BMPN Webinar Transcripts


The Balanced Mind Parent Network Expert Chat with Dr. Mani Pavuluri, Author of "What Works for Bipolar Kids"

July 11, 2008

Chat With Mani Pavuluri, M.D., Ph.D., FRANZCP
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Dr. Mani Pavuluri? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Summer. Watch your email for more details.

Biography

Dr. Pavuluri is an associate professor in Child Psychiatry and the Founding Director of the nationally recognized Pediatric Mood Disorders clinic and Pediatric Bipolar Research Program at the University of Illinois at Chicago. She is listed as one of the "Top Psychiatrists of America" by the Consumer's Research Council, and is a member of The Balanced Mind Parent Network's Scientific Advisory Council.


Mani Pavuluri MD   
Dear Families, I am so thrilled to be with you, and what can be more fulfilling than to be of some use in my profession in this profound way! :)

Nanci - The Balanced Mind Parent Network   
Dr. Pavuluri recently published a book for parents "What Works for Bipolar Kids" that is an excellent resource. Dr. Pavuluri, would you like to start out by telling us a little about your new book? 

Mani Pavuluri MD   
Yes I hope you like it! I wanted the book “What Works for Bipolar Kids” to be most practical, and help you with day to day struggles, in a way that you can apply for yourself, and take care of yourself as parents, as you are in it for the long haul! I want to hold your hand through this book as I talk to you! 
And it tells you about school issues, home, marriage, kids, other kids, friendships and medication and treatment and so on!  

Davanna  
Hello Dr. Pavuluri. What is the recommended dosage of Risperdal for a 5 year old? Are there drugs that you feel would be more effective? 

Mani Pavuluri MD 
Second generation antipsychotics are very effective, predictable more often than not, and quick to see if they work. For example, Risperdal at .25 mg once a day or twice a day is a good start.  

Candy   
Could you comment on some of the complementary treatments such as Co-Q-10, or other supplements such as omega-3 oils? And, how do we determine the appropriate dosages? 

Mani Pavuluri MD   
I think it is variable as to how much kids like to take or tolerate. I have used Omega oils such as Omega Brite capsules up to 4g a day on average. I don’t usually use complementary meds a lot. But I do not discourage parents from trying. I do not like that mega vitamin therapy at all, too much money for not clear results in my opinion. But some swear by it. 

AZmom   
Are there any new meds out there that look promising in treating bipolar disorder? For instance, a one a day pill that does all (i.e., treat depression, racing thoughts, up & down moods)? 

Mani Pavuluri MD   
My answer to this is so twisted! I tell my kids to pretend it is all one pill in three parts as we don’t have a single pill! I wish. Sometimes, I would like to think second generation anti-psychotics are closest to it if any; but tolerance is very high unless you give mood stabilizer along with it.   

Candy   
What is your experience with using melatonin for sleep? 

Mani Pavuluri MD   
I like it a lot as it is tried in kids for primary insomnia and was found to be safe. I use it at 2 mg to 3 mg a night dose. But it works in some and not in others. But definitely a choice!  

Nanci - The Balanced Mind Parent Network   
Lets switch topics from medications to parenting. We have quite a few questions on that subject! 

cello   
What should be a parent's first response when your child is "on a mission" (mission mode)? 

Mani Pavuluri MD   
"Honey what is it that you want? Let us figure it out!" Use a non defensive approach to try to understand, get them on your side before trying to diffuse the behavior.

Waterlily9   
Are limits and boundaries really important for smart bipolar kids? I always promoted her independence before. . .  
Mani Pavuluri MD   
I think limits and boundaries are important but all of this is grey zone. If you can let her be the butterfly and let her realize the potential while you tolerate the exploration, I say go for it! But if you are falling off the center of gravity, then there is a problem and you gently state what is hard for you and negotiate the outcome! Limit setting for the sake of limit setting is not what I suggest! Children prefer to be treated with respect. If boundaries are pushed way too much, say ‘Yikes we need to think thru this’. I mean, let them know that we need to talk and what is hard if they push you over the top.  

desperate   
My 15 yr old son has difficulty stopping talking, arguing etc. I give him the cue that he is at the point at which he needs to stop, but he just doesn't do it. I feel bad about walking away from him when he won't shut down or gets verbally aggressive. Is this common with adolescents with BPD? Any suggestions on what I can do to help him (and ME!)? 

Mani Pavuluri MD   
Wow, put on a kind mom hat for a bit, if you know you paid your dues, put on the hat of 'satisfied mom of you have done what you need to do' hat. Move on after a statement that ‘you got the point and you both know what your son is talking about, and you need to do other stuff. If he follows you incessantly, then say 'STOP" and go ahead and be tough and look after yourself. I call these steps a, b, c.  

wrenae   
What do you recommend regarding how we react to issues of aggression? We give a short time-out, and try our best not to react with our emotions (that is sure tough at times!) We do know that our daughter (age 6) doesn't want to hurt people and that it only happens at most extreme mood states. What should we do in response to these incidents? 

Mani Pavululuri MD
This is common. If it is occasional and as these kids in general are good sweet kids anyways, I would let it go. Influencing by discussing good and bad and correcting is more important than time outs. You can start fresh again after you have sorted it out i.e. usually thru dialogue and maybe taking a break after some time away from each other to think for a bit! We need to move on from bad spots and celebrate good spots! We can’t mop, mop, mop. (Like mopping the floor AFTER spilling).  

Candy 
  
I have had family members say that if the child can control his behavior for a definite time period that it is not really bipolar, for instance why can they go to grandpa' house for a week and not have any rages the whole week. How do we as parents respond to this? 

Mani Pavuluri MD   

Smile and accept the parents view. Take care of your own adolescent sense of inner self to not react and be a grown up with your parents! Kids tend to be intense with parents and not others, especially with mom. Explain a bit and then let it go. And yes, kids can be very good for example in summer camps etc. and the minute they come home, it is hell again!

AZmom   

How common are eating disorders in teens with bipolar disorder? Also, do you see more instances of low self-esteem and problems with handling parental authority in teens with BP than in teens without BP? 

Mani Pavuluri MD  
 
I see eating disorders with type 2 bipolar, associated with substance abuse and cutting arms etc. There is severe affect dysregulation with low self esteem to the extent of major depression at times. The mistake people make is treating this like depression. You need to start with mood stabilizer combination along with an antipsychotic and that seems to work better!   

Nanci - The Balanced Mind Parent Network 
  
Lets talk about diagnosis and symptoms. 

cnphess   

Chronic irritability seems to be a frequent symptom. Is this a sign of mania or depression or both? 

Mani Pavuluri MD  

Both. But it is bothersome regardless. It is sign of affect dysregulation compounded by stress whether perceived or real.  

cbrduo 
  
Do you believe there is such a condition as "medication resistant" bipolar? And if so, what other options are there to stabilize moods? 

Mani Pavuluri MD  
 
Just as in Tuberculosis treatment that involves triple therapy and quadruple therapy. It is that way, but we need to know the symptoms, types of drugs, doses, combinations to carefully orchestrate treatment and then we offer rainbow therapy to bring normalcy to life for parents and kids alike by fostering strengths.   

AZmom   

If bipolar symptoms didn't appear in a child until the early teen years, and the child has been stable on meds for a few years, do you think it's possible a child can outgrow bipolar disorder? Maybe not need the meds as an adult as they mature? Have you seen young adults able to stop the meds? 

Mani Pavuluri MD  
 
A great deal depends on parents modeling and nurturing and fostering.  Some teens can reduce meds and others have stopped and returned to taking meds. I also like to give hope and say yes! 

cnphess  
 
Does a manic response to antidepressants or stimulants indicate bipolar disorder? 

Mani Pavuluri MD   
It indicates a pathophysiologic process that could potentially be bipolar disorder, but basing the diagnosis solely on it is not correct. Having said that, a great deal of families give that history while the florid symptomatology is in full swing. So it is easy to understand the potential role of such chemical triggering accentuating the underlying process.   

garyfakhoury   
Dr. Pavuluri, does the medical-scientific community yet know what causes bipolar disorder? 

Mani Pavuluri MD   
Adult studies of typically manifesting bipolar disorder is shown to be genetic, but the pediatric variant is yet to be explained as to what causes it. All I know is that there are clear brain based changes in these kids. That tells me it is brain disorder. 

Davanna   
Does diet affect BP in any way? Do you have recommendations on diet? 

Mani Pavuluri MD   

Well people talk about carbohydrate craving. I do not know much about that specifically. But one thing I noticed is: if they are hungry, boy they are irritable! Keeping them fed to the extent that they do not become hypoglycemic especially after school is all I can say regarding the diet! Keeping up with the golden rule of everything in moderation is a good one right?!  

judy   
Dr. Pavuluri, some of your research involves the functional MRI. What are you hoping to learn from these studies and can it help prove the bp diagnosis? 

Mani Pavuluri MD   
Well I do not know about proving and for sure diagnosing based on this foot print of brain activation patterns. But what we found is that it is solidly useful in understanding these kids. Negative emotions lead to excessive activation of amygdala like a fountain of emotions hitting at you; for example a small criticism they perceive as a large one and they will hit the roof! They cannot think clearly with their frontal part of the brain that gets switched off in problem solving if they are way too excited! They cannot process facial emotions as effectively to tune in or stop where they need to stop in conversations etc! So the wiring is affected in general. Emotionally affected regions are also negatively influencing the thinking regions. That connection between feeling and thinking is critical in understanding how these kids function and use therapy for that matter or manage class rooms and teachers! 

rainbow   
How many of these children have social skills issues? I have been searching for social skills classes but can not find one that is geared towards children with emotional dsyregulation. Most classes seem to be geared towards kids with Aspergers. 

Mani Pavuluri MD   
Well maybe your therapists can read my book and start similar techniques in your area! Rainbow therapy is all about building self esteem and being a good friend and tuning in! I think you can directly teach these skills as I suggest in my book as well. I believe in generalizing to real life experience, so you will get tons of tips to foster the peer relations thru the book.  

007   
Do you have any advice on how to heal the rift between siblings who have been traumatized by the violent episodes of their sibling? Or to get them to accept the need of their own taking of medication, even vitamins, which they can't because then it makes them feel as if they are the same as their out of control sibling? 

Mani Pavuluri MD   
Well, tell each kid that they have their own story and help them gently understand what each problem is and the answer for each one which is different. Beyond that, again I explain in my book: 
1. Get siblings to understand and empathize with affected kid with bipolar disorder who is suffering. 
2. Get them to realize that they can help that person by using empathic statements. 
3. Try and spend time with each sib separately with you but then realize that BP kid may need more time as they are indeed affected; it is not all bad as sibs learn thru this tough process that growth, i.e. emotional development, is rich, continuous and stretched in their lives.  

Nanci - The Balanced Mind Parent Network   
We are almost out of time, I'd like to put through one last question and I apologize that we couldn't get to everyone's questions. We had a tremendous turnout for today's chat. 

exmish   

Given the relative newness of pediatric BP as a diagnosis, etc., and all of the negative outlooks (e.g. high mortality rate due to suicide), what would you say are reasons for parents of bp kids to have hope? 

