17 AUGUST 2002: THE KIDS
ARE NOT ALRIGHT.
Cover story for Time
Magazine this week:
Young and Bipolar
Once called manic depression,
the disorder afflicted adults. Now it’s striking
kids. Why?
BY JEFF KLUGER AND SORA
SONG
It wasn’t every day that
Patricia Torres raced down the streets of Miami at 70
m.p.h. But then it wasn’t
every day that her daughter Nicole Cabezas
hallucinated wildly, trying
to jump out of the car, pulling off her clothes and
ranting that people were
following her, so this seemed like a pretty good time
to hurry. Nicole, 16, had
been having problems for a while nowever since she
was 14 and began closeting
herself in her bedroom, incapable of socializing or
doing her schoolwork, and
contemplating suicide.
The past few months had been
different, though, with the depression lifting and
an odd state of high energy
taking its place. Nicole’s thoughts raced; her
speech was fragmented. She
went without sleep for days at a time and felt none
the worse for it. She began
to suspect that her friends were using her, but that
was understandable, she
guessed, since they no doubt envied her profound gifts.
“I was the center of the
universe,” she says quietly today. “I was the chosen
one.”
Finally, when the chosen
one was struck by violent delusionsthe belief that she
had telekinetic powers,
that she could change the colors of objects at
willTorres decided it was
time to take Nicole to the hospital. Emergency-room
doctors took one look at
the thrashing teenager, strapped her to a gurney and
began administering sedatives.
She spent two weeks in the hospital as the
doctors monitored her shifting
moods, adjusted her meds and talked to her and
her parents about her descent
into madness. Finally, she was released with a
therapy plan and a cocktail
of drugs. Six months later, doctors at last reached
a diagnosis: she was suffering
from bipolar disorder.
While emotional turmoil is
part of being a teenager, Nicole Cabezas is among a
growing cohort of kids whose
unsteady psyches do not simply rise and fall now
and then but whipsaw violently
from one extreme to another. Bipolar
disorderonce known as manic
depression, always known as a ferocious mental
illnessseems to be showing
up in children at an increasing rate, and that has
taken a lot of mental-health
professionals by surprise. The illness until
recently was thought of
as the rare province of luckless adultsthe
overachieving businessman
given to sullen lows and impulsive highs; the
underachieving uncle with
the mysterious moods and the drinking problem; the
tireless supermom who suddenly
takes to her room, pulls the shades and weeps in
shadows for months at a
time.
But bipolar disorder isn’t
nearly so selective. As doctors look deeper into the
condition and begin to understand
its underlying causes, they are coming to the
unsettling conclusion that
large numbers of teens and children are suffering
from it as well. The National
Depressive and Manic-Depressive Association
gathered in Orlando, Fla.,
last week for its annual meeting, as doctors and
therapists face a daunting
task. Although the official tally of Americans
suffering from bipolar disorder
seems to be holding steadyat about 2.3 million,
striking men and women equallythe
average age of onset has fallen in a single
generation from the early
30s to the late teens.
And that number doesn’t include
kids under 18. Diagnosing the condition at very
young ages is new and controversial,
but experts estimate that an additional 1
million preteens and children
in the U.S. may suffer from the early stages of
bipolar disorder. Moreover,
when adult bipolars are interviewed, nearly half
report that their first
manic episode occurred before age 21; 1 in 5 says it
occurred in childhood. “We
don’t have the exact numbers yet,” says Dr. Robert
Hirschfeld, head of the
psychiatry department at the University of Texas in
Galveston, “except we know
it’s there, and it’s underdiagnosed.”
If he’s right, it’s an important
warning sign for parents and doctors, since
bipolar disorder is not
an illness that can be allowed to go untreated. Victims
have an alcoholism and drug-abuse
rate triple that of the rest of the population
and a suicide rate that
may approach 20%. They often suffer for a decade before
their condition is diagnosed,
and for years more before it is properly treated.
“If you don’t catch it early
on,” says Dr. Demitri Papolos, research director of
the Juvenile Bipolar Research
Foundation and co-author of The Bipolar Child
(Broadway Books, 1999),
“it gets worse, like a tumor.” Heaping this torment on
an adult is bad enough;
loading it on a child is tragic.
