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The ADHD Diagnostic Bubble.

“My hometown has this problem, when they don’t know what is wrong with your child, they say it is ADHD”
(A frustrated mother)

“He will blurt things out; he does not know when it is time to joke around and when it is not… He will ask the silliest questions, like: What if an elephant can stand on mom’s head?” “What if a person comes out of a comic book, what would happen?”

With these words a Floridian mother described the behavior of the child whose story I chose to begin my debate over the inflated ADHD statistic. I perceive this case as a portrait of maternal courage and determination because when the question was:

Should I allow the school official to scare me or stand firm for my son’s well-being?

She opted for the latter and stopped the 30 mgs of Ritalin their pediatrician was prescribing for an alleged ADHD diagnosis that was actually made by the boy’s teacher. The busy physician didn’t hear the mother’s concerns about the worsening of behaviors, after the medication was started and decided to rely on the educator’s judgment. Frustrated but vindicated, the mother said:

“The school wanted him back on Ritalin. His teacher threatened to send him back every day that he misbehaved. I told her: do it!.”

Then she gave the following family history:

“His Dad is exactly like him… my father-in law has depression and on my side of the family, my mother had “manic-depression” and she died 3 weeks ago… my aunt has depression and my brother is a bad case of OCD.”

This boy’s Mental Status Examination showed an above average intelligence and good concentration. His artistic skills are evident in this drawing of a “new Picachu.”
After one sees a talented boy with a clearly elevated mood and a family history loaded with mood problems, the question is:

What kind of rationale could have been followed to diagnose a child like this with ADHD?

There are many possible explanations that I discuss in several sections of this book but a short answer could be:
DSM-IV
Yes, even if we identify the elevated mood in the boy depicted above he could qualify for an ADHD label, according with the official diagnostic manual known as the DSM-IV and elaborated under by the American Psychiatric Association (APA).
I know of excellent psychiatrists and pediatricians that will detect the presence of mania in the boy described above and diagnose him as having ADHD and bipolar because the APA says so.
I have treated many children in such situation when they arrive to the inpatient unit with a full-blown episode of mania, psychosis, panic attacks and several other presentations that result from the injurious effects of amphetamines and antidepressants on bipolar individuals. In other cases it is a psychosis with hallucinations exacerbated by Ritalin and other stimulants.
I have a simple rule of thumb that I share with those friends that still have a big number of ADHD children in their practices:

If you diagnose more than two cases of ADHD in any given week you need to review your diagnostic criteria.

This is not to subtract merit to the validity of ADHD as an authentic psychiatric condition but to reinforce my disbelief of the current statistics attributed to this illness. I do not believe in the APA-endorsed statistics because I can not see any reason to explain why this should be the only country with an incidence of ADHD greater than 5% of school-age children. In fact, many developed nations report that ADHD occurs in less than 1% of the school-age population. Not surprisingly more than half of the Ritalin manufactured in the world is sold in USA.
This is one of the reasons I have asked, in several articles published by psychiatric journals, how my opponents could explain that only 1% of the patients I treat have ADHD and the other 99% are doing well?
If the whole idea presented in this book is wrong, it should be expected that a significant part of that 99% of my patients would decompensate, because I have diagnosed many of them as bipolar, obsessive-compulsive, psychotic, social anxiety, etc., and they actually have ADHD. In fact, the opposite is the truth: They are stable and doing well.
Nevertheless, in every single scientific article on the ADHD subject you will read the same chant chorused:

“ADHD is the most common mental health disorder of childhood, affecting 3 to 5% of the school-age children.”

When I see that phrase I can’t help but think of the historical blunder recorded when the Inquisition forced the Italian astronomer Galileo to declare that the Earth (and not the sun) was the center of the universe.
By the way, the National Institute of Mental Health (Consensus Statement, 11-18-98, page 5) acknowledges that other nations have a lower rate of ADHD:

“Although the prevalence of ADHD in the United States has been estimated at about 3 to 5 %, a wider range of prevalence has been reported across studies. The reported rate in some other countries is much lower. This indicates a need for a more thorough study of ADHD in different populations and better definition of the disorder.”

