Young and Bipolar

JEFF KLUGER AND SORA SONG / Time Magazine 11aug02

[Excerpt only. For complete article go to Time website]

Once called manic depression, the disorder afflicted adults. Now it's striking kids. Why?

It wasn't every day that Patricia Torres raced down the streets of Miami at 70 m.p.h. But then it wasn't every day that her daughter Nicole Cabezas hallucinated wildly, trying to jump out of the car, pulling off her clothes and ranting that people were following her, so this seemed like a pretty good time to hurry. Nicole, 16, had been having problems for a while now—ever since she was 14 and began closeting herself in her bedroom, incapable of socializing or doing her schoolwork, and contemplating suicide.

The past few months had been different, though, with the depression lifting and an odd state of high energy taking its place. Nicole's thoughts raced; her speech was fragmented. She went without sleep for days at a time and felt none the worse for it. She began to suspect that her friends were using her, but that was understandable, she guessed, since they no doubt envied her profound gifts. "I was the center of the universe," she says quietly today. "I was the chosen one."

Finally, when the chosen one was struck by violent delusions—the belief that she had telekinetic powers, that she could change the colors of objects at will—Torres decided it was time to take Nicole to the hospital. Emergency-room doctors took one look at the thrashing teenager, strapped her to a gurney and began administering sedatives. She spent two weeks in the hospital as the doctors monitored her shifting moods, adjusted her meds and talked to her and her parents about her descent into madness. Finally, she was released with a therapy plan and a cocktail of drugs. Six months later, doctors at last reached a diagnosis: she was suffering from bipolar disorder.

While emotional turmoil is part of being a teenager, Nicole Cabezas is among a growing cohort of kids whose unsteady psyches do not simply rise and fall now and then but whipsaw violently from one extreme to another. Bipolar disorder—once known as manic depression, always known as a ferocious mental illness—seems to be showing up in children at an increasing rate, and that has taken a lot of mental-health professionals by surprise. The illness until recently was thought of as the rare province of luckless adults—the overachieving businessman given to sullen lows and impulsive highs; the underachieving uncle with the mysterious moods and the drinking problem; the tireless supermom who suddenly takes to her room, pulls the shades and weeps in shadows for months at a time.

But bipolar disorder isn't nearly so selective. As doctors look deeper into the condition and begin to understand its underlying causes, they are coming to the unsettling conclusion that large numbers of teens and children are suffering from it as well. The National Depressive and Manic-Depressive Association gathered in Orlando, Fla., last week for its annual meeting, as doctors and therapists face a daunting task. Although the official tally of Americans suffering from bipolar disorder seems to be holding steady—at about 2.3 million, striking men and women equally—the average age of onset has fallen in a single generation from the early 30s to the late teens.

And that number doesn't include kids under 18. Diagnosing the condition at very young ages is new and controversial, but experts estimate that an additional 1 million preteens and children in the U.S. may suffer from the early stages of bipolar disorder. Moreover, when adult bipolars are interviewed, nearly half report that their first manic episode occurred before age 21; 1 in 5 says it occurred in childhood. "We don't have the exact numbers yet," says Dr. Robert Hirschfeld, head of the psychiatry department at the University of Texas in Galveston, "except we know it's there, and it's underdiagnosed."

If he's right, it's an important warning sign for parents and doctors, since bipolar disorder is not an illness that can be allowed to go untreated. Victims have an alcoholism and drug-abuse rate triple that of the rest of the population and a suicide rate that may approach 20%. They often suffer for a decade before their condition is diagnosed, and for years more before it is properly treated. "If you don't catch it early on," says Dr. Demitri Papolos, research director of the Juvenile Bipolar Research Foundation and co-author of The Bipolar Child (Broadway Books, 1999), "it gets worse, like a tumor." Heaping this torment on an adult is bad enough; loading it on a child is tragic.

Determining why the age-of-onset figures are in free fall is attracting a lot of research attention. Some experts believe that kids are being tipped into bipolar disorder by family and school stress, recreational-drug use and perhaps even a collection of genes that express themselves more aggressively in each generation. Others argue that the actual number of sick kids hasn't changed at all; instead, we've just got better at diagnosing the illness. If that's the case, it's still significant, because it means that those children have gone for years without receiving treatment for their illness, or worse, have been medicated for the wrong illness. Regardless of the cause, plenty of kids are suffering needlessly. "At least half the people who have this disorder don't get treated," says Dr. Terrence Ketter, director of the bipolar disorder clinic at Stanford University.

