StorkNet interview with
Judith S. Lederman and Candida Fink, M.D.
Authors of
The Ups and Downs of Raising a Bipolar Child

Judith S. Lederman
In her new book, The Ups & Downs of Raising a Bipolar Child: A Survival Guide for Parents, Judith S. Lederman presents her own personal seesaw experience as parent of child with bipolar disorder. Lederman decided to write her book after years of coping with her son, who was diagnosed at age eight. After helping her son through four hospitalizations and a plethora of psychotrophic medications and treatments, Lederman describes the project as revenge and survival against a disease that branded, isolated, and deeply affected not only her son, but also the entire family.

"I knew that he was not alone. Somewhere in my heart I knew that neither of us were alone," explains Ms. Lederman. "But there were too many days where no matter what I did for him, his moods were calling the shots."

A journalist, Scout leader and public relations professional, Lederman in addition to writing about her son's illness, has penned other articles on parenting subjects for national media, including The New York Times. Among her favorite topics to write and talk about is the state of childcare. She has hosted the radio show, "Beyond Childcare With Judith Lederman" and has appeared on Oprah, Court TV, CNN, Dateline NBC and in many other news outlets. She lives in Westchester, New York. Please visit Judith's site: Parenting Bipolars, A Survival Guide for Parents.

Candida Fink, M.D.
Candida Fink, MD is a Board Certified Child and Adolescent Psychiatrist who graduated from Boston University Medical School and did her postgraduate training through Harvard Medical School. She did her general psychiatry residency at Beth Israel Hospital in Boston and completed her child psychiatry fellowship and a neurodevelopment fellowship at Children's Hospital in Boston.

Dr. Fink has worked extensively with children and adolescents with complicated psychiatric illness. She practiced in a number of inpatient and residential treatment programs in Arizona, Nevada and New York. She developed and directed a specialized residential treatment unit for adolescents with mental illness and mental retardation in Phoenix, Arizona.

She was Medical Director of the child and adolescent inpatient unit at West Hills Hospital in Reno, Nevada, as well. In 1998 she was recruited to be the Medical Director of the adolescent inpatient unit at New York Hospital, Westchester Division, in White Plains, New York, an affiliate of the Cornell College of Medicine. Dr. Fink was an Assistant Professor of Psychiatry at the Cornell College of Medicine during her tenure there. She has also taught residents, fellows, and medical students from Harvard Medical School, University of Arizona School of Medicine and University of Nevada School of Medicine.

Dr. Fink's current practice is focused on complex diagnostic and treatment questions in children and adolescents with mental illness. She is an expert in psychopharmacology and developmental psychopathology. Mood disorders, especially the diagnostic and treatment questions surrounding pediatric bipolar disorder, constitute much of her practice. Dr. Fink is particularly interested in the neurodevelopmental understanding of emotional and behavioral disorders in children. She has a strong background in cognitive/behavioral approaches to mood and anxiety disorders. Dr. Fink continues to maintain a specialty interest in learning and developmental disabilities and their overlap with psychiatric symptoms. The mother of two daughters, ages 12 and 8, she lives in Westchester, New York. Please visit Dr. Fink's website.

To Purchase:

"Bipolar disorder is a very real, very treatable physical brain disorder. This energetic disturbance with its fluctuating mood states frequently co-exists with other mental illnesses, such as ADHD, anxiety disorder, eating disorder, obsessive-compulsive disorder, substance abuse, and Tourettes syndrome."

Read more on Judith's website here.

Authors Judith Lederman and Candida Fink, M.D. are here to discuss bipolar disorder, which has recently been identified as one of the most misunderstood and under-diagnosed conditions of childhood. In their new book, about to be released November 4th, they explain that bipolar is a very treatable physical brain disorder. Their comprehensive, compassionate and practical guide to coping with this challenging diagnosis guides the reader in providing care and support for the child and the entire family.

Our guests answered questions about mood disorders, bipolar disorder, diagnosis, dealing with health care professionals, puberty and hormonal shifts, choosing a school, medications and their importance, how to handle situations with a child with special psychiatric needs, and many related issues. Take a moment to read the review of The Ups and Downs of Raising a Bipolar Child, then review our interview with the authors who answered a variety of helpful questions.


Kathi: My son is now 7 and last summer was evaluated by a psychiatrist. One week before Kindergarten ended he went into a rage and threatening to use his 'super powers' to 'kill' the playground teacher. He was an easy baby and a particularly difficult toddler and preschooler. At this time he's doing great, but the past 3 years he has been particularly difficult during Spring.

The doctor's 'diagnosis' was for me to read The Bi-Polar Child and then come back in six weeks and tell him what I think (since I spend more time with him). I read (choked down) the book and some of it I felt 'fit' and some of it did not fit at all. I am not really sure where to go from here. Neither my husband or I want to see this doctor again. Frankly, my husband wants to chalk it up to him being a kid but then he has little respect for the profession.

We are considering UCLA as that is where our boys have their pede's and our insurance is flexible.

The first doctor said he was 'leaning' toward bi-polar for him due to our family history (I am bi-polar II).

I plan to buy your book and wonder if you have any other suggestions for me. I don't want to jump the gun and medicate him if he doesn't need it but it was terrible to watch how hard this past spring was for him. Thanks in advance and sorry so long! Kathi

Judith S. Lederman: Hi Kathi. Determining whether a child is suffering from bipolar disorder is truly not an easy thing--even for psychiatrists, pediatricians and other healthcare providers. How much more difficult is it for parents like us!