It seems obvious that top experts recognize a need to improve the ways we use to diagnose ADHD but nobody wants to take the first step in changing what is being taught in American academic centers about ADHD and mood disorders. That change is necessary because the academics are obligated to follow guidelines, similar to what Federal Judges have to do when applying mandatory sentences in certain types of cases. In other words, if DSM-IV states that children who exhibit defiant behavior should be diagnosed with Oppositional-Defiant Disorder (ODD), that is exactly what they have to do.
Hundreds of youths and their parents know from personal experience that current parameters to diagnose children with mental illness are obsolete and confusing but the establishment persist in its mistakes. This is why I keep copies of the evaluations I have done on children previously diagnosed as Conduct Disorder or Oppositional-Defiant Disorders (with names deleted) and they are available to anybody who questions this pronouncement:

How could these diagnoses have validity if not even one child, out of hundreds, persisted showing disordered conduct, after I detected the real illness and was treated with the appropriate medication.

Why nobody comes forward and tries to discuss my findings I can not understand, but I provide more details on this subject in the chapter “There Is No Such Thing as ODD.”
At this point, I want to introduce the official definition of the word prevalence because I am obligated to use it many times. Several medical dictionaries define it as:

“The number of cases of a disease existing in a given population at a specific period of time or at a particular moment in time.”

With that in mind, take a look at a report from “U.S. News & World Report” (11-23-98) on a long and expensive study conducted by the National Institute of Mental Health to determine the effectiveness of Ritalin alone vs. Ritalin combined with psychosocial interventions. The lead investigators in this study are highly regarded researchers but they also seem to have fallen into the generalized mistake of labeling children with mood disorders as ADHD.
I am 100% sure they misdiagnosed some of their volunteer patients because they report data on children who have ADHD and Conduct Disorder as well as ADHD and Oppositional-Defiant Disorder and we know that ODD and CD are in fact diagnostic disguises for other conditions. I have conclusive evidence (already published in psychiatric journals and reproduced in this book) demonstrating that when ADHD is diagnosed in the same person also labeled with CD or ODD, and exhibits clear mood problems, the real illness is not ADHD.
Now look carefully at what the NIMH’s document mentioned above says under “Introduction,” page 5:

“Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, estimated to affect 3 to 5 % of school-age children.”

If we interpret this statement following the definition of prevalence presented above, how many individuals in the USA should have ADHD?
The 2000 census counted 281,421,906 people living in this country and 20% (more than 50 million) of that population represents school-age children, the number of American children with ADHD should be close to two million. However, I am not the only one questioning the real number of children with ADHD. One of the best textbooks of Psychiatry (Kaplan & Sadock, 9th edition, 2003, page 1223) reports that in the USA there is a wide range of fluctuation on statistics about this condition. It also says that the incidence (defined as the number of new cases) of ADHD in Great Britain is less than one percent.
Furthermore, considering that many studies have demonstrated the high number of children who have been misdiagnosed as ADHD, I can not help but wonder what the researchers are going to do with the thousands of books and research studies that were based on faulty ADHD statistics?
This issue actually represents a Pandora Box of astronomical proportions that many are afraid to open. Just imagine the nightmare that will arise from the admission that more than half of research studies in pediatric psychiatry are meaningless because they used samples contaminated with wrongly diagnosed patients.
To put it in simple words, many children with mood disorders, anxiety, OCD, PTSD, psychosis, sexual abuse and neglect, etc., were mislabeled with ADHD to participate in research investigations whose outcomes are now used as the “law of the land".
A sad example will be the so-called “Multimodal Treatment Study of Children with Attention-Deficit Hyperactivity Disorder, also know as the MTA.” Despite the reputation and qualifications of the lead investigators in this study, which are highly regarded researchers, the outcomes are irrelevant and ill-founded. That is the case because they also have fallen into the generalized mistake of labeling children with mood disorders as ADHD and defining them as having Oppositional-Defiant Disorder or Conduct Disorder, which have proven to be invalid diagnosis in my data.
To give you an idea of how “lost in space” this study was, look to what the journal Clinical Psychiatry News, (January 2001) reported in reference to the MTA findings:

Medications were effective for children with ADHD but not for those with “ODD symptoms.”

