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Hey everybody, welcome back to a clinical [00:01:00] episode of the podcast. I’m excited to be talking with you today about pediatric bipolar. I cannot believe that we have not talked about pediatric bipolar in nearly 500 episodes of this podcast.
My guest today is Elizabeth Errico. Elizabeth founded the Children’s Mental Health Resource Center after more than 20 years as a mental health professional. Throughout those years, she saw countless families struggle to find answers and support from a complex mental healthcare system that often ignores or minimizes their concerns. CMHRC grew out of the awareness that these families and their providers deserve better access to information, resources, and expert guidance as they seek accurate diagnosis and effective treatment.
We talk today about many aspects of pediatric bipolar; we talk about the history of the diagnosis and why it’s so misunderstood, we talk about differentiating pediatric bipolar from ADHD, DMDD, ODD, and other alphabet soup diagnoses, we talk about [00:02:00] communicating with families about a pediatric bipolar diagnosis, we talk about treatment options for pediatric bipolar and many other things. Elizabeth has a ton of experience in this area and I am very grateful to have her.
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All right, let’s get to my conversation with Elizabeth Errico about pediatric bipolar.
Elizabeth, hey, welcome to the podcast.
Elizabeth: Thank you so [00:03:00] much for having me.
Dr. Sharp: I’m glad to have you. We’re talking about pediatric bipolar, which is a topic that we have not talked a lot about, somehow in almost 500 episodes of this podcast, we have not talked extensively about pediatric bipolar. So I’m so grateful that you are here and willing to chat with us about this topic.
Elizabeth: Thank you, I’m grateful to be here because as you just outlined, this isn’t a topic that gets talked about very much. It’s important for providers to know what they’re looking for when a pediatric bipolar is a concern because not enough people get trained in it.
Dr. Sharp: Absolutely. There’s a lot of confusion and maybe misinformation out there as well. I look forward to clearing some of these things up and hopefully, folks will walk away with a good understanding of pediatric bipolar.
I’ll start with the question I always start with, which is, why this? Of all the things you [00:04:00] could spend your life, energy, and time on, why pediatric bipolar stuff?
Elizabeth: Bipolar disorder is to some degree one of the least well-funded, least well-examined mental health conditions out there that has changed in the last two years with a huge influx of research dollars that have been put towards bipolar.
When you consider how difficult it is to diagnose and treat bipolar in adults, and then you add that to the pediatric population, families are stuck in a circumstance where they are not getting accurate diagnoses, they’re not getting effective treatment plans put in place, they are losing their childhood to [00:05:00] misdiagnosis and the wrong medications.
When I was working at the Juvenile Bipolar Research Foundation, as the executive director, I was seeing family after family who were coming to us, desperate for help. They were falling through the cracks of the mental health care and physical health care systems in the country because providers were not being able to identify what was going on with them.
Their parents were being told that it was their parenting that was the problem, kids were being told that they were bad kids and being disciplined at school and having all of these character or logical assessments being made of them that were inaccurate.
The pain that I saw these families in was awful. And so my colleagues and I decided to form a new [00:06:00] organization where our whole purpose is to educate providers and to shepherd families through the process of finding the right diagnosis and effective treatment for the disorder. And so it’s become a mission for all of us that we not let families go through the years and years of struggle.
The statistics on treatment onset delay are horrifying. It’s an average of 10 years from the time a parent finds out or discovers that there’s something going on with their kid that needs addressing, to the point where they have an accurate diagnosis and an effective treatment plan. And that’s a childhood loss. And so we feel as though no family should have to go through that.
Dr. Sharp: Oh yeah, that is an entire childhood, the kid is not a kid anymore after 10 years. That’s terrible. [00:07:00] Tell us about your organization; that’s maybe a good place to start and what y’all do, what you’re about, and then we’ll get into more bipolar-specific clinical information, but I’d love to hear about your organization.
Elizabeth: We were founded to, as I said, be a resource for families and for providers in the area of juvenile-onset bipolar but we realized that most folks who have juvenile-onset bipolar don’t know that’s what it is. And so if we were to present ourselves exclusively of being about bipolar disorder, folks wouldn’t know that we had the services they needed. And so we branched out and we now address any and all mood disorders that exist in children, because it’s very hard for folks to differentiate among them.
[00:08:00] We still keep as a core part of what we do, education around bipolar and support around bipolar, because it’s so difficult to identify for many people, but we work with families who have any mood disorders. We coach them on how to talk to their providers, how to know which providers they need to be trying to find, and how to identify what providers they’re going to be comfortable working with.We educate them on symptom presentation, on updated research, what’s happening right now. We work with their providers so that they understand what effective treatment modalities are for bipolar, which oftentimes aren’t what most providers default to in their practice. We try to make sure that everybody has the education and support to positively [00:09:00] impact the kids who are living with the disorders.
Dr. Sharp: It’s super important; all the things that you mentioned, I feel like are areas that are really tough for parents, especially if they are potentially in the throes of a kid struggling or having a mental health crisis.
Let’s talk about some details around pediatric bipolar, I would love to start with the history. For context, I came into the scene, so to speak, in graduate school. I started in 2003. At that time, pediatric bipolar was pretty hot, so to speak. It was very popular. Any kid with any kind of explosive, tantrums or disruptive behavior was getting diagnosed with pediatric bipolar.
