It's Nobody's Fault (34 page)

Depakote, another anticonvulsant, is also often prescribed for bipolar disorder. There are fewer side effects with this medicine than with either Lithium or Tegretol. The “nuisance” side effects are stomachache and nausea, but the major problem—which seems to occur only in very young children—is liver toxicity. Liver function should be checked regularly, particularly in the first six months a child or teenager takes the medication.

Not surprisingly, treating the two poles of this disorder—mania and depression—can be quite complicated, especially since antidepressants have been known to bring on a manic episode. That happened with a teenage girl I recently treated for major depressive disorder. The Zoloft she had been taking for her depression for nearly two years eventually brought on a manic episode. It’s very important to remember that the antidepressant didn’t
cause
her mania; that was there to begin with, and the episode was bound to happen some time. The medication just pushed her into the manic phase. (What’s more, the mania didn’t go away when the medication was stopped.) Some people with bipolar disorder require not just one medication but several working at once. For instance, antipsychotic agents such as Haldol may be given in conjunction with the mood stabilizer during the onset of the manic episode.

The biggest problem associated with the treatment of bipolar disorder is getting kids to take their medication. Studies show that one-third of all adolescents stopped taking their Lithium within a year of its being prescribed. Patients never run out of reasons to stop taking their medicine. They start to feel normal, and they forget that it’s the Lithium that’s making the difference. Or they’ll start to pine for that great feeling they used to have in the manic phase and decide to go for it again. Many kids deny that they are sick, so they stop taking the medicine to prove their point. Unfortunately, relapse rates are very high, and sometimes kids do not respond as fast or as well the second time medication is tried as they did the first time.

When it comes to the problem of noncompliance with medication, parents don’t always help either. They mean well when they say things like, “There’s nothing wrong with her. Maybe she shouldn’t be taking medication” or “Let’s experiment. Take him off the Lithium,” but their refusal to accept the fact that it’s the medicine that’s making their kids
better only makes the problem worse. It’s hard to think of a youngster taking a mood stabilizer for a lifetime after only a single episode, I know, but parents need to understand that a serious disease—which bipolar disorder most assuredly is—calls for serious treatment. Bipolar disorder is a treatable illness, but the only way the medicine can work is if the child takes it. Moms and dads who have doubts should know that more than 90 percent of adolescent manic patients who discontinue treatment for bipolar disorder will have a recurrence of the disease within 18 months.

In addition to medication we recommend psychotherapy for youngsters with bipolar disorder, and we encourage their families to join them. Therapy can help everyone concerned to understand the nature of this complicated illness and deal with the strong emotions that it brings to the surface. One patient with bipolar disorder I have been treating is a 16-year-old girl who blames her father, who also has bipolar disorder, for her disease. “He’s never been any good, and now he’s passed on his lousy genes to me so I have to suffer,” she said. The therapist can help her and her father understand the truth about the disease.

A therapist will help families deal with practical as well as emotional issues. They’ll learn how to cope with the medication, how to detect the early signs of a relapse, and how to identify the stressors that might trigger an episode. For instance, a college student with bipolar disorder should know that pulling all-nighters to study can be dangerous, since a lack of sleep can precipitate a manic episode. Drinking and taking drugs may also act as triggers.

Bipolar disorder calls for prompt, active treatment. Severe mood changes and high-risk behaviors during a child’s formative years may have lasting effects on his development. Left untreated, this dangerous disorder may lead to alcohol and drug abuse and even suicide. The suicide statistics for this disorder are staggering; some 15 percent of all patients with bipolar disorder commit suicide.

Parents of children with bipolar disorder have their work cut out for them, and some are better at it than others. One set of parents I know nearly drove themselves to distraction looking for early signs that their son was having a relapse. They were constantly hovering, on the lookout for signs of mania. “One of us is always watching Lee. I’m afraid to go out at night any more. What if he goes haywire while I’m at the movies?” the mother said to me. The parents were obviously passing along their anxiety to their son. Lee called me one afternoon without telling his mother and father. “I can’t take it. I’d rather go back to the hospital,” he told me. “If I laugh two seconds longer than anybody else, they think I’m manic. If I’m upset because I got a bad grade, they’re worried I’m going to fall into a depression.” It is important for parents to be knowledgeable about the disease and watchful for signs of a relapse, but it’s equally important to keep surveillance efforts under control.

With bipolar disorder there are times when hospitalization is necessary. Kids who are
very
distressed and
very
dysfunctional may need the around-the-clock medical care and attention that only a hospital can provide. When a kid is not taking care of himself—not bathing or eating or sleeping—and he’s in a severe state of mania, he needs medication and intensive supervision until he gets back on track.

Many parents have difficulty accepting the behavior associated with bipolar disorder as a real illness. Sharon’s parents had always been very proud of their teenage daughter. Smart, outgoing, and funny, she had many friends, and all the parents in the neighborhood used to enjoy her company. Sharon was constantly being invited to her friends’ homes for dinner or a sleepover date. All of a sudden things began to change. Sharon became obstreperous, disruptive, noisy, and very disrespectful to her elders. “She’s turned into a real troublemaker,” one of the neighbors told Sharon’s mother. “I’m sorry, but we just don’t want her over here anymore.”

