The Balanced Mind Parent Network Expert Chat with Janet Wozniak, M.D. Co-author of Is Your Child Bipolar

Chat With Janet Wozniak, M.D. (2009)
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Janet Wozniak, M.D? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network expert chats occur throughout the year. Watch your email for more details. 

Dr. Janet Wozniak of Harvard


Dr. Janet Wozniak is the Director of the Pediatric Bipolar Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital, and a member of The Balanced Mind Parent Network's Scientific Advisory Council. Dr. Wozniak's research focuses on the characteristics, longitudinal course and treatment of pediatric bipolar disorder.     

Nanci - The Balanced Mind Parent Network   
I'd like to start by welcoming Dr. Wozniak.

Janet Wozniak MD    
I am happy to take any questions.

Nanci - The Balanced Mind Parent Network   
Great, we have several on hand already.

How are bipolar disorder and anxiety issues connected? Which comes, first the chick or the egg?

Janet Wozniak MD    
There is a strong bidirectional overlap between anxiety disorders and bipolar disorder. That is, in a sample of bipolar youth, at least half have significant anxiety of various forms, and in anxious children we see higher than expected rates of bipolar disorder; so we know that they 'travel together' but we do not understand the nature of the relationship. It may be likely the genes that are associated with bipolar also produce changes that bring anxiety. 

Sometimes the child has anxiety first, sometimes mood first, and sometimes both come on together. A lot of kids start off with significant separation anxiety along with the moodiness of preschool age and then go on to have full-blown mania depression. We do not know the 'chicken and egg' part, but many parents feel that if their child’s anxiety is treated, the mood reactions would diminish. The problem with this approach is that the best medications for anxiety are the SSRI antidepressants, and these will make mania much, much worse!  

So if both co-occur, our standard treatment approach is to use a mood stabilizer, anti-manic treatment then sequence in an anti-anxiety treatment. We tend to use benzodiazepines, BuSpar, or Neurontin for the anxiety, as these won't make mania worse.

I always find it interesting that person can be shy and inhibited and wild and disinhibited all at the same time, but that is the nature of anxiety plus bipolar.

Sometimes a clinician will cautiously introduce an SSRI. These can be used, but should be sequenced after an anti-manic agent, and used in small amounts with a lot of monitoring for mania.

I read your book and felt that it really described my 9 year old son. However, getting a local therapist to agree and diagnose him with bipolar seems impossible. Why do clinicians/counselors avoid this diagnosis?

Janet Wozniak MD    
The main one is that many clinicians likely graduated from programs with minimal training in identifying this diagnosis. But I am always amazed at the power of prejudice; that people 'don't believe' that it (bipolar disorder) can exist in children. Rather than get tangled in an argument over the word 'bipolar', instead identify target symptoms such as irritability, depression, anxiety, and impulsivity, then work with a clinician to use medications to get at these problems. 

Mood stabilizers are excellent anti-aggressives and many clinicians use these even if they do not use the 'bipolar' diagnosis. If your clinician thinks it is depression and anxiety and wants to try an antidepressant, you need to worry that such a med could make mania worse or could lead to more disinhibition so you can work with that clinician, using the antidepressant and stopping if worsening of symptoms occur and/or you can suggest a second opinion about the medication.

Can you describe what mania has looked like to you? Can it come on quickly but be of short duration? What have been typical triggers you have seen with mania in elementary and middle school aged children?

Janet Wozniak MD    
Mania is characterized by dramatic moods of irritability and euphoria. The children (and many adults) are often 'labile' in their mood and can change minute to minute. Most parents I see describe what they call 'rapid cycles' of changes throughout every day; flipping from rage, to lower level irritability, to sadness and to euphoria (goofy, giddy, silly, high, energized).

In the book I wrote we described this '5 pointed star' of mood changes:

  • irritability
  • rage
  • depression (sad, crying, hopeless)
  • euphoria (singing, dancing, high, hyper, more than even typical for a youngster of that age)
  • and then a 'typical' kid

Parents see all points of the star for varying degrees, cycling in complicated ways from day to day, week to week, month to month, season to season.

Irritability is most commonly described to us, but most who are highly rageful (most, not all) have euphoric spells, too. But most parents don't mind the euphoria nearly as much as the rage/aggression/violence. 'Tantrum' is a word to describe the typical emotional lability (changeability) of children, but bipolar children are much, much more extreme in their moods than even typical children of young age. There's a lot more to say about this...I can go on but maybe there are some other questions?