Mani Pavuluri MD   
Well this is easy! I truly believe that these kids are smart, funny, caring, loving, not incapable of bonding which is harder in autism, they are "teach-able," have committed parents, sibs will be nurtured as a team within family, and if you break the day and times in schedule into bits and enjoy the moments you can enjoy, and build one piece at a time and preserve yourself as a parent while you do it, your kid will grow tall, big and wonderful before you know it and you can all talk about these in toasting ceremonies as  jokes! and listen, you will be saving for tuition and not trust fund ok?! Now you all look after yourself. Promise?? 

Nanci - The Balanced Mind Parent Network   
If you are interested in Dr. Pavuluri's book you can order it through our online bookstore. The forward was written by The Balanced Mind Parent Network's Executive Director, Susan Resko, and many of the parent quotes came from The Balanced Mind Parent Network members. Dr. Pavuluri, thank you so much for sharing your time, experience and encouragement with all of us today. 

wrenae   
This is all fabulous stuff! Great questions and answers! I can't wait to get Dr. Pavuluri's book... thanks so much for the chat session! 

Mani Pavuluri MD   
It is my pleasure and this is very rewarding for me you know! :) 

desperate  
 
Thank you for setting up this chat! I've been jotting down notes for the past hour. 

bm   

My friend goes to Dr. P and worship's her. She bought be the book and says it's perfect for us. 

rainbow   

Your book is amazing. I love it! I have bought it for my friend and I am going to buy it for my son’s new teacher next year 

judy   
Dr. Pavuluri has so much heart. I love her! 

cello   
I am so glad to be reminded of the role of empathy in communicating, in discipline and all of its problems... 

rainbow   
She is amazing Her book is incredible I wish the chat was longer I have so many more questions 

Mani Pavuluri MD   

I am excited that I am part of this wonderful group of people. What a way to live, lucky me, please feel free to ask me if there is burning question, I am here!

Waterlily9   
With a kid who had a plan to run away, and says they won't again, how can you trust them when they lie sometimes? 

Mani Pavuluri MD   
Each day is fresh day right? We can only influence them one day at a time with no crystal ball. I think not having that expectation of knowing definite answers and leave it to God if you believe in him/her, then that is it! 

rainbow  
 
Can you tell me how much of these issues are learned behaviors between siblings My 9 yr old son has bp and ADHD, my 8 yr old has been diagnosed ADHD not bp. I truly think he has bp also but the doctors do not agree. 

Mani Pavuluri MD  
 
Well regardless of diagnosis, there is affect dysregulation let us say! Learned behavior is not to be ruled out! But the answer is the same if you are not medicating, help them through Rainbow therapy principles of appropriate behavior. It is focused on parenting these difficult kids regardless! 

Nanci - The Balanced Mind Parent Network
Dr. Pavuluri, thank you again for being such a tremendous resource to our families. I'm going to have to close the chat room now so that I can copy over the transcript. I know that many of our members are looking forward to reading the chat session. 

Mani Pavuluri MD   
Bye now, take care!!!! Thanks for this wonderful opportunity!


The Balanced Mind Parent Network 2008 Expert Chat with Janet Wozniak, M.D.

June 19, 2008

Chat With Janet Wozniak, M.D.
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Janet Wozniak, M.D? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Summer. Watch your email for more details. 

Biography 

Dr. Janet Wozniak is the Director of the Pediatric Bipolar Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital, and a member of The Balanced Mind Parent Network's Professional Scientific Advisory Council. Dr. Wozniak's research focuses on the characteristics, longitudinal course and treatment of pediatric bipolar disorder.     


 

Nanci
Dr. Wozniak, along with Mary Ann McDonnell, A.P.R.N, has recently published a new book on pediatric bipolar disorder, Is Your Child Bipolar? The Definitive Resource on How to Identify, Treat and Thrive with a Bipolar Child.  It is an excellent resource and is available in our online bookstore. Dr. Wozniak, would like to make any opening remarks? 

Janet Wozniak, MD   
Thank you for inviting me today. 

Nanci   
We're glad to have you and we have lots of questions coming in already.

Kim   
What are your feelings on stability for kids with BP--what's the best you have seen and how much break-through symptoms should we expect?

Janet Wozniak, MD   
Stability is difficult to achieve. There are no studies addressing this, most medication and treatment studies are too short term. In clinical practice, we are always rolling with the punches. Children are a moving target with changes occurring due to age, course of illness and stressors. Usually we must settle for a reduction of symptoms, a decrease in frequency and intensity. If we try to stamp out symptoms 100% we run into med side effects. 

This is a common question in follow up visits: Should we try for better control with unknown side effects or unknown new med effects? Or should we settle for what we have? The answer is guided by how impairing the current state of affairs is. If a child is really struggling, we try to address better mood control or treatment of co-morbid conditions.

bsm   
If a child is on the highest amount of Abilify or any other medication, and the mood is still not stabilized, would you add another type of medication or try something new altogether?

Janet Wozniak, MD   
Whether to switch or add may depend on how useful treatment #1 has been. If it has offered partial help, for say rages, but irritability or elation or depression remain, I might add. If the treatment has only helped a tiny amount or maybe not at all, we switch to a new one. 

Usually a clinician would do this with a cross taper, starting a new med in the setting of the old. Even if the intention is to stop the first med, there is an opportunity to see the result of the combined treatment. 

questions   
If you have one child diagnosed with bipolar disorder and another child diagnosed ADHD but had a bad response to both Strattera and Concerta what is the likelihood that the diagnosis might really be bipolar disorder?  If so, what medications would you recommend to start with? Would you go right to a mood stabilizer or would you use Tennex or another medication first to try another way to treat the ADHD?

Janet Wozniak, MD   
It is a question of which medication to start with and which to add. Currently research and treatment guidelines have been vague about this, leaving it up to clinician judgment as to which mood stabilizer to use. If the diagnosis is ADHD and there is a bad effect to an ADHD med then the general plan would be to try a different ADHD medication. There is an awful lot of inter-individual variation to treatment response and it’s worth trying a different medication.

If the bad outcome you allude to is a clear manic picture (medication induced bipolar disorder), then we still consider the diagnosis to be ADHD, but proceed cautiously.  Often the discussion with the parents would be to consider using an anti-manic treatment in order to make the ADHD treatment work without the manic effect. The anti-manic agent alone might but is unlikely to treat those ADHD symptoms you were after in the first place.

As this is a more complicated solution, we have to consider whether the ADHD treatment should be non-pharmacologic. Your idea of second line ADHD treatments, like Tenex, is also reasonable, as this might not make moodiness worse (although it could!) but unfortunately may not be a great ADHD treatment! 

JennyPenny   
My son 15, diagnosed EOBP approx 2 years ago, asked the other night if he could drink alcohol when he got to college. He said, "If I can't because of the meds, I will go off them so I can....I don't want to be the only one that can't have fun going out". How do you handle this type of challenge?

Janet Wozniak, MD   
I am rather strict, mean and nasty about alcohol because I have seen the terrible effects of alcoholism first hand in my sister and father. I tell teens (and younger kids too) that the reasons to abstain or limit alcohol are not because 'they will die' from an adverse reaction with meds (this just isn't true unless the amount consumed was massive, like with alcohol poisoning). The reason to stay clear is the meds won't work as well with alcohol clouding your brain, and you are on those meds for a reason. You might get depressed, fail classes, become irritable, etc. Also, you are receiving treatment for bipolar and/or ADHD and both are associated with higher rates of abuse and addiction.

No one sets out and say 'I hope I become an alcoholic.' Addictions and patterns of abuse sneak up on you, cloud your thinking, and misuse occurs as your brain becomes confused about what is best for you. Alcohol plays nasty tricks on logical thinking! Also, alcohol is fun and safe for some people, but if you already have a mood disorder or ADHD, the likelihood is that for you, it will turn from a short bit of fun to more depression and poor judgment.

Alcohol is a depressant; it makes depression worse or brings it on. And then it makes you think that you need the alcohol to feel better. If you can point to any blood relatives with alcoholism or drug problems, you should, so your young one understands that he/she is at even greater risk. Addictions run in our genes!  Well, it is a subject that makes me passionate, I have a 15 year old daughter and see kids again and again get stuck on alcohol and drugs.

Nanci   
Dr. Wozniak, we have several questions about co-morbidities or multiple diagnoses. In your book you talk about 'bipolar plus'. Could you share some of your perspectives on this issue?

Janet Wozniak, MD   
Bipolar disorder rarely occurs alone. The most 'plus' condition is ADHD and of course if you have mania, then depression is also common. Both ADHD and depression can be misdiagnosed as either ‘yes bipolar’ or ‘no bipolar’, because of overlapping symptoms. But it is important to note that treating the bipolar may leave a child with left over issues of untreated depression and ADHD.

Other common (50%) disorders are the anxiety disorders. Some parents note that the emotional outbursts seen in bipolar disorder start in scenarios which cause anxiety (public speaking, meeting new people, something going wrong, separations, etc.).

Another important plus condition is autism spectrum. Bipolar children often have poor social skills, can be bossy, difficult or have poor reciprocal play. But it is part of a good evaluation to also consider the possibility of aspergers/pdd/ autism spectrum as a complicating 'plus' condition as well. (Hey, thanks for reading my book!).  
genejeanie   
Regarding weight gain with the meds, do you have any specific suggestions for controlling this?

Janet Wozniak, MD   
As much as possible, we use medications that have less weight gain associated with them. Among the atypical anti-psychotics this usually means Abilify. However, children may not respond to this or have weight gain with this (even if the studies say it is minimal, for some children the weight just comes on). Sometimes the weight gain is early and fast in treatment. If the symptoms are severe, we may continue, but if there is any option to stop the treatment, this is the best way to reverse the trend.

Finally, if we must use a medication that causes weight gain, we may combine it with a different med that could be useful (or at least do no harm) and also lead to weight loss. Sometimes this can happen with stimulant meds, used to treat co-occurring ADHD.

Another medication is topiramate (Topomax). Not a great mood stabilizer, but maybe a bit helpful. Not a great anti-anxiety agent, but maybe helps a bit. BUT its side effect is appetite suppression and weight loss, so a low dose addition of 100-200mg may have few annoying side effects (of sedation or cognitive clouding) and lead to weight loss or lack of weight gain.

Another is Naltrexone, used to quell drug/alcohol cravings. Also leads to weight loss and decd appetite. Another is Metformin, used for adult onset diabetes. There is one study of Metformin plus atypicals, a few of Topomax and none to date of Naltrexone. All short term. Weight gain is a problem in America in general, and a major problem for our children using psychotropics.

Charlie   
What is your opinion on brain scan technology as a diagnostic tool to help determine what is really going on from at least a biological perspective?

Janet Wozniak, MD   
One mother begged me for a brain scan. She wanted to carry around a picture to 'prove' to others why her child was so problemed. The brain scans generally look totally normal, even though we know the problem with bipolar disorder is 'in the brain.' That is because our technology can hardly capture the amazing complexity of the brain. The published studies you see in medical journals are group effects. Even in those studies no one brain scan could be determined as bipolar or not.