I know that my co-author, Candida will give you the doctor's perspective. In my own opinion and from my own experience, this illness has such a variable nature (it CAN fluctuate seasonally) and it is so often found in combination with other problems (ADHD, OCD, etc.), that we as parents may always be dealing with an element of doubt. Since there is no blood test or gene test yet that can determine whether a child is definitively bipolar, doctors tend to treat the symptoms. If your child is currently doing well, leave well enough alone and enjoy the stability of the season. But do keep an eye on moods and behavior and if his energy level shifts, address the problem pronto. Your best bet is to find a doctor who can take a careful family history (history can indicate whether bipolar illness is somewhere on your family tree), observe your child closely, medicate if necessary accordingly, and guide you through the "therapy zone"--helping you and your child get the support you both need to navigate his issues. ~Judy Lederman

Beth: Dear Judith and Candida, I just read that they now call all manic depressives, bi-polar. Is this true? One Internet page I was reading was discussing how "some" bi-polars experience the manic part in the Spring and the depression starts in the Fall. I'd love to know more if this is true. Thank you.

Judith S. Lederman: Beth: Manic-depression has been called many things. My father-in-law was diagnosed with "Involutional Melancholia" back in the 50's. Now it is called Bipolar Disorder. Bipolar Disorder is an extreme energy and mood disturbance that fluctuates between high energy/mania and low energy/depression. In adults the mood changes can span over months. Children can cycle daily--even hourly--back and forth from mood to mood. Sometimes the moods are influenced by seasonal affective disorder--the amount of sunlight--but not always. Sometimes the moods are triggered by other influential factors. Mood stabilizers, light treatment, omega three oils are all used to try and control the chemicals that cause the moods to flip flop. I'm sure my co-author, Dr. Fink can tell you more... ~Judy Lederman

Gayesy: Hello! I am so very glad that you are here to answer questions about this topic and the timing couldn't be better for me. My six-year-old was diagnosed with ADHD back in March. After much soul-searching we decided to give him a trial on Ritalin. It sent him totally "nutty". He has been having huge mood swings for some time now (started before the Ritalin trial, but it's getting worse over time): it's almost like I'm living with several different little boys. I have been reading and reading about early-onset bipolar and what I read sounds just like my child.

My problem is that no professional will take my concerns seriously (except the pediatrician, but he says he isn't expert enough to diagnose and that's fair enough). One psychiatrist told me I had a very bright child (he is almost off the scale in IQ), and needed to learn some discipline techniques! (Like I haven't tried just about everything already!) Another one has been more helpful but says that "in America (I'm in Austalia) anyone who ever has a mood swing is labelled bipolar these days", discounting all my research in a single swoop.

What do I do? I am not actually WANTING a diagosis of bipolar (I hope I am wrong), but if this is the problem then I want my son treated as soon as possible, not only for his benefit but for the whole family. I'm really not sure how much more of this we can all take to be honest. Thank you so much and bless you for your work.

Judith S. Lederman: Hi, Gayesy. Nobody wants a diagnosis of bipolar disorder, but getting a diagnosis can be a relief in that finally the batch of symptoms that you and your child have been dealing with have a name! Visit the Child & Adolescent Bipolar Foundation at www.bpkids.org and check out their listing of health care providers who deal with early onset bipolar disorder. Hopefully there is one or two in your neighborhood--and in your insurance network. (There are two listed there in Australia.)

Because bipolar disorder is so new, many health care providers--even savvy and long-time practicing psychiatrists, may not be that familiar with the "kiddie" version. It is also a very controversial diagnosis and it pairs with and imitates other psychiatric disorders (like ADHD) so sometimes there is a "trial & error" period that can result in a child getting medications that actually exacerbate the condition (stimulants and SSRI antidepressants are known to do that). I will probably say this frequently on this board--Get Thee to a Knowledgeable Child Psychiatrist. This is the only way you'll be able to assess and know exactly what you're dealing with! Good luck. ~Judy Lederman

Anita: Hi! I am wondering how bipolar is diagnosed in children. What steps are involved? I know that other conditions might mimic bipolar in a child (or coexist with it). How can they be ruled out and a firm diagnosis be made? Thanks so much!

Candida Fink, M.D.: Dear Anita - Your question is at the heart of much current research in child psychiatry. The answer is not clear yet. But here is some of what we know.

Bipolar disorder is not diagnosed by a blood test or a scan or even a psychological; "pen and paper" test. The diagnosis of all psychiatric disorders is made by history and observation. To be "diagnosed" means to exhibit a certain pattern of symptoms that are consistent with a pattern of mood called "bipolar disorder."

Adults have typically been called bipolar if they exhibit patterns of periods of mania and periods of depression, with the episodes lasting weeks to months usually. To be bipolar someone must have at least one episode of mania. To be manic one must have the following symptoms (from the DSM IV).

A distinct period of abnormally elevated, expansive or irritable mood lasting at least one week. During this period 3 or more of the following symptoms must be present (4 if the chief mood in the above criteria is irritable)

  • inflated self esteem or grandiosity
  • decreased need for sleep
  • very talkative - pressure to keep talking
  • racing thoughts or "flight of ideas" - hard to follow their speech
  • distractibility
  • increase in goal directed activity or psychomotor agitation
  • excessive involvement in pleasurable activities that have a high potential for painful consequences

As you can see, a number of these symptoms overlap with ADHD--excessive motor activity, excessive talking, distractibility, impulsivity (pursuit of pleasurable activities disregarding consequences). This is why the debate rages about the overlap between bipolar disorder and ADHD. To be manic though, there must be some element of either euphoria (extremely happy - unreasonably and persistently so) and/or grandiosity - way out of proportion sense of one's powers and abilities. If they are just irritable or moody--without grandiosity or some periods of euphoria--it is harder to diagnose mania--because irritability and moodiness (mood reactivity) can be a symptom of many things--depression, anxiety, sleep deprivation, pain, and typical adolescence to name a few.