Determining why the age-of-onset
figures are in free fall is attracting a lot of
research attention. Some
experts believe that kids are being tipped into bipolar
disorder by family and
school stress, recreational-drug use and perhaps
even a
collection
of genes that express themselves more aggressively in each
generation.
Others
argue that the actual number of sick kids hasn’t changed at
all; instead, we’ve just
got better at diagnosing the illness. If that’s the
case, it’s still significant,
because it means that those children have gone for
years without receiving
treatment for their illness, or worse, have been
medicated for the wrong
illness. Regardless of the cause, plenty of kids are
suffering needlessly. “At
least half the people who have this disorder don’t get
treated,” says Dr. Terrence
Ketter, director of the bipolar disorder clinic at
Stanford University.
Yet scientists are making
progress against the disease. Genetic researchers are
combing through gene after
gene on chromosomes that appear to be related to the
condition and may offer
targets for drug development. Pharmacologists are
perfecting combinations
of new drugs that are increasingly capable of leveling
the manic peaks and lifting
the disabling lows. Behavioral and cognitive
psychologists are developing
new therapies and family-based programs that get
the derailed brain back
on track and keep it there. “We did a good job for a
long time of putting a lid
on [the disorder],” says Dr. Paul Keck, vice chairman
of research at the University
of Cincinnati College of Medicine. “Now the goal
is to completely eradicate
the symptoms.”
For Lynne Broman, 37, of
Los Angeles, just taming the disorder would be more
than enough. A single mom,
she is raising three children, two of whomKyle, 5,
and Mary Emily, 2are bipolar.
At the moment it’s Kyle who is causing the most
trouble. He has been expelled
from six preschools and two day-care centers in
his short academic career
and has made a shambles of their once tidy home. Kyle
was hospitalized for violent
outbursts at age 4 and still has periods when he
goes almost completely feral.
He once threw a butcher knife at his mother,
nearly striking her before
she ducked out of the way. “That day started out
fine,” Broman says, “but
he turned on me like a rabid dog.”
Until quite recently, a child
who behaved like this would have been presumed to
have either Attention-Deficit/Hyperactivity
Disorder (ADHD) or oppositional
defiant disorder. Bipolar
would not even have been considered. And with good
reason: the classic bipolar
profile, at least as it appears in adults, is almost
never seen in kids.
Most bipolar adults move
back and forth between depressions and highs in cycles
that can stretch over months.
During the depressive phase, they experience
hopelessness, loss of interest
in work and family, and loss of libidothe same
symptoms as in major (or
unipolar) depression, with which bipolar is often
confused. The depressive
curtain can descend with no apparent cause or can be
triggered by a traumatic
event such as an accident, illness or the loss of a
job.
But in bipolar disorder,
there is also a manic phase. It usually begins with a
sort of caffeinated, can-do
buzz. “Sometimes the patients find the highs
pleasant,” says Dr. Joseph
Calabrese, director of the mood-disorders program at
Case Western University
in Cleveland. As the emotional engine revs higher,
however, that energy can
become too much. Bipolars quickly grow aggressive and
impulsive. They become grandiose,
picking fights, driving too fast, engaging in
indiscriminate sex, spending
money wildly. They may ultimately become
delusionally mad.
With kids, things aren’t
nearly so clear. Most children with the condition are
ultra-rapid cyclers, flitting
back and forth among mood states several times a
day. Papolos, who co-wrote
The Bipolar Child, studied 300 bipolar kids ages 4
through 18, and he believes
he has spotted a characteristic pattern. In the
morning, bipolar children
are more difficult to rouse than the average child.
They resist getting up,
getting dressed, heading to school. They are either
irritable, with a tendency
to snap and gripe, or sullen and withdrawn.
By midday, the darkness lifts,
and bipolar children enjoy a few clear hours,
enabling them to focus and
take part in school. But by 3 or 4 p.m., Papolos
warns, “the rocket thrusters
go off,” and the kids become wild, wired, euphoric
in a giddy and strained
way. They laugh too loudly when they find something
funny and go on long after
the joke is over. Their play has a flailing,
aggressive quality to it.
They may make up stories or insist they have
superhuman abilities. They
resist all efforts to settle them and throw tantrums
if their needs are denied.
Such wildness often continues deep into the
nightwhich accounts in
part for the difficulty they have waking up in the
morning. “They’re like Dr.
Jekyll and Mr. Hyde,” says Papolos, “which is how
their parents describe them.”