However, the brain scan studies increasingly are zeroing in on the limbic system as the site of abnormal structure and functioning. This increases our knowledge of what is actually going wrong when people have mania or depression. BUT we are still a far way away from really understanding it or intervening with treatments specific enough.

Any program that tells you that a brain scan can aid in diagnosis is lying. Maybe in 10 years, we will have some ability to use brain scans to aid diagnosis and treatment, but likely in combination with clinical judgment and other tests, like genetics or neuropsych testing. 

Nanci   
Let's talk a little about parenting issues.

bsm   
With the increased frequency of divorce in families with special needs children, are there any books or other types of support to help with co-parenting issues?

Janet Wozniak, MD   
I am not certain about books, but the families in which I have seen the best success use a mental health professional as a consultant to rough times. Even if divorced, 2 parents can meet with a counselor or therapist to discuss the best course of action for a special needs child. The discussions can range around using medications or not, the elements of an education plan, when and how to issue consequences. When and how to get homework and projects done. Where to send to camp and how to pay. When to hire tutors or in home behavioral support (trained nannies). Whether to allow sleepovers!

There are so many things to negotiate, and all more complicated with special needs kids. If you are not divorced but have a special needs child, recognize what a major stress this is going to exert on your relationship and take measures to be proactive. Divorce is common, and may be more common when children have problems. Recognize that as a risk factor and take time to work with rather than against your spouse.

JTmom
Several medications run the risk of tardive dykinesia.  Can you comment on this side effect?

Janet Wozniak, MD   
When I prescribe Abilify and the other atypical antipsychotics I warn about obesity/potential for diabetes as being a common outcome (but luckily reversible and easy enough to monitor). BUT I also warn about the rare risk of Tardive Dykinesia (TD). We in psychiatry know a lot about because the old time antipsychotics (thorazine, mellaril, haldol, which by the way were miracles to have and have saved many lives) these meds carry a high risk of TD, as many as 40% of those who used them over time developed TD.

TD is not dangerous, doesn't hurt, doesn't shorten your life. But it can be odd looking, even 'disfiguring.' TD is an involuntary movement disorder that involves the muscles most commonly around the lips, nose and mouth. It can look like lip smacking, lip licking or tongue movements. It can be mild, like a little habit, or odd with grimacing and distracting movements. Once it gets set in motion, it might not go away, even if you stop the medication.

While it was common with the old time meds, this new 'second generation' of anti-psychotics has very, very low rate of TD. But what is this rate? Because length of treatment increases the risk (i.e. the med for 10 years carries more risk that 5 years), we do not fully know how many will develop this over time. Higher dose is also associated with it occurring, a good reason to keep doses as low as possible (but enough to do the treatment job, of course).

Some quote the rate as 1%, some as high as 3-5%, others think it just does not occur. Because TD can look like motor tics (very common, 1% risk, higher in psychiatric populations), sometimes we don't know if the movement is TD or a tic. Some people have also been on the old time agents, so the TD is from that.
Tardive in part means that this is a side effect that occurs late in treatment, not in the first weeks or months. So I often tell parents, let's see if the med is useful and how useful. If it provides dramatic relief, then the risk of TD seems like a small price to pay. If the improvement is not much, then why risk anything? Stop the med and try something else.

Nanci   
We are almost out of time. Dr. Wozniak would you like to talk briefly about your new book (which is available in our bookstore online)?

Janet Wozniak, MD   
Thanks, Nanci. I call it 'cast of thousands' because of all the help that has gone into it, mostly the stories and wisdom of families we have known. My co-author is Mary Ann McDonnell, active in parent advocacy and expert nurse clinician. We also have the wonderful voice of Judy Brenneman, mother and writer extraordinaire. 
I hope it can 'clone' us and bring the words we usually deliver to families one at a time to many families at a time. I think it provides information, support and suggestions that parents of bipolar children will find helpful. Please send me your feedback! I already wish we included a chapter for children to read when they find the book on their mom's bedside table....

Nanci 
I have to say that it really connected with me when I read it so I think you succeeded in the cloning! I felt that you truly understood what parents go through and the questions we struggle with.

Janet Wozniak, MD 
I enjoyed this chat! Invite me again!

Nanci 
We will! Do you have time for one more question?

Janet Wozniak, MD 
yes

Nanci 
We haven't talked about complementary treatments at all; this next question is about the effect of diet. Perhaps you could also comment briefly on some of the other complementary treatments such as vitamin/mineral supplements, Omega 3's or light therapy.

Janet Wozniak, MD 
No links yet, but many parents have shared with me their stories of stumbling on allergies which helped their children, everything from red dye to potatoes! I do not routinely recommend diet restrictions, because for many it is likely barking up the wrong tree.

I do like omega-3s and have been very influenced by epidemiologic data demonstrating lower rates of mood disorders in countries that consume a lot of omega-3s and the fact that our brain cells 'prefer' omega 3s in the cell membranes,, but will use the less flexible omegas if we don't take in enough of the 3s.  The research leads me to believe that omega-3s are a useful supplement to conventional treatments. It will be the rare individual who has a mood problem completely cleared up by these supplements. But maybe it offers some extra support.

Janet Wozniak, MD 
I am about to work on a chapter on alternative treatments for a special edition of the Psychiatric Clinics of North America. I’ll have more to say then.

Nanci 
Dr. Wozniak, thank you so much for your time and for sharing such comprehensive and detailed information with our members. We very much appreciate your contributions.

Janet Wozniak, MD 
My heart goes out to anyone who frequents your website. I know your life is full of struggle.


The Balanced Mind Parent Network Expert Chat with Dr. James Hudziak

April 17, 2008

Biography

Dr. James Hudziak is Professor of Psychiatry, Medicine and Pediatrics at the University of Vermont. He is director of the Division of Child and Adolescent Psychiatry as well as the Behavioral Genetics Division. In addition to his appointments at UVM, Dr. Hudziak is an Adjunct Professor of Psychiatry at Dartmouth Medical School and Professor of Genetics of Childhood Behavior Problems at the VU University of The Netherlands. He is currently the President of the American Psychopathological Association (APPA), a sitting member of an NIMH study section, and serves on the American Board of Psychiatry and Neurology Residency Review Committee in Psychiatry. In 2006 he was elected as Chairman of the Professional Advisory Council for the The Balanced Mind Parent Network.               


Nanci - The Balanced Mind Parent Network
Dr. Hudziak, thank you for taking time to meet with us.

Dr. James Hudziak 
It is nice to be here. Although, today in Vermont it is sunny, 65 degrees...

Nanci-The Balanced Mind Parent Network
Would you like to start out by telling our members a bit about your research on the impact of genetics and environmental factors?

Dr. James Hudziak 
Our work is aimed at understanding how genetic factors and environmental factors interact on why some children might be sad, anxious, aggressive. By the study of entire families, twin pairs, and siblings we get hints about how certain illnesses travel in families. By the study of environmental mediators and moderators we hope to determine how some of this suffering can be ameliorated. That is our research dream.

Nanci - The Balanced Mind Parent Network 
Can you share any results of your studies or is it too soon to draw conclusions?

Dr. James Hudziak
The APPI recently published a book on this topic that I edited calledDevelopmental Psychopathology and Wellness: Genetic and Environmental Influences. This book introduces much of that work. Its main point in some ways is that the child psychiatric illnesses are influenced in equal parts by genetic and environmental factors. Thus in some ways, our motto is: Genes make the Environment Matter! In the final chapter of that book I elaborate our family-based approach, which aims to support the entire family through careful assessment and then through the use of health promotion, prevention, and intervention approaches help the entire family.

Susan
What is the APPI?

Dr. James Hudziak
Sorry, the American Psychiatric Press or exactly, American Psychiatric Publishing Inc*

Nanci - The Balanced Mind Parent Network
I don't know if these findings are good news or bad news. In essence, we are dealing with a bit of a vicious circle. The stress of a mental illness causes the family environment to deteriorate which then causes more problems for the kids.

Dr. James Hudziak
Whether the news is good or bad, I think it is important for us in the field of medicine to understand just what you have written and thus understand that the best way to help children who suffer from severe emotional or behavioral problems is to focus our efforts on helping the families.

Nanci - The Balanced Mind Parent Network
True. Another argument for insurance parity so that families have access to the resources to help them!

Dr. James Hudziak
This is one of the reasons I am so impressed by the efforts of family based organizations such as The Balanced Mind Parent Network.

Nanci - The Balanced Mind Parent Network
Thank you.

child psych class
Does early identification of bipolar disorder predicts substance abuse in adolescence and adulthood.

Dr. James Hudziak 
We believe early identification is key. We begin our research in three year olds and move forward in our research in the Netherlands (where I work with the VrijeUniversity) in the study of over 30,000 twin pairs we follow children through early childhood and into young adulthood. We have shown that early onset is correlated with a number of later negative outcomes. Others have shown the relations to substance abuse as you have predicted, so yes.

Susan
How do we participate in these studies?

Dr. James Hudziak 
Susan, that is a bit difficult as the majority of our work is done in Amsterdam, The Netherlands. Our family studies are done in Vermont, and typically with families we see regularly, so joining either study would mean a major lifestyle change.

Lizzie
Dr. Hudziak, A few people have told me that their bipolar children have had SPECTs and EEGs in hopes that they could get more info about their children’s' illnesses - particularly help with medication issues. What do you think about these tests as tools in BP treatment?

Dr. James Hudziak
I do not think these techniques have ANY role what so ever as diagnostic tests in BP Treatment. Certainly there is wonderful neuroimaging research underway that hopefully will one day illuminate discoveries in diagnosis and treatment of BP in children but we are simply not there yet. I strongly resent the organizations who sell false hope to families with the use of techniques that simply have not been validated.

momof11
I have a question. Since bipolar disorder is genetically based and the vast majority of the children with it have a parent who also has the disorder, wouldn't it be prudent for the child's psychiatrist to suggest the parent with symptoms also receive treatment in order to change the environment in which the child lives?

Dr. James Hudziak
Momof11 (does this mean you have 11 children?)

momof11
Yes. All biological and full siblings.

Dr. James Hudziak
To your question however. Your point is exactly the reason we have pioneered the family based treatment approach in our clinic. We think that because these are genetic conditions that the genes that influence the behaviors in the children could also affect parents’ ability to deal with the stresses associated with these heritable conditions thus we assess and offer treatments to all parents of our children who suffer these treatments can be in the form of health promotion, illness prevention and intervention they include providing families with family coaching, behavioral techniques, cohesiveness exercises, and when appropriate psychotherapeutic and pharmacologic interventions.

Jess
Dr. Hudziak, have you seen families whose children's medications are supplemented with neurofeedback? If so, any anecdotal data?

Dr. James Hudziak
I have seen families who have participated in neurofeedback without positive results (this may be the reason why they ended up in my clinic) thus it would be imprudent of me to comment on the data, because the only kids I have seen are the ones in which neurofeedback did not work. There may be others in whom it helped and thus they did not end up seeing me.

