• Dr. Lawrence Diller
• Dr. Kiki D. Chang

One of the difficulties that a physician faces is the time necessary to arrive at an optimum dose, and the patience required to allow the medication to work at therapeutic levels. So often, parents arrive with a list of medications taken, having tried them for short periods, stating that the medication did not work. As a general rule, an antidepressant may take from 4 to 6 weeks, whereas Ritalin would show efficacy much more rapidly. Blood testing for levels of depakote permit very precise dosing information, and help assure the child's safety as well. There are also relatively objective ways to judge the effect of the medication on behavior, including scales which rate symptom severity. Some of the rating scales which are used in my practice are the Kiddie-Young Mania Rating Scale, and the Child and Adolescent Mood State Scale by Robert Kowatch, M.D. for Bipolar Disorder (CAMSS). We also utilize the Childhood Depression Inventory (CDI) for depression. These scales provide a numerical system of evaluation to monitor the effectiveness of the prescribed medication.

This is a very complex question. There may be a population of children for which non-medication interventions would be preferable, but these interventions may not be readily available to the families, whether due to limited financial resources or because HMOs will not cover enough therapy sessions. There are also, undoubtedly, large numbers of children who are not receiving medication who could be benefiting from it. I think the greater problem is the shortage of child psychiatrists in most areas. We need folks who are specifically trained to treat children with appropriate psychotropic medications. Thus, in certain geographical areas, children are probably under or mis-diagnosed, and perhaps not treated as properly as they could be.

Yes, I specialize in bipolar disorder, but with this diagnosis there are often many other related diagnoses which must be addressed: depression, ADHD, cyclothymia, anxiety disorders, oppositional defiant disorder, conduct disorder, etc.

We have very specific features to look for, based on the DSM IV. However, in my own practice, family history becomes very important as a tool in helping to make a more conclusive diagnosis. I have been conducting a study of children who have bipolar parents. We have recruited these families in order to study them, and our first step is to give a structured diagnostic interview to establish any psychiatric diagnoses in the children . We have been working with six to eighteen year olds. For some subjects, we perform brain imaging with magnetic resonance imaging (MRI). We are particularly excited about our studies using functional magnetic resonance imaging (fMRI), which shows us which areas of the brain the child is using when they perform various tasks. Then we may compare these images with "normal" healthy children. This is very exciting research, and it should allow us to understand better which areas of the brain may be dysfunctional in bipolar disorder.

We are finding it to be an excellent mood stabilizer for bipolar children. We will be presenting the results of a research study on the efficacy of Depakote in children with bipolar parents who have mood or behavioral problems in October, 2000. So far, we are encouraged by our results.

It appears that there has been a general increase in the diagnosis of bipolar disorder in children, and this might be due to in part to an increasing public awareness that the disorder may appear in children, or in part, perhaps, to an over-diagnosis of the disorder in certain areas. However, there is a theory of genetic anticipation, which may hold true with bipolar disorder, and that theory is that with each succeeding generation, the mood problems may present themselves at an earlier age. Since the brain chemistry of a six year old is very different from that of an adult, bipolar disorder may be difficult to diagnose in small children.

It is used for seizure disorders, however we find it to be effective in treating bipolar disorder. Some of the most common side effects are sedation and an increase in appetite, which often leads to weight gain. That can be problematic, especially for adolescents who are concerned about body image.

I can only speak for myself. I do not use MAOIs due to the dietary restrictions. Tricyclics are very rarely used.