My advisor was a big proponent of pediatric bipolar. It has shifted over the years, [00:10:00] but that’s why I’ll stop my story there and defer to you. I’d love to hear the history of this diagnosis.
Elizabeth: Your history is a snapshot of that period of time where you’re right, it had become in vogue to diagnose kids with pediatric bipolar. And that was in part a pendulum swing in the opposite direction from the years and years in which it was believed that kids can’t have serious mental illnesses. And so bipolar wasn’t considered and that’s reflected in the way the DSM criteria is written because it’s all written with adult symptomology in mind.
In the late 90s, a few prominent psychiatrists wrote some books. One is The Bipolar Child by Demitri Papolos, there’s a book by Rosalie Greenberg on bipolar in [00:11:00] childhood. It became something that everybody started learning about. And so it started getting diagnosed much more frequently.
The pendulum, of course, as it does, swung back in the other direction. In the mid-2000s to late 2000s, we saw backlash against that. In fact, the DSM committee introduced a brand new disorder that had not been identified through research. It had been created essentially through consensus around the idea that there needed to be an alternative to bipolar disorder in the DSM. And so they created the diagnosis of disruptive mood dysregulation disorder.
They did know that they wanted to differentiate it from bipolar as they saw them to be [00:12:00] very rare cases of bipolar presenting kids. And so they included the criteria in the DSM that if a child has had a manic episode, then the diagnosis of DMDD doesn’t apply.
Unfortunately, what has happened is that it’s difficult for providers to identify manic episodes in children when they don’t know what to look for:
a) Because the symptomology is so different from adult presentation.
b) Because it’s not in the DSM in the juvenile presentation.
And also because manic episodes cycle very quickly in children, typically, so even though that’s in there, folks swung in the other direction, were diagnosing DMDD instead, and we then discovered that there was a whole generation of kids who may have qualified for the bipolar [00:13:00] diagnosis, but weren’t given it.
And so even today, the statistics that come out of the National Institutes for Mental Health are showing that fully one-third of all of the kids and teens who are diagnosed with major depression likely have bipolar, it’s just that their manic episodes have not been identified correctly.
There’s a huge uphill battle and reframing for people that there’s a middle ground between these pendulum swings of kids can’t have bipolar or every child with a behavioral issue has bipolar. There’s room in between, and we pushed the idea that accurate diagnosis is what matters, not what the diagnosis is.
Dr. Sharp: I look forward to getting into the diagnostic pieces. I think those are really interesting to my audience, specifically. I would love to go back and clarify something. This [00:14:00] is super interesting. I was always under the impression that DMDD emerged from research showing that kids, gosh, how would I phrase it? I don’t know. My words are escaping me now.
I had a really great question though, but it was something around the research, it emerged from this research showing that kids went down this trajectory of kids that were historically diagnosed with bipolar, when they follow them, they were more likely to end up either anxious or depressed versus permanently bipolar, so to speak.
And we figured there’s something else that must be going on, that’s more of a milder mood disorder, but it sounds like that was maybe not the case. What am I getting wrong here?
Elizabeth: None of the diagnoses in the [00:15:00] DSM were initially introduced as a result of research that all of the diagnoses and the criteria are consensus-based. Committees come and they develop what are the criteria that are going to be listed.
And so whenever we look at the DSM, it’s one of the things that puts an over-reliance on the DSM is that providers assume that everything that is in there has a list of research that supports it but the truth is that it’s all consensus-based.
We have drifted more towards research as we’ve evolved as a field but initially, when DSM-3 was coming out, it was really about taking a clinical observation and organizing it. And [00:16:00] so when we’re basing our understanding of diagnoses on clinical observation, we are, by default, leaving out anything that we are disinclined to observe.
And so that is part of what gets into that tricky area around mania with kids because if you don’t know what mania looks like and you’re only going based on your clinical observation, you’re not going to be able to identify whether or not DMDD is the correct or incorrect diagnosis because you’re missing these enormous exclusionary criteria. So it’s tricky and a lot of providers are actually surprised to hear that a manic episode is exclusionary for DMDD.
Dr. Sharp: I think it’d be really worthwhile to dig into the [00:17:00] manic side of things in particular, as far as what this looks like. Let me zoom out maybe just for a second though, and first say, you hinted at how pediatric bipolar and adult bipolar can present differently. I would love to talk big picture about those differences because that’s another, I don’t know if misconception is the right term, but at least in this latest iteration of the DSM, it is presented as largely similar and there’s not separate criteria for pediatric bipolar. What do you see as the differences there?
Elizabeth: We’ll start with the cycling. That’s a huge difference in that in the criteria for adults, we’re looking at days, weeks, months [00:18:00] of a depressive episode or manic episode, in kids, it doesn’t present that way. Kids, rapid cycle. And so they are going to be demonstrating sometimes manic episodes and depressive episodes within the same day. That is not something that anybody is taught to look for.
So when they’re seeing these wild mood swings throughout the day, they’re not thinking bipolar because they’re not, in their minds, lasting long enough to qualify for the bipolar diagnosis, but what the kids are experiencing in those abrupt mood fluctuations are condensed depressive and manic episodes.
And because for kids, depressive symptoms and [00:19:00] manic symptoms can both present as irritability, it’s perceived as oppositional or defiant behavior rather than irritability as a result of either mania or depression. And so kids who are chronically irritable experience rigidity, refusals to try new things, refusals to do things that they would have enjoyed.