Jess
The neurofeedback literature I have read stresses the family dynamics as a factor in treatment--they say, for example, that once the "identified problem" family member makes progress through neurofeedback, the whole family dynamic shifts.

Dr. James Hudziak
Well here is my beef on that point (although it has nothing to do with neurofeedback). I think the family as the 'identified problem' approach is much closer to the truth, more humane to the children who suffer these extraordinary disorders. So I think using the identified patient approach is like putting the cart in front of the horse. That said, I agree that anything that helps the family is a good thing.

SunWillShine
Can controlling the environment of a child potentially bipolar (with bipolar siblings and/or parents) help delay onset, or even prevent it from manifesting? If not, can it help ensure a better outcome?

Dr. James Hudziak
That is a question that needs to be answered. I am hopeful that the answer is "to a degree". In other words, environmental interventions may provide some relief and diminish the degree to which a child and his/her family will suffer. However, as all of us know, in many instances, the illness emerges despite all efforts. In that case, help with the environment may help diminish the collateral burden of the illness.

tex mom 
I am more concerned with how we can ameliorate the disease now that we have diagnosed it in our child. What environmental factors are within our control to change?

Dr. James Hudziak
Ameliorate will be tough. Diminish is likely a more reasonable goal. As so little research has been done in this area the first thing we should all do is stand up and shout to our leaders begging for more research in this area. That said, we are experimenting and in fact have papers in review, about the positive benefit of sports participation, sleeping at least 8 hours a night, diminishing family conflict, all as positive environmental mediators of child psychopathology.

We will be presenting data in Istanbul in two weeks at the International Child and Adolescent Child Psychiatry meetings that illuminate our work on how TV and video games correlate with more negative outcomes in aggressive children. In our clinic we then aim to teach families the goals of less TV and Video gaming by asking them to do more family based non-tech things - e.g. reading to your child an hour a night, playing games and catch etc. In fact we now have a sports big brother and big sister program we are developing in which healthy teens teach at risk BP kids a sport skill so that they can have a new hobby. We aim to do the same with music etc.

tex mom
I can tell you , in our case, sports, sleep and routine seem to help the most.

Dr. James Hudziak
I am so pleased to hear that Texmom. I have devoted a large effort to these approaches.

Nanci - The Balanced Mind Parent Network
Dr. Hudziak, are there clinics similar to yours in other parts of the country? And how would we go about finding them if they exist?

Dr. James Hudziak
Nanci, I think our clinic is somewhat unique in that we feel rather strongly that although everyone of our families is a clinic family (e.g., we need to diagnose and work with the family towards wellness), we also strongly believe that we can learn from every family, every child we see so in that way, every family is also a research family. Thus we partner with the vast majority of our patients to join us in our family studies in which each of these approaches is being tested in such a way that we can then communicate to the rest of the field the relative utility of each approach. Thus our clinic is a bit weird.

Nanci - The Balanced Mind Parent Network
That kind of weird we could all use!

Nanci - The Balanced Mind Parent Network
This next question is one that many of our families raising teens with BP are struggling with.

AZmom
My 16 y.o. daughter did not have BP symptoms until she was about 13 years of age. She is currently on three meds, is stable, and her life is pretty much that of a typical teen. She is enrolled in an online school, because she just cannot rise and function early enough in the day to attend the local high school (although she would like to do so). Is this problem with rising in the AM one of those things that goes along with BP?

Dr. James Hudziak
AZmom, I have been blessed with having 4 children, two of whom have crossed the teen barrier. I also study large numbers of well teenagers and teenagers who struggle and I can report that they all have trouble rising in the morning. It is my opinion that this is getting to be a major problem in our society. I think schools conspire against our kids getting sleep by loading on too much homework.

But I think an even bigger problem is the internet. Kids are IM'ing, Chatting (like this I guess), face booking gaming, until very late at night. The combination of technology (staring at a screen) with the sadness and loneliness many teens feel I think leads to terrible habits that disrupt sleep. I do not know what the secret recuperative powers of sleep are, but they are clearly important, to teens more than any other age group, and I think we are doing a poor job of teaching the importance of sleep. This is why so many of my teen patients are upset with me as I put a limit on their online use and their TV time as part of our therapeutic contracts. Long answer, sorry, but this is a big issue to me.

Nanci - The Balanced Mind Parent Network
I think this is a big issue for many of us! Regarding school attendance, I know that some districts around the country have gone to giving high schools take the later start times and the elementary schools take the earlier ones. It seems to make a lot of sense.

Dr. James Hudziak
I think so as well. It would even make more sense if they built in more study time into the school day so kids could live a more full life.

Nanci - The Balanced Mind Parent Network
I agree!

momof11
Massive online games are also problematic and I feel addictive.

Dr. James Hudziak
momof11 I also agree. Online gaming pulls kids further and further away from dealing with the stress of being a teen.

child psych class
One of our students noticed that NIMH doesn't have clear statistics on the prevalence of bipolar disorder

Dr. James Hudziak
child psych class - great point. My group has written a number of papers on the fact that there remains a great deal of debate about how best to 'diagnose' bipolar disorder in children. This is a subject our group puts a lot of energy into. There are multiple different definitions and with each different estimates of prevalence. The best predictions at this point are that the Narrow or Classic manifestation of Pediatric Bipolar disorder is probably less than one percent. However, the more common presentation of rapid mood swings, aggression, inattention, and unhappiness may occur as often as 4%.

Suffice it to say that much more research needs to be done in the area of understanding the many different presentations by age and gender of this broad group of disorders. We think this work will need to proceed before we make the big discoveries in designing new treatments. Tough to read, but I think a fair rendering of where we are. So once again, we need MORE RESEARCH!

Nanci - The Balanced Mind Parent Network
What is your group's perspective on the presence of irritability as a factor in diagnosing BP in children?

Dr. James Hudziak 
I think this is one of the presentations that is generally accepted and that needs more study. My sense is the best way to proceed in the area of assessment and diagnosis is to bring all the definitions to the table and to determine how best to combine and contrast the many definitions in order to find common ground and to identify unique factors and symptoms that may signal a different type of disorder. With this approach, genetic neuroimaging, and treatment research could arguably move ahead at a much more rapid pace.

child psych class
There is also the question about the possible adverse effects of multiple simultaneous medication with kids, and how this might also impact on otherwise normal development, such as attention, concentration, mood regulation, etc....how can research even clearly tease out effects when a child is taking 4 medications for bipolar disorder?

Dr. James Hudziak
I do not know. It is a big question that I think needs to be studied. When you have so many variables in play, it is almost impossible to design an experiment to answer that question. So excellent question and the type that will need MORE RESEARCH.

Nanci - The Balanced Mind Parent Network
Ahh, I detect a theme here . . .

Dr. James Hudziak
I am just a simple Vermonter......

momof11
Could you comment about the use of supplemental melatonin and sleep in bipolar children/teens.

Dr. James Hudziak
I know it is commonly done. Using melatonin for sleep is not something I typically do, but as I said, is commonly used. There are a couple of reports in the literature on the use of melatonin, but to be clear, I have not been too terribly impressed with that literature.

Nanci - The Balanced Mind Parent Network
This next question speaks to the challenge we as parents face with the tendency for our kids to 'hold it together' at school and fall apart at home.

natalie
What can I do as a parent to help my gifted, bipolar son pass his classes? His school psychologist says he presents himself as "normal", but at home he is a wreck. He is currently taken meds and seeing a therapist. He really needs some modifications at school, but the psychologist says he doesn't qualify. Help!

Dr. James Hudziak
Tough and fair question. We use a multi-informant approach here to estimate the health and struggles of our kids in multiple settings. To illuminate, we ask for reports from teachers, from mom, from dad and from the kid himself. In this way we do not emphasize 
disagreement but rather think that everyone is correct. So in the case of your son, it may be that he works very very hard at school to normalize his behavior. Upon arriving home, exhausted, and feeling safe with his family, he may simply let go, decompensate, or simply have run out of energy. Thus we would want to focus on improving his at home functioning (again, nutrition, exercise, sleep, a careful consideration of his medication regimen and a contingency management approach - reward system - for him getting his stuff done at home). I am on thin ice here as I try to never comment on the care of a child we do not see, so please take this answer as an overview of how we might address a generic situation.

natalie 
Thanks!

child psych class
Is there a so-called cutting edge treatment that has shown great promise?

Dr. James Hudziak
My sense is that medicine in general, and child psychiatry specifically, would be better served if we used the motto, that "complex medical conditions (like diabetes, asthma, depression, bipolar disorder, hypertension, etc) need complex solutions, and thus complex treatment approaches". I think the search for a silver bullet or a single cutting edge treatment has really been an unlikely outcome from the start. So I vote for answering your question by saying the cutting edge treatment is complex, requires family based health promotion, illness prevention, and intervention approaches that are family specific.

Nanci - The Balanced Mind Parent Network
We have time for one more question.

momof11
In your study, are you seeing bipolar disorder and related disorders in a continuum in family members - such as the development of schizoaffective disorder or schizophrenia in siblings?

Dr. James Hudziak
A very important question, that is of course dependent upon which diagnostic definition one uses. So, although features of the broad condition (not the narrow definition) can be studied in one way and will give one set of results, a study of the narrow condition will give another result. To date studies have shown that with both definitions they tend to run in families, but a strong case for anticipation in siblings has yet to have been made.

Nanci - The Balanced Mind Parent Network
Dr. Hudziak, thank you so much for sharing your expertise and perspectives with us.

momof11
Thank you very much for your time.

Dr. James Hudziak
As my fellow Vermonter, Willem Lang likes to say on NPR, "I gotta get back to Work" Thanks for having me.

Nanci - The Balanced Mind Parent Network
Our pleasure!

GoodMom
Thanks for being here!

AZmom
Thank you!

Nanci - The Balanced Mind Parent Network
I know that I learned a great deal from this chat and I wish there were more psychiatrists with your perspective and understanding of the impact of this disorder.

Dr. James Hudziak  
There are probably a ton.

Dr. James Hudziak  
Take care and goodbye.


The Balanced Mind Parent Network Expert Chat with Ellen Leibenluft, M.D., of NIMH

March 5, 2008

Chat With Ellen Leibenluft, M.D.
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Ellen Leibenluft, M.D.? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring.

Biography
Dr. Leibenluft is Chief of the Unit on Affective Disorders in the Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, National Institute of Mental Health. She received her B.A. from Yale University in 1974 and an M.D. from Stanford University in 1978.  She is now actively involved in research on bipolar disorder in children and adolescents, with a particular emphasis on differences between children and adults in the presentation of the illness; neural mechanisms underlying the symptoms of the illness; and the development of new treatment strategies for early-onset bipolar disorder. 


Nanci - The Balanced Mind Parent Network 
Dr. Leibenluft, would you like to start out by talking about the research that you are doing with the NIMH?

Dr. Ellen Leibenluft
First, I want to say that it’s a pleasure to be here "chatting" with you all. Our research is focused on the brain mechanisms that underlie bipolar disorder in children, and also very severe irritability. We hope that these studies will move us closer to better treatments and even prevention of the illness. We are also interested in children with have a sibling or parent with bipolar disorder, and therefore are at risk for the illness. 