Preverbal toddlers and infants
cannot manifest the disorder so clearly, and
there is no agreement about
whether they exhibit any symptoms at all. However,
many parents of a bipolar
say they noticed something off about their baby almost
from birth, reporting that
he or she was unusually fidgety or difficult to
soothe. Broman insists she
knew her son Kyle was bipolar even when he was in the
womb. “This child never
slept inside,” she says. “He was active 24 hours a day.”
For Broman, making that diagnosis
may not have been hard since the condition, as
Ketter puts it, “is hugely
familial.” Broman herself is bipolar, though her
illness was not diagnosed
until adulthood. Children with one bipolar parent have
a 10% to 30% chance of developing
the condition; a bipolar sibling means a 20%
risk; if both parents are
bipolar, the danger rises as high as 75%. About 90% of
bipolars have at least one
close relative with a mood disorder.
For all that, when the disorder
does appear in a child, the diagnosis is often
wrong. ADHD is the likeliest
first call, if only because some of the manic
symptoms fit. The treatment
of choice for ADHD is Ritalin, a stimulant that has
the paradoxical ability
to calm overactive kids. But giving Ritalin to a bipolar
child can deepen an existing
cycle or trigger one anew. Brandon Kent, a
9-year-old from La Vernia,
Texas, in whom ADHD was diagnosed in kindergarten
(they did not yet know he
was bipolar), took Ritalin and paid the price. “It
sent him into depression,”
says his mother Debbie Kent. “Within a couple of
months, he was flat on the
couch and wouldn’t move.” By some estimates, up to
15% of children thought
to have ADHD may actually be bipolar.
Similar misdiagnoses are
made when parents and doctors observe symptoms of the
low phase of the bipolar
cycle and conclude that a kid is suffering from simple
depression. Treat such a
child with antidepressants like Prozac, however, and
the rejiggering of brain
chemistry may trigger mania. Some researchers believe
that nearly half of all
children thought to be depressed may really be bipolar.
For most kids, the consequences
of not identifying the illness can be severe,
since the bipolar steamroller
gets worse as children get older. Though they tend
to be verbally skilled and
are often creative, bipolars find school difficult
because the background noise
of the disorder makes it hard for them to master
such executive functions
as organizing, planning and thinking problems through.
The most serious symptoms
may appear when kids reach age 8, just when the
academic challenge of grade
school starts to be felt. “They’re being asked to do
things that they’re very
poor at,” Papolos says, “and it’s a blow to their
self-esteem.” If school
doesn’t kick the disorder into overdrive, puberty often
does, with its rush of hormones
that rattle even the steadiest preteen mind.
Still, all these natural
stressors and the new awareness of the disorder may not
be enough to account for
the explosion of juvenile bipolar cases. Some
scientists fear that there
may be something in the environment or in modern
lifestyles that is driving
into a bipolar state children and teens who might
otherwise escape the condition.
One of the biggest risk factors
is drugs. People with a genetic predisposition
to bipolar disorders live
on an unstable emotional fault line. Jar things too
much with a lot of recreational
chemistry, and the whole foundation can break
away, especially when the
drugs of choice are cocaine, amphetamines or other
stimulants. “We do think
that use of stimulating drugs is playing a part in
lowering the age of onset,”
says Hirschfeld.
Stress too can light the
bipolar fuse. Many latent emotional disorders, from
depression to alcoholism
to anxiety conditions, are precipitated by life events
such as divorce or death
or even a happy rite of passage like starting college.
And bipolar disorder can
also be set off this way. “Most of us do not think
environmental stress causes
the disorder,” says Dr. Michael Gitlin, head of the
mood-disorders clinic at
UCLA. “But it can trigger it in people who are already
vulnerable.”
A decidedly more complicated
explanation may be gene penetrance; not every
generation of a family susceptible
to an illness develops it in the same way.
Often, later generations
suffer worse than earlier ones because of a genetic
mechanism known as trinucleotide
repeat expansion. Defective sequences of genes
may grow longer each time
they are inherited, making it likelier that
descendants will come down
with the illness. This phenomenon plays a role in
Huntington’s disease and
could be involved in bipolar. “There’s a stepwise
genetic dose that can increase
the risk,” theorizes Ketter.