The parents are usually the ones instigating those activities. So when a child refuses, it’s not perceived as a loss of interest in things that used to bring them joy, it’s perceived as a refusal to follow instructions. Mom comes and says, we’re going to the water park today, get your bathing suit on and the kid says, no.
Mom doesn’t think, gee, [00:20:00] why doesn’t he want to do this thing that he used to love; mom thinks, why is he making us all late? We’re meeting people. We have to get going, put on your bathing suit.
And so there’s this tendency to view a lot of the typical depressive characteristics and criteria through the lens of opposition, through the lens of defiance, through the fact that the child doesn’t have the autonomy to make his own decisions. So when someone else comes in and makes a decision for them that they can’t follow through on, the perception is, this kid is difficult.
The same is experienced on the manic side when the child is unable to contain their energy, is unable to control the behaviors that are happening as a result of that symptom and they’re viewed as disruptive, they’re [00:21:00] viewed as disrespectful, they’re viewed as intentionally allowing themselves to get out of control and hyperactive instead of recognizing that the child is not able to control what’s happening to them in that moment. And so it’s a lot about the difference between signs versus symptoms.
As a clinician, we look at symptoms as the experience that the patient is having while signs are the observations we have of those symptoms. And so while the symptoms that the child has experienced may be a loss of interest in things they used to enjoy, it may be that they are experiencing shifts in their sleeping patterns or eating patterns as a result of depression but the observation that we have of it is, my child isn’t following [00:22:00] instructions, my student isn’t doing what is being asked of him in the classroom and that filter through our observation distorts our ability to be able to identify active symptoms when they’re there.
Dr. Sharp: That’s interesting to make that distinction between signs and symptoms. I like that. I would love to clarify a little bit, what you described as this rapid cycling manic and depressed episodes sometimes occurring in the same day or two days; how do you distinguish that from typical kid behavior?
That sounds like both of my kids, on any given day, they can be at 7 or 8 or 9 or 2 whatever, I’m guessing a lot of people have the same question, when does it cross into pathological territory, so to speak?
[00:23:00] Elizabeth: That’s a great question because oftentimes, those manic episodes are happening so quickly that they are misperceived as hyperactivity. And so one of the most commonly misdiagnoses that is given for a child who actually has bipolar is ADHD.In that case, once those stimulants are given, the proof is in the pudding, so to speak. A child who has bipolar who’s given stimulants, there are only two things that can happen afterwards, either it has no effect, and if that’s the case, then you’re lucky or it creates mania, and that can include aggression, hostility, violence.
I know of many children who have been put on stimulants [00:24:00] thinking it was ADHD who then didn’t sleep for three days because they were triggered into a manic episode. So the medication response itself is a clue, but also on a more fundamental level, kids who have bipolar disorder are experiencing distress so we have to go back to the first two categories of things that we look for when we’re even determining whether or not any set of experiences is symptomatic or not, is it causing subjective distress and is it an obstacle to normal daily functioning?
If we take a big picture look at the DSM, every behavior, every criteria in there, every symptom is a normal human behavior that has been taken to a degree where it is no longer [00:25:00] considered to be an expected part of daily life. And when it crosses that threshold of causing subjective distress and being an obstacle to normal daily functioning, then we know that we’re pushing into territory where there may be some kind of pathology there.
Dr. Sharp: That makes sense. Gosh, it feels really tricky. And then there’s this question of, which we are getting into, how do you differentiate it from some of these other disorders? ADHD is a big one, DMDD is a big one, maybe even depression or defiant behavior. Can you talk about some of the major differential diagnoses with pediatric bipolar and what you see is getting misdiagnosed or not?
Elizabeth: We call it the alphabet soup [00:26:00] because the diagnoses that they get are ADHD, ODD, DMDD, and GAD. That’s the attention deficit, mood dysregulation, it’s the generalized anxiety; it’s all of these things that are seen as existing in silos and having disparate causes when in fact they all wind up under the same umbrella.
And so usually when we see a family, when they’ve come to us and they say, okay, our child has been diagnosed with DMDD, generalized anxiety and ADHD, we say, okay, slow down because that’s the red flag combination. Usually, the ADHD is capturing the mania and the manic episodes, the DMDD is capturing some of that irritability [00:27:00] that goes along with both depression and mania, and then the anxiety is representing a lot of the depressive episodes as they manifest in children.
Also very common is ODD. As I said, opposition is how these symptoms are perceived by others. And so when we see that, we think, okay, let’s step back, this may all fall under one umbrella. To circle back to the question you had about differentiating it from adult symptomology, the other piece of it is that kids don’t have autonomy over their lives in the way that adults do, and so certain symptoms as they’re described in the DSM simply don’t apply to children.
The examples that I always give in mania are [00:28:00] spending sprees. 7-year-olds don’t have credit cards. They can’t go on spending sprees unless they’ve got their parents credit card in their tablet and they’re playing a game, and they’re just racking up charge after charge, which we do see but they can’t go drive to the mall and spend $3,000 because they don’t have the means to do it.
The other example is hypersexuality which in a prepubescent child may be difficult to identify as such, may be perceived as that they don’t have very good physical boundaries, that they may not respect other people’s personal space, that they may ask precocious questions but when we can look at it within the context of the other symptoms and how they present, we can then correctly identify that, oh, that’s [00:29:00] hypersexuality in a child, and do that in a way that is contextually appropriate.