From my perspective that outcome ratifies my theory because those “ODD” children could not respond to medication for ADHD because they did not have it.
But if you still have doubts about what I state in this book take a look at the outcome of a short study I conducted in Phoenix, AZ. It was a review of the diagnostic accuracy in children referred from the community to two inpatient units, one for children and another for adolescents. It shows the following:

From May 1999 until January 2000, 84 patients, ages four to 17 years and a half, were admitted to my care. They were referred to the hospital by their psychiatrists. Four of them came from two Indian Reservations.

In this Managed Care environment, we do not have to explain that hospitalization was the last resource after long attempts to control their symptoms or behavior in the outpatient setting.

As you can imagine, 43 of the 84 children and youths were on stimulants when they arrived at the hospital. Nine were on antidepressants, despite having clear signs of an elevated mood.

For 7 patients the referring psychiatrist did not include the diagnosis of Sexual Abuses of a Child, even though such history had been previously documented. In nine other cases the missing diagnosis was of substance abuse.

When the children were evaluated by me, four of the “violent ADHD” had their diagnoses changed to Intermittent Explosive Disorder (IED), a condition that gets worse on stimulants like Ritalin and the amphetamines.

I should explain that if these numbers do not add to the total of 84 it’s because in several cases a particular patient carried more than one diagnosis. But the really astonishing finding is that 64% of those patients arrived at the hospital with a wrong diagnosis and, consequently were on the wrong medication. Children in full state of mania (racing thoughts, grandiose demeanor, aggressive or “dare devil” behavior, insomnia, etc.) were still receiving amphetamines. A few others were having hallucinations (“hearing voices”) while being “medicated” with stimulants.

I feel comfortable stating that my diagnoses were correct because, once hospitalized and re-diagnosed with treatment changes, all these patients got better. Not surprisingly, some of the letters inserted in the chapter “What Parents Have to Say” come from this experience. One of them, the mother of a 9-year- old boy had said to his previous psychiatrists:

“Doctor, I am Bipolar and I take lithium. I think that my sons got what I have.”

That boy ended up in the hospital because his psychiatrist, instead of listening to her, handed out a Ritalin prescription with this pronouncement:

“He is too young to be Bipolar and we have to increase his medication.”

I know this is the reality in many pediatric psychiatric hospitals but, unfortunately, as Larry David says, every day I have to “curb my enthusiasm” because nothing is going to change in the near future. Most psychiatric researchers may ignore these findings with this comment “This is not scientific data.”
Because this might occur, here is a second set of data that should help you to make up your mind about who could represent the truth in this debate.
During a five-month period I treated 645 patients in a Southern state on an outpatient basis but in the same age group as the inpatient sample. This is the outcome:

Almost half (48%) of the patients that had been evaluated and/or treated with medications and psychotherapy carried a wrong diagnosis. Very few, 2.5%, had never been treated with psychiatric medications.

Like the inpatient group, several children also said, “nobody asked before”. Some of them were talking about auditory hallucinations, but unfortunately two were referring to sexual abuse. You will find more details in the chapter “The Perfunctory MSE”.

Finally, the last set of patients to be discussed is categorized as youths incarcerated due to “unruly” or “incorrigible” behavior.

I found that almost 100% of those diagnosed with the popular combination ADHD, CD and ODD had a mood disorder, anxiety, psychosis or IED. Clinicians kept combining these 3 diagnoses even though DSM-IV clearly states that Conduct Disorder (CD) and Oppositional-Defiant Disorder (ODD) should not be diagnosed together.