The episode duration is one of the biggest questions in diagnosing kids. Kids are typically described as having mood cycles very frequently--up to many times per day. This is quite different than the criteria listed for mania in the DSM IV. However, we know that kids brains are less specialized in their development, so we might expect to see mood episodes that were less well defined. And, even in adults there is research indicating that mood reactivity and irritability--without necessarily sustained mood episodes--could be a variant of bipolar disorder. The problem is, as I noted above, irritability and reactivity can be the result of many different disorders and circumstances, so relying on pure irritability and "moodiness" --ie up and down many times per day--is not adequate to make the diagnosis of bipolar disorder in kids or adults at this time.

Keep in mind that we are still diagnosing by description in psychiatry. We don't diagnose a particular area of the brain or transmitter pathway that is "broken." We describe a collection of symptoms that are present in large groups of people and we create categories that we call "disorders." The brain doesn't "get bipolar disease." Pathways are disrupted in the brain and we see a pattern that we call "bipolar disorder." It is our description--not the brain changes--that we call bipolar. This is very imprecise and artificial. As brain science progresses we will be much better able to define and clarify the different brain pathways that become disturbed and present as mood disorders.

It's like the old days when doctors could only say that a patient had fever. It wasn't until better research led to the discovery of bacteria and viruses that actually cause fevers, and we could diagnose and treat more precisely.

I wish the answer were less complicated, but understanding this information is really important in pursuing help for your child. ~Candida Fink, M.D.

Tammy: I am wondering what percentage of children who have been diagnosed with ADHD actually have bipolar instead (or as well as the ADHD). Thank you.

Candida Fink, M.D.: Dear Tammy: This question is very difficult to answer in any firm way. It is clear, from many studies, that Bipolar Disorder and ADHD overlap in adult patients. But the distinction is fairly clear by the time a person's brain is fully "grown up." In children, the initial interest in pediatric bipolar disorder was raised by the finding in one university clinic that a large group of children with severe, treatment resistant ADHD might actually be suffering from some form of bipolar disorder. The distinctions are harder to make in children--and the studies are still working on defining the distinctions--so we don't know yet what the data will say about percentage rates of ADHD and bipolar disorder in kids.

We know that a recent large study of adults indicated that about 3% of adults in a community sample (meaning just everyday people--not people in a clinic or hospital) meet the diagnostic criteria for some form of bipolar disorder. That is a lot of people! Presumable about 3% of children then are future bipolar patients.

The studies of ADHD in children show about 5% of kids meet criteria for ADHD in a community sample. So, how those numbers overlap and change over development from childhood to adulthood remains to be seen. Are some of these 5% also diagnosed with bipolar disorder? Are some misdiagnosed and are really only bipolar disorder? The studies are being done as you read this, but it will be years before we have more answers. ~Candida Fink, M.D.

Gayesy: If it is found that a child has bipolar, what is the chance that a parent also has the condition? And conversely, if a parent is bipolar, what likelihood is there that the children will have the condition? Thank you.

Candida Fink, M.D.: Dear Gayesy: The genetics of bipolar disorder are complex and so there is not one answer to your question. We know that bipolar disorder is highly heritable. For example, in identical twins (with the same genetic makeup) there is a very likelihood that they will both have Bipolar Disorder. With parents, the risk is lower because children don't have identical genes to their parents. But it is still a high risk. These numbers, though, come from people diagnosed with Bipolar I disorder, the most classical and severe type of bipolar. We have much less information on genetic risks of Bipolar II and Bipolar Not Otherwise Specified.

In terms of understanding early onset bipolar disorder, the data seems to indicate that it is even more "heritable" (genetic in origin) than late onset bipolar. In other words, a child can only develop early bipolar disorder if they have a lot of the genes needed to create the disorder. Otherwise, the disorder would show up in more typical form in adulthood.

But we don't yet have numbers. This information that we have indicates strong genetic associations between parents and children in both directions. Better numbers will be available as the genome studies are completed. The genetic research is moving ahead quickly and will give us a lot more data on the actual causes of bipolar disorder as well as the risks of it developing.

Cindy: If a child is diagnosed with bipolar and appropriate treatment is found, what does the future hold? Are things likely to improve and stay manageable, or do things get worse as adolescence and adulthood approach? I know that my husband's uncle with bipolar has had many failed relationships and even years unable to work because of his condition and it worries me greatly that if my little boy is diagnosed with bipolar his future will be a big mess.

Candida Fink, M.D.: Dear Cindy: Prognosis is variable in bipolar disorder. In adults with classic Bipolar I disorder the symptoms can be managed well in over 50% of patients, with good function being maintained. In even more patients the episodes of mania and depression can be reduced in severity and frequency with treatment. Suicide risk in these patients is dramatically reduced with the use of Lithium as a maintenance drug.

In children, the diagnoses are still very poorly defined, and prognosis is not well studied. We have no large scale studies looking at these children as they grow up. A tiny study was done in Australia that showed boys with ADHD and manic symptoms did not typically have bipolar disorder at age 21 but they did have lower levels of function. We know that children who are struggling with mood instability and significant behavioral disturbances have higher risks of problems in adulthood.

What we don't know yet is how protective it is to have early diagnosis and treatment of bipolar and mood disorders in children. In ADHD treatment we have some data - ie that children who are treated for their ADHD show lower risks of substance abuse in adulthood. We don't know yet what treatment for pediatric mood disorders will offer.

My conclusion based on what we do know is that untreated mood disorders clearly have higher risk of problems later on. Judicious, careful treatment is unlikely to make things worse and may well make things better. In response to your concern that if your son is diagnosed his life will be a mess--remember that the disorder is present with or without the diagnosis. If he has a mood disturbance--his life will suffer from it--regardless of whether or not he is "labeled." Lack of appropriate support and treatment will create a mess. Identifying it and seeking intervention is your best bet for preventing more difficulties later on. ~Candida Fink, M.D.

