The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood DisorderThe Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder

As all medical students learn on their pediatrics rotations, children and adolescents are not “little adults.” However, all too often the world of psychiatry addresses childhood disorders based on concepts generalized from adult psychiatric diagnoses and treatments. This has been especially true in the case of bipolar disorder. Until about 10 years ago, bipolar disorder was believed rare in children, not commonly occurring until late adolescence and early adulthood.

The first edition of The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder (2002) was at the forefront of an explosion of professional and public interest in pediatric bipolar disorder, beginning at the close of the 20th century and continuing to this day.^{1 - 2} This book was instrumental in conveying the possibility to thousands of parents that their child might have bipolar disorder—many made their way to our clinic, literally clutching a copy of the book. Thus, it created a great service in helping unmask this hidden illness. However, some of the information regarding symptoms of bipolar disorder in children was misleading and potentially inaccurate, possibly leading to inaccurate diagnoses by parents and clinicians.

In the third edition of The Bipolar Child, authors Demitri Papolos and Janice Papolos have expanded and updated their book, including new research and treatment developments and completely revising the chapter dealing with school issues. As in the first edition, it strives to be a comprehensive guide to childhood bipolar disorder for laypersons, but it should be of interest to professionals as well.

Part 1 of the book focuses on “Diagnosis and Treatment.” In the first edition, this was the centerpiece of the book, leading thousands of parents to contact child psychiatrists with the concern that their child had bipolar disorder. The symptoms presented by the authors resulted from online questionnaires filled out by parents who reported their child to have a bipolar disorder. No research-based or clinical follow-up interviews were used to confirm the diagnosis. Thus, many symptoms not typically associated with or specific to bipolar disorder were included (eg, poor handwriting, carbohydrate craving, night terrors), leading to potential confusion for both the lay and professional reader. These symptoms have been downplayed a bit in this third edition, but they are still included. However, instead of a checklist of symptoms, the authors now include their Child Bipolar Questionnaire, which has had some preliminary tests for reliability and validity.³ However, the authors still present symptoms as if they were established facts and mislead the reader by statements such as “in our research. . . . ” They also do not acknowledge the current controversy in the field—ie, that many experts believe there is now an epidemic of overdiagnosis of bipolar disorder in children⁴ and that even the experts often disagree on what the core symptomatology of childhood mania should be.⁵ The authors do address the dilemma of the “bipolar not otherwise specified” diagnosis—ie, that there are no current criteria for this common diagnosis in children and that children often do not meet bipolar I or II criteria due to their relatively short cycle of mood symptoms.⁶ However, on page 32 the authors do not resolve the following paradox: they state that bipolar children often do not meet diagnostic criteria for bipolar disorder. The authors do not explain how then we can still diagnose these children as having bipolar disorder. For example, they miss the possibility that many children who fall just short of full criteria for bipolar disorder may be in early, prodromal stages of the disorder.⁷

Researchers in the field of pediatric bipolar disorder usually agree with the authors' impassioned pleas (eg, pp 55-57) for this disorder not to be ignored and for more accurate and earlier identification and treatment of patients.⁸ Yet, those in the psychiatric field also should be careful not to make inaccurate diagnoses and include inappropriate children in research studies. It is this push and pull that makes some leery and others cheer about the rapid growth in interest in this disorder.

Chapter 3, “How to Find Good Treatment,” is highly informative for parents, providing specific things to look for when seeking someone to evaluate their child for possible bipolar disorder. Chapter 5, “Prescriptions for Treatment,” provides much more detail regarding medications commonly used to treat bipolar and other psychiatric disorders. The authors do leave out some important recent studies (eg, regarding toprimate, lamotrigine and oxcarbazepine, and omega-3 fatty acids) and include some inaccuracies (eg, that lamotrigine and carbamazepine should not be taken together with divalproex is untrue). The authors also do not clearly indicate which medications are approved by the US Food and Drug Administration for what aspects of bipolar disorder (mania, depression) and that none are approved to treat children younger than 18 years with bipolar disorder. They do a good job of discussing the potential risks of using selective serotonin reuptake inhibitors in children with bipolar disorder, but then provide overblown concerns regarding the use of stimulants and atomoxetine while ignoring studies that contradict their concerns.^{9 - 10} Chapter 5, “The Genetic Aspects of Bipolar Disorder,” is a well-written and up-to-date summary on genetics; however, it gives minimal information about the connection with children and adolescents diagnosed with bipolar disorder.

Part 2 of the book, “Inside the Brain and the Mind,” focuses on psychological and neurobiological aspects of development that may be relevant to mood disorders in children. Chapter 7, “What Causes This Condition?” contains an interesting section proposing a more child-relevant structured diagnosis of juvenile-onset bipolar disorder. Again, the authors do not present the research to back up the proposed criteria. The rest of the chapter provides an abundance of information on biology and neurology as it relates to possible etiologies of bipolar disorder.

The strength of the book, especially for mental health professionals, is found in Part 3, “Living and Coping with Bipolar Disorder.” While the first 7 chapters focus on what happens internally in the child with bipolar disorder, this section focuses on what happens in the child's surroundings. Chapter 8, “The Impact on the Family,” is a rich and detailed look at how having a child with a serious psychiatric disorder can affect daily life. Just reading this section could provide much-needed reassurance for parents who are experiencing such a situation, but the authors give added value by also providing some concise and potentially useful behavioral intervention strategies. Here, they refer frequently to The Explosive Child—an excellent book dealing with children who have behavioral outbursts. Chapter 9, “School: A Child's World Beyond Home,” and Chapter 10, “The Neuropsychological Testing of a Bipolar Child,” are perhaps the most valuable sections of the book. These 2 topics can be crucial for the well-being of any child with a psychiatric disorder, yet few psychiatrists or other mental health professionals are trained in these areas. The chapter on schools provides detailed examples about specific accommodations that may be included in an individualized educational plan and provides sample letters that parents can use and templates that a psychiatrist can give to parents. The chapter on neuropsychological testing explains the scoring of a common intelligence test, the Wechsler Intelligence Scale for Children, 4th edition, and what each subset of this test measures. The rest of this section provides information on adolescence, hospitalization, and insurance. The book concludes by reporting what parents want for the future of bipolar disorder research and providing further resources for families.

The Bipolar Child relies a bit too much on information provided from families experiencing life with a child with predominant mood symptoms. It does not necessarily describe the world of a child with only bipolar disorder. The authors do not address the issue that the prevalence of childhood bipolar disorder appears to be much lower outside the United States¹¹ or why this disorder is receiving so much attention now. The overwhelming detail may cause laypersons to skim large sections. Nonetheless, for those interested, the sections on genetics and neurobiology are current and well written. It gives a broad description of the presentation, assessment, and treatment of children with psychiatric symptoms and is recommended to parents who have a child experiencing serious mood or behavioral problems. The third part of the book is recommended reading for psychiatrists who treat children and adolescents and also may be useful to other clinicians such as pediatricians.

Overall, the authors should be commended for bringing a huge amount of relevant information together in a single tome and for making it readable and interesting. The Bipolar Child makes a valiant attempt to describe a misunderstood disorder that has been causing great harm to many children and families. The book's biggest shortcoming is its lack of balance (too much taken from the authors' own experiences), but that is common to all such books that are not peer reviewed. Its main benefit is allowing parents to gain more insight into the world of bipolar disorder treatment and research. As long as parents are cautioned to take some of the data with a grain of salt, it is a book easily recommended to families as well as professionals involved with a child struggling with this devastating illness.