Unfortunately, Sharon’s parents were not able to recognize how severely ill their daughter was. As a matter of fact, the father thought he could solve the problem himself. Convinced that Sharon was just being willful, he decided to punish her for her behavior. Needless to say, the
punishment did not improve Sharon’s demeanor or her behavior; if anything, her disease grew steadily worse. Her parents, finally realizing that they couldn’t fix things for their child, brought her in to see me.

Most children being treated for bipolar disorder will need help regaining their confidence and self-esteem, especially after a manic episode. There’s a good chance that children who go through a manic episode are severely embarrassed by their behavior afterward, and even though they had no control over what they said or did, they may need to be forgiven by their families, their friends, their teachers, and even their doctors.

I’ll never forget a girl I treated for bipolar disorder in the hospital several years ago. In the throes of a manic episode she was completely out of control, screaming curses and ethnic slurs at me and being sexually provocative. We soon got her Lithium to the right level, and she was fine. In fact, she was a lovely girl, charming and good-humored. As she was leaving the hospital, I could see that she was in tremendous pain when she said good-bye to me. With tears in her eyes she said, “I can’t stop thinking about the terrible things I said to you. I called you such awful names.”

I told her not to give it another thought. “That was your illness talking, not you,” I explained. What I told the girl was true, of course, but that didn’t make the burden that she was carrying any less heavy. Understanding, sympathetic parents can do a lot to lessen a child’s load of guilt and shame.

T
he first time I met Thomas, he was 15 years old, and his parents had just about given up on him. According to Mom and Dad, Thomas had been a problem child for a long time; he was always acting “kind of weird,” they said. A few days before I saw him, Thomas’s school bus driver said the boy had “flipped out” and refused to get off the bus when they reached the school. A couple of teachers finally had to pull him off the bus and into the building. Thomas’s parents had been trying to cope with their son’s behavior by themselves for several long months, but the night before our meeting, he had crossed over the line. When Thomas’s father came home after work, Thomas walked up to him and, without saying a word, punched him in the face, hard. The event could have been interpreted as typical adolescent conflict gone haywire, but after spending only a few moments with Thomas I realized that there was something a lot more serious going on. Thomas was hearing voices, and those voices told him that his father was out to get him. That’s why he struck his dad. He couldn’t get off the school bus because he was too frightened. The lights in his homeroom emitted rays that were controlling his mind.

Sixteen-year-old Miranda was transferred to my care from the emergency room of a nearby hospital. Miranda had gone to the ER by herself after school that afternoon because she wanted to have X rays taken. Miranda was convinced that there were rats living in her stomach, and she wanted proof. When Miranda’s mother and father were called, they were horrified but not really surprised. They hadn’t heard about the rats before,
but they knew very well that Miranda sometimes saw and heard things that weren’t there. She thought that the television was talking to her, and she had been communicating regularly with Marilyn Monroe and Elvis Presley; in fact, Marilyn had recently been telling Miranda not to bathe, change her clothes, or go to school. Recently Miranda had started to use drugs and hang out with a bad crowd.

All children enjoy make-believe. One of the best pans of childhood is being able to pretend, to create fantasies and make up stories. Even imaginary playmates are acceptable under the right circumstances; they’re part of the package of being a normal, well-adjusted kid. However, being controlled by rays from lights in the classroom and taking orders from Marilyn Monroe—these are a far cry from the enchanting world of make-believe. They are the symptoms of a extremely serious brain disorder called schizophrenia.

Schizophrenia affects about 1 percent of the country’s population. According to the National Institutes of Mental Health, about a million people in this country are being treated for schizophrenia on an outpatient basis. In childhood the gender distributions of schizophrenia is marginally weighted toward boys, but by adolescence the female-male ratio is just about even. Among adults there are as many women diagnosed with schizophrenia as there are men.

Childhood onset schizophrenia—before the age of 12—is extremely uncommon. (The youngest patient I ever saw with diagnosed schizophrenia was a five-year-old girl named Deborah, who thought she had a baby caught in her throat.) The earlier the disorder shows itself, the more severe it will be. It is during adolescence, most commonly at about age 18, that schizophrenia is most often diagnosed. That’s when a child is most likely to have his first
break from reality.
The break is usually dramatic, and it can sometimes be quite sudden. I’ve spoken to parents who describe their child as perfectly normal one day and totally off the wall and out of control the next. (These are the parents who usually show up in the emergency room.) It’s more common, however, to see a gradual decline in a child’s behavior before the first big break, some early signs that trouble is on the way.

Children later diagnosed with schizophrenia fall into two broad categories. The first group is the childhood asocials; these are the withdrawn kids, the ones whose behavior has always been strange. “He never seemed quite right” and “She was always a little off are descriptions we commonly hear from the families of these children. There is a great deal of evidence to suggest that those families are correct in their not-very-scientific assessment. Some years ago an experiment was conducted with the home movies of the families of children who were eventually diagnosed with schizophrenia. In each case the families had more than one child, but only one of the kids had schizophrenia. With 100 percent accuracy the mental health professionals who viewed those old home movies could pick out the child with schizophrenia when he was only five or six years old. There was nothing specific about their findings. There was simply the sense that there was something “not quite normal” about the child in question, in the way he interacted with the other kids or with the camera. These youngsters are often aloof, not interested in socializing.