Jodi: Judith and Candida, I'm not sure if you deal with adults, but here goes... I'm 27 years old and have one child. When I was younger I looked after myself, my house, everything. I now have gained a lot of weight, have a bad temper, and am just not motivated. I'm a SAHM (stay at home mom) but the computer rules me. I'm sad to say that I don't do housework. My house is a mess, beyond a mess. I'm neglecting my husband and my child and I feel awful. I even tried Flylady's suggestions once and I did really good for a bit--then that was it--it stopped. I'm not happy with who I am or what I'm doing. I hate where we live and what I've become. I'm also dealing with a special needs child which really is hard. I guess I'm contacting you as a last ditch effort. Sometimes I think I might have a disorder, but I want to be normal. I don't want to go on meds and see a shrink. Please, any advice would be great.

Candida Fink, M.D.: I am so sorry to hear how much you are struggling. You sound very tired and sad and overwhelmed. I hope that you will speak to your physician about these symptoms immediately. Your low energy and other symptoms could be caused by medical diagnoses such as low thyroid or vitamin deficiencies. Depression is also a medical illness. And your physician can diagnose this and treat it effectively. It is not a weakness or a lack of willpower. If it is depression, you are suffering from a major medical illness that carries risks of other complications (depressed people suffer from more heart disease for example). Depression is no less of an illness than something like diabetes. You wouldn't think someone was weak for treating their diabetes, would you? Diabetics have to manage their illness with medication and diet and lifestyle adjustments. It is identical with depression and other mood disorders. And, like diabetes, if depression is untreated, many more complications will develop. If only for your child, who clearly needs you around and healthy to get through his challenges, please seek medical attention for this serious condition immediately. Sincerely, Candida Fink M.D.

William: Since our 10 year old son has been put on medication he's gaining weight. Is this normal, and what can we do? He's active and we don't allow him to just sit and watch TV or play video games. Should we try another med? My wife doesn't seem to be concerned, but I am. William

Candida Fink, M.D.: Hi William. Weight gain is a common side effect of medications for mood disorders. Sometimes it is so much of a problem that you have to change medicines. Sometimes it is manageable. The decision is really based on the balance of good effects and side effects. If your son is having a great, positive response to his medication, you may want to push harder to find ways to manage the weight gain, or you may tolerate a little weight gain as a side effect. If the medicine isn't giving him a lot of benefit for his mood disorder, you may want to discuss with your doctor the idea of changing medicines. Unfortunately, weight gain is a side effect of almost all of the medicines, but there are some newer options without this risk. So speak to your doctor about this difficult issue. Good luck.

Ann: I have a 10 year-old who has been diagnosed with depression and possibly bipolar. The psychologist, and child psychologist she has been seeing for the past two years, are very concerned about her. I have been dealing with her ups and downs for so long that I have been wondering what I am doing wrong with her. I am divorced from her father and she doesn't have a real good relationship with him. Her father has a history of bipolar himself, and it's in his family. My daughter is currently on Zoloft and it helps control her outburst and she is able to focus on doing her homework to a point. The doctors have given me literature to read about medication treatments to prepare me for what she may have to go through. The doctor thinks we may be able to control her with medication for awhile, and then she may get worse and need other types of medication. Are there any other things I need to talk to her doctors about? Anything else I need to be looking out for? Thank you. Ann

Judith S. Lederman: Hi, Ann. First of all you are doing nothing wrong with your daughter. You are doing everything right! You are getting her help and for that you should be congratulated. <applause!> Whether her moods are situational or biological, you should not judge your parenting by her ups and downs. That is unfair for any parent but especially for one like you who is obviously trying to get your daughter treatment. My co-author Dr. Fink can tell you more about the medications, but I will tell you this: many children with bipolar disorder don't do well on SSRI's (like Zoloft) or stimulants (like Ritalin or Adderall) unless they take a Mood Stabilizer first. Make sure that your daughter's docs have a good familiarity with all the meds out there and don't be scared if they start experimenting with them until they find the right cocktail (the mix that will hopefully get your daughter into a better state). Monitor your daughter's moods (There are some great mood charts on the CABF site) to see how the medications are working and to assess their value. Make sure that she continues in therapy with a trusted therapist because the therapy/medication combo has been shown to be far more effective than drugs or therapy alone. Be there for her and remember that you ARE a good mother. Let that become your new mantra. Good luck! ~Judy

Liz: My husband has been diagnosed as bipolar, type 2. I've been told there is a genetic factor in developing bipolar disorder. Exactly how significant is the genetic link? What is the probability that my precocious four-year-old daughter will develop this disorder? (By the way, her pediatrician said she was precocious, not me *wink*.)

She has not had any significant behavioral problems to date. What types of behaviors or changes in behavior should I watch for? I hope and pray that she doesn't develop this disorder, but if she does, I want her to get help right away. Looking back, we believe her father actually fell into the category of early onset, but wasn't diagnosed until his late 30's. I'm sure you can imagine the trouble he got into before he was diagnosed, and we don't want that to happen to our child.

With early onset bipolar disorder, are there any developmental milestones that are considered triggers? My husband's psychiatrist told us that the onset of puberty would often trigger the first depressive cycle. He didn't really seem to know much about early onset bipolar disorder. Are there other points in my daughter's life that we should be particularly vigilant about watching for signs?

Judith S. Lederman: Yes, bipolar disorder is congenital and if one parent (or grandparent or sibling) has it, a child has a chance of having that gene. It is widely believed that even if you have the gene, it may not necessarily express unless an environmental trigger makes it happen. So there is nature as well as nurture involved when a child develops bipolar illness. What that trigger is, can vary from one child to the next and will depend on the psychological makeup of the child. It sounds like you are very worried about your daughter developing bipolar disorder.

