Is My Child "Bipolar"?
Siegfried Othmer
This diagnostic category for childhood misbehavior can be said to be currently under construction, and this is only the first "disclaimer" for what follows. The second disclaimer is that with respect to neurofeedback it is not all that important whether particular diagnostic criteria are met. After all, no one is trying to make a decision here as to whether to medicate and how to do it. We are simply bringing a technique to bear that can help the child toward improved self-regulation.
Not long ago it was believed that Bipolar Disorder is something that developed over many years, and did not really "mature" into the full-blown syndrome until a person reached his twenties or even later. Over the past few years we have seen an intrusion of Bipolar Disorder into younger and younger children, some as young as 18 months (Papolos). This earlier onset is one piece of evidence for the proposition that the mental health of children is in some ways more precarious than that of earlier generations. It also had to be recognized that the marker for this condition was the high variability in mood---the rapid cycling part---rather than the specific behaviors we associate with adult Bipolar Disorder---mania and major depression.
The principal markers for early onset Bipolar Disorder are rage and wildly explosive behavior, as well as mindless and even violent defiance. These symptoms may alternate with periods of calm, and the cycling between them may be rapid, with cycling at greater than daily rates (called ultra-rapid cycling by Papolos). Given the fact that rapid cycling in adults is a sign of advanced stage in development of the condition, seeing rapid cycling so early in childhood has ominous implications for the further development of this condition. If the cycling is diurnal, one may have a situation in which the child actually does relatively well in school but falls apart later in the day at home.
Other symptoms that have been identified with this condition are marked irritability, oppositionality, aggressive behavior, racing thoughts, and grandiosity. On the other side there can be over-sensitivity generally. Often Bipolar Children can show the symptoms of Oppositional-Defiant Disorder and of Conduct Disorder (a propensity to start fights and to set fires. There is also overlap with other conditions, such as Tourette Syndrome, Obsessive-Compulsive Disorder, and temporal lobe or complex partial seizures and the sub-clinical variants of these conditions. In the case of co-occurrence with Tourette Syndrome one may see not only motor and vocal tics but risk-seeking behavior and hyper-sexuality. There may be extreme sensitivity to humiliation or perceived slights. The child may be very difficult to reward or to sanction. Co-occurrence of Obsessive-Compulsive Disorder involves the presence of obsessive and compulsive behaviors. (However, such behaviors may be unobtrusive to the parent, who may indeed have no idea about their existence.) In the case of temporal lobe seizure susceptibility (even in the absence of overt seizures) one may see night terrors, hallucinations, paranoia, suicidal ideation, and episodic bizarre behavior. If the child also exhibits a strong craving for sweets, there may also be a hypoglycemic or dysglycemic tendency that would tend to make all other symptoms worse. Other common symptoms relate to sleep and appetite disregulation. Another signature is that these children have a history of being very active in utero.
One reason that more children of this kind are being seen today than
ever before has to do with the fact that so many more children are being
medicated these days with stimulants and anti-depressants. These children
may initially respond favorably to such medications, but after a time
their behavior deteriorates. Since the intensive medical treatment of
these children is the new ingredient here, there is the strong suspicion
that these medications, when they are inappropriately prescribed, actually
make things worse for the child over time. This is certainly the impression
of Demitri Papolos, author (with his wife Janice) of the book The Bipolar
Child. Papolos suggests that as many as 60% of children diagnosed with
unipolar depression may convert to the bipolar form over time, and that
the use of either stimulants or anti-depressants with this population
may in fact precipitate rapid cycling.
The medical recourse for these children is the use of anti-psychotic and
anti-convulsant medications and/or lithium. These may include Risperdal,
Zyprexa, Neurontin, Depakote, and Tegretol. These are major medications,
with non-trivial side effects. They may be used in conjunction with stimulants
and anti-depressants.
From our neurofeedback perspective, Bipolar Disorder in children is to be seen through our basic Disregulation Model. This means that these young brains are simply not sufficiently regulated so as to be stable, and the resulting instability manifests itself in a variety of classic forms. In this manner, we interpret both the mood instabilities, the sleep and appetite disregulations, and the hypoglycemia as all manifesting one or another aspect of brain disregulation. This instability can be so severe as to manifest in night terrors or even in overt seizures. The uncontrollable rages may also be seen as disregulations that are paroxysmal, or seizure-like.
Neurofeedback can then be seen as a means of training the brain toward stability and improved self-regulation. The relative ease or difficulty of accomplishing this is not somehow proportionate to the severity or intractibility of the behavior. Some children are more readily trained than others, and the adverse behavior simply falls away and becomes a non-issue. It is therefore not to be assumed that overt seizures are more difficult to control with neurofeedback than less catastrophic temper tantrums. That may indeed be the case, but not necessarily.
The urgency of bringing the technique of neurofeedback to this vulnerable population is great, given the likelihood that the strong medications currently employed will ultimately exact a price in terms of further brain disregulation. After all, the outcome of long-term application of these medications is unknown, and it will probably be years before an empirical basis exists to assess such effects.
A parent may feel relieved to experience the rather immediate symptom reduction afforded by these medications, but the attempt should be made to employ other remedies so that these medications may be tapered down over time, hopefully before the brain grows dependent on them.
Finally, then, how is the question to be answered, "Is my child bipolar?" Hopefully, the vigilant parent would regard any of the above symptoms, if they are persistent and obtrusive, as a reason to seek help. Whether a child meets a specific set of diagnostic criteria may be important if the administration of Zyprexa is at issue, but not when the question is whether the child, or the family, needs some kind of help. Parents should not accept symptoms like the above as part of the normal experience of family life. Also, parents should not assume that tendencies in these directions are necessarily the outcome of bad parenting, even though we know it is difficult to parent these children well.
Finally, it is the strength of the neurofeedback technique to increase the stability of function of the nervous system. There may be no better remedy on the horizon to complement the medical response than neurofeedback. It is recommended that parents of such difficult children seek out a practitioner and explore this remedy for their family. There may be a life-long benefit from such intervention.