- Adverse response to antidepressants/stimulants
- Remember- what other conditions could explain irritability/aggression on stimulants ? Anxiety.
- Sometimes the stimulants themselves can cause a side effect called ‘dysphoria’, wherein children become very ornery (due to overdosage of dopamine/nor-epinephrine)
- Kids with PDD, and kids with mental retardation or in-utero exposure to alcohol may be extra sensitive to the serotonin in antidepressants, and may become agitated.
2. Family history of Bipolar disorder (make sure diagnosis is not ‘self-made’- please click here to visit my blog about how I asses for mania in adults)
HOW I ASSIMILATE ALL THIS DATA INTO A FINAL CONCEPTUALIZATION
1.Once I have asked all of these questions, I make a sort of checklist of the symptoms that could suggest mania.
- I would like you to envision an instrument like those applause-meters they show on TV shows, where the louder the noise the audience makes, the higher the dial goes.
- With every symptom that the parents/child endorsed, the dial turns a little bit more on the “Bipolar-o-meter” (if you will). Non-specific symptoms make the dial turn a little bit, specific symptoms make the dial turn a lot.
2.Next, I ask questions to assess for competing etiologies, i.e., I look to see if there are any conditions that could explain certain symptoms
- For e.g., a history of sexual abuse could explain why Jimmy gropes private parts, and why he has to put on an aura of bravado and has intense rages when left alone in a room with a man, and why he has a hard time paying attention when he is in a new place. Similarly, if the child has PDD, this could explain why the child seems uninterested in being polite and subservient with adults, which may come across as grandiose).
- With every such finding, the dial on the “Bipolar-o-meter” starts coming down a bit
3.Finally, I look at the Bipolar-o-meter and have a discussion with the parents about the probability of mania. (Just to be clear, I don’t literally draw a ‘Bipolar-o-meter’ on a sheet of paper, it is more of a metaphor. I hope I haven’t confused you!) The discussion could sound like any of these:
- Mr. and Mrs. Smith- based on the standards used today, there is a way the medical community conceptualizes and describes ‘childhood mania’. Based on what you have told me today, I feel that your child does NOT fit that description. Can I guarantee that your child will never develop mania in the future? Of course not. But based on what I see and hear today, it seems like it is unlikely that your child has bipolar disorder.
- ·Mr. and Mrs. Smith- based on the standards used today, there is a way the medical community conceptualizes and describes ‘childhood mania’. Based on what you have told me today, I feel that your child may show the following features that remind me of this description : they have decreased need for sleep, they show a pattern of engaging ion dare-devil acts, there is a certain sense of grandiosity that you describe and I see in the session today, you report a pattern of intense rages over trivial issues, and last but not least, you describe hypersexual behaviors in the absence of any known exposure to sexual content or trauma. Can I be 100% sure that your child has bipolar disorder? No. But I think it might be worthwhile to consider the risks vs. benefits of a trial of a mood stabilizer.