Yet scientists are making progress against the disease. Genetic researchers are combing through gene after gene on chromosomes that appear to be related to the condition and may offer targets for drug development. Pharmacologists are perfecting combinations of new drugs that are increasingly capable of leveling the manic peaks and lifting the disabling lows. Behavioral and cognitive psychologists are developing new therapies and family-based programs that get the derailed brain back on track and keep it there. "We did a good job for a long time of putting a lid on [the disorder]," says Dr. Paul Keck, vice chairman of research at the University of Cincinnati College of Medicine. "Now the goal is to completely eradicate the symptoms."

For Lynne Broman, 37, of Los Angeles, just taming the disorder would be more than enough. A single mom, she is raising three children, two of whom—Kyle, 5, and Mary Emily, 2—are bipolar. At the moment it's Kyle who is causing the most trouble. He has been expelled from six preschools and two day-care centers in his short academic career and has made a shambles of their once tidy home. Kyle was hospitalized for violent outbursts at age 4 and still has periods when he goes almost completely feral. He once threw a butcher knife at his mother, nearly striking her before she ducked out of the way. "That day started out fine," Broman says, "but he turned on me like a rabid dog."

Until quite recently, a child who behaved like this would have been presumed to have either Attention-Deficit/Hyperactivity Disorder (ADHD) or oppositional defiant disorder. Bipolar would not even have been considered. And with good reason: the classic bipolar profile, at least as it appears in adults, is almost never seen in kids.

Most bipolar adults move back and forth between depressions and highs in cycles that can stretch over months. During the depressive phase, they experience hopelessness, loss of interest in work and family, and loss of libido—the same symptoms as in major (or unipolar) depression, with which bipolar is often confused. The depressive curtain can descend with no apparent cause or can be triggered by a traumatic event such as an accident, illness or the loss of a job.

But in bipolar disorder, there is also a manic phase. It usually begins with a sort of caffeinated, can-do buzz. "Sometimes the patients find the highs pleasant," says Dr. Joseph Calabrese, director of the mood-disorders program at Case Western University in Cleveland. As the emotional engine revs higher, however, that energy can become too much. Bipolars quickly grow aggressive and impulsive. They become grandiose, picking fights, driving too fast, engaging in indiscriminate sex, spending money wildly. They may ultimately become delusionally mad.

With kids, things aren't nearly so clear. Most children with the condition are ultra-rapid cyclers, flitting back and forth among mood states several times a day. Papolos, who co-wrote The Bipolar Child, studied 300 bipolar kids ages 4 through 18, and he believes he has spotted a characteristic pattern. In the morning, bipolar children are more difficult to rouse than the average child. They resist getting up, getting dressed, heading to school. They are either irritable, with a tendency to snap and gripe, or sullen and withdrawn.

By midday, the darkness lifts, and bipolar children enjoy a few clear hours, enabling them to focus and take part in school. But by 3 or 4 p.m., Papolos warns, "the rocket thrusters go off," and the kids become wild, wired, euphoric in a giddy and strained way. They laugh too loudly when they find something funny and go on long after the joke is over. Their play has a flailing, aggressive quality to it. They may make up stories or insist they have superhuman abilities. They resist all efforts to settle them and throw tantrums if their needs are denied. Such wildness often continues deep into the night—which accounts in part for the difficulty they have waking up in the morning. "They're like Dr. Jekyll and Mr. Hyde," says Papolos, "which is how their parents describe them."

Preverbal toddlers and infants cannot manifest the disorder so clearly, and there is no agreement about whether they exhibit any symptoms at all. However, many parents of a bipolar say they noticed something off about their baby almost from birth, reporting that he or she was unusually fidgety or difficult to soothe. Broman insists she knew her son Kyle was bipolar even when he was in the womb. "This child never slept inside," she says. "He was active 24 hours a day."

mindfully.org note: For the complete article visit the Time website.

—Reported by Dan Cray and Jeffrey Ressner/Los Angeles, Jeanne DeQuine/Miami, Melissa Sattley/Texas, Cristina Scalet/New York and Maggie Sieger/Chicago