One might argue that the authors attempted to squeeze too much information between one set of covers. It does seem that there are actually two books here: one, a medical analysis of the etiology of Bipolar Disorder, particularly early onset in very young children; and another book guiding parents in recognizing the symptoms and navigating the medical, insurance, and governmental mazes to obtain treatment for their children. Be that as it may, the authors have written a very provocative treatment of Bipolar Disorder that brings into print what psychiatrists, mental health professionals, and many parents have been concerned about for some time. For the past decade or so, there has been growing concern about the precision of children's diagnoses vis-à-vis Attention Deficit Hyperactivity Disorder. While many parents and school officials wonder if the ADHD diagnosis is rendered too often, there is another school of thought emerging that as many as a third of ADHD diagnoses are in reality cases of early onset Bipolar Disorder.
The authors are not alarmists; their stance, research, and professional networking is mainstream. But this work is alarming. It argues from the testimony of hundreds of parents connected to the authors from around the country by the Internet, that their children were much more violently ill than DSM-IV criteria for ADHD would admit, and that traditional ADHD treatments were not working, in fact making the situations worse. Admitting that the ADHD/bipolar differential is tricky for the diagnostician, the authors have arrived at useful clinical clues. For example, when a hyperactive child breaks something, more often than not he is angry with himself for his clumsiness. The bipolar child, on the other hand, often demonstrates an outward rage or anger with his destructive actions directed at family and peers. The Papoloses note also that bipolar children are more inclined to night terrors and violent imagination in story telling and art work.
The authors point out that pediatric pharmacology in the treatment of early-onset Bipolar Disorder is extremely critical and presents a wide array of problems. As noted above, Bipolar Disorder can be mistaken for ADHD. The standard medication for the latter has been stimulants, which unfortunately will severely aggravate the manic tendencies of the bipolar client. Other clients may present as depressed, and even though the FDA has severely cautioned against the use of SSRI's with depressed children, it has not forbidden their use outright. In children and adults, SSRI's have been found to trigger manic episodes where the depressed mood was a feature of misdiagnosed Bipolar Disorder.
Even when the diagnosis of Bipolar Disorder is correctly made, the medication problems for children are significant. Over the years the common practice has been the use of such mood stabilizers as Lithium and Depakote. These medications have required regular blood work, which has made compliance an issue with children who naturally despise needles. More recently, anticonvulsant and atypical psychotic medications have proven useful in severe cases. However, these medications involve significant side effects ranging from aggravated weight gain and acne to such extremes as facial distortions and the other trademark symptoms of psychotic medications. The Papoloses examine each medication, pro and con, to assist parents and practitioners in treating and educating their clients.
Parents are reminded that dating back to 1973 federal law has mandated the educational opportunities of children with mental disorders. In a similar vein, children's rights to medical treatment, including institutionalization for weeks or months, are also reviewed under the provisions of Medicare and Medicaid, among other plans. The authors are thorough in spelling out the rights and the best procedures to follow in dealing with the bureaucracies of government, schools, and insurance companies. A number of useful organizations, with phone numbers and web sites, are provided. However, in the two states whose budgets I monitor, New York and Florida, Medicaid funding for children has been significantly reduced due to strapped state budgets. At this writing, California is considering wholesale reduction of service as well. Consequently, even those parents who are faithful to the advice rendered by the Papoloses may have difficulty in accessing service. The authors' advice here, while correct may be a bit too rosy in the present health care environment. In addition, I attempted to use several of the web sites, and some of them have been disbanded.
But in the final analysis, this work fulfills what I think were the intentions of the authors. First, it provides assurances to parents that the bizarre and deeply troubling behavior of their children may have organic causes for which they are not responsible. Caregivers are reminded that they are not alone, that they have rights, and most importantly, that there are support groups and practitioners who are beginning to understand the scope of their problems. Second, this work is successful in encouraging practitioners to think more expansively about the pervasiveness of early-onset Bipolar Disorder. Until fairly recently popular wisdom had that Bipolar Disorder was "a grownup's disorder." Today any practitioner will tell you that in the absence of significant personal and family history, the establishment of a bipolar diagnosis is extremely difficult. So much the more for children, particularly when we are not conditioned to routinely look for manic depressive features.
The Papoloses also discuss the troubling prospect that disorders of mood are gradually increasing in scope and intensity in America and appearing at earlier ages than ever before. I do not expect that this contention will go unchallenged. But if the authors are anywhere near correct in this contention, our research into the causes and treatment of many children's mental disorders, which now appear inherited and to emanate from the frontal regions of the brain, must accelerate not only for the safety of our children and families, but as a humane gesture to their suffering.
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- Reviewed in the United States on January 29, 2004
- Reviewed in the United States on December 28, 2001
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- WhiteWitchReviewed in Canada on August 5, 2012
Great book for understanding the illness!