Nanci - The Balanced Mind Parent Network 
If people are interested in participating in a study, how do they go about finding the studies and qualifying?

Dr. Ellen Leibenluft 
Call us at 301-496-8381. Someone will call you back, explain what we are doing, and send you materials. We work very hard to try to give children and their parents a positive experience.

Diane 
If we're in an NIMH study, can we receive referrals to local therapists? Also, what's the difference between "mood disorder" and bipolar disorder in terms of symptoms and treatment?

Dr. Ellen Leibenluft 
All of our participants are in treatment with a psychiatrist in their community, and we do facilitate referrals. Bipolar disorder is one form of mood disorder....the most common mood disorder is major depressive disorder (sometimes called unipolar depression)....lows without the highs. So mood disorder is the general term, and bipolar disorder is one illness in that category. 

hallie 
What should we do when our child seems to have paradoxical reactions to all meds? Is there a place where our child can be evaluated for other medical conditions that might be complicating things?

Dr. Ellen Leibenluft 
Hopefully, your psychiatrist or pediatrician should be able to facilitate that. In addition to medical conditions, sometimes children with severe learning disabilities or other developmental problems are also very sensitive to medications, so a very thorough psychiatric and psychological evaluation may also make sense.  

Nanci - The Balanced Mind Parent Network 
Along those lines, what are your thoughts on the role of neuropsychological evaluations for diagnosis and treatment?

Dr. Ellen Leibenluft 
That's an excellent question. I think the first thing is to be sure that you are working with a psychiatrist who is working with you to really do a thorough evaluation. Neuropsych evaluations cannot really make a diagnosis of bipolar disorder....that is done on the basis of the symptoms that you have noticed, and that your child reports. But learning problems and/or speech and language difficulties can be very common in children being assessed for bipolar disorder, and neuropsych evaluations can definitely be helpful with that.

One thing to add...your psychiatrist should advise you as to whether a neuropsych evaluation can be helpful.

Diane 
Are their other "mood disorders," aside from bipolar that present with mood swings, depression, high energy, and aggressive behavior?

Dr. Ellen Leibenluft 
Sometimes people with major depression (unipolar) depression, can be very anxious and irritable. The anxiety can look like high energy, although it's different in that nothing productive is getting done...instead pacing, unable to sit still etc. and the irritability of unipolar depression can certainly lead to aggression.  

kittnash
As for your interest in children with a higher risk, does the sibling or parent need to have bipolar disorder? Or is a mood disorder enough of a link? Also, what is the upper age limit of children in your study?

Dr. Ellen Leibenluft 
For our studies, either a sibling or parent has to have bipolar disorder. We study youth aged 7-18.  

Virginia 
Could you talk a bit about "impairing irritability"? My 10 year old son has been diagnosed as having bipolar NOS -- we've never seen him display what I'd consider "mania," but his extreme irritability in the classroom (we see it at home too) is what led to his evaluation for a mood disorder.

Dr. Ellen Leibenluft 
That's a really huge issue in pediatric bipolar disorder.....to what extent is extreme irritability diagnostic of bipolar disorder, as opposed to another mood disorder or another psychiatric illness. BP NOS is used typically for one of two reasons....the child has distinct times when they have manic behavior but it lasts a few days (less than the 4 technically required), or the child doesn't have distinct times when they are manic. Instead, the child just has irritability all the time. We have done a lot of research on the children who don't have episodes, but are very irritable all the time, and indeed we are continuing to recruit them for studies.

We actually find that, in terms of family history, what illnesses they are at risk for in the future, and brain function, the very irritable children without clear episodes differ from the ones who are clearly bipolar (the clearly bipolar ones have clear manic episodes). The chronically irritable ones without clear episodes are at risk for major depression in young adulthood (not bipolar disorder necessarily) and they have different family histories. Also, the two groups differ in brain function. So the conclusion is that the BP NOS without clear episodes may be an irritable form of depression, rather than bipolar disorder itself.  

Nanci - The Balanced Mind Parent Network 
We had two questions about definitions for terms we've used today. BP NOS stands for Not Otherwise Specified. Neuropsych evaluations are neuropsychological evaluations, here's a link that describes these in more detail: http://www.medpsych.net/neuropsych_evaluation.htm  

Dr. Leibenluft, do you want to add anything to explaining these terms?

Dr. Ellen Leibenluft 
Thanks Nanci! Yes, if your child is given the diagnosis of BP NOS, you should ask the clinician what he/she means....why isn't your child clearly bipolar? Without clear episodes, we think that it's important that other diagnoses get considered also.

Regarding neuropsychological evaluations, a PhD level psychologist gives your child paper and pencil or verbal tests to determine IQ, use of speech and language, school achievement, and other issues, depending on the reason for the referral.

Laura 
My 16-yo daughter was diagnosed as bp about 1.5 yrs ago. She is currently doing very well on meds; however, she has a terrible time waking up and getting going in the AM. I've read that morning sluggishness is typical for those with BP. She is really concerned about being able to arise at 6 AM for high school classes. It's as though her brain doesn't engage until about 10 AM. What do other people with bipolar disorder do to wake up for jobs & school?

Dr. Ellen Leibenluft 
That's a really excellent question. There are some data to indicate that people with bipolar disorder are "phase delayed" meaning that they want to go to bed late and sleep late. Timing your exercise can be important...morning exercise would be better for her than evening exercise. Avoid stimulating activities at night (if you can get her to do that!) and avoid bright lights. Also talk to her doctor...are her medications giving her a "hangover" perhaps?

Mitzi

Do you feel Bipolar disorder in children/teens derails their social/emotional development? If so, how do we help them "catch back up"?

Dr. Ellen Leibenluft 
Great question. We have a big interest in bipolar youth's social development, and indeed our research shows that they have difficulty labeling face emotions (as do the very irritable children, by the way). We just found that children at risk for bipolar disorder also have trouble labeling face emotions, so it may be that there is something connected between social development and emotional development in children with bipolar disorder, and unfortunately they struggle with both.

Your question highlights the importance of treatments in addition to medication for children with bipolar disorder. Many children benefit from individual or group settings where they can learn about their emotions and how to read other people as well as try to regulate their own.

Nanci - The Balanced Mind Parent Network 
This next question sort of piggy backs off of the one about waking up but hits on the broader issue of motivation.

kittnash 
How does bipolar disorder affect a child's general motivation? I know that often times the medication can make a child sleepy and thus unwilling to go to school. But does bipolar disorder by itself inherently make a child lack motivation? I just wonder if my child's behavior is "normal".

Dr. Ellen Leibenluft 
Another great question. Depression, which of course is an important part of bipolar disorder, can definitely decrease motivation. Indeed, "anhedonia" or the inability to experience pleasure (and if nothing is pleasurable, then nothing is motivating!) is considered to be a core symptom of depression. So one thing to think about is might there be some depression? And then definitely the medications can be an issue.

If the motivation problem is particularly with school, then of course its worth delving into whether there might be things going on at school that could be addressed. 

fkmad 
Do you find that early history (even as early as infancy) is significant in children with bipolar disorder? For example, not gradually learning to wait to nurse or eat before melting down, or a constant need to be in arms (not satisfied ever with swings, bouncies) - on its own or at that early point, it would not seem more than personality. So, in a group of children/teens diagnosed with bipolar disorder, is there a common thread of certain types of behaviors that may have been present long before anyone would have reason to suspect something more than a feisty personality?

Dr. Ellen Leibenluft
Again a great question. One of the problems is that the child is already having difficulties by the time they come to us, and then we would all have the tendency to look back and remember problems that we might have forgotten if the child hadn't had any problems since infancy. It’s very hard to really test these questions retrospectively...looking back. Another reason why it's very important to follow children "at risk" very carefully...so we can figure out what really are early warning signs, and eventually be able to act on them.

Laura 
Do you see adolescents with bipolar disorder who, as they reach adulthood, improve to the point where they can go off meds? What do you think of reducing meds for an 18-year old whose disorder didn't appear until the teens - just to see if maturing has helped?

Dr. Ellen Leibenluft 
That's something that is really difficult to answer generally, and depends a lot on the specific history. Obviously, that's a decision that really needs to be carefully considered by child, parents, and doctor working together. If meds were withdrawn, I would want to do it very slowly, so that you could see if symptoms were emerging when they are still mild and reverse course if needed. nbsp;

kat 
Could you discuss memory impairments with bipolar disorder in general and as a side effect of meds. My 9 yr. old doesn't seem to have any other significant side effects with meds, yet her memory and learning abilities fluctuate from day to day. Many times at the end of the day she can't recall what her favorite part of the day was even if it was something that she was really excited about. Also she will seem to learn a new skill (academic) only to fail on it when tested the next day or week later.

Dr. Ellen Leibenluft 
In BP in general there is some evidence for possible deficits in verbal memory, but the data are somewhat mixed. Topiramate is one medication that has been particularly linked with memory problems, but many of the medications can be associated with this problem, so it's important to discuss with her doctor. This could also be a situation with a neuropsychological evaluation might be helpful, if your doctor agrees.  

jeangal 
Should all children that have been diagnosed with bipolar disorder have an MRI or some other type of brain scan. What kind of information can be provided by such tests that might help with diagnosis or treatment?

Dr. Ellen Leibenluft 
We don't routinely recommend MRIs or other brain scans for children with bipolar disorder. If there are neurological problems or some unusual symptoms it might be helpful, but that's something to discuss with psychiatrist and pediatrician, not something to do routinely. Diagnostically these scans can rule out certain medical conditions that might look like bipolar disorder or other psychiatric illness, but those conditions are relatively rare.

mak 
where does anxiety begin and b/p symptoms end , or do they appear to overlap?

Dr. Ellen Leibenluft 
Wonderful question. In both adults and children with bp, the rates of "comorbid" (meaning, existing at the same time as bipolar disorder) anxiety disorders are very high...somewhere around 60%. It’s important to sort this out, because treatment aimed at the anxiety (which can be cognitive behavioral therapy for example) can possibly be very helpful for children with bipolar disorder and anxiety. We don't know why the two travel together...another thing we're looking at actually.

Larry

What about the role of sensory and regulatory disorders and bipolar in younger children? When do they get teased out, or do they share an ongoing comorbidity?

Dr. Ellen Leibenluft 
Another great question. The term sensory and regulatory disorders can be used to describe a variety of different problems, so it's important to find out exactly what physicians or other therapists are diagnosing....what exactly are the problems that they are describing with this term. Again many children with bipolar disorder have learning disabilities or speech/language difficulties, or social difficulties. So knowing what specifically is the problem is important in designing a treatment.

hallie 
Have you seen children/youths who do not benefit from medication? If so, what has helped them?

Dr. Ellen Leibenluft
I would say that the children we see almost always get some benefit from the medication, although it often is not as much benefit as we would like. In addition to the medication, we think a lot about school setting, etc.  Can adaptations in the environment help? Also, have speech/language/learning been assessed well...are there interventions there? Is there anxiety...intervention there? As you all know so well, these children have very complex problems, so we go back and make sure we've really worked to understand the whole child...not just their BP, although of course their BP is so important.