Nanci - The Balanced Mind Parent Network   
Can you talk about the rage element a bit. Would that qualify as mania or something else? And at what point is it necessary to remove a child from the home because of the rage?

Janet Wozniak MD    
In psychiatry we have neglected the spectrum of irritability. Odd really, as anger is so disabling to individuals and families. But if we hear that someone has an 'anger problem' most clinicians will look to see what the source is and anger can occur with depression, depression and oppositional/defiant disorder.  This last, ODD, is indeed an 'odd' diagnosis because it rarely occurs all on its own but instead is fueled by the impulsivity/frustration of ADHD, unhappiness of depression or disinhibition of mania. 

One of the contributions from my group in describing and treating children whom we now diagnose as 'bipolar' has been to raise awareness that rage can exist in children; that is, anger is not just typical 'tantrums' or poorly parented children. However, I must say I worry that sometimes I make the point too well the anger/rage we see is EXTREME and it makes people unnecessarily afraid of these children. Most of the most severe rage occurs at home.

You only need one such episode at school to get kicked out! Or, hopefully, placed in a therapeutic setting. But a lot of the children I see with severe rage at home, at school appear ADHD-like or depressed-like or anxious-like. They just keep a low profile.

Think of the brain like the way we think of the heart. To bring out the abnormal functioning, we put the person on a treadmill. We give a heart 'stress test'.  For most individuals, being at home with our loved ones, forming the most intense emotional bonds, this is our brain's emotional stress test. So no wonder that the most dramatic symptoms are at home first. Just like for the cardiac patient, the most dramatic symptoms are walking up the hill on the golf course.

Nanci - The Balanced Mind Parent Network   
That would explain why mom is so often on the receiving end of the rage.

Janet Wozniak MD    
Yes, our brains do something different when we are with our mothers. We use the 'emotional centers'. These 'emotional centers', the limbic system, is likely the 'weak area' for bipolar folks. Even with bipolar adults, it is the spouse or children or closest friends who get the brunt of the abnormal behavior.

Stacey W.    
I am glad you mentioned ODD... how do you differentiate between ODD and bipolar?

Janet Wozniak MD    
Almost all of the bipolar kids I see also have ODD, and in fact a major portion of them have SEVERE ODD.  It is not just, "I won't clean my room, make me!"  It is, " You $$%*&@#$'ing ##$%*&%#, why should I clean my #%$^%^ room???"

It is an important distinction. I think it is a different type of ODD, a severe, grandiose, delusional form that we often see in bipolar. Akin to the adult calling the President to tell him how to run the country (bad example during the Bush administration, ha ha). Or the adult telling his boss off. Bad idea. So in my mind the diagnosis of only ODD is not very helpful. To say someone has problems with authority doesn't help make a treatment plan. The most useful thing to do is to figure out why.  Is it:

  • manic level grandiose defiance, '"whh should I do what YOU say?"
  • or depressed level “I won't do it, can't do it, no energy, no motivation”
  • or anxious, "I won't do it, you can't make me, I am terrified to leave the house, terrified of what might happen”
  • or ADHD level....."homework is hard for me, I won't do, don't make me”

With a lot of the kids I see, it is ALL of these at various times, a lot of different reasons for ODD. We start with the most severe, the manic level and then work on down the list.

Nanci - The Balanced Mind Parent Network   
We have several questions about ADHD so let's switch gears to that comorbidity.

Dr. Wozniak, my 17 year old daughter is diagnosed Mood Disorder NOS and ADHD. She is currently stabilized on Abilify 10mg but while the mood stuff is much better, she still struggles with school related issues. It appears she has little or no executive functioning. I would like to discuss putting her on an ADHD medication with her pdoc but fear increased mania (which still breaks through at times). Do ADHD meds help kids with mood disorders focus better or should we be going for neuropsych testing and educational accommodations?

Janet Wozniak MD    
If ADHD and mood issues co-occur, after mood issues are better (they are seldom 'perfect') then my practice is almost always to try to treat the ADHD. When stimulants make mania worse (and they might as much as 50% of the time) generally things settle quickly when withdrawn, within a day or few days. Not like with antidepressants; with these a bad (manic) reaction can take weeks to settle or longer!