The set of patients in correctional settings is discussed in more detail in the chapter “A Human Touch Behind Bars.” Here I will only say that 56% of the youths had a wrong diagnosis, repeated many times, despite multiple evaluations by several psychiatrists in the community. If you wonder how something like this could happen in a country with such sophisticated medical technology, here is a clue:

Less than 1% of the youths in the correctional system I surveyed had been diagnosed as having a mood disorder when they living in their community of origin.

That’s a significant contrast with the scenario that many investigators have reported in adult-population jails. In that setting almost everybody agrees that there is an overrepresentation of psychiatric diagnosis (other than ADHD), when compared with people in the community.
What could be the explanation for such difference between incarcerated youths and jailed adults?
Wouldn’t it be reasonable to think that the “today’s emotionally-distressed adult inmate” was once a child with emotional problems? That is an answer that I can’t wait to hear but also that I don’t foresee coming in a near future.
Meanwhile, I try to join efforts with parents and patients to deal with this archaic psychiatric establishment that runs the show in our professional setting.
The only positive signs, so far, come from the publication of new papers reporting the presence of mood disorders in children. But there is also a continue flow of discouraging news, like this one:
The December 2000 issue of “Psychiatric News” (page 42) brought a report entitled “Study to Assess Ritalin Use in Preschoolers with ADHD.” It talks about a research project to investigate the effect of methylphenidate (Ritalin, Concerta, Metadate and Focalin’s generic name) in children under the age of 6.
As doctors should know, the FDA has approved Ritalin only for children over 6, but pediatricians and psychiatrists have been prescribing it for practically any age. This new study appears to be already condemned to result in another disappointment for the clinicians on my side of the controversy because, despite the fact that very talented people are going to participate in it, I think it will be “more of the same” since they are already talking about “extremely high scores on the ADHD symptoms.” My concern with their methodology is that to estimate those scores they are using tools that are not specific for ADHD. Some of these rating scales mix together symptoms of mood disorders, anxiety, PTSD, OCD with those usually attributed to ADHD, which leads me to suspect that those “severe” ADHD cases are not going to be real ADHD but in fact missed cases of “something else.”
Because I understand how disrespectful this could sound to the researchers involved in the above-mentioned project I want to clarify that it is not my intention to hurt or to offend anybody and especially those that have made significant contribution to psychiatry. To one of them, in particular, I am grateful for granting me the opportunity to enter into a very good fellowship program in child psychiatry. But the fact is that even the “Grandfather of psychiatry,” Sigmund Freud was wrong multiple times and we all can make mistakes.
Just consider this: I found a vignette supposed to describe a “textbook case” of ADHD in a book written (in the 90s) by a world famous ADHD authority in which he confuses manic-depressive illness with ADHD. He even reports clear mood swings in his patient and a family history of bipolar disorder but ends diagnosing ADHD. It is very possible that this researcher would diagnose (in 2005) that person as having a mood problem if conducting the evaluation these days. Similar change in theoretical orientation would be a blessing for the outstanding researchers responsible for the MTA mentioned above. This study is revered by clinicians, journalists and researchers as if it were a revealed truth from God when the fact is that it has multiple weaknesses. One of them, already mentioned above, was the inclusion of children with diagnoses of ODD and CD in conjunction with ADHD.
In my experience, such diagnostic mélange 99% of the time indicates “none of the above” and that explains why Ritalin didn’t work in the patients who had dual diagnosis of ADHD and ODD. My question to this group of devoted and famous researchers, on this particular matter, is:

Why to even think that amphetamines could change the behavior of a child who is defiant and oppositional toward authority figures?

Trying to understand such beliefs, a famous psychologist and researcher, Dr. Michael Manos once told me that children with ADHD become aggressive and defiant secondary to chronic frustration and, in fact, that theory sounds like a reasonable explanation for some of the impulsive aggression. On the other hand, when we look at the conduct of a 4 year old boy killing rabbits and birds and laughing about it, to attribute such a bizarre behavior to ADHD appears to me as a high dose of denial of those reluctant to diagnose serious mental illness in children.

