Did you miss our chat with Dr. Kiki Chang? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Fall. Watch your email for more details. 

Biography
Dr. Chang is an Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine, Division of Child Psychiatry. He is Director of the Pediatric Bipolar Disorders Clinic, where he specializes in pediatric psychopharmacology and the treatment of depression and bipolar disorder in children and adolescents.                

Nanci - The Balanced Mind Foundation   
Dr. Chang, do you have any opening comments?

Kiki Chang MD   
Thank you Nanci - The Balanced Mind Foundation.  No comments, just welcome and I hope this will be helpful!

wrenae   
Dr. Chang... thanks for being here! When do you draw the line between "prodromal" and diagnosing BP? What is it that confirms a diagnosis?

Kiki Chang MD   
We still use DSM IV criteria for our diagnoses. That means technically that is when they cross to full bipolar disorder.  But realistically, kids are ill far before that usually. We are study kids who are a bit less ill, but still ill: they have ADHD and mood problems, or they have depression, but all of them have a parent with bipolar disorder, so we consider them high risk to develop full mania.

njardali  
what is prodromal?

Kiki Chang MD   
We call these kids prodromal, although we don't know for sure if they will progress to develop a full manic episode. Some consider BP NOS kids prodromal as well.

Kiki Chang MD   
I'll just keep typing until a new question comes in because I can always discuss this topic ad naseum!

Nanci - The Balanced Mind Foundation   
Dr. Chang, you mentioned that you still use the DSM IV criteria. Could you comment on your perspectives about the validity of the current criteria which don't really address pediatric BP and what if anything you would change for future criteria?

Kiki Chang MD
Sure - big question. Basically, the current criteria are valid because that is what we decided - these are the criteria. People who argue that the diagnostic criteria are wrong are not really accurate. We made up the term bipolar disorder, and we said "it has to be this". Therefore it is valid.

Now...the real question is, in adults with "true" bipolar disorder, what did it look like when they were children? Because, at that point, many of them might not have met the criteria (probably duration of 4-7 days) but, they clearly already had a bipolar-type of illness. Thus, how do we classify that illness, when we are not sure they will develop "real" adult BD? That's why it will be so much more helpful to be able to use biological markers to help in diagnosis - brain imaging findings, genes - but we are still a ways off from that.

Joey   
What is the treatment of choice in regard to medicine for a child suspected of having a bipolar disorder?

Kiki Chang MD   
It depends on the mood state of the child, whether there is psychosis, and any kind of factors regarding sensitivity to certain side effects. For example, if it is a 15 year old boy, with no psychosis, and currently manic, the first line choices right now include: lithium, quetiapine (Seroquel), risperidone (Risperdal), aripiprazole (Abilify). Possibly ziprasidone (Geodon) too. Olanzapine (Zyprexa) is going towards second line due to weight gain potential, but still a very effective medication. Divalproex, valproate (Depakote) is also heading towards second line because of one negative study.  However, most kids with full BD are on more than one mood stabilizer, so it’s very common to combine an atypical antipsychotic (AP) with lithium or Depakote still. For bipolar depression, not as clear yet. I can answer more on this if people have questions about it.

Nanci - The Balanced Mind Foundation   
We have a lot of medication questions so I'll try to group these together and not duplicate.

Kiki Chang MD   
OK

Bryan   
Hi Dr. Chang, I'm a therapist in the Chicago area and my younger clients (elementary school age) have not had a lot of success with medications for bipolar disorder. Do you know of any medications that work really well with younger kids with bipolar?

Kiki Chang MD   
Most of the meds are only being studied down to 10 years old. So, it is unclear what works for kids younger than that, although it is probably similar. Yet, I would expect (and do see this) that younger kids don't always respond the same way. So sorry, no special meds for the younger set.

kt   
What is your experience or opinion about the effects of protein, folate or vitamin B's in the diet as well as light therapy?

Kiki Chang MD   
My opinion on complementary approaches in general: most are okay, as long as they do not inhibit you from continuing or starting traditional medications and therapy. So far as whether they work or not, jury is completely out on that. I believe some kids may respond to different vitamins, diet changes, etc, but these are on an individual basis and no way to predict.

Mostly, the one thing I recommend is omega-3's and light box for clearly seasonal mood changes (depression only).

Cindy   
I read in a book about BP III. This author called it basically a manic episode brought upon by SSRI medication. Can you explain mania that is triggered by SSRI's or stimulant medications?

Kiki Chang MD   
This is an "unofficial" term. We don't know what it means to have antidepressant induced mania (AIM). Technically by DSM-IV, this does not count as a manic episode. But clearly, it probably means that the person is more likely to have BD than not. Although I have seen a few cases where there were no subsequent spontaneous manic episodes. However, I want to emphasize that SSRI’s clearly can trigger or worsen mania/mixed states in kids with BD. Not all kids, but it is something that should only be carefully used. Stimulants are less worrisome than we thought 7 years ago.