Try not to put her under a microscope but DO keep an eye on her moods. When something is wrong, you as a mom will usually be the first one to know it. Many of the moms I interviewed for my book said that they knew by intuition--a gut feeling--that their child wasn't reacting the way "normal" children reacted. Many children with the illness had SEVERE separation anxieties. Many parents had been through ridiculous numbers of childcare providers because no one could handle their child. Many witnessed extreme tantrums that seemed to never end and some very young children even threatened themselves or others--had very poor impulse control. Mind you, none of these things in and of themselves means that your child has bipolar disorder. Only a good and experienced child psychiatrist is qualified to make that determination. Regarding puberty, shifting hormones can trigger or exacerbate the mood swings. But if you're not seeing anything but a precocious four-year old, RELAX! Enjoy your beautiful child and give her your all! And trust your own maternal instinct. Mother almost always knows best! ~Judy

Orlyn: My husband is bipolar and he takes quite a cocktail of medications to control his disorder. However, sometimes during times of stress or illness, the medications aren't enough and he has a "breakthrough" cycle. So far, my toddler hasn't shown any signs of the disorder, but I would like some suggestions on how to talk to her about her dad's occasional erratic behaviors. His manic phase tends to be more on the aggressive, angry side. It clearly upsets her when daddy is angry and she doesn't understand. Do you have any suggestions for helping her understand the situation?

Judith S. Lederman: How do you explain to a child why Daddy gets angry? Tough question. There is a brand new children's book that is a MUST-READ for any child with a Bipolar parent. It is called Sometimes My Mommy Gets Angry by Bebe Moore-Campbell and it discusses just this sort of situation in words and illustrations that a child can easily relate to. Even an older child (and spouse) may have trouble understanding that moods are driven by something other than anger targeted at them. When your child gets a little older she may need therapy to help her realize that it is the illness, not her Daddy that says mean things and loses control. I realize that this is a tough situation for both of you, and it may be doubly hard for you because there will be times when you will have to "take over" in terms of letting your child know that she IS good even if Daddy is having an off day. Good luck. ~Judy

Rachael: Hello and thank you for being here! I'm just a bundle of nerves. My daughter is 9 years old. Over the last year I've noticed her emotions at a high or a low, but decreasingly in between. At first I thought it was changing hormones already, but her body isn't changing. So now I'm worried. My mother is diagnosed bipolar, but she is so far, the only one in our family. I don't suffer from mood disorders, nor does my brother. Back to my daughter... she is increasingly going "over the edge" over small things like having to go on errands with me, losing at a game, if a friend forgets to call her, being asked to get back to her homework, just about anything. She cries easily, and her anger is just getting out of hand. Then other times, she's like someone else - calm, happy, and easy to talk to. I never know which person I'm going to meet. I keep thinking this is prepuberty, but then, I don't know. I'm very scared as her mother. Judith, please tell me what it is like, and if you have any tips. Candida, should I have her diagnosed? Do all kids who go get checked for this turn out to be bipolar? Worried and scared. Rachael

Candida Fink, M.D.: Dear Rachel, You are in the middle of a developmental "storm" that can be tough to navigate with or without a mood disorder. Even though your daughter's body isn't changing yet, her hormones are changing rapidly. So at least some of this is "pre teen" moodiness. Also, as children approach adolescence, not just hormones change but the brain itself changes. Patterns of communication between brain cells reorganize and the brain takes on (gradually) more adult like patterns. But this is a very difficult period because change is happening so quickly.

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Adolescence is a time when mood disorders can present - because the brain looks more adult - and so adult disorders can become visible. Just like diabetes, the genes for mood disorders can lie dormant until a certain developmental period is achieved - then the illness presents itself.

Certainly not all children who are evaluated are diagnosed with mood disorders - bipolar, depression or otherwise. Keep in mind that mood shifts from moment to moment don't equal bipolar disorder. They can by symptomatic of many things, including typical adolescence.

Questions to ask yourself include whether or not her mood swings are interfering with her function at school or with friends. Or are you just getting this at home. How long does she take to settle from an "episode" of upset? Check with other parents to get some sense of how much of this is typical in your daughter's peers. Does your daughter present with mood symptoms in between her "reactions?" Is she less interested in activities or friends, has her sleep or appetite changed, is her energy different, is she having trouble concentrating, or is she suddenly involved in too many things or thinking she can manage too much or that she is overestimating her abilities?

Talk to your daughter. Ask her if she has noticed that her moods are sometimes difficult for her to control or tolerate - that she sometimes seems to be having a hard time. She may reject the conversation outright, or she may be relieved to talk to you about it.

Bottom line - if you are concerned about her function--and her moodiness is becoming more and more of an issue--you should see a child psychiatrist for a thorough evaluation. Even if she isn't diagnosed, you will then have more of an idea what to look for in the future. Sincerely, Candida Fink M.D.

Liz: I was just diagnosed a year or so ago with Bipolar disorder. Its not extreme. I was just having major cycling at one point when my stress was high and it was affected by my sleep patterns. I seem to have found the magic combination of pills--I am taking Wellbutrin and Lamictyl. My question is, is bipolar hereditary? I know depression seems to be. My son is 9 and I see signs of some emotional issues. I am worried about him because obviously I would not wish this on anyone. But I just want to be prepared for any future setbacks he may have.

Candida Fink, M.D.: Dear Liz - Great news that you are taking such good care of yourself and managing your own mood disorder effectively. That will benefit you and your family. Yes, mood disorders have a genetic connection--so that if you have a close relative with a mood disorder--you are more likely to have mood disorder. Not every child with a parent with bipolar or unipolar depression will develop a mood disorder. But you are right to have an eye out for any indications. If you are concerned, you should see a child psychiatrist who can do a comprehensive evaluation. From there you will be able to decide if your son needs treatment (which could include therapy or medication or other interventions) or if you should just continue to keep an eye on things. The psychiatrist could also recommend further testing as part of the evaluation.