Diane

Is lithium still the "gold standard" or has it been replaced by the new anti-psychotics?

Dr. Ellen Leibenluft 
Excellent question. We don't have a "head-to-head" trial that would allow us to answer that question. Fortunately people are doing more clinical trials in youth now, so hopefully we will know soon. I think you should work with your doctor to see which might be best for your child.

Nanci - The Balanced Mind Parent Network 
I'd like to go back to your comment about looking at the school setting. Many of our families run into the challenge of not knowing what degree of accommodations are appropriate for their child. There are sometimes concerns that the child is being manipulative to get out of homework, or otherwise does not fully 'apply' themselves. Is there a way to differentiate between what is truly a disability due to the disorder and when it is appropriate to push the child to do more?

Dr. Ellen Leibenluft 
Another great question, without an easy answer. When children try to get out of homework, it's often because they feel like a failure when they try to do the homework. Again, careful assessment is so key...what exactly is going on with the child, both in terms of his/her academic skills, and the emotional piece (discouragement etc), as well as possible depression. You want to try to create success experiences, and use those to build on so the child can go from success to success...so in a sense it's pushing, but a certain kind of pushing.  

Nanci - The Balanced Mind Parent Network 
We have a tremendous number of really great questions, more than we can possibly cover. Dr. Leibenluft, do you have time for one or two more?

Dr. Ellen Leibenluft 
Yes! You folks are great...it's really a pleasure to chat!

larry 
do you worry about pharmaceutical opportunism with pediatric bipolar, especially in the era of direct to consumer advertising?

Dr. Ellen Leibenluft 
That's a very complicated question. In our health care system, pharmaceutical companies play an important role in developing and testing new medications. Of course, as consumers and parents, we all want to stay focused on what's best for our health and that of our families, so we want to stay educated (as you are so obviously are!) and make informed decisions about treatments.

KimLori

< onset early strategies treatment new the to speak you>

Dr. Ellen Leibenluft 
There's a lot of research going on in terms of both medications and psychotherapeutic approaches. There are always new medications coming out for bipolar disorder (recently a number of antipsychotics, as others mentioned).nbsp; We need to learn much more about which are best for children, and how they stack up against the older medications like lithium, etc. Many people are also testing emotion regulation therapies. For many of the medications used in adults with bp, we don't really know how effective they are in kids with the illness.

Nanci - The Balanced Mind Parent Network 
Dr. Leibenluft, thank you very much for sharing your time and expertise with us this afternoon. It is a tremendous opportunity for us to have you available as a resource and I hope you enjoyed chatting with us as much as we enjoyed having you as our guest.

Dr. Ellen Leibenluft 
I am very grateful to you all for your questions, and to Nanci for making it all happen!


The Balanced Mind Expert Chat: David Miklowitz, Ph.D, Author of Bipolar Disorder: A Family Focused Treatment Approach

February 18, 2008

Chat With David Miklowitz, Ph.D.
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with David Miklowitz, Ph.D? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Watch your email for more details. 

Biography

David Miklowitz is the author of Bipolar Disorder: A Family Focused Treatment ApproachThe Bipolar Disorder Survival Guide, and The Bipolar Teen: What You Can Do to Help Your Child and Your Family, as well as numerous research articles. Dr. Miklowitz’ research focuses on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder.                               
                                             
 


Nanci-The Balanced Mind Parent Network
I am very pleased to welcome today’s guest, David Miklowitz, PhD.. He is the author of “Bipolar Disorder: A Family Focused Treatment Approach”, “The Bipolar Disorder Survival Guide” and “The Bipolar Teen: What You Can Do to Help Your Child and Your Family” as well as numerous research articles. Dr. Miklowitz’ research focuses on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder.

Nanci-The Balanced Mind Parent Network 
Dr. Miklowitz would you like to make any opening remarks to our group?

David Miklowitz PhD
It's a pleasure to be here. I'm ready whenever you are - just to say I'm a big fan of The Balanced Mind Parent Network!

Nanci-The Balanced Mind Parent Network
Thank you! Perhaps you could start out by talking a little about your new book “The Bipolar Teen”?

David Miklowitz PhD
Sure - we just published a new book called "The Bipolar Teen." This book is intended for parents of the 12-18 set who are often struggling not only with the disorder but trying to distinguish being a teen from being a bipolar teen. The book focuses on coping strategies, especially those to use when a kid is cycling into mania or depression

David Miklowitz PhD
Any questions from my fellow "goldfish?" (Editor’s note: The default chat icon was a goldfish and we had a chat room filled with ‘fish’!)

Nanci-The Balanced Mind Parent Network
Let’s start with a general one from Steph.

Steph
What are the typical signs of bipolar in a child?

David Miklowitz PhD
First look for changes in mood from a baseline state - sudden increases in irritability or giddiness, combined with increases in activity and energy, seeming to need to sleep less (not the same as insomnia), highly reactive moods, sometimes grandiose thinking; sexual preoccupations.

For depression look for lethargy, irritability, withdrawal, not being interested in friends, losing interest in school, negative and pessimistic thinking, hopelessness. Above all look for deteriorations in functioning and changes from a baseline state.

yasa
How do you tell if the issue is BP related, PMS related, or just regular teenage obstinate behavior?

David Miklowitz PhD 
Good question. First, consider the timing of the symptoms in relation to the menstrual cycle - if the irritability just occurs in the 5 - 6 days before the onset of her period and then goes away it's probably PMS related; bipolar tends to cycle throughout the month continuously. Bipolar is not diagnosed just by one behavior like being obstinate - you have to see clusters of symptoms like those above combined with a deterioration in functioning (for example, grades drop)

teddyone
Do you think it is helpful if the parents of a child with bipolar disorder just work on the "big" behaviors of the child instead of focusing on the little things that really don't matter? (Like going to your child when he needs something rather then expecting him to wait and come get you etc)

David Miklowitz PhD
Yes, I do think focusing on the big goals is a better strategy. These kids have significant frontal-cortical deficits, which means they will have trouble shifting from one activity to another or inhibiting their negative emotional reactions. Stick to your guns with rules like when they have to be home, no drugs or alcohol, no opposite-sex overnight guests, etc but let other things go like unwashed dishes, nasty tones of voice, forgetting to feed the dog etc.

Beverly
Hello -- My daughter's "depressive" state looks more like angry/revengeful. She doesn't have the sad/crying behavior that we would think would be classic depression. When she is in this state she becomes destructive and hurtful, especially when there is accountability. My husband and I have made a Parent/Child contract with her, and she was included in all aspects of rules/consequences (hoping that she would feel she had power/choices). However, she places blame for her choices on everyone else, and acts out against consequences (escalating the situation). How do we help her to begin to accept responsibility, and make better choices for herself? It is like "Groundhogs Day" here; we talk and work on the same issues everyday (& in therapy) without any change.

David Miklowitz PhD 
First, it sounds like she tends to have mixed episodes rather than depression only - more like depression combined with irritable mania or agitation. It's very hard to implement behavioral contracts when the kid's mood is cycling but you should forge ahead anyway, just with lowered expectations.

Also, the pattern you're describing of not taking responsibility is a teenage thing but it is exaggerated by bipolar disorder. Make sure the rewards and consequences are meaningful to her (use of cell phone, computer, car are the most common) - if the contracts aren't working for her ask her to design her own. Learning to take responsibility is a gradual process so if you see any evidence at all make sure to reinforce her (praise her, reward her in some other way) as well

Nanci-The Balanced Mind Parent Network 
This question ties in to some of the previous one, but relates to the sibling and family dynamic. In the interest of keeping the peace in the family, and picking the 'big battles' how much do we compromise the 'rights' of our other children and expect them to concede or acquiesce to their ill sibling?

David Miklowitz PhD
This is a very tough balancing act. First, it's important to educate siblings about the fact that the older or younger sibling has bipolar disorder and what this means for them (e.g. it may mean giving up certain things, being embarrassed by your sibling at others, feeling that your sib gets all the attention

At times you have to compromise the rights of well sibs but make sure you balance it with paying more attention to them at a different time - spend more time with them, ask them how things are going, tell them you understand how hard it is, but make sure they also have insight into how they may be triggering the bipolar sib with certain looks, accusations, etc. We have an education sheet in our Bipolar Teen book which is aimed at siblings and parents which you can use to start a discussion with them about what bipolar is and what it will mean for your family life.

yasa
How do you handle it when your child acts overwhelmed and/or wants to blame behavior and/or thinking on their disorder instead of focusing and dealing with the real issue?

David Miklowitz PhD
I have seen this happen when bipolar becomes like a "blank check" that enables the kid to do and act however he pleases (how many of us have heard "well, what can I say? I'm bipolar you know"). Think of bipolar as worsening a kids’ ordinary teen reactions to things, kind of like an amplifier, but he or she is still responsible for those reactions. So, a good response might be "yes, you're right, you're bipolar and that probably affects how you react. But that doesn't mean you're not responsible for how you treat others."

Also, yasa, when kids are cycling avoid trying to get them to talk about the real issue until they've calmed down.

gene
How should we be speaking to our kids about the potential for hypersexuality?

David Miklowitz PhD
Gene, good question. When they are old enough to contemplate sexuality, or have their first boyfriend/girlfriend, have that first discussion you would have with any teen about sex but combine it with, "you know, bipolar has a way of affecting your judgment...how will you know when it's what you want versus whether it's what your bipolar disorder wants?"

Educate them about sexual risks; also, if they are planning on staying out late try to make sure they have a responsible friend along. If you have a good relationship with this friend you can even talk to him/her about the sexual risks you are afraid your kid will take and how they can be a good influence...but this varies with the situation.

Make sure their freedom to go out in high risk situations like parties is limited when they are clearly cycling, even if it makes you feel like a jailer at times.

jake 
Our 15 year old son rejects any suggestions by us or by therapists, teachers, etc. He maintains that he has to figure out things for himself (unfortunately, he is seldom successful). Therapy is useful to me in parenting, but seems to be a waste of time for him. Any ideas?

David Miklowitz PhD 
Therapists report mixed luck with adolescents, especially boys. Have a talk with the therapist about whether s/he is making any headway, whether your son seems to be opening up. Some kids do better in groups than individually. Tell him that the purpose of therapy is to help him figure things out for himself and figure out who he is and wants to be.

If it just seems to be going nowhere, though, get a second opinion from a different therapist - sometimes you have to therapist-shop before you find the right one.

tangles 
I find it interesting that you work with both adults and teens. The transition from teen to adulthood seems to be particularly difficult for many. What are your recommendations for easing this transition?

David Miklowitz PhD 
Tangles, the period of time from 17-20 is often the toughest on families. Kids are trying to make transitions to adulthood but are still back in grade school in terms of their emotional and social development (bipolar has a way of delaying and derailing ordinary development). The trick is to figure out what the kid is and is not capable of doing individually. If he says he wants his own place, go through with him what that entails - how will he remember to fill his medications? Do his laundry? How will food work out? Can he live with someone responsible? Can your house be adapted so that he has more independence (e.g. a basement apartment)?

