An interview with Gianni Faedda , author of Parenting Your Bipolar Child

New Harbinger Publications: The typical onset of bipolar disorder (BD) is late adolescence or early adulthood. How common is the childhood onset of the disease?

Gianni Faedda: This is a very complex question. First, it depends on how BD is defined: mania (BP-I) is far less common than hypomania (BP-II when alternating with Major Depression). Second, it depends on how one defines “onset”: a mild symptom, a severe symptom, a cluster of symptoms, a certain duration of symptom, meeting diagnostic criteria, and so forth. It appears as if in some people the illness might manifest somewhat differently depending on their age. For instance, in children symptoms are more chronic yet fluctuating rather than the more clearly defined episodes of adulthood. Some cases do not reach full syndromal expression until adulthood, but some symptoms are usually present (often undetected) since childhood or adolescence. And even though they might not be technically described as adult BD, these forms already have all the features of BD.

Just like other medical illnesses, BD develops and progresses over time on a genetic vulnerability; it is usually not an all or nothing type of event, like a seizure or an injury. The unfolding of the disorder is a lot more complex than the “onset” age can tell us.

The effects of BD on a mature adult, however, will be quite different from those on a child or an adolescent, regardless of how we define onset.

NHP: What are the symptoms of childhood BD?

GF: We have dedicated a good half of our book to this topic, because it is so essential to successfully diagnosing, treating, and monitoring BD. Briefly, intense moodiness, extreme emotional outburst, and a flair for drama or confrontation and arguments is often the main complaint. Extreme changes of energy (from hyper and driven to exhausted and lethargic), concentration (sometimes very sharp and attentive, other times unable to focus), interest (from having many interests, plans and ideas to having no interest in anything) or sleep (from being a short sleeper to feeling tired in spite of long sleep hours). The main feature of this disorder is variability, a continuous series of shifts, inconsistency and unevenness of all functions, physical, mental and emotional.

NHP: Should the parents of a child diagnosed with attention deficit hyperactivity disorder (ADHD) worry that their child actually has BD? How do you recommend avoiding a misdiagnosis?

GF: Parents of children with ADHD should be knowledgeable about BD and vice-versa. The two disorders not only occur together quite often, but they also share several symptoms. The differential diagnosis between these disorders is extremely difficult in some cases, and it should be the result of a thorough assessment by skilled clinician. A more common issue is BD being misdiagnosed as ADHD, and delays in instituting proper treatment or inappropriate treatment can be very costly for the child and the family. One (or several) family member with history of depression, manic-depression, alcohol or drug-abuse can also suggest BD, while a history of ADD can suggest ADHD might be the problem. Sometimes only after several years of observation or medication trials it is possible to be more definitive with the diagnosis.

NHP: Early in the book you mention emotional shock absorbers. Could you explain what that term refers to?

GF: Life is full of events, some pleasant other unpleasant. When we manage to maintain emotional balance, we have successfully used our “emotional shock-absorbers”. These can be defined as those mechanisms that allow us to soften the impact of an event on our emotional life. Without them, we are too sensitive, too vulnerable to life events.

NHP: How does the lack of emotional shock absorbers affect a child with BD?

GF: Take a small disappointment, like the cancellation of a play date. While a normal reaction would be disappointment and transient sadness, perhaps even a tear or two, the reaction of a child with BD might be more extreme, with sobbing, severe sadness and even thoughts of suicide, or an angry, even aggressive reaction completely out of proportion with the trigger.

NHP: What can result if a child with BD goes undiagnosed or untreated?

GF: Like diabetes or seizure disorders, BD progresses and worsens without proper treatment. Many fail to recognize the lethal effect of delaying treatment, ranging from complications (developing a comorbid substance abuse due to self-medicating) to disability (dropping out of school), crime, and even suicide. All these awful consequences can be prevented by early diagnosis and treatment of BD. Most adults do much better after they are properly diagnosed and treated, and we see the same results in children and adolescents.

NHP: What are some treatment options for children with this disease, and how might that treatment change as they grow up?

GF: The same interventions that seem to help adults gain (or improve) control over their symptoms have been found to be effective in children, although the amount of data available on the effect of age on the efficacy of some interventions (especially pharmacological) is still lacking. Helping the patient (in ways that are age appropriate) recognize symptoms and patterns of behavior can be as effective in children and adolescents as in adults. Sleep hygiene and regular exercise, a balanced diet and an active social life are crucial to the well being of children and adults alike. Some important interventions, including parenting techniques and school interventions and accommodations, are essential in treating a youngster, have a role in young adults but are not usually necessary in adults. Addressing issues of self-esteem, social and interpersonal issues can be as helpful in children as it is in adults.

NHP: Having a child with this mental illness is hard enough, but if you have other children it must be difficult to balance the needs of your BD child with the rest of the family. What are some suggestions that you can offer parents in that situation?

GF: Very often, when a member of the family is not well, the whole family suffers. The needs of a child with BD can be so extensive that all the attention that both parents can offer is at times insufficient. We think that sharing the burden of helping a child with BD go through months or years of illness requires input from several members of a treatment team. At different times the team might be instrumental in reminding parent about the need to take care of their own issues (medical, psychiatric, social, financial etc.), at other times will require providing some support or respite to a sibling who is being victimized, or educate the school personnel on BD and how to best help the child with BD.

In general, however, successful treatment is more likely if the parent/s are healthy and take good care of themselves. This might seem selfish, but an exhausted, sleep-deprived overworked parent is not always able to respond therapeutically to the child’s needs.