The first part of determining
how those genes work is figuring out where they
are hiding, and the National
Institute of Mental Health is looking hard.
Investigators at eight research
centers around the country, working under an
nimh grant, are studying
the genomes of 500 families with a bipolar history to
see what genetic quirks
they share. So far, at least 10 of the 46 human
chromosomes have shown irregularities
that may be linked with the condition. The
most interesting is chromosome
22, which has been implicated not only in bipolar
disorder but also in Schizophrenia
and a little-known condition called
Velo-Cardio-Facial syndrome,
which has Schizophrenia links as well. The seeming
relatedness of disorders
that so prominently feature delusions has not been lost
on researchers, though with
so much still unknown about chromosome 22to say
nothing of the other nine
tentatively linked with bipolarno one is ready to
draw any conclusions. “There
are probably genetic variants that cut across
multiple systems in the
brain,” says Dr. John Kelsoe, psychiatric geneticist at
the University of California,
San Diego.
While this wealth of chromosomal
clues makes fascinating work for geneticists,
it promises little for bipolar
sufferers, at least for the moment. What they
want is reliefand fast.
Thanks to rapid advances in pharmacology, they are
finally getting it. In fact,
children on a properly balanced drug regimen
supplemented with the right
kind of therapy can probably go on to lead normal
lives.
For decades, the only drug
for bipolar patientsand one that is still an
important part of the pharmacological
arsenalwas lithium. It works by
regulating a number of neurotransmitters,
including dopamine and norepinephrine,
as well as protein kinase
C, a family of chemicals that help determine the
neurotransmitter amounts
that nerve cells release. With its hands on so many of
the brain’s chemical levers,
lithium can help bring bipolars back to
equilibrium. For 30% of
sufferers, however, it has no effect at all; for others,
the side effects are intolerable.
“It’s still a miraculous drug,” says Keck.
“But some people simply
don’t respond to it enough.”
New drugs are stepping into
the breach. Rather than rely on the imprecise relief
that a single drug like
lithium provides, contemporary chemists are
investigating a battery
of other medications. Depakote, an anticonvulsant
developed to calm the storms
of epilepsy, was found to have a similarly soothing
effect on bipolar cycling,
and it was approved in 1995 to treat that condition
too. The success of one
anticonvulsant prompted researchers to look at others,
and in the past five years,
severalincluding Lamictal, Tegretol, Trileptal and
Topamaxhave been put to
use.
Anticonvulsants are not the
only drugs being reformulated. Also showing promise
are the atypical antipsychotics.
The best-known antipsychotic, Thorazine, is a
comparatively crude preparation
that controls delusions by blocking dopamine
receptors. In the process,
it also causes weight gain, mood flattening and other
side effects. Atypical antipsychotics
work more precisely, manipulating both
dopamine and serotonin and
suppressing symptoms without causing so many
associated problems. There
are numerous atypical antipsychotics out there,
including Zyprexa, Risperdal
and Haldol, and many are being used to good effect
on bipolar patients.
For any bipolar, the sheer
number of drug options is a real boon, as what works
for one patient will not
necessarily work for another. When Brandon Kent, the
9-year-old Texas boy, started
taking Depakote and Risperdal, his body began to
swell. Then he switched
to Topamax, which made him lethargic. Eventually he was
put on a mix of Tegretol
and Risperdal, which have stabilized him with few side
effects. Kyle Broman in
Los Angeles is having a harder time but has grown calmer
on a combination of Risperdal
and Celexa, an antidepressant that for now at
least does not appear to
be flipping him into mania.
But drugs go only so far.
Just as important is what comes after medication:
therapies and home regimens
designed to help patients and their families cope
with the disorder. Early
last year the National Institute of Mental Health
launched a five-year, $22
million study, the Systematic Treatment Enhancement
Program for Bipolar Disorder
(step-bd) to refine bipolar therapies. Some 2,300
volunteers are participating
in the program, and enrollment is expected to reach
5,000. Of all the treatments
the STEP-BDdoctors are studying, the most basic and
perhaps the most important
one for children and teens involves lifestyle
management.
>From infancy, kids can easily
be unsettled by disruptions in their circadian
cycles, as parents of newborns
and toddlers learn whenever they try to change
nap times. Bipolars, regardless
of age, are also reactive to fluctuating
schedules; many things can
destabilize patients, but Keck believes that sleep
deprivation and time-zone
changes are the most upsetting.