And so that speaks a little bit to the question of differentiation; no kids should be diagnosed with bipolar disorder without a very thorough differential diagnosis. But when you dig into those diagnoses, you see that symptoms present differently.
Charles Popper, who’s adolescent psychiatrist, he is a lecturer at McLean Hospital, part of Harvard Medical School, he wrote a wonderful paper on differentiating ADHD from bipolar. Dr. Papolos’s and Dr. Steven Mattis, who’s a neuropsychologist, wrote a wonderful paper on the neurodevelopmental differences between bipolar and ADHD.
They looked at [00:30:00] three subsets; they looked at kids with ADHD, they looked at kids with bipolar, and they looked at kids who had both, to identify these markers that can be seen in testing that differentiate which is which.
The quick summary there is that kids who have ADHD experience, it’s the signs that are the same, it’s not the symptoms. For example, breaking things, parents often complain that their children break things. In ADHD, that breaking of thing is often accidental; it is through the course of moving too quickly, of not paying attention to their surroundings, of lack of ability to figure out where they are in [00:31:00] space.
With a kid with bipolar disorder, when they break things, it’s intentional most of the time. It is an expression of anger, frustration, distress. So the fact that they’re breaking things isn’t sufficient to determine a diagnosis. Also with bipolar and ADHD, there are 15 different differential criteria that Dr. Popper offers in his paper.
I had another one in mind to mention, it just blew right out of my head. I’ll come back to it when I remember but the bottom line is, Dr. Popper’s point ultimately was, you can’t diagnose ADHD until you’ve ruled out a mood disorder. That’s the order of operations in the diagnostic process, but that’s not what’s done [00:32:00] for the most part because clinicians are not given the luxury of the time necessary to do a complete differential diagnosis.
So when we’re working with families, we’re looking at the criteria for bipolar, for ADHD, DMDD, ODD, PTSD, generalized anxiety, major depression, pervasive depressive disorder or persistent depressive disorder, as it’s called now, cyclothymia.
We’re looking at all of these diagnoses because there’s so much symptom overlap and because there’s the filtering that goes through our observation of those symptoms that we have to look at detectives to go through and dig into the history and figure out how long has this been going on? What is the seeming origin of [00:33:00] these symptoms? And move away as much as we can from the idea that there’s any intentionality behind any of the behaviors.
I’ve remembered, another example that Dr. Popper gives of differentiating ADHD from bipolar is attention. Kids with ADHD can lose the ability to attend to things that they enjoy, that they want to be attending to. With bipolar, motivation can overcome inattentiveness and motivation cannot as commonly overcome inattentiveness in ADHD. So there are these details that have to be examined through the differential diagnosis to be able to determine, yes, it’s the same symptom but which diagnosis is it actually a part of?
Dr. Sharp: Sure. [00:34:00] I like that distinction as well; motivation can overcome inattention or not. Yes. Gosh, there’s so many questions. All of a sudden I’m wishing we had four hours instead of an hour and a half.
Elizabeth: I can always come back.
Dr. Sharp: My gosh, I’m going to give it a good shot, but there’s so much to look through here. I’m going to keep focusing on this differential diagnosis component, especially with DMDD. With irritability being a symptom or sign of both depression and manic episodes in kids, I am curious how you distinguish between DMDD and pediatric bipolar.
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Elizabeth: With DMDD, part of the criteria is that the mood remains irritable in between mood episodes. That is not the case with bipolar. With bipolar disorder, for the most part, kids who have bipolar are kind, gentle, empathetic, and there is a marked [00:37:00] difference between how their affect and their behavior in between mood episodes, they are likely to experience tremendous regret and remorse after they have been verbally aggressive, or they have been irritable.
They will express distress with their own behavior, they’ll apologize to their parents. They will be sometimes racked with guilt over what they did. In between you’re seeing that kindness, that gentleness, that empathy, and in some cases, an ability to over-empathize with others and absorb the pain and distress that other people are experiencing and be triggered by it.
Whereas with DMDD, one of the characteristics listed is that the [00:38:00] irritable mood is chronic and pervasive in between mood episodes. And so that’s a huge indicator. As soon as we hear the parent talking about the child’s remorse, we start thinking, we’ve got to dig in here and figure out which one we’re seeing.
Dr. Sharp: I got you. With all the overlap with all the diagnoses we mentioned; DMDD, GAD, ODD, ADHD, depression, all these things; do we have anything that you would call defining or pathognomic features of pediatric bipolar at this point? Anything where you could say, oh yeah, if this is present, it’s basically a guarantee we’ve got pediatric bipolar, or if these three things are present at the same time, basically it means pediatric bipolar.
Elizabeth: That’s an interesting question. No, not [00:39:00] to my knowledge. I would say that there’s a phenotype of bipolar that was recently identified in the glacial movement of academia, it’s recent. It was 2005, 2006 that this new phenotype was identified. It does have a biomarker.
Unlike the other diagnoses in the DSM, it requires every single criteria must be met in order for the diagnosis to be given. It’s not 5/8 or that sort of thing. Every single one. One of them is a biomarker of temperature dysregulation. And so when that is present amongst all the other symptoms, it is an identifier that [00:40:00] says we can rule out traditional bipolar. We can rule out the others because of this is present.