But since ADHD is SO disabling, it is worth trying to see if you can help with it. There are one or 2 small studies showing that a stimulant can be safely added to a mood stabilizer with help for ADHD. If the mood is still unstable, the stimulant may not work well. So go back to the mood medications and try to improve the mood. 
When and if to add a stimulant is a clinical judgment call, but is often a good idea given the major upside and minimal downside even of a bad reaction. Beware though that our current ADHD medications are good for focus, attention, concentration, but are not so great for executive functioning things like working memory, planning, global organization. These are parts of what we are calling executive functioning, and if you don't have these pieces it is highly disabling, even if you are very smart. We can see high IQ and poor executive functioning and this can be more devastating to functioning than the reverse. That is, low IQ but intact executive functioning may lead to better academic performance. This is very frustrating for the high IQ/poor executive functioning kid who ends feeling really stupid. So you need to go both routes, consider medication, but work for school support as well.

Our now 17 year old son was diagnosed with major depression at 15, bipolar at 16, second opinion said ADHD and not bipolar, 3rd opinion at 17 said to defer any Axis I diagnosis until adult, mixed personality with antisocial and narcissistic. We have experienced the reluctance to diagnose an adolescent as bipolar, and prior to educating ourselves, shared that view to some degree. 

Your book was very helpful and very relevant to our situation. How do we overcome providers’ reluctance and get treatment for our son? Is there other research besides that at Harvard and Mass General that supports your findings? The recent press about Dr. Biederman may be impacting the situation.

Janet Wozniak MD    
In fact, most of the research on pediatric bipolar has been done by other sites. Dr. Boris Birmaher in Pittsburg, Dr. Kiki Chang at Stanford, Dr. Barbara Geller at Washington University in St. Louis, Dr. Robert Kowatch and Dr. Melissa Delbello in Cincinnati and Dr. Robert Findling in Cleveland.

All of them could likely offer an 'expert' opinion either privately or via a colleague or in the context of a research study. If your son is included in a research study on bipolar, it is a good confirmation of that diagnosis because generally researchers want only true 'cases' or else the research won't be valid so it can be a more rigorous way to get a diagnosis regarding the personality disorders. Some clinicians think 'either-or' that is, either bipolar or personality disorder (narcissistic, antisocial, borderline). BUT like with the other 'axis I' diagnoses (Axis I disorders are considered biologically based), people often have more than one thing. 

Personality disorders can benefit from therapy (e.g., Dialectical Behavioral Therapy (DBT) - is great for borderline disorder) and help you understand some patterns of interaction, but do not guide medication treatment or help you understand the 'out of control' part. We do not focus on the personality disorders in our research much, but there is considerable overlap in the criteria for these and other disorders so both bipolar and narcissism can co-exist. Some clinicians are more trained in and comfortable with the personality disorders as ways to describe emotional dysfunction. As long as you agree on the target symptoms, e.g., rage, grandiosity/entitlement, hopelessness, etc, the treatment can proceed.

I am glad you found the book helpful!

Nanci - The Balanced Mind Parent Network
We're almost out of time, do you have time for one or two more questions?

Janet Wozniak MD 

Your mention of the limbic system brings to mind Dr. Amen's work. Have you used or looked into the use of SPECT scans or QEEG's or Occular Light Therapy as possible effective complimentary strategies or diagnostic tools for children with mood spectrum, frustration tolerance, anxiety, ADHD etc. issues? How about the use of bio feedback?  

Janet Wozniak MD 
No matter what you read in brochures, these scans DO NOT make or even confirm clinical diagnoses. I wish they did! We still have to rely on stories of symptoms over time from the individual and his/her significant others (usually parents in my clinic). Some day these scans might help with diagnoses.

Even in studies such as from the NIMH (Ellen Liebenluft, MD et al, another excellent research group confirming the diagnosis of pediatric bipolar) the imaging results are useful only when groups are compared. No clinician can take a scan and tell you what the diagnosis is.

The programs that sell these scans usually ask for a lot of history as well, and I believe they use that to 'guide' the reading of the scan. These scans are not therapeutic either; however, biofeedback is used primarily for anxiety treatment with success, e.g., slowing breathing and heart rate, quelling the panic response. To my knowledge, there is no evidence to date that it is helpful for ADHD.

