Chat With Ellen Leibenluft, M.D.
The Balanced Mind Foundation Live Event Transcript

Did you miss our chat with Ellen Leibenluft, M.D.? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Spring. Click here for more details.

Biography
Dr. Leibenluft is Chief of the Unit on Affective Disorders in the Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, National Institute of Mental Health. She received her B.A. from Yale University in 1974 and an M.D. from Stanford University in 1978.  She is now actively involved in research on bipolar disorder in children and adolescents, with a particular emphasis on differences between children and adults in the presentation of the illness; neural mechanisms underlying the symptoms of the illness; and the development of new treatment strategies for early-onset bipolar disorder. 

Nanci - The Balanced Mind Foundation 
Dr. Leibenluft, would you like to start out by talking about the research that you are doing with the NIMH?

Dr. Ellen Leibenluft
First, I want to say that it’s a pleasure to be here "chatting" with you all. Our research is focused on the brain mechanisms that underlie bipolar disorder in children, and also very severe irritability. We hope that these studies will move us closer to better treatments and even prevention of the illness. We are also interested in children with have a sibling or parent with bipolar disorder, and therefore are at risk for the illness. 

Nanci - The Balanced Mind Foundation 
If people are interested in participating in a study, how do they go about finding the studies and qualifying?

Dr. Ellen Leibenluft 
Call us at 301-496-8381. Someone will call you back, explain what we are doing, and send you materials. We work very hard to try to give children and their parents a positive experience.

Diane 
If we're in an NIMH study, can we receive referrals to local therapists? Also, what's the difference between "mood disorder" and bipolar disorder in terms of symptoms and treatment?

Dr. Ellen Leibenluft 
All of our participants are in treatment with a psychiatrist in their community, and we do facilitate referrals. Bipolar disorder is one form of mood disorder....the most common mood disorder is major depressive disorder (sometimes called unipolar depression)....lows without the highs. So mood disorder is the general term, and bipolar disorder is one illness in that category. 

hallie 
What should we do when our child seems to have paradoxical reactions to all meds? Is there a place where our child can be evaluated for other medical conditions that might be complicating things?

Dr. Ellen Leibenluft 
Hopefully, your psychiatrist or pediatrician should be able to facilitate that. In addition to medical conditions, sometimes children with severe learning disabilities or other developmental problems are also very sensitive to medications, so a very thorough psychiatric and psychological evaluation may also make sense.  

Nanci - The Balanced Mind Foundation 
Along those lines, what are your thoughts on the role of neuropsychological evaluations for diagnosis and treatment?

Dr. Ellen Leibenluft 
That's an excellent question. I think the first thing is to be sure that you are working with a psychiatrist who is working with you to really do a thorough evaluation. Neuropsych evaluations cannot really make a diagnosis of bipolar disorder....that is done on the basis of the symptoms that you have noticed, and that your child reports. But learning problems and/or speech and language difficulties can be very common in children being assessed for bipolar disorder, and neuropsych evaluations can definitely be helpful with that.

One thing to add...your psychiatrist should advise you as to whether a neuropsych evaluation can be helpful.

Diane 
Are their other "mood disorders," aside from bipolar that present with mood swings, depression, high energy, and aggressive behavior?

Dr. Ellen Leibenluft 
Sometimes people with major depression (unipolar) depression, can be very anxious and irritable. The anxiety can look like high energy, although it's different in that nothing productive is getting done...instead pacing, unable to sit still etc. and the irritability of unipolar depression can certainly lead to aggression.  

kittnash
As for your interest in children with a higher risk, does the sibling or parent need to have bipolar disorder? Or is a mood disorder enough of a link? Also, what is the upper age limit of children in your study?

Dr. Ellen Leibenluft 
For our studies, either a sibling or parent has to have bipolar disorder. We study youth aged 7-18.  

Virginia 
Could you talk a bit about "impairing irritability"? My 10 year old son has been diagnosed as having bipolar NOS -- we've never seen him display what I'd consider "mania," but his extreme irritability in the classroom (we see it at home too) is what led to his evaluation for a mood disorder.

Dr. Ellen Leibenluft 
That's a really huge issue in pediatric bipolar disorder.....to what extent is extreme irritability diagnostic of bipolar disorder, as opposed to another mood disorder or another psychiatric illness. BP NOS is used typically for one of two reasons....the child has distinct times when they have manic behavior but it lasts a few days (less than the 4 technically required), or the child doesn't have distinct times when they are manic. Instead, the child just has irritability all the time. We have done a lot of research on the children who don't have episodes, but are very irritable all the time, and indeed we are continuing to recruit them for studies.

We actually find that, in terms of family history, what illnesses they are at risk for in the future, and brain function, the very irritable children without clear episodes differ from the ones who are clearly bipolar (the clearly bipolar ones have clear manic episodes). The chronically irritable ones without clear episodes are at risk for major depression in young adulthood (not bipolar disorder necessarily) and they have different family histories. Also, the two groups differ in brain function. So the conclusion is that the BP NOS without clear episodes may be an irritable form of depression, rather than bipolar disorder itself.  