The interesting thing about that diagnosis is that when the temperature dysregulation is treated; two or three of the other symptoms dissipate without direct treatment because they’re being triggered by the temperature dysregulation.
Dr. Sharp: That’s fascinating. I assume that these kids are running hot or cold?
Elizabeth: It can be either, although more commonly it’s hot and it’s not. The issue is that their body is not expelling normally generated heat, and so it’s holding onto it. And so there’s a differential between proximal and distal body temperature that’s outside of the range of expected.
It’s very easy for parents to identify based on the [00:41:00] characteristics that go along with it. There’s a slightly more complicated way that it’s identified from a scientific and research standpoint, but we could spend hours on that as well.
Currently, it’s being called thermoregulatory sleep dysregulation disorder. Years ago, it got the moniker fear of harm because that was one of its hallmark symptoms, which was exaggerated and extreme fear response, and a misfiring of the fight or flight response when it was not needed based on environmental stimuli. And so that moniker just stuck. And so folks call it FOH for short. We could spend hours and hours on that one.
Dr. Sharp: I have to look into that more deeply. I have not heard of that before, so check it out. Let’s [00:42:00] transition to the evaluation process. I think people are anxious to hear about this. I’m curious from your perspective, what each stage of the evaluation process looks like.
We can start at the interview and then talk about actual assessment tools and go from there. What are best practices here in the interview portion?
Elizabeth: We are using a lot of assessments to look at. One of the things that we do is we always use the Child Bipolar Questionnaire and the Jeannie and Jeffrey Illustrated Interview for Children. Both of them were developed by Dr. Papolos and his team at the Juvenile Bipolar Research Foundation.
Both of these are taken at home. The Child Bipolar Questionnaire is done by the parents and then the Jeannie and Jeffrey Illustrated Interview for Children [00:43:00] is, I don’t know if it’s still the only, but when it was developed, it was the only assessment that was designed for children to take without it being administered by a professional.
And so it’s all done in cartoons. The answers are Likert scale. And so the child can see a representation of what that symptom might look like or feel like when they’re experiencing it, and then they’re able to rate it based on its level of severity, which gives the clinician who’s reviewing it insight into the degree to which it’s disruptive.
We also always encourage people to use the Pittsburgh Sleep Questionnaire because that gives information on disrupted sleep patterns that are often missed in kids who have bipolar. Because parents will [00:44:00] think that their child just doesn’t want to go to bed when in reality they’re experiencing late day mania that’s disrupting their ability to fall asleep. So we do encourage the use of the Pittsburgh Sleep Questionnaire in addition to the Child Bipolar Questionnaire and the Jeannie and Jeffrey.
In the clinical interview, we’re looking for clarification on a lot of the questions that have been answered, looking to dig deeper. A lot of times, with sleep, parents will say, oh, no, my child sleeps, they sleep fine. What they’re not realizing is that their child isn’t getting quality sleep; that mania can disrupt the sleep cycles.
And so we’ll say, okay, why don’t you try tracking your sleep with a Fitbit or the Withings company has a great map that goes [00:45:00] between the box spring in the mattress that will record data on REM sleep and all the different sleep cycles, and then they look at that and they say, oh, my child isn’t getting any restorative sleep and so they’re realizing that that’s also a factor.
And so we’re looking at what assumptions are the parents making about the behavior to strip that away. Parents will start talking to us and will say, he didn’t want to do such and such and so he responded this way. And we say, don’t tell us what you think was the motivation, don’t tell us what how you are interpreting what he did or said, just give us the facts.
I always joke it’s like that old Dragnet tv show Just the facts, ma’am. We want to pull away all those levels of interpretation [00:46:00] as we’re gathering data just like detectives. We go back very far into the child’s history. We review pediatric records, sometimes going back to birth. We review emails that go back and forth between the school and the parents. We start noticing diurnal patterns in the mood fluctuations.
And when we’re seeing that there’s every afternoon at 3.25, this kid is starting to become dysregulated, we’re looking at what are those diurnal patterns telling us about their mood cycling and so we’re able to identify when they’re rapid cycling by looking at those patterns.
And so it’s a lot of digging in and being a detective, and then once we have the facts, then we say, okay, parents, talk to us about what [00:47:00] your gut is telling you about how your child is doing. Parents very often at that point will start talking about the emotions that they have when they’re witnessing their child.
And if we think of parents as amateur clinicians, that’s their instinct telling them what their child is experiencing. And so then we’re able to start labeling the sadness, the frustration, the loss of interest and things that they loved, the hyperfixations, what we call mission mode. It starts to come out when we are then able to look at what are the parent’s instincts and what are the facts.
Dr. Sharp: I like the distinction between parent’s instincts and the facts. It [00:48:00] reminds me of how complicated this whole process is because you’re filtering all this information most of the time through two layers of subjectivity; there’s the parent’s interpretation and perception of the kid’s behaviors and memory for that for that matter, and then that gets filtered through the clinician’s perceptions and assumptions and how they ask the questions and what information they’re eliciting and so forth. It’s a complicated process. I’m just acknowledging that.
Elizabeth: It is. One of the things that we’ve been able to do that it’s actually quite helpful is, because we work with such a wide community of families, we’re able to collect what we like to call community sourced symptom descriptions. And so we have lists of what do these [00:49:00] symptoms look like when a kid is experiencing it and what is it?