You will be much more prepared to help your son with whatever comes his way if you are active in getting information and support. You have done so for yourself, and I know you will do so for your son. You could ask your own psychiatrist about a referral to a child psychiatrist. Wishing you the best. ~ Candida Fink M.D.

Debsy: My four-year-old daughter has times when she will be very depressed and quiet, and hang out in her room a lot. She is being really mean to her sister. She has taken to hitting her, pulling her hair and not talking nicely to her at all. She talks back to her father and me, and doesn't seem to care how she treats anyone. Another thing is that she is constantly either in tears, very happy, or very sad. And other times she talks so fast it comes out as jibberish! This summer she was just fine and now that Fall is upon us she is like another person! Do seasons play a role in their behavior? And if so how and what can be done to help my little one? I should add that her father was just recently diagnosed bipolar. What steps do I need to take? It has been one thing to have my husband diagnosed, but to now look at my daughter, it just overwhelming in itself! I think what you guys are doing is just wonderful!

Judith S. Lederman: Hi Debsy. Wow, it sounds like you've got a lot on your plate. Yes, the moods in a child diagnosed with bipolar disorder can certainly be exacerbated by seasons. There are numerous therapies that can help this, including medication and carefully monitored "light therapy" (carefully monitored because too much light can make a bipolar child more manic).

If you suspect that your daughter's moods are extreme, here are some steps to take. First of all, identify a good Child Psychiatrist in your area who is knowledgeable about various mood disorders in children. Make an appointment to meet. Before your appointment, carefully record your daughter's moods. If you would like, download a mood chart from www.bpkids.org. They've got several on the site. There are also some in our book, The Ups & Downs of Raising a Bipolar Child. When you visit the psychiatrist for the first time, show him/her the mood chart and give him your family history, especially the part about your husband being diagnosed bipolar. He will be able to determine based on the information you give him and bring him, and on his observations and testing of your daughter, whether this might be a case of early onset bipolar disorder or some other problem. He will also be able to recommend a course of treatment. Good luck. ~Judy

StorkNet Member: At what age would you expect a child to benefit from "talk therapy"? I realize that bipolar is a physical disorder and medications are needed to control it. However, I also feel that talk therapy has a place in the treatment plan. Both for the person affected with the disorder and for his/ her family members. My daughter has not shown signs of the disorder; however my husband has the disorder. Also we are the primary caretakers for my mother-in-law who lives with us and is suffering from Alzheimers.

On top of this my father lived with us when he had cancer until his death. It's been two years since his passing, but my 4-year-old still talks about how much she misses her grandpa. She remembers every hospital he was ever in and regularly asks to visit him at the hospital. To add to her sense of loss her favorite cat died. Then her other grandfather passed away in April. I think she is keying off my depression, grief, and stress levels.

I'm already in talk therapy for my own issues and I see a psychiatrist for antidepressants and anti-anxiety medication. My marriage is not a very healthy one (for reasons besides my husband's illness.) I'm making plans to leave and take my 4-year-old daughter.

When should I (if at all) get my daughter involved in therapy? Her pediatrician, preschool teachers, and dance class teachers all tell me she is well adjusted and a high achiever for her age. I just worry because she has so much than Barbie on her tiny little kiddy plate. She seems to worry a lot about me, her daddy, and her grandma. She also misses my father and her cat a great deal.

Yesterday she told me she was really sad that my father had died, but she was afraid to talk about it because she didn't want to make me cry. I tried to explain that crying wasn't bad, and that it was good to share sad feelings with each other. She has also expresses a great deal of fear about dying. She is so worried that she is going to die or that I'm going to die in the very near term.

I'm wondering if she needs an outside person to talk to and if she's old enough to benefit from it.

Candida Fink, M.D.: I would absolutely encourage you to bring your daughter into some form of counseling at least briefly. First of all, she may be a "high achiever" but these high functioning kids are often very sad inside. Sounds like she wants to protect you from being sad - she needs to have a place to talk where she isn't afraid her thoughts and feelings will hurt someone. In addition, she will learn early on that talking and sorting things out is acceptable and a good way to solve problems and to learn how to feel better. She can develop "prophylactic" emotional skills that will help her navigate what lies ahead for her. She is a high risk kid - due to the family stress and her biology. Helping her feel strong and active in her emotional life will be extremely valuable to her as she grows. Take care of yourself and your little girl. ~Candida Fink MD

Judith S. Lederman: There are therapists that specialize in younger children and different kind of therapies that work for them. Play therapy, for instance, encourages a child to play and as she does, she will express her feelings. Given the stress that your daughter is under, the instability of your household and your own stress level, it is probably a good idea to find her someone to talk to on an occasional basis. If she is doing well and seems to like it--and the therapist feels she is benefiting--keep it going. I also recommend that you find yourself someone to talk too, besides the psychiatrist, because the optimal treatment for most psychiatric stresses and disorders is medication along with therapy. If you don't want to see a therapist, then join a support group to help you get through this difficult period in your life. Things will get better for you and your daughter. Good luck! ~Judy

StorkNet: Some of our readers have asked for feedback regarding a FDA public health advisory released on October 27th 2003 that discusses reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. One specific woman asked because her daughter is having some outbursts. Here is what Dr. Fink has to say:

Candida Fink, M.D.: This is a recycled issue - it was popular in the early days of Prozac. One of the possible side effects of the antidepressants is a paradoxical agitation. I have seen it on a number of occasions. It is not clear if there are certain types of kids who are more prone to this type of agitation - but there have been some suggestions that bipolar kids are at more risk. We know bipolar adults have some risk of becoming manic when they are given antidepressants.