When you look closely you often find that the kid is really terrified - beneath the grandiosity and bravado is the fear that he can't take care of himself and will always be dependent on parents (which can make kids hate their parents for reasons they can't admit to themselves) - so conflict arises at this time.

Deah 
Do kids with bipolar disorder have trouble socially and tend to become reclusive, or is that a sign of something else - like Asperger's Syndrome?

David Miklowitz PhD 
No, that is a sign of bipolar disorder, especially the depressive states - most people withdraw and avoid social contact. If the child has always been socially reclusive, had odd mannerisms and social habits (i.e. looking at his shoes whenever he talks, using odd word emphases, speaking ritualistically), and it has always been that way, it may be a form of Aspergers.

David Miklowitz PhD 
In my opinion, Aspergers is being over diagnosed in bipolar kids - you really have to see a longstanding pattern of social deficits before diagnosing it.

Nanci-The Balanced Mind Parent Network 
I wonder if you could expand a little more on your thoughts about Aspergers? We have historically had a lot of families at The Balanced Mind Parent Network with kids with the dual diagnosis of bipolar disorder and Aspergers, and have had several questions today submitted about treating these diagnoses through therapy, or making the distinction between the two.

David Miklowitz PhD 
Sure. First, think about the diagnosis of Aspergers - social isolation, lacking social skills, being unable to communicate nonverbally (e.g. no facial expressions), getting obsessively fixated on one interest or activity to the exclusion of all else, engaging in repetitive ritualistic behaviors, and being physically awkward and uncoordinated.

Sometimes kids with bipolar disorder get this way when depressed. The key question is, when they are not depressed, are any of the above features present? Is this an ongoing state of the child, or only when he or she is in a mood disorder episode? Have these symptoms been present since early childhood (Asperger's is believed to have a very early onset) - i.e., did she have good friends as a kid, or have there always been reports that the kid was awkward, shy, didn't acknowledge people with nonverbal gestures, etc.?

Also, think about treatment - what are the implications for treatment if the kid has Aspergers as well as bipolar? Usually this will mean some kind of individual or group social skills training, which may be useful anyway if the kid just has social problems but does not have Aspergers.

One other feature - did the child reach other developmental milestones like crawling or walking late? This is key to the diagnosis of Aspergers.

autumn 
We have a 16 year old boy who has been mentally ill since 9 years old. We are having trouble getting a handle on the anxiety. Can you recommend best meds, coping skills, or hospitalization success?

David Miklowitz PhD 
Anxiety disorders are comorbid with bipolar disorder in 30%-50% of cases. Sometimes the anxiety is a sign of the depression and sometimes it's a separate condition. First, you may have to consider SSRI antidepressants (which as we all know carry risks of additional cycling), which are often used for anxiety. His doctor may also recommend an atypical antipsychotic like Seroquel which is a good anti-anxiety agent.

For psychotherapy, see books like "Mastering your Anxiety and Panic" by Craske and Barlow - this is a self-help workbook. Is there a mindfulness meditation group available? Some colleagues of mine at Oxford University found that mindfulness meditation was effective for anxiety in bipolar disorder.

lbd 
Even on medications, my daughter is irritable, very active, has highly reactive moods. From your experiences working with kids with bipolar disorder, is it safe to get her off meds to get a baseline and then treat again if needed?

David Miklowitz PhD 
Ibd - if you want to do a medication washout, it's best to do it in a hospital setting, especially if your child has a history of suicidality, psychosis, aggressive behavior, etc. If you are going to take her off medicines, do it under a doctor's supervision, usually one medication at a time, going down slowly on the dosage of each and watching for any return of symptoms. Usually, though, we want to see some period of recovery (eg 6 months) before a medication washout is safe.*

autumn 
How do you know when to hospitalize?

David Miklowitz PhD 
Autumn, first it's good to have the criteria laid out before the kid gets severely ill so you'll know it when you see it. Any suicidal behavior (particularly an attempt like swallowing pills, even if not apparently serious), suicidal ideation which is reasonably specific (e.g., I think about swallowing all my pills at once and checking out) and is getting more frequent; excessive drug/alcohol use (e.g. comes home high (eg on Ecstasy) or drunk regularly; out of control behavior (e.g. aggressiveness, breaking into sudden cursing in class, plus the other symptoms of mania); and being unable to take care of himself (stops bathing or eating).

Bren
Is it much worse for teens on the BP spectrum to experiment with drugs and alcohol? If so, how do parents approach that? How do they help their kids to navigate those waters?

David Miklowitz PhD 
Bren, yes it is more dangerous. Drugs and alcohol make the symptoms worse and can even convert a kid with a mild form of BP into a more severe bipolar I form. Also, bipolar makes it more likely that a kid will develop a substance dependence disorder than a healthy teen who uses the same amount.

A good book on this is "Motivational Interviewing" by Miller and Rollick. Jump on the issue earlier rather than later; if the kid has had, say, one instance of using Ecstasy or cocaine, institute home drug testing as a way of preventing future episodes. He'll hate it, of course, and may even try to doctor the samples, but it lets him know you're concerned about this and will be watching. Some parents use the kid's intention to go to a "Rave" or a party with kids who are known to use drugs as a time to use drug testing (eg it's fine to go to the concert but keep in mind we'll be doing a drug test Sunday morning) Talk to your kid about negative peer pressure, show you understand the dynamics of how peers can pressure you into doing things you don't want to do.

Nanci-The Balanced Mind Parent Network 
I know we started a little bit late this morning, do you have time to take a few more questions?

David Miklowitz PhD 
Yes, happy to take more questions.

momx3

There is so much focus these days on medications, and the media hype about overmedicating kids. In your opinion what is a good balance between medications and therapy?

David Miklowitz PhD 
momx3, this is really the $64,000 question (is it $64 million now?) The recent PBS special on "The Medicated Child" made it look like drugs were the only option, which is a shame. The research literature generally favors combining psychotherapy with medications. For example, in the STEP bipolar study of adults we found that weekly psychotherapy in conjunction with mood stabilizers helped speed up recovery from depression, whereas combining mood stabilizers with antidepressants didn't.

Make sure you have your kid in a weekly therapy with a practitioner who knows about bipolar disorder and makes this the centerpiece of the treatment - family therapy is particularly effective, especially if it's oriented around strategies the families can use to prevent mood swings (e.g., identifying early warning signs and calling the physician; strategies to keep the family environment structured and low-key).

A good question to ask your kid's psychiatrist is, if he or she is about to add a third or fourth medication or raise dosages significantly (and you suspect this is a lot of "trial and error" planning), ask him/her to recommend a therapist first who specializes in BP spectrum disorder - maybe try that before going the extra step of adding yet another medication*

tshura
Does your book deal with family therapy?

David Miklowitz PhD 
Yes, it does, we talk about it at some length. We also have a separate book called "Bipolar Disorder: A Family-Focused Treatment Approach" which is primarily for clinicians working with families of BP persons but has a lot of suggestions for parents as well.

Nanci-The Balanced Mind Parent Network 
We have had a tremendous response and many more questions than we could possibly cover in an hour. Probably enough material for another book!

David Miklowitz PhD 
Time for one more?

Nanci-The Balanced Mind Parent Network
If you have the time, absolutely!

David Miklowitz PhD 
sure

Western Cardinal
I am both a therapist specializing in pediatric bipolar and a parent of 2 bipolar kids, Lately I have been in a situation where I have to dispute the information about pediatric bipolar with other professionals who swear there is no such thing as pediatric bipolar that it is incomplete parenting. I always bring up the medicine issues that if medicine solves many of the problems then it is definitely pediatric bipolar but we all know that medicine is not a panacea. Any idea on how to combat this line of thinking?

David Miklowitz PhD 
Yes, I have run across this as well. I think your colleagues have not read much of the research literature in the past 20 years! Yes, BP may be being over diagnosed now (witness the study that found a 40-fold increase) but that may be a good thing since it was way under diagnosed for so long. All you can do is educate them about why you think it's bipolar and not something else like ADHD (focus on the cycling of mood and the cardinal symptoms of the disorder), point out that there is no evidence that poor parenting causes a syndrome like this...or meet them halfway and suggest that a particular patient get both a mood stabilizer and family treatment to deal with parent/child conflicts. But hang in there and don't budge!

Nanci-The Balanced Mind Parent Network 
Dr. Miklowitz, thank you so much for sharing your time and expertise with us. The information and insights you provided have been extremely helpful and informative. Thank you as well for all of your research and work to benefit our kids and our families.

David Miklowitz PhD 
It's my pleasure. I have enjoyed this hour and all of the questions have been great. Good luck!

yasa 
Thank you SO VERY MUCH doctor!!! I REALLY appreciate this daytime chat as evenings are just IMPOSSIBLE for me to get to when both BP teens are home!! :) Thanks a whole lot!!!!

tshura
thank you!

bren 
Thank you!

Deah 
Yes, thank you!

mitzi 
This has been so very helpful!!!! Thank you so much! I, too, appreciate the daytime CHAT!

teddyone 
Thank you so much for your time spent with us!

Steph 
Thank you

Laura 
Thank you for writing a book concentrating on teens - our "bipolar child" is growing up!

Rae 
Thank you

Western Cardinal 
I will be at a National Assoc of Social Worker conference in Albuquerque next week educating school social workers on both the symptomology of Pediatric bipolar versus ADHD but also various methods for helping kids with non-medical ways to deal with it in addition to medical ways I will be using your book as a reference.

David Miklowitz PhD 
My pleasure, and thanks to Nanci and The Balanced Mind Parent Network for making this kind of forum possible.

Nanci-The Balanced Mind Parent Network 
We're always delighted to have these chats!

tshura
Indeed, thank you Nanci


The Balanced Mind Parent Network Expert Chat with Eric Youngstrom, Ph.D.

December 18, 2007

Chat With Eric Youngstrom, Ph.D.
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Eric Youngstrom, Ph.D? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Watch your email for more details. 

Biography

Dr. Youngstrom’s areas of specialty are child and adolescent bipolar disorders and developmental psychopathology. He is Principal Investigator on a five-year study of assessing bipolar disorders in children in community-based mental health settings. In addition, he is associate director of the Center for Excellence in Research and Treatment of Bipolar Disorder (CERT-BD) in the Psychology Department of the University of North Carolina at Chapel Hill. 

Dr Youngstrom studies the emotions, developmental psychopathology, and the clinical assessment of children and families. He has published more than 85 peer reviewed publications on the clinical assessment, emotion, or bipolar disorder, and he has served as an ad hoc reviewer on more than thirty prominent psychology and psychiatry journals. 

Dr. Youngstrom is a member of The Balanced Mind Parent Network's Scientific Advisory Council.


Nanci - The Balanced Mind Parent Network 
Dr. Youngstrom, do you have any opening comments or shall I send through the first question?

Eric Youngstrom PhD 
If you folks have been kind enough to put together a list of questions, then I'd like to get as far through it as we can!

Diane
My question for the doctor is: How do you know if a medication(s) is "good enough" and you should just stick to it (them) or if it is worth trying others to try to get things even better?