Because across the board, I always say the details are different, but the themes are exactly the same from one family to another, and once you start being able to identify those common themes, we have these lists that parents have helped us compile of what it actually looks like when their child is dysregulated with either a manic, depressive or mixed mood episode.
Parents usually, after looking at that, say to us, it was at that moment that I thought, oh, this isn’t just my child; other people have seen this before. Because when they go in with their anecdotes, very often psychiatrists in particular will not connect those anecdotes to [00:50:00] these symptoms that are in the DSM that were written for adults, and so our community sourced criteria is that bridge.
Dr. Sharp: Right. I know we’ve touched on two of those, but I would love to highlight any of those little anecdotes that you can think of, off the top of your head, things that we may miss or overlook, not be aware of, that y’all are seeing or hearing over and over.
Elizabeth: One thing that happens a lot is when the parents are engaging in that clinical interview, and then the children are brought in, the children will frequently deny everything that the parents have said. When they filled out the Jeannie and Jeffrey, and they did it themselves and they gave their answers, they will deny that any of it occurs.
There’s a real refusal to be able to [00:51:00] acknowledge that they’re experiencing the problems at all in the first place. We also find, just pulling something up here because we get a lot of reports from families and we document it all and keep track so I’m looking at some of it now to find a good one to share.
Dr. Sharp: Of course. I think it’s these real-life examples that bring things to life and animate these symptoms or signs.
Elizabeth: There was the experience that is somewhat common of a child being diagnosed with ADHD and then given a stimulant, and then they don’t sleep for days. One mother said to us, we followed the doctor’s instructions; we went to the doctor, we said, our child is [00:52:00] having trouble sitting still in class, is being disruptive at school, is having trouble following instructions at home. The pediatrician said, oh this is ADHD, gave a stimulant, and then the child did not sleep for three days and the mother was up the entire time and was saying a child with ADHD doesn’t respond this way to this medication.
I have one report from a gentleman who’s now an adult who describes when he was first given those stimulant medications as a child, he ran out into the street almost immediately. He lived in a city, he ran out to the street and his parents had to chase him for close to an hour before they were able to catch him because he was waving in and out of traffic, he came home and didn’t sleep for two [00:53:00] days.
So those are big clues. Kids with bipolar are, as I said before, very empathetic most of the time, so they’re very overly sensitive. They can’t handle feeling excluded, feeling as though they don’t belong. They become extremely sensitive to anything that could be perceived as criticism.
Even if it’s intended as constructive criticism, it’s a real blow to their sense of self, their sense of their self-efficacy, their sense of self-confidence and competence. They have tantrums and outbursts that last much longer than a typical childhood tantrum.
A neurotypical child has a tantrum that lasts for 15, 20 minutes. They pull [00:54:00] themselves together. They move on with their day. A child with bipolar disorder can have tantrums that last 90 minutes, 120 minutes. I’ve heard cases where they’ve lasted for four hours.
Commonly, it involves destructive behaviors either towards themselves, towards other people, towards property. Kids will go into their rooms, have tantrums, throw things, knock over bookshelves and be inconsolable.
That’s one of the other pieces that when you have kids who are neurotypical or maybe have ADHD or unipolar depression, when they experience distress, for the most part, there’s always going to be exceptions, but they want to be comforted. They want that sense of security that comes from comfort from their parents.
A child with bipolar disorder may fall [00:55:00] down and hurt themselves, and when a parent instinct is to comfort, that bipolar child is going to start screaming and yelling that it was the parents fault, that they were walking too fast, and that was why they fell down and they were walking too fast because the parent was walking too fast and they couldn’t keep up.
And why weren’t you paying attention? And the parent is thinking, I was right here next to you the whole time. There’s an inability to take responsibility for or accept the fact that they just fell, they tripped, there was something. There’s a blame that happens, there’s an aggressiveness, there’s a rejection of comfort, and there’s an extended tantrum that is, to the parent, immediately recognizable as out of the ordinary.
Whether they have other children or not, but most especially if they have other children, they’re able to say, this isn’t how my other children handle disappointment. This isn’t [00:56:00] how other kids handle stubbing their toe. This isn’t how other kids handle being told no. No is a huge trigger for kids with bipolar and parents may be baffled as to why their child is reacting in such an extreme manner to simply being told, no, we’re not going to have pizza for dinner.
It has to do with some of those neurodevelopmental issues that kids with bipolar have where their executive functioning skills are not developed to the point where one would expect them to be, based on their age, and so their planning, their processing and their ability to adopt and change gears, and make a different plan in their head becomes disrupted. Traditionally, the response is one that is aggressive.
Dr. Sharp: Sure. [00:57:00] So much information to take in here. This is great. Lots to think about. I would like to talk with you about the part of this process where you are talking with families about the diagnosis and maybe delivering that diagnosis for the first time, managing any emotions that might come up around that, how do you approach that process?
Elizabeth: What we do in our diagnostic consultation process is we do this deep dive into the child’s history, the family’s history, family dynamics, school, everything usually takes a few months. On average, it takes two to four months to do a complete review and a whole series of clinical interviews with the parents, with the kid.