The most important thing to remember is that all medications have benefits and risks. The idea is to outweigh the risks with the benefits. Depression and anxiety in children present risks of suicidal ideation when they are not treated. While suicidal ideation is possibly a serious risk of the medicine--although I think the data is still quite preliminary on this question--we have to be careful about all the serious risks when we give medications to children. Careful monitoring and judicious dosing are essential.

You should, of course, discuss these questions and concerns with your child's doctor. But if overall things are a lot better on the medication, be careful not to throw out the effective treatment because of a possible side effect seen in some kids - if your child isn't exhibiting these effects. Important questions are whether or not there were self-harm thoughts before the medication? Is the overall picture better or worse?

Try charting numbers of outbursts over medication trials. It is hard to remember accurately frequency and severity - so you are dealing with more 'objective" data if you have charted the episodes when they occur and then compare this to what dose of medication or what medication your child is taking. Always stay in contact with your child's doctor. Regards, Candida Fink M.D.

Bridget: Hi. My husband was diagnosed with bipolar disorder about eight or nine years ago when he was 16. He now takes medicine every day and night. I have known him for almost four years and have been married for about a year and a half. I really had no idea what bipolar was until I met him. A few months after we got married, he decided he didn't need his medicine anymore and went off of it. He acted soooo different. It was actually very scary! He would never sleep, and was very hyper. I was only 18, now 19. I really don't know how to explain how I was feeling except I was so scared he was never going to be 'normal' again. He didn't want to take his medicine again. It was so hard getting him to. We stayed at his parents while he was acting like that because I didn't know what to do. He had a very good job and lost it. We had to move because we couldn't afford the rent. It was just so awful. (By the way, it's been over a year, and we are doing so well, he has a very good job once again!) Anyway, we just had a baby in July. I really hope he isn't bipolar, but sometimes I do wonder. He is always very wiggly, never still unless he's asleep. It is so hard to get the little booger to nap, and he's only 3 1/2 months. He is already rolling over both ways. (Since before three months. He started one way at 6 1/2 weeks.) Maybe he's just very strong and active. At six weeks his doctor said he was very alert and strong. So what are the chances that he is bipolar? Does it sound like he might be? Or am I just worrying like first time moms do? Thanks in advance.

Candida Fink, M.D.: Dear Bridget - It sounds like you and your husband have conquered some big challenges already in your young lives. Good for all of you that he is getting treatment and doing well.

In terms of your baby - it is probably too early to tell anything at this time - except that he is active and strong. The most important thing for you to do is to be with him and love him and interact with him as much as possible. Babies learn how to soothe themselves from their parents soothing them and holding them. He will learn these skills from you now. If he does develop bipolar later in life - these skills will help him to manage the disease successfully.

By being brave and facing the illness you and your husband have created a positive legacy for your son - that will allow him to seek help if he needs it and to understand that mental illness is nothing to be ashamed of. Good luck to you - and keep holding that baby close to you! ~ Candida Fink M.D.

Shawn: My 10 year old son has some issues that involve attention, anger, anger toward siblings, anxiety, distraction, organization, and mood swings. His father was diagnosed as bipolar a few years ago, so naturally I worry that it will trickle down to my two boys. What should I be aware of and when should I seek a more formal diagnoses?

Candida Fink, M.D.: Dear Shawn, Since your son is exhibiting some mood symptoms and life difficulties, and his father is diagnosed with bipolar, you should get a complete evaluation to understand what is going on with your son. Keep an eye out for sleep problems - times of extremely high energy and little need for sleep. Also notice if he is "grandiose" in his thoughts - does he think he can run the universe or that he is better than everyone at everything or does he have huge projects going on that he can't possibly accomplish? Is there sadness or a lack of interest in things that he usually enjoys? Does he seem sluggish at times? Any hopelessness in his thinking? Does he still play with friends? Most importantly - take these types of observations and bring them to a child psychiatrist for a complete workup. Good luck to you and your son ~Dr. Fink

Meredith: Hello. I have a six-year-old child who hasn't actually been diagnosed with bipolar (yet, anyway) but has been described by his psychiatrist as having "mood instability." It is thought that this is due to anxiety rather than bipolar, but I am hoping that you could give some advice/tips for helping me deal with the mood swings and behaviour. The hardest things to cope with are the raging tantrums, the silly, risk taking behavior (we get a lot of injuries around here unfortunately), and the extreme negativity at times. I am finding "normal" discipline only works sometimes, when his mood is "normal." Thank you!

Candida Fink, M.D.: Dear Meredith - You hit the nail on the head when you say that typical parenting only works when your child is in a regular mood cycle. When the rages are close to the surface, it is important to shift your expectations - expect that almost every request or correction will be met with an outburst. And then, before you make the correction or request, ask yourself if it is really important enough to trigger an outburst over. Since the child is not able to control these outbursts, it makes sense to reduce the frequency however you can, even if it means dropping some things that you would always expect from a non-bipolar child. The child may have to leave the house without matching socks or wearing a crazy outfit that they picked out. They may have to have peanut butter and jelly for every meal for a week. They might not share well during those times.

With the risk taking behavior your best bet is creating an environment with as few risks as possible, and then supervising as well as possible. There is a limit to how much you can do this. But with a child who does not yet have good "self-control" wiring, you can't expect him to make those judgments for himself. His judgment is more like a two-year-old's rather than a six-year-old's. Good luck! ~ Dr. Fink

Lisa: I m bipolar II, currently not cycling and not medicated. I gave birth to my son on 8-22-03 and was wondering what are his chances of becoming bipolar also? I know he's too young to tell now, but are there signs in young children I should look for? If I do see some signs at what age do I start trying to do something about it, and what would I do? Thanks, Lisa

Candida Fink, M.D.: Dear Lisa: Of course you will be anxious about the possibility that your child may eventually develop a mood disorder. But you are way ahead of the game by being knowledgeable about your own illness and the genetic connections of mood disorders.

