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Psychiatry Newsletter - Pediatric Bipolar Disorders: Seeking the Right Child, the Right Time

Hopkins BrainWise-Spring 2013

Pediatric Bipolar Disorders: Seeking the Right Child, the Right Time

Date: April 15, 2013


Dr. Robert Findling
Dr. Robert Findling

“You’ve got this vague, fuzzy thing behind an opaque screen. How do you figure out what to do with it?” That’s child psychiatrist Robert Findling’s take on what clinicians face in pediatric bipolar disorders.

As new director of Child and Adolescent Psychiatry, Findling brings broad expertise on those illnesses and others to Johns Hopkins. His Clinical Manual of Child and Adolescent Psychopharmacology is in its second edition. Cognitive-Behavior Therapy for Children and Adolescents—he’s a co-author—is just out. He’s published on pediatric psychotic disorders and juvenile schizophrenia.

But Findling’s prime area is pediatric bipolar illness, a condition whose unspecific symptoms hamper diagnosis, especially in young children. That alone encourages controversy—sometimes from clinicians, but more from a public a bit too ready to blame symptoms on bad parenting or kids being kids. “There’s been too much heat, not enough light,” Findling says. So he takes refuge in sound research.

For the past seven years, he has co-headed the Longitudinal Assessment of Manic Symptoms (LAMS), a NIMH-funded study that’s followed some 700 children whose elevated irritability, sudden mood changes and periods of more than kid-typical giddiness suggest bipolarity. The research—Findling now directs it from Johns Hopkins—aims to sort out what the symptoms mean. Do they mark a distinct childhood illness? Who comes out OK?

 Here’s what he says:

 We know you were set on becoming a neurosurgeon until a child psych rotation in med school turned that around, but what sparked your pediatric bipolar interest?

Early on, a colleague in Cleveland with adult patients with bipolar disorder didn’t know where to turn to help their troubled children—some as young as 6 or 7. The patients would say: I’m terrified for my son. How can I keep him from suffering as I have? So the youngsters came to my office. With their cluster of symptoms—often compounded by ADHD or oppositional defiance disorder—they didn’t look quite like kids I’d seen in training.

 You quickly saw a pressing need both for the LAMS study and a different approach, yes?

Correct. Most studies of pediatric bipolar start with the adult disease in mind. Then they look at symptoms in children to see whether they match that better than other childhood disorders.

 Sort of like trying on Cinderella’s glass slipper?

Yes. But that can wrongly presume that the “bipolaresque” kids are the only ones who suffer from bipolar disorder. Perhaps worse, it assumes that youth who are “bipolaresque” indeed have bipolar illness and are likely to suffer from it as adults. And we now know that many do not. LAMS, however, started without presumptions, with only this cluster of symptoms. So we follow the children and, ideally, the study clarifies the disorder, tells us who has it—and where it’s going—and who doesn’t.

We also have the youngsters undergo neuroimaging and cognitive testing, seeing if biological measures help us improve diagnosis. Are there clear differences in brain structure? In processing of information?

 Where are you headed?

The long-term reports from LAMS are almost out—what happens to these children with time. That’s where the rubber meets the road. Then, immediately, we should start translating that into prevention, change the course of things. We know that for bipolarity, the earlier the onset, the worse the adult outcomes. So if LAMS tells us who’s at risk, there’s a real opportunity to intervene before the most pernicious effects take hold.

 Nip it in the bud, then.

We hope. Nip at buds too early and you risk not getting the right bud. And if you’re a long time away, age-wise, from a condition’s most extreme expression, you’re more likely to be imprecise. These are vulnerable, vulnerable children: Misdiagnose and treat too early and you expose kids to medicines with real side effects, not to mention label them for life. Fail to catch it early enough and you add to human suffering. We struggle with this. Is there any better justification for research?

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