By the way, regarding the 'validity' of pediatric bipolar disorder: Barbara Geller MD, a major contributor to and pioneer in pediatric bipolar research, published her Magnus Opus (or at least one of them) in the Archives of General Psychiatry a few months back. Nanci, you should excerpt this on the website. She provides compelling evidence that childhood bipolar disorder becomes adult bipolar disorder. In fact, in our adult clinic, 70% of the adults, when asked with detailed questions, described a prepubertal or adolescent onset of their disorder.

Most of adult bipolar disorder (at least in clinical settings) is pediatric onset!

Help! What do you suggest for those of us in really small rural towns where there isn't a medical professional with experience treating a bipolar/adhd diagnosis? Our 10 yr old daughter was diagnosed bipolar and ADHD. She is currently on Abilify and Focalin for treatment. We're new to all of this and don't really know what is SSRI or enough about medication but don't typically see these medications on the forums or other sites as typical treatment. Are these good treatment choices for her?

Janet Wozniak MD   
With this brief information, I will say that Abilify and Focalin sounds like a typical treatment for a 10 year old with bipolar and ADHD. 

The downside to rural settings is the lack of professionals, but rest assured, even families in NYC have difficulty finding a pediatric psychopharmacologist.

Nanci - The Balanced Mind Parent Network  
Our staff and volunteers can help with searches for clinicians in your area. 

Nanci - The Balanced Mind Parent Network  
One last quick one on PDD (Pervasive Developmental Disorder).

My 4 year old has bipolar and PDD. I’m having a hard time telling them apart.

Janet Wozniak MD   
PDD refers to problems in:

  • social interaction (poor reciprocal relationships) and
  • communication (language delays, quirky language, repeating a lot, a general lack of 'pragmatic' skills for communicating language)
  • behavior (but the behavior is a restricted repertoire of interest, rigid thinking, sometimes odd play or physical habits like flapping).

PDD is not a mood disorder, although some percentage (in our clinic about 20%) of PDD children have bipolar disorder. While bipolar kids have social problems, only about 20% or less of them have formal PDD or autism spectrum. This has been muddied because the atypical antipsychotic medications, e.g., Risperdal, have been studied and approved for bipolar disorder, but also for irritability in autism. We might wonder if high levels of irritability in autism is actually bipolar + autism. We had a hard time recruiting autistic spectrum children with irritability for a study of this because when the irritability was at a high level, the child often met the criteria for bipolar disorder.

Nanci - The Balanced Mind Parent Network  
That has been a frequent topic of debate on our groups and forums, the relationship between BP and autism/aspergers.

Janet Wozniak MD   
A complicated problem but well worth our research. We are increasingly turning to this research because in my clinic, well over half are children with this combined problem. They are harder to treat, experience a lot of side effects, don't respond in predictable ways to medication and standard dosing, and have A LOT of co-occurring anxiety.  

Also, we see 'autism spectrum', not just the most severe autism, as part of PDD. Children with PDD are reactive to changes in environment, transitions, sensory overload. But when the reaction is rage, screaming, violence, then we wonder about bipolar disorder and go on to consider that in the diagnosis along with the PDD. Rage is not bipolar. But high levels of persistent irritability along with at least 3-4 other symptoms of mania including euphoria, distractibility, agitation, grandiosity, flight of ideas (in thinking), reckless activities/poor judgment, decreased sleep, and talkativeness is the definition of mania.

Nanci - The Balanced Mind Parent Network  
Dr. Wozniak, thank you so much for sharing your time and expertise. We had a great audience today with many more questions than we could get to, but I hope that we were at least able to touch on a range of topics that related to many of the questions. One member did ask if you were available for phone consultations.

Janet Wozniak MD   
My assistant Meghan is at (617) 503-1451 and can tell folks about how to access me in the clinic or through studies or for one-time consultations.

Nanci - The Balanced Mind Parent Network  
Thanks! Any closing remarks?

Janet Wozniak MD   
Please have me back again! The questions are all very good and interesting to me.

Nanci - The Balanced Mind Parent Network  
We'd be delighted, you are a very popular guest!

Janet Wozniak MD   
Good luck to everyone in working your way through the diagnosis and treatment maze.

Thank you!

Thank you very much.

Thank you!!!

very helpful thank you

much appreciated!!!

Janet Wozniak is the co-author of  Is Your Child Bipolar? The Definitive Resource on How to Identify, Treat and Thrive with a Bipolar Child. 

Last updated: July 23, 2010


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