RAE   
You mentioned omega 3's. Can you comment on recommended dosages, whether these should be used alone or with medications and whether omega-3's can cause activation?

Kiki Chang MD   
I've never seen them cause activation. There are no good studies showing efficacy in kids with bipolar disorder, so it’s hard to really recommend a good dose, although probably 1-3 gm/day is reasonable. There is a whole debate about the EPA/DHA ratio that I won't go into, because it is still not clear. They should of course not be used alone in a child with full bipolar disorder. Really, they are probably helpful in general for long term mood effects, good for your heart, and give you shiny fur.

jerrypb   
A number of our The Balanced Mind Foundation parents of bipolar disorder/mood dysregulated kids have tried or are considering trying "Empower Plus," which I have only heard is a vitamin and amino acids therapy; but kids have to be titrated OFF of all meds to be on this. A couple of people are swearing by it, and most don't know. Have you heard of Empower, and if so what do you know within the medical community?

Kiki Chang MD   
Yes, I've heard of it, but again there are no real studies in kids with BD. I know the company is trying to do larger studies. Remember - placebo works to treat mania in 30% of cases.  (but if it works, great, but I would not recommend this at all at this time).

Nanci - The Balanced Mind Foundation   
I believe that Dr. Mary Fristad is starting a study on Empower Plus and there is a two year study under way that is double blind, placebo controlled. Clearly from the conversations on our forums this is a highly debated topic.

andrea   
Briefly, what was the negativity found in the study with the Depakote?

Kiki Chang MD   
Oh, no negativity, just that Depakote ER did not beat placebo in treating children with mania 10-17 years old. Response rates were around 25% for both groups (Depakote ER and placebo). The paper is still being reviewed.

TShura   
Have you found that as a child enters more into middle teens that they seem to stabilize somewhat?

Kiki Chang MD   
I've seen it go every which way. Clearly, puberty is one point in which symptoms change - usually mood episodes extend in duration (from days to weeks). Also more classic symptoms of mania and depression. But mid adolescence - anything can happen then.

Joey   
What, if anything exists regarding neurofeedback and mood dysregulation/bipolar in children?

Kiki Chang MD   
Again, unfortunately the published studies just aren't there, although I have heard some positive reports coming to me from families who have done the neurofeedback (EEG related). Doesn't seem like it would be harmful (just potentially to your pocketbook).

TShura   
What is neurofeedback?

Kiki Chang MD   
Well, by hooking up some basic EEG type electrodes to the skull, one can see brain waves (electrical neuronal activity). Kids can learn relaxation techniques, cognitive methods, etc, to change the shape/size of these waves. And so if they learn to change a certain wave a certain way, it may be associated with symptom improvement. It's been touted for ADHD and anxiety, although I think anxiety makes more sense to me. I think in the right hands it could work well (but hard to know who is a reliable specialist - check the The Balanced Mind Foundation Find a Doctor listings probably).

joan   
Dr Chang -- I've been wondering about Wellbutrin -- often prescribed for children who have trouble focusing. Do you think it works well for that? And what do you recommend for BP kids who also have attention problems?

Kiki Chang MD   
There are positive studies - Wellbutrin does beat placebo for improving attention and decreasing hyperactivity. We tend to use if in adolescents with depression and mild ADD.  Also, it has some lore (and a little bit of data) as being less likely to trigger mania (slightly). So sometimes we do use it for kids with BD and depression, instead of an SSRI. Oh - for attention first line stimulants, second atomoxetine (Straterra), with a mood stabilizer of course.

Wellbutrin is not really the slam dunk treatment for ADHD. Once the mood is fairly stabilized (as much as possible) we still recommend stimulants (Ritalin, Adderall, etc). Second line probably Strattera, and then next guanfacine, modafinil, Wellbutrin, etc.

Nanci - The Balanced Mind Foundation   
Dr. Chang, many of our children show a multitude of symptoms and often it is hard to know whether to treat the individual symptoms (anxiety, ADHD, depression, OCD, etc.) or to target the overall mood disorder/BP. What is your strategy in these situations of comorbidities?

Kiki Chang MD   
First treat mood, then treat comorbidities. Often individual symptoms are left over from inadequate mood stabilization. Sometime it’s hard to tell though.

Nanci - The Balanced Mind Foundation   
That was going to be my next question. At what point do you determine that the underlying comorbidities are significant enough to warrant separate treatment, particularly if the traditional mood stabilizers have not sufficiently addressed the mood disorder.