[00:58:00] And then in the end, we say, look, this is the differential diagnosis and we go through; this is why we don’t think it’s this, this is why we think that this is going to be the most likely diagnosis. By the time we’ve gotten to that point, and we don’t look for bipolar, we look for the accurate diagnosis. Sometimes we’re saying to parents, it’s not bipolar it’s something else.But by the time we get there, parents have had the entire process of the assessment over the course of months to get used to the idea. So very often what we see is relief in families, that there’s finally an answer that makes sense.
One parent that we worked with said that she kept taking her son to [00:59:00] doctors and psychologists and social workers who kept telling her it was, ODD or DMDD. She kept going back. Smart lady, with the criteria from the DSM printed out and saying, but he doesn’t have this and he doesn’t have this, how can it be this diagnosis if he doesn’t have these things?
Finally, there was a psychologist who said, I think this may be bipolar. It was only then that the family said, oh, now it makes sense. And so that’s really the predominant experience that we have, which is families that say, thank goodness we have an answer that finally makes sense, where all of these different things now fit under one umbrella. It’s a relief for them.
And then what we do is our relationship with [01:00:00] them doesn’t end just because that process has concluded. Those families become part of our support groups, those families become part of our community of networking with other parents.
We have books that we got them on our website or on Amazon that actually go through the bipolar diagnosis for kids. It has checklists. Sometimes we have families who take them and they go through, they fill in all the notes sections, they check things off, and then they take those to their providers and they say, look at this, here’s all the criteria and here’s what my kid is manifesting at home.
And so they’re then able to get that research batch treatment that we document in the book as well. There’s a [01:01:00] tremendous relief that maybe now we’ve found the thing that is going to help. We have this system that’s based on the idea that we’re going to try kids out on all these medications. The language that’s used is they have to fail on those medications before it can be upgraded to a bipolar diagnosis.
Doctors in systems, they say, I can’t prescribe a mood stabilizer until we’ve already tried Prozac and Zoloft. We can’t prescribe Lithium or Lamotrigine or Oxcarbazepine until we’ve tried the stimulants and the SSRIs, all of which make bipolar disorder symptoms worse, not better.
And so we go in there with research that shows that this is how symptoms present in kids, these are the [01:02:00] medications that are supposed to be used to treat these symptoms in bipolar disorder. Oftentimes, the proof is in the pudding; they get started on a mood stabilizer, and suddenly, they’re doing better.
And that’s another one of Dr. Popper’s 15 criteria for differentiating ADHD and bipolar is Lithium doesn’t do anything for ADHD. It does a lot for bipolar. And so sometimes we have to try the cure to see if that’s the illness.
Dr. Sharp: Sure. I think that’s a really nice segue into a full discussion of treatment options. You’ve mentioned a few, but let’s talk through what kind of recommendations you’re making for families.
Elizabeth: We don’t make medication recommendations. First of all, we talk about treatment as a three-legged stool. There’s [01:03:00] medication, there’s psychotherapy, and there’s lifestyle interventions. Those three things are all interdependent.
You can’t just take a medication and expect that’s going to solve everything, you can’t go to therapy and not practice any of those principles outside of the therapeutic setting and expect things to get better, and you can’t just change what time your kid goes to bed at night and think that’s going to solve a mental illness. So we talk about medication, therapy and lifestyle changes as being integrated with one another and essential to one another for success.
We go so far as to share research backed data on what medications are most effective and to state the obvious, which is that antidepressants work for unipolar depression, mood [01:04:00] stabilizers work to stabilize mood in bipolar disorder. And so that’s what they’re used for in adults, that’s what they’re used for in kids.
We do, in our book, have a list of the commonly used mood stabilizers and the degree to which psychiatrists who specialize in this have preferences. We focus on the psychotherapeutic aspects and the lifestyle interventions.
From a psychotherapeutic standpoint, we discourage a lot of things that most counselors and teachers rely on as tools. We do not recommend the use of reward systems or token economies for kids who have mood disorders, most [01:05:00] especially bipolar because it creates.
Dr. Rosalie Greenberg has a great section in her book on this, where she talks about the amount of anxiety that is provoked in a bipolar child when they are offered a reward for something that they have difficulty doing because just as motivation can be a way to overcome inattention, it works in the opposite direction.
Lacking motivation, there’s no way to overcome that, there’s no way to conjure or tap dance your way around something that a kid with bipolar doesn’t want to do. They cannot mount the motivation to accomplish it. And so if you’re offering them a reward for doing something that they don’t think they can do, it creates a cycle of perceived [01:06:00] failure.
And so most parents will come to us and say, I offered this great reward, why did they sabotage themselves? I wanted to give it to them and then I couldn’t. It’s because they couldn’t get there. And so failure up front is preferable to failure down the line once you’ve exhausted all of your energy on trying. So we discourage that. No reward chats, no token economies. None of that is for kids.
We discourage the use of CBT until they’re stable and have been stable for a while. The reasoning behind that is that kids who have bipolar are often quite bright. In fact, that’s another one of Dr. Popper’s differentiation criteria that kids with bipolar are often gifted intellectually, and they were in some artistic [01:07:00] way.
And so one of the things that happens with kids who have these disorders when they’re engaging in CBT is that they are able to understand the concepts that are being presented to them beautifully. They understand them quickly. They’re able to explain them back. They’re able to describe circumstances in which they can be used, but when they become dysregulated, their limbic system takes over and they cannot access any of that rational information and so they cannot implement any of those CBT strategies.