Nanci - The Balanced Mind Foundation 
We had two questions about definitions for terms we've used today. BP NOS stands for Not Otherwise Specified. Neuropsych evaluations are neuropsychological evaluations, here's a link that describes these in more detail: http://www.medpsych.net/neuropsych_evaluation.htm  

Dr. Leibenluft, do you want to add anything to explaining these terms?

Dr. Ellen Leibenluft 
Thanks Nanci! Yes, if your child is given the diagnosis of BP NOS, you should ask the clinician what he/she means....why isn't your child clearly bipolar? Without clear episodes, we think that it's important that other diagnoses get considered also.

Regarding neuropsychological evaluations, a PhD level psychologist gives your child paper and pencil or verbal tests to determine IQ, use of speech and language, school achievement, and other issues, depending on the reason for the referral.

Laura 
My 16-yo daughter was diagnosed as bp about 1.5 yrs ago. She is currently doing very well on meds; however, she has a terrible time waking up and getting going in the AM. I've read that morning sluggishness is typical for those with BP. She is really concerned about being able to arise at 6 AM for high school classes. It's as though her brain doesn't engage until about 10 AM. What do other people with bipolar disorder do to wake up for jobs & school?

Dr. Ellen Leibenluft 
That's a really excellent question. There are some data to indicate that people with bipolar disorder are "phase delayed" meaning that they want to go to bed late and sleep late. Timing your exercise can be important...morning exercise would be better for her than evening exercise. Avoid stimulating activities at night (if you can get her to do that!) and avoid bright lights. Also talk to her doctor...are her medications giving her a "hangover" perhaps?

Mitzi

Do you feel Bipolar disorder in children/teens derails their social/emotional development? If so, how do we help them "catch back up"?

Dr. Ellen Leibenluft 
Great question. We have a big interest in bipolar youth's social development, and indeed our research shows that they have difficulty labeling face emotions (as do the very irritable children, by the way). We just found that children at risk for bipolar disorder also have trouble labeling face emotions, so it may be that there is something connected between social development and emotional development in children with bipolar disorder, and unfortunately they struggle with both.

Your question highlights the importance of treatments in addition to medication for children with bipolar disorder. Many children benefit from individual or group settings where they can learn about their emotions and how to read other people as well as try to regulate their own.

Nanci - The Balanced Mind Foundation 
This next question sort of piggy backs off of the one about waking up but hits on the broader issue of motivation.

kittnash 
How does bipolar disorder affect a child's general motivation? I know that often times the medication can make a child sleepy and thus unwilling to go to school. But does bipolar disorder by itself inherently make a child lack motivation? I just wonder if my child's behavior is "normal".

Dr. Ellen Leibenluft 
Another great question. Depression, which of course is an important part of bipolar disorder, can definitely decrease motivation. Indeed, "anhedonia" or the inability to experience pleasure (and if nothing is pleasurable, then nothing is motivating!) is considered to be a core symptom of depression. So one thing to think about is might there be some depression? And then definitely the medications can be an issue.

If the motivation problem is particularly with school, then of course its worth delving into whether there might be things going on at school that could be addressed. 

fkmad 
Do you find that early history (even as early as infancy) is significant in children with bipolar disorder? For example, not gradually learning to wait to nurse or eat before melting down, or a constant need to be in arms (not satisfied ever with swings, bouncies) - on its own or at that early point, it would not seem more than personality. So, in a group of children/teens diagnosed with bipolar disorder, is there a common thread of certain types of behaviors that may have been present long before anyone would have reason to suspect something more than a feisty personality?

Dr. Ellen Leibenluft
Again a great question. One of the problems is that the child is already having difficulties by the time they come to us, and then we would all have the tendency to look back and remember problems that we might have forgotten if the child hadn't had any problems since infancy. It’s very hard to really test these questions retrospectively...looking back. Another reason why it's very important to follow children "at risk" very carefully...so we can figure out what really are early warning signs, and eventually be able to act on them.

Laura 
Do you see adolescents with bipolar disorder who, as they reach adulthood, improve to the point where they can go off meds? What do you think of reducing meds for an 18-year old whose disorder didn't appear until the teens - just to see if maturing has helped?

Dr. Ellen Leibenluft 
That's something that is really difficult to answer generally, and depends a lot on the specific history. Obviously, that's a decision that really needs to be carefully considered by child, parents, and doctor working together. If meds were withdrawn, I would want to do it very slowly, so that you could see if symptoms were emerging when they are still mild and reverse course if needed. nbsp;

kat 
Could you discuss memory impairments with bipolar disorder in general and as a side effect of meds. My 9 yr. old doesn't seem to have any other significant side effects with meds, yet her memory and learning abilities fluctuate from day to day. Many times at the end of the day she can't recall what her favorite part of the day was even if it was something that she was really excited about. Also she will seem to learn a new skill (academic) only to fail on it when tested the next day or week later.