Kiki Chang MD   
Basically we try to use meds that will cover bases. For example, if there are problems sleeping, and some anxiety, along with depression or mania symptoms left over, instead of using 2-3 diff meds, we may use quetiapine (Seroquel) at night. Or, for anxiety and sleeping problems, gabapentin. We try to avoid SSRI’s if possible. Sometimes, especially for severe anxiety/OCD, we use SSRI’s carefully. Any time the symptoms are problematic, we try to identify the source and treat the source, rather than go for just the symptom. But that is challenging sometimes.

Kiki Chang MD   
Any questions about brain imaging, genetics, or family therapy?

Kiki Chang MD   
Not that I am trolling...

Nanci - The Balanced Mind Foundation   
Actually yes, we have one on brain imaging, let me find it. . .

Kiki Chang MD   
No problem, whatever people want to know I am happy to give my 2 cents!

Anna   
Dr. Chang, have you found SPECT brain scans to be at all helpful in either diagnosing or treating BD or mood dysregulation?

Kiki Chang MD   
Nope!

Kiki Chang MD   
Okay - longer answer... No way. No way can you use SPECT or any other brain imaging tool to diagnose BD. Now, can it be used to help guide treatment of whatever condition you have? Possibly. Can it help diagnose you to have some other condition, such as "increased sub-cortical limbic blood flow"? Probably - but I don’t know what that equals in psychiatric terms. No good studies, yet, sorry.

Nanci - The Balanced Mind Foundation   
As a follow up, there are several research studies using imaging to better understand BP. Can you comment on the role of imaging for research rather than diagnostics?

Kiki Chang MD   
Sure - imaging, mostly MRI types, is really helpful in research. We have been discovering various brain regions involved in mood dysregulation (and BD specifically). There are structural abnormalities in some of these regions. There is neuronal loss in some of these regions. But sometime it is hard to tell what is causing the disorder, and what the disorder causes. Mood episodes might lead to neurotoxicity and then prefrontal degeneration over time. Medications also affect brain function (of course) - but also affect the structure. Fascinating findings are coming out regarding lithium and neuroprotection in the brain. We are trying to identify brain markers that could be used to predict the development of BD in kids. But we’re not there yet.

TShura   
What do you mean by neuronal loss?

Kiki Chang MD   
Adults with bipolar disorder have loss of gray matter in the prefrontal cortex and probably impaired functioning in this area. Postmortem studies in adults with bipolar disorder showed neuronal and glial cell loss (compared to "healthy" age-matched controls).

bonnie   
What is the research on DNA, genetics etc. We have 4 living generations with bipolar. I don't have it but my kids do. What gives with that?

Kiki Chang MD   
It's not dominant - which means it is not passed along to everyone in each generation. There are likely many, many genes that create risk (or protect) for bipolar disorder. But we do know that it is highly genetic and heritable. More genes you have for bipolar disorder, the less environmental stress you need to develop the full disorder.

andrea   
Dr. Chang, what do you have to say about Family Therapy as it relates to this disorder?

Kiki Chang MD   
Family therapy can potentially be extremely helpful. I'm referring to David Miklowitz's study in Archives of General Psychiatry this year - he used Family Focused Therapy (FFT) and found effects (mostly in depression) in teens with BD. We are doing a study using FFT (16 weekly sessions with the family - parents, siblings, etc.) to see if we can prevent or delay onset of full mania in kids at high-risk for BD.

Overall, if you can decrease family stress, improve communication and problem solving skills, and educate all family members about good sleep hygiene, medications, symptoms, etc, it's got to help!

Kiki Chang MD   
Any last questions before we all go get some lunch?

Nanci - The Balanced Mind Foundation   
What is your experience with the effectiveness of therapy at different degrees of instability? Does there have to be a certain level of stability achieved or should therapy be applied regardless of a child's mood?

Kiki Chang MD   
Good question. Example - 17 year old girl with acute psychotic manic episode. During first month of recovery, utility of individual CBT is low. However, utility of family (and patient) psychoeducation is high. Then as recovery continues, more typical therapy approaches can be used. But in the depths of depression or mania, more crisis management is needed. Therapy is best to PREVENT episodes, not treat them.

Nanci - The Balanced Mind Foundation
Dr. Chang, thank you so much for sharing your time and expertise. We had a packed house and many, many more questions than we could cover in the hour. We so appreciate the work you are doing for our families and for our children.

Kiki Chang MD   
Thank you all for chatting, it was very enjoyable for me. If people have more questions about our work, they can go to http://www.pediatricbipolar.stanford.edu/.

Nanci - The Balanced Mind Foundation   
I'd like to remind our members to take a look at our chat schedule for our regular weekly chats and an exciting line up of expert chats coming up in 2009. Thank you all for joining us and we'll have a transcript available shortly.