved treatment options." We are looking at how medications impact brain function so we know medications are affecting the right section of brain in both disorders," Pavuluri explains.
Through research, answers to these issues are coming.
"Although we’re getting some interesting results," Chang warns, "there are no tests yet specific enough to accurately predict the risk of developing bipolar."
In the meantime, parents can do their own research. Pavuluri offers parents advice in her book, What Works for Bipolar Kids. In addition to Greenberg’s books, she coproduced a DVD entitled Rescuing Childhood.
"In medicine in general, not just psychiatry," Greenberg says, "getting a good history of the problem is key in getting a proper diagnosis. We are not yet at the place where we can get a blood or urine test, X- ray or MRI to diagnosis depression. This is where psychiatry struggles behind general medicine."
"We are incrementally building on our preliminary results," says Pavuluri. "We will, in the next couple of years, be publishing the results of larger studies."
As Greenberg notes, "We live in a very exciting time."
Kathryn Davis is a New Jersey writer and mom and The Parent Paper’s columnist for special-needs issues.