Dr. Ellen Leibenluft 
In BP in general there is some evidence for possible deficits in verbal memory, but the data are somewhat mixed. Topiramate is one medication that has been particularly linked with memory problems, but many of the medications can be associated with this problem, so it's important to discuss with her doctor. This could also be a situation with a neuropsychological evaluation might be helpful, if your doctor agrees.  

jeangal 
Should all children that have been diagnosed with bipolar disorder have an MRI or some other type of brain scan. What kind of information can be provided by such tests that might help with diagnosis or treatment?

Dr. Ellen Leibenluft 
We don't routinely recommend MRIs or other brain scans for children with bipolar disorder. If there are neurological problems or some unusual symptoms it might be helpful, but that's something to discuss with psychiatrist and pediatrician, not something to do routinely. Diagnostically these scans can rule out certain medical conditions that might look like bipolar disorder or other psychiatric illness, but those conditions are relatively rare.

mak 
where does anxiety begin and b/p symptoms end , or do they appear to overlap?

Dr. Ellen Leibenluft 
Wonderful question. In both adults and children with bp, the rates of "comorbid" (meaning, existing at the same time as bipolar disorder) anxiety disorders are very high...somewhere around 60%. It’s important to sort this out, because treatment aimed at the anxiety (which can be cognitive behavioral therapy for example) can possibly be very helpful for children with bipolar disorder and anxiety. We don't know why the two travel together...another thing we're looking at actually.

Larry

What about the role of sensory and regulatory disorders and bipolar in younger children? When do they get teased out, or do they share an ongoing comorbidity?

Dr. Ellen Leibenluft 
Another great question. The term sensory and regulatory disorders can be used to describe a variety of different problems, so it's important to find out exactly what physicians or other therapists are diagnosing....what exactly are the problems that they are describing with this term. Again many children with bipolar disorder have learning disabilities or speech/language difficulties, or social difficulties. So knowing what specifically is the problem is important in designing a treatment.

hallie 
Have you seen children/youths who do not benefit from medication? If so, what has helped them?

Dr. Ellen Leibenluft
I would say that the children we see almost always get some benefit from the medication, although it often is not as much benefit as we would like. In addition to the medication, we think a lot about school setting, etc.  Can adaptations in the environment help? Also, have speech/language/learning been assessed well...are there interventions there? Is there anxiety...intervention there? As you all know so well, these children have very complex problems, so we go back and make sure we've really worked to understand the whole child...not just their BP, although of course their BP is so important.

Diane

Is lithium still the "gold standard" or has it been replaced by the new anti-psychotics?

Dr. Ellen Leibenluft 
Excellent question. We don't have a "head-to-head" trial that would allow us to answer that question. Fortunately people are doing more clinical trials in youth now, so hopefully we will know soon. I think you should work with your doctor to see which might be best for your child.

Nanci - The Balanced Mind Foundation 
I'd like to go back to your comment about looking at the school setting. Many of our families run into the challenge of not knowing what degree of accommodations are appropriate for their child. There are sometimes concerns that the child is being manipulative to get out of homework, or otherwise does not fully 'apply' themselves. Is there a way to differentiate between what is truly a disability due to the disorder and when it is appropriate to push the child to do more?

Dr. Ellen Leibenluft 
Another great question, without an easy answer. When children try to get out of homework, it's often because they feel like a failure when they try to do the homework. Again, careful assessment is so key...what exactly is going on with the child, both in terms of his/her academic skills, and the emotional piece (discouragement etc), as well as possible depression. You want to try to create success experiences, and use those to build on so the child can go from success to success...so in a sense it's pushing, but a certain kind of pushing.  

Nanci - The Balanced Mind Foundation 
We have a tremendous number of really great questions, more than we can possibly cover. Dr. Leibenluft, do you have time for one or two more?

Dr. Ellen Leibenluft 
Yes! You folks are great...it's really a pleasure to chat!

larry 
do you worry about pharmaceutical opportunism with pediatric bipolar, especially in the era of direct to consumer advertising?

Dr. Ellen Leibenluft 
That's a very complicated question. In our health care system, pharmaceutical companies play an important role in developing and testing new medications. Of course, as consumers and parents, we all want to stay focused on what's best for our health and that of our families, so we want to stay educated (as you are so obviously are!) and make informed decisions about treatments.

KimLori

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Dr. Ellen Leibenluft 
There's a lot of research going on in terms of both medications and psychotherapeutic approaches. There are always new medications coming out for bipolar disorder (recently a number of antipsychotics, as others mentioned).nbsp; We need to learn much more about which are best for children, and how they stack up against the older medications like lithium, etc. Many people are also testing emotion regulation therapies. For many of the medications used in adults with bp, we don't really know how effective they are in kids with the illness.

Nanci - The Balanced Mind Foundation 
Dr. Leibenluft, thank you very much for sharing your time and expertise with us this afternoon. It is a tremendous opportunity for us to have you available as a resource and I hope you enjoyed chatting with us as much as we enjoyed having you as our guest.

Dr. Ellen Leibenluft 
I am very grateful to you all for your questions, and to Nanci for making it all happen!