For this reason, parents
of bipolar kids are urged to enforce sleep schedules
firmly and consistently.
Bedtime must mean bedtime, and morning must mean
morning. While that can
be hard when an actively manic child is still throwing a
tantrum two hours after
lights-out, a combination of mood-stabilizing drugs and
an enforced routine may
even bring some of the most symptomatic kids into line.
Teens, who are expected
to do a lot more self-policing than younger children,
must take more of this responsibility
on themselves, even if that means a
no-excuses adherence to
a no-exceptions curfew.
Also important is diet. Caffeine
can be a mania trigger for bipolars, so teens
are advised to stay away
from coffee and tea. Bipolar kids of all ages must also
be careful with less conspicuously
caffeinated foods such as sodas and
chocolate. And for adolescents
and teens, staying free of alcohol and drugs is
critical. Not only is the
risk of addiction high, but treatment of the
underlying bipolar problem
is much more difficult if the patient’s mind is
clouded by recreational
chemicals.
For children old enough to
benefit, the second leg of treatment is individual
therapy, which includes
social-rhythms worklearning to balance meals, sleep,
studies and recreation.
If a triggering incident such as a divorce or death
kicked the condition off,
the doctor can help the child process that too.
The last, perhaps hardest
element of treatment is family therapy. Bipolar
disorder, like Schizophrenia,
depression and certain anxiety conditions, is
powerfully influenced by
surroundings. When an identical twin suffers from
bipolar, the other twin
has only a 65% chance of developing it too. Conversely,
adopted children with no
genetic legacy for bipolar have a 2% chance of coming
down with the condition
if they are raised in a home with one nonbiological
bipolar parent. Clearly,
something is in play besides mere genes, and that
something is environment.
Raise a child in a steady and stable home, and you
reduce the odds that the
illness will gain a toehold, which is why counselors
work hard to teach parents
and kids how to minimize family discord.
One strategy is to avoid
too much negatively expressed emotion. Tough love, for
example, is a good idea
in principle, but in some situations it can do more harm
than good, especially if
it makes kids who can’t control their behavior feel
worse about themselves.
When family arguments do break out, they need to be
conducted in a controlled
way. Psychology professor David Miklowitz of the
University of Colorado encourages
families to avoid what he calls the “three
volley,” a provocation followed
by a rejoinder, then a rebuttal. Hold the
volleys to just one or two,
and you’ll avoid some domestic breakdowns.
The most important thing
parents and siblings can do is simply to serve as the
eyes and ears of the bipolar
child. A teen in a depression can’t see the hope
beyond the gloom. A child
in a manic cycle can’t see the quiet reality behind
the giddiness. It’s up to
people whose compasses are more reliably functioning
to step in and point the
way. Says Dr. Gary Sachs, director of the Bipolar
Treatment Center at Boston’s
Massachusetts General Hospital and principal
investigator for the STEP-BDproject:
“Treatment is modeled on Homer’s Odyssey.
When Odysseus gets blown
off course, he asks the help of his crew.”
In the future, kids should
be getting yet more assistance as they sail. At the
Stanley Research Center,
in Massachusetts General Hospital, investigators are
beginning a yearlong study
of at least 10 bipolar drugs, comparing the merits of
each and the ways they can
best be combined. Others are looking at such
unconventional treatments
as omega-3 fatty acids, found in fish oil, which may
inhibit the same brain receptors
that lithium affects. Elsewhere, researchers
are running brain scans
to determine which lobes and regions are involved in
bipolar disorder and how
to target them more accurately with drugs.
Investigators also hope
to develop a blood test that will allow bipolar disorder
to be spotted as simply
as, say, high cholesterol, eliminating years of
incorrect diagnoses and
misguided treatments.
Getting all this work done
rightand getting the treatments to the kids who need
itis one of the newest
and most challenging goals of the mental-health
community. Doctors who recognize
bipolar disorder and know how to handle it are
in critically short supply.
Growing up is hard enough for children who are
bipolar. The last thing
they need is a misdiagnosis and treatment for something
they don’t have.
Reported by Dan Cray and
Jeffrey Ressner/Los Angeles, Jeanne DeQuine/Miami,
Melissa Sattley/Texas, Cristina
Scalet/New York and Maggie Sieger/Chicago