It’s quite frustrating to look at IEPs and all these other things that say child will use these strategies when they become frustrated. No, their limbic system is taken over. They are a wild animal trapped in a cage. You’re never going to get them to be able to [01:08:00] use this breathing technique that you taught them when they were regulated, when they’re dysregulated.
And so very often, over a period of time, as the child demonstrates their intellectual capacity to understand process and share back these strategies, but their inability to implement them when they’re needed, it’s perceived as resistance, as being an intentional choice and then they wind up going down that path of the parents being told they don’t want to get better.
And so we encourage a focus on DBT strategies that are teaching them mindfulness or teaching them to identify what’s happening in their body; what are their triggers? If you identify when you are regulated, that being hungry or tired is a trigger for [01:09:00] a mood disruption, then you can teach how do I identify the fact that I am starting to get hungry so that you can intervene before the dysregulation occurs.
We do encourage the use of DBT and mindfulness in terms of identifying how they’re feeling, cultivating and developing insight before you’re worrying about implementing skill development. And that’s pretty much across the board for kids with bipolar.
Dr. Sharp: That makes sense. You talked about lifestyle changes or support, I would love to touch on that before we wrap up because it’s important and it’s something a little different than medication, which is, for better or for worse, pretty [01:10:00] well-known, I suppose. What about the lifestyle side?
Elizabeth: The lifestyle side of it comes into recognizing that part of bipolar disorder is difficulty with sleep and so developing sleep hygiene. Sometimes, we have to do full circadian rhythm resets for kids because it’s not uncommon for them to develop night-day reversals.
We have a book also called Managing Temperature and Sleep Disruptions. We go through that on, these are strategies that you can use to reset circadian rhythms so that you are able to go to sleep at night at the time that you’re supposed to so that you can stay asleep and have restful sleep so that you can wake up in the morning when it’s time to wake up and feel [01:11:00] refreshed and be ready to start the day.
We do talk also about temperature regulation because of this particular phenotype of bipolar disorder. We do a lot around managing temperature disruptions and how to proactively avoid the temperature dysregulation that triggers some of these symptoms.
We also are starting to talk about food and diet. There’s a lot of research happening right now in the world of adult bipolar that is reconceptualizing bipolar disorder, not as a mood disorder, but as an energy disorder, and looking at the disruptions that go along with bipolar disorder episodes as originating on a cellular level.
There are a lot of studies looking at [01:12:00] the use of metabolic therapies to treat bipolar disorder. In fact, we are starting one shortly in conjunction with the Baszucki Group who’s funding. It’s a study looking at the use of the ketogenic diet in children to treat bipolar disorder.
And so diet is also another part of it, whether you want to go full keto or not, moving your child away from a standard American diet with highly processed foods, lots of dyes and all sorts of things that our grandmothers wouldn’t have recognized on a label, that’s also important as well. Making sure that they’re controlling sugar, controlling other things in their diet that may be creating yet another obstacle that they don’t need to have to face on a day to day [01:13:00] basis in terms of regulating their mood.
Dr. Sharp: Sure. These things are all important. I had a pretty wide ranging discussion about this and any number of these things we could go really deep on, but I just appreciate you being willing to shine a light on something that’s pretty fraught and misunderstood. There’s complex history in the mental health world. I think there’s so many things that folks can take away from this conversation and actually put into practice in their businesses.
Elizabeth: I think one of the most important things that we emphasize over and over again is that because there are these pendulum swings for so long, there tend to be camps that get set up of no kids can’t have bipolar. Yes, kids have bipolar.
We want to bring that pendulum back to the middle and say [01:14:00] whether or not they have bipolar is only relevant insofar as we want the right diagnosis. The only way that you can rule out bipolar is by being willing to consider it in your differential diagnosis.
Dr. Sharp: It’s a great point. I think not many of us probably start from that place, it’s easy to rule it out. There’s so much good information here. If people want to learn more about the organization or get more resources, what’s the best way to do that?
Elizabeth: They can find us at www.cmhrc.org, that stands for Children’s Mental Health Resource Center. They can also reach us by just emailing info@cmhrc.org. [01:15:00] We have a lot of services for providers, for families.
We have professional discussion groups where we get interdisciplinary groups of providers together to discuss bipolar and its presentation in children. That’s a 6 session series that we do with providers. We have parenting classes where we teach parenting strategies that are effective when you’re dealing with kids who have mental illness. That’s a 9 session series that we do.
We have school advocacy where we work with schools in order to make sure that children’s mental health needs are being met, not just in terms of generic mental health, but in terms of how to make accommodations for kids who have mental illnesses and need to be able to succeed in school. As I said, we work to better the entire system so that families and kids can get to a place of stability [01:16:00] sooner rather than later.
Dr. Sharp: It sounds amazing. So many cool things that y’all are up to. We’ll definitely put all that in the show notes. Once again, thanks for being here, Elizabeth. This is a really cool conversation and maybe our paths will cross again here sometime soon.
Elizabeth: I look forward to that. I’ll send you a webinar series that we did with Dr. Papolos on the phenotype of bipolar referred to as FOH. You can take a look at it. It goes through the history of the development of the diagnosis as well as the development of its treatments.
Dr. Sharp: That’d be great. I really appreciate it. Thanks again for being here.
Elizabeth: Thank you for having me.
Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode, always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the [01:17:00] episode will be listed in the show notes so make sure to check those out.
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