An exchange of letters published in the Journal of the American Academy of Child and Adolescent Psychiatry, 38:5 (May 1999): 495-496. Reprinted here with permission of Lippincott Williams & Wilkins.
CHILDREN WITH BIPOLAR DISORDER
To the Editor:
We lead an Internet support group for parents of young children and adolescents with bipolar disorder. Our group currently numbers over 200 families in the United States, Canada, and Great Britain and has served more than 400 families since its founding 3 years ago. Many children in our group have attained stability with mood stabilizers, making it possible for them to experience more normal development as well as express their considerable talents and remarkable creativity.
We commend the JAACAP for publishing the exciting research findings of the past decade on childhood-onset bipolar disorder. As parents, we are keenly aware that childhood passes in the blink of an eye. While professionals may split hairs at leisure, the window of opportunity in which parents may educate and influence a child slams shut far too soon. Early diagnosis and treatment for these delightful but often exhausting children is literally a lifesaver. We look forward to future reports on treatments such as rTMS (repeat transcranial magnetic stimulation) and cognitive therapy, and new medications without such devastating side effects as the excessive weight gain that damages our children's fragile self-esteem.
We read with great interest the debate between Dr. Biederman and Drs. Klein, Pine, and Klein (1998) on whether mania is mistaken for attention-deficit hyperactivity disorder (ADHD) in children. Most of our children initially received the ADHD diagnosis, were given stimulants and/or antidepressants, and either did not respond or suffered symptoms of mania such as rages, insomnia, agitation, pressured speech, and the like. In lay language, parents call this "bouncing off the wall." First hospitalizations occurred often among our children during manic or mixed episodes (including suicidal gestures and attempts) triggered or exacerbated by treatment with stimulants, tricyclics, or selective serotonin reuptake inhibitors. Many of these same children are now doing well on lithium or other mood stabilizers, along with cautiously monitored adjunctive medications. We also find family and individual therapy, charting of symptoms, special education services in public or therapeutic schools, participation in parent support groups, and occasional respite for the parents to be essential elements in managing the illness.
Drs. Klein et al. declare the high number of children who exhibit all diagnostic criteria of both ADHD and bipolar disorder to be "inconsistent with outpatient status." This may be due to the understandable reluctance of parents to leave our beloved, despondent, and vulnerable children in locked hospital psychiatric wards with parental visits limited to an hour per day. It says even more about managed care insurers' deplorable refusal to approve inpatient care for seriously ill children not acutely suicidal, limiting inpatient days to an absurdly low number such as 2 or 3 (in which stabilization is unlikely) and refusing to approve placement in day hospital programs.
We invite researchers to contact our group about ongoing studies and encourage professionals to refer parents of diagnosed children to us for support. Our Parents of Bipolar Children Web site is at www.bpparent.org and our Resource List for Parents of Bipolar Kids is at www.bpso.org. [The web site has moved to www.bpkids.org. The Resource List, or any successor document, may be found there. – firstname.lastname@example.org]
Martha E. Hellander
Acting Executive Director
Child and Adolescent Bipolar Foundation
Founder, Parents of Bipolar Children
Fort Collins, CO
Biederman J, Klein RG, Pine DS, Klein DF (1998), Resolved: mania is mistaken for ADHD in prepubertal children. J Am Acad Cbild Adolesc Psychiatry 37:1091-1099
To the Editor:
Most of the many children in whom we diagnose probable bipolar disorder (BPD) manifest rapidly cycling variation in the presence, or severity, of psychomotor acceleration and other DSM-IV manic symptoms. These manic exacerbations are distinctly apparent to their caregivers and frequently are accompanied by euphoria, especially when they occur in the late afternoon and/or evening, although dysphoric manic or "mixed" states also are common. Cycles of acute manic worsening usually last only a few hours, seldom longer than a few days.