As I told another member - it will be hard to define a specific mood disorder in a very young child. Unmanageable mood episodes--when a toddler or preschooler doesn't seem to be learning how to soothe himself--would be a possible clue. Severe separation anxiety, sleep disturbances, or night terrors are other possible indicators of future mood disorder. I would develop a strong working relationship with your pediatrician and let her know of your concerns early on. This way you can work together to monitor your child's emotional and behavioral development. If your pediatrician seems uninformed about this area, try to educate her. If she isn't willing to learn, find one who is. Best of luck to both of you - Dr. Fink

StorkNet Member: Thank you for coming to StorkNet to help clear away some of the "mud" surrounding mental illness. Growing up, I had some friends with bipolar. As a high school teacher, I've had children in my classes with bipolar.

My son is in preschool, age 3 1/2, and his best friend at preschool is bipolar. The parents are still looking for the magic pill to medicate him with and all I know is that there have been a lot of trials with meds and nothing is doing what they hope.

How do I teach my son to deal with the emotional outbursts and keep him from emulating them? This child swears and really flips out when he is "manic."(When I say "swears" I mean that he is usually yelling while in that state.) He is such a sweet little boy otherwise, and I don't really want to discourage the friendship because learning how to deal with this is really a lifeskill for my child.

Suggestions about how to teach a "normal" child to deal with his bipolar friend?

Candida Fink, M.D.: You have really stumbled into such an important area for your son and for his friend. The compassion you express for your son's peer will come across loud and clear to your son and he will model that approach since that is what you have shown him. As your son becomes more verbal you can use words to talk about his friends "anger" troubles or "feelings" troubles. It is helpful to identify that there is a problem but also being clear everyone has problems and this little boy can still be friend's with your son.

Modeling is usually short-lived - even in siblings. Since children almost always want to do well and be successful with adults they will do what they can to meet your expectations. If your son doesn't get positive reinforcement for the behaviors he will stop doing them quickly. The problem with a bipolar child is that they don't know how to stop the behaviors so they just keep repeating the same patterns.

Learning how to avoid triggers and how to walk away from an escalating peer are lessons that your son can learn more of as he grows - assuming he continues this friendship. Those concepts are more abstract and will require a later developmental stage for your son to appreciate.

Best of luck to you and your son's friend's family. They are lucky to have you in their lives ~Dr. Fink

Sophie: I have been following your interview with great interest and firstly would like to say a big "thank you" to you both for your wonderful information and support.

I have a question: I read in one response that bipolar children don't do well on drugs such as Ritalin and Zoloft. What actually happens if a bipolar child takes such medications? The reason I am asking is that my 8-yr-old boy with ADHD had a terrible reaction to Ritalin some time back (made him even more hyper and violent, and he started talking about killing himself and the rest of the family). He is presently on a trial of a low dose of Zoloft for depression and anxiety. His behavior at home has seemed better but his teacher tells me that at school he has been particularly defiant, rude, hurting and being nasty to the other children, refusing to do his work, climbing on the furniture, etc, etc. Previously he was quite well behaved at school but very difficult at home.

I am very concerned! Am I right to worry about bipolar or does the problem sound like something different? Thank you.

Candida Fink, M.D.: Dear Sophie - There are conflicting sides to this discussion in terms of if certain medicine actually create mania in children. Both the stimulants and the antidepressants such as Zoloft can have side effects that include agitation. Sometimes these are temporary - while the medication is being adjusted, other times it is not. It sounds like the Ritalin response was quite intense and not something to "tough out." The Zoloft response is harder to know - I would definitely review your concerns with your psychiatrist.

Just because a child has agitation as a side effect to these medicines doesn't mean the child is bipolar. But it may be that bipolar kids have some higher risk of these side effects. It is important to discuss this possibility with your doctor and to look at other symptoms that your child is experiencing to look at the possibility of a bipolar diagnosis. Best of luck to you -Dr. Fink

Sheri: My 15 year old son was diagnosed when he was 12. He will be 16 in March. He has been in and out of treatment for about five years. He is in denial of the illness and most of the time refuses to take any medication. He currently is taking (when he takes it) Ambilify. When he takes it, it seem to help. His biggest problem is school. Although he is very bright and has already passed the High School Qualifing Exam in our state, he does poorly on his report cards and his attendance is very poor. He is currently enrolled in an alternative high school which he hates. He calls it the "retarted school." My question is how do I get him to understand his illness and how important it is for me to take his medication on a regular basis. His father is bi-polar and our marriage has been, in the past, very unstable. In the last two years, his dad has made a huge breakthrough in dealing with his illness and therefore, our relationship is much better. We have two other children who do not have the illness. We love him dearly, but he is such a strain on the family and personally I am exhausted! Any suggestions on how to get him to accept his illness? Thank you.

Judith S. Lederman: Hi Sherri. Your problem is not uncommon. First of all, know that you are not alone. Many other moms of teens are grappling with these issues.

It sounds to me like there are many things keeping your son from accepting his illness. First of all, with a bipolar father, he probably has always seen the "abnormal" bipolar behaviors of his father as "normal." Perhaps his father's acceptance and treatment can help your son better understand the illness.

I suggest you find support groups, either locally or online, for your son and for you. Sometimes bipolar kids run their own "kids only" support groups which helps them relate to each other on a "kid level" and accept their own illness.

It is hard for anyone to accept a bipolar diagnosis. It means that a person has a lifelong condition and will likely be on meds and in varying states of mind, for the rest of his or her life. Before acceptance, there is a grieving process to go through and denial is part of that process. With therapy (in school and out of school) and support (within your family and beyond it), he can get through it. Keep doing what you're doing and make sure you take time for yourself too! Happy holidays! Judy

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