Eric Youngstrom PhD 
Thanks for an easy question as a "warm up"! ;-)  I think that the most important thing is good communication with the provider. The biggest problem for the provider-family alliance is avoiding piling on too many medications too quickly -- everything that gets added may help with multiple symptoms (not just what it was selected for); and everything also carries the possibility of unintended side effects. So the treatment parameters and algorithms start with one med, then switch or add one. Polypharmacy is tempting because families need help and want it quick, but going slower and having excellent communication may prevent more complications. 

Kalee

Is it appropriate to use medications in a very young child, age 3 for example?

Eric Youngstrom PhD 
The honest answer is that no one knows for sure. It is not good news with things get so "off the hook" with a 3 year old that meds become necessary. ...but the cause for hope is that the brain shows a tremendous capacity to restabilize, and it can grow stronger with age.

I actually was thinking about this while hiking over the weekend. The image was of gardening. When you plant a seedling, it is very flexible and vulnerable. You may need to provide a stake to support it, or cover the roots to protect it from cold. After some years of growth, though, it turns into a tree, and it can handle all that the elements throw at it. Medication may be like the stake or the insulation, helping straighten things out early, and then things grow strong enough to maintain very well without it. We just don't know yet.

Nanci - The Balanced Mind Parent Network 
Great analogy

Tam 
How do you convince your psychiatrist/doctor to believe that there is a possibility of BP in children that does NOT fit with the DSM IV criteria for adults?

Eric Youngstrom PhD 
Okay, Tam -- re: convincing your doctor.... I think that there are at least three options. None perfect, and not all three will work for everyone:

(a) Bring them the evidence -- pull down peer reviewed articles, and also show them the data from your life (life charts, home video, detailed notes...)

(b) Change doctors if they won't listen, and if you have options in your community

(c) Don't worry about the name. Some doctors get hung up on controlling the diagnosis and the label, and resist being told "how to practice." If you are stuck with them (i.e., no options in the community, see (b) above), then focus on getting help for the behavior or the symptoms. Let them call it whatever they want, so long as they are focused on helping you solve it. In the end, if your child gets better in spite of the doctor having a different label than you do, you still got what you came to the office for.... Help for your child (and you can enjoy the last laugh about the diagnostic formulation after your child is stable, right? ;-))

exmish 
What course do you recommend that parents take when we encounter _________ (schools, doctors, law enforcement, etc.) who don't believe there is such a thing as pediatric bipolar disorder?

Eric Youngstrom PhD 
Exmish -- I think that we have three options when confronted with skepticism: Educate, Ignore, or flow around.

re: Education, I am actually impressed by skeptics who are critical thinkers who just haven't seen the data. They are easy to work with. Show them the data, discuss it, and any objective read of the research indicates that there is probably such a thing as Pediatric bipolar, and they need to be open to the possibility.

re: Ignore. The world is full of yin-yangs. If they don't affect your child's care, and if they aren't affected by data, ignore them.

Nanci - The Balanced Mind Parent Network 
I love that concept!

Eric Youngstrom PhD 
re: Flow around. These are the most difficult. You need their help for your child, and you can't ignore them. They demonstrate skulls too thick to be affected by data. So you finesse them -- don't fight over the label, and focus them instead on the behavior or the problems. "Gee, okay, maybe there isn't bipolar. What can you do to help my child blow up less often?" ;-)

exmish 
I LOVE that response....it validates what we've been doing all along. THANK you!

Eric Youngstrom PhD 
(Exmish -- thanks for the feedback!)

Nanci - The Balanced Mind Parent Network 
Can you comment at all on neuropsych testing? This is an issue many of our members struggle with pursuing - pros and cons. Does it help in the debate with schools and other professionals and does it give us meaningful information about our child?

Eric Youngstrom PhD 
Neuropsych -- great question! Okay, I am a psychologist. Testing is our big contribution to the world. What I am about to say is pretty radical given that professional affiliation...

I teach testing, and I think that as a field, we do too much of it. In health care, we literally spend billions of dollars a year on tests that we don't need.  Too much testing not only costs money, but it can actually make it harder to make a good decision -- paralysis of analysis, and too much information.

I think that if I am going to give a test, it should answer one of the "3 Ps": does it Predict something important (graduating school, suicide attempt, treatment response, etc); does it Prescribe a different treatment, or does it tell you something about the Process of working with the person (how they are responding or not, or the outcome).

Okay, so neuropsych tests are typically expensive. How do they do against the 3 Ps? 
They don't seem to predict diagnosis. Aude Henin and Andy Nierenberg just published a paper in JCCP showing that there were almost no differences between youths with BP vs youths coming to the clinic for other reasons.

Megan Joseph, a student with me, found the same thing in her Masters thesis review and analyses of new data. Where neuropsych testing could be valuable is not so much in making the case for whether or not a kid has bipolar, but instead it helps in establishing the PROCESS of helping them in school.

Bottom line -- if one of my daughters might develop bipolar, I would not ask for neuropsych testing to help clarify the diagnosis. If she were having trouble academically, I would try to get her mood stable first. If she continued to have trouble in school, then I would ask for the neuropsych testing to figure out what else the school could be doing differently to help her learn. If you have already gotten neuropsych testing, then I would concentrate on leveraging it to get more educational support services in the school -- that is where it is going to be most valuable.

Nanci - The Balanced Mind Parent Network 
Can you briefly expand on that to talk about the process - the types of learning challenges our kids have and how the schools can accommodate in a way that still sets our children up for being productive and proficient in later life.  Many of our members are going through that exact situation - it's not about the diagnosis, it's about how to help our kids succeed in their education.

Eric Youngstrom PhD 
Okay, back to how neuropsych testing can help in school -- I think that it can reveal strengths and weaknesses in how people process information. The strengths may be used to compensate for some of the weaknesses. Common weaknesses are things like working memory (training in note taking can make a big difference), processing speed (untimed tests, etc.). What is striking to me is that if you approach a school psychologist or a MDE (multidisciplinary evaluation) team with a diagnosis like "bipolar" they often fight it, where if you present it as a neurocognitive deficit, their training kicks in and they are like, "Oh, okay, we can help with that. We deal with that all day long."

Nanci - The Balanced Mind Parent Network 
I have to add a word of agreement on Dr. Youngstrom's last comments. We are in the midst of the neuropsych process and everything he says rings true regarding information and how the schools react.

Eric Youngstrom PhD 
(thanks, Nanci -- glad to hear I'm on the mark!)

Twinmom

What would account for a decline in neurocognitive abilities over time?  We’re seeing this with my child.

Eric Youngstrom PhD 
Twinmom -- explanations for neurocog decline over time: Short answer is we don't know yet. Possibilities include neurocog changes due to mood episodes (scarring hypothesis), failure to acquire new skills due to disruptive behavior (not on task in class, so not learning), or side effect due to the meds.

re: side effects -- Lithium and divalproex have show evidence of neuroprotection in animals, making it less likely that they are hurting performance. But they are still associated with side effects that can undermine performance on tests. The other newer meds are a pretty big unknown.

gensmom 
Why do our kids tend to be able to hold it together in one place but not others (i.e. at school, but not at home and vice versa?

Eric Youngstrom PhD 
Why does mom seem to see more of the problems than anyone else? Okay, the "Is It All in Mom's Head" question is one that I have been interested in for a long time.

My dissertation was on this, back before I was even working on bipolar. And I just presented a paper on this at the Association for Behavior and Cognitive Therapy in November. It was a pretty technical paper, pitched at psychologists, but the gist was:

Kids with bipolar show more than typical levels of problems based on teacher or youth report. Put another way, parent-teacher and parent-youth agreement about symptoms in bipolar is actually significantly higher on average than normal. The problem is that parents and teenagers don't agree much to begin with, about anything. And anyone who's had a kid has had the experience of going to a parent-teacher conference and wondering whether the teacher is talking about the same kid.

The correlation between parent and teacher is r = .2. If mom is at the end of her wits, and reports a score of 80 on the CBCL (Child Behavior Check List), then this means that on average a teacher will report a score of 56 -- slightly on the high side of the normal range.

Nanci - The Balanced Mind Parent Network
Would that be because the teacher doesn't see the majority of the behaviors that the parent sees?

Eric Youngstrom PhD

Kids with bipolar average closer to a 60 -- significantly more problems in school than the kids without bipolar. The problem is that professionals (and teachers) don't appreciate how differently kids behave in different settings. They look at mom's 80 and the teacher's 60 and say "They don't agree" rather than realizing that mom is describing a problem that is so bad that it's starting to leak into other settings and affect school much more than expected.

Eric Youngstrom PhD 
Right -- parents can see a lot of things that teachers just can't. We ask parents to fill out the GBI for research, and we use it clinically a lot, too. 73 items. We have a paper coming out where we asked teachers to do it, and we had to throw out 2/3 of the items -- teachers just couldn't provide good info on them. So that's evidence that mom can report on 3 times as many mood symptoms as a teacher can.

exmish 
(We've seen exactly that with our son's IEP process and his 3-year review -- they were able to empirically attest to his slower processing speed and such and made the appropriate accommodations)

Nanci - The Balanced Mind Parent Network 
That is extremely helpful to hear because many of our families run into this on a daily basis. Any suggestions on how to 'sell' the school on this dichotomy? And then we are at our closing hour for questions.

Eric Youngstrom PhD 
re: selling the school on the dichotomy -- that's a great question. The teacher paper is coming out in J Clinical Psychology -- special issue that Mary Fristad and Sheri Johnson put together... I can send the preprint to any interested (back channel me). I can send the powerpoints to people, too.

Eric Youngstrom PhD 
I also want to echo what Nanci said -- moms often are the "lucky" person that we test limits with first when growing up. Kids often will challenge mom before challenging dad (if he's around) or teachers. And mom is the person who's around when the sleep disturbance issues are feeding into the mood. And mom is on the front line of enforcing the home rules (and also left holding the bag with getting the child thrxough homework from the school). And moms are crucial in children learning how to express and regulate their emotions. So when a child has a mood disorder, mom is the first one to know about it.

Nanci - The Balanced Mind Parent Network 
I'd like to thank Dr. Youngstrom for a very informative and educational chat session. You've shared a tremendous amount of information and insight that will benefit all of our members

gensmom 
Thanks for your time - very informative!

twinmom 
Thanks.

exmish 
thank you so much -- you're obviously very intelligent, but also very approachable...refreshing!! :)

Tam 
Many thanks!

robin-wi 
ty :)

Eric Youngstrom PhD 
Thank you all -- this was a lot of fun, and I am very glad if it was helpful.

twinmom
You were very thoughtful in your responses. Thanks so much

Nanci The Balanced Mind Parent Network

Good night all, especially those on the east coast!

Eric Youngstrom PhD 
Glad to have good company, and I appreciate the offer! Best wishes to all for the rest of the holiday season....

Nanci - The Balanced Mind Parent Network 
To you too!

Tam 
Merry Christmas!

twinmom 
Let's hope for happier, more stable new years.

Eric Youngstrom PhD 
Amen to that, and best to all.


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