Most of the children in whom we diagnose probable BPD also meet DSM-IVcriteria for ADHD (and oppositional defiant disorder). Nonetheless, "stable, continuous mania (Klein et al., 1998) is uncommon among our presumed bipolar children, whose psychomotor acceleration typically waxes and wanes. Klein et al. (1998) obviously are correct in asserting that the phenomenology of childhood BPD is not identical with that of classic adult bipolar I disorder, but the difference is not in the symptoms of childhood hypomanic/manic states; it is in the atypical longitudinal course of childhood manic symptom presentation, including the short durations of acute manic symptom worsening and the frequent interepisode persistence of less severe manic symptoms. The DSM-IV duration criteria of 7 and 4 days for adult manic and hypomanic episodes, respectively, are arbitrary and intrinsically irrational. Interepisode persistence of bipolar symptoms is common in adult patients (DSM-IV course specifier: "without full interepisode recovery"). Moreover, the range of bipolar spectrum illnesses remains unclarified in the DSM series. Consequently, many adult bipolar conditions probably are significantly underdiagnosed, Klein et al. (1998) notwithstanding.
Identifying atypical bipolar illnesses in patients of any age is difficult. Nonetheless, the effort to do so must be made. If ultrarapid cyclic exacerbation and interepisode persistence of manic symptoms (i.e., grandiosity, early nighttime decreased need for sleep, psychomotor acceleration) were more generally recognized as valid features of bipolar spectrum illness, then the diagnosis of BPD, based on acceptance of these longitudinal features and strict application of the DSM-IV symptom criteria, would be found by unbiased observers (Biederman, 1998) to be common among referred children (and adults).
Dennis Staton, Ph.D., M.D.
Dwight Lysne, M.D.
Biederman J, Klein RG, Pine DS, Klein DF (1998), Resolved: mania is mistaken for ADHD in prepubertal children. J Am Acad Child Adolesc Psycbiatry 37:1091-1099
Dr. Klein et al. reply:
We are keenly aware of the anguish that children with bipolar disorder present to their families and are extremely pleased to learn of the Internet support group. The experience reported by M. Hellander and T. Burke is indeed moving, but it does not document that mania often masquerades as ADHD in preadolescent children. We do not propose that bipolar disorder is nonexistent in children; rather, we propose that bipolar disorder, as defined in the DSM-IV, is rare in young children, and we question the validity of the evidence presented to support the claim that a sizable proportion of children with ADHD suffer from full-fledged manic depression. As clinicians, we use mood stabilizers in some young children with a variety of psychiatric disorders, with apparently good effects. However, response to medication is not a confirmation of diagnosis. The efficacy of mood stabilizers in children remains untested, and claims of efficacy for a specific childhood syndrome must await scientifically rigorous testing. Our argument should not deter clinicians from treating children with mood stabilizers when these appear to hold promise. However, results from such experiences remain in the realm of anecdotal evidence.
Drs. Staton and Lysne note the importance of bipolar spectrum disorders and also raise interesting points concerning the limitations of the DSM-IV for the diagnosis of bipolar spectrum disorders. This important diagnostic issue has generated a great deal of interest, as it should. However, the debate is limited to a specific question, i.e., the presence of full-fledged bipolar disorder in many preadolescents with ADHD. We question the evidence bearing on this point, but we do not attempt to address the occurrence of bipolar spectrum disorders in preadolescent children with ADHD. Definitive resolution of any nosological and therapeutic debate requires objective data which should included (1) independent gathering of diagnostic information by trained clinicians blind to the presumptive diagnosis, on several occasions, with proper calculation of symptom and diagnostic reliabilities; (2) controlled follow-up and family studies applying similar standards; and (3) comparative, independently assessed, controlled treatment trials designed to protect against allegiance effects. Science progresses by independent replication. The popularity of many treatments that have been discredited by systematic study attests to the need for controlled studies before confidence can be placed in testimonials.
Rachel C. Kein, Ph.D.
Daniel S. Pine, M.D.
Donald F. Klein, M.D.
New York State Psychiatric Institute
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