By the same token, it would be equally difficult to use Dr. Manos’ rationale to explain the extreme reaction of another child who “destroyed his room” (his mother’s words) because he was grounded for refusing to go to sleep at midnight.
Furthermore, why children who are able to show remorse, and most of time are compassionate and caring, would be intentionally “bad” at other times?
I strongly believe that when they show inappropriate behavior we should search for a reason that could explain it instead of looking for “the right punishment.” Unfortunately, the child-blaming label of Oppositional-Defiant Disorder (ODD) diagnosis is based on the opposite premise.
I regret to oppose those who have taught many generations of psychiatrists and psychologist but my obligation to patients and their parents stands above personal sympathies. Besides, to accept the validity of ODD and Conduct Disorder as real diagnoses would betray my clinical and research findings.
I have hundreds of patients who are functioning at their maximum after ODD/CD were replaced by the correct diagnosis, and this data is available to anybody who want to see it, but to conclude I am going to reproduce a letter published by the scientific newspaper NeuroPsychiatry (May 2001):

I disagree with a comment included in the report about the Multimodal Treatment Study of Children with ADHD (February, cover story). The writer said that the trial “sparked controversy in some quarters when its initial findings, published in December 1999, were misinterpreted as a blanket endorsement of pharmacotherapy over behavioral therapy.”

I believe the results were correctly understood, and after evaluating more than 2000 children over the past four and a half years, I am convinced that “true” ADHD children do well on medication alone. Therapy actually helps mostly the family and educators than the child.

Like diabetes, ADHD is a biological condition and requires a medication that remedies the “chemical imbalance.” Type II diabetes can be corrected with diet and weight reduction but Type 1 requires insulin. The same is true with ADHD: The “pure” variety requires medication, but patients with co-morbidity need some other type of intervention, besides the pharmacological one.

On the other hand, many investigators are overlooking a scary truth that nobody wants to acknowledge: Most children diagnosed as having ADHD are actually affected by a condition falling within the realm of the bipolar spectrum disorders. These children are labeled as having ADHD plus conduct disorder, or ADHD plus oppositional-defiant disorder, or ADHD plus anxiety. (DSM-IV prohibits the diagnosis of oppositional-defiant disorder if the child meets the criteria for Conduct Disorder.)

I surveyed 450 children in Arizona and 618 in Tennessee with bipolar spectrum disorders and found that between 45 and 56% of them had been misdiagnosed, in some cases for as long as 5 years. Several other clinicians have found the same, but we have no voice. Even people, like Dr. Janet Wozniak, with her impressive Harvard Medical School credentials, cannot get the point across; instead, researchers are still saying that ADHD is more common than mood disorders. Children are being placed in jail or residential treatment centers because their elevated mood and lack of insight is viewed as “oppositional-defiant” behavior. Once again, the victim is taking the blame.

Manuel Mota-Castillo, MD

Another child & adolescent psychiatrist, Dr. Irene Abramovich, who practices in West Hartford, Connecticut, sent the following letter to the same publication, Neuropsychiatry:

I would like to join Manuel Mota-Castillo, MD, in his evaluation of the current controversy concerning attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (May, “Letters).

It has become customary in my practice to see a couple of children a week with florid bipolar disorder who have been treated for a nonexistent ADHD by their pediatricians or, even worse, by one of our colleagues. Not infrequently, I see adults with the same presentation who wobbled through life trying different remedies for ADHD, not finding any help and gradually losing their grip on life because they had been treated for the wrong condition. Unfortunately – and Dr. Mota-Castillo is right again - the voices of Drs. Janet Wozniak and Joseph Biederman are not heard.

I believe that several factors contribute to this sad picture. For one, pediatricians wrongly feel competent to diagnose and treat any psychiatric condition despite their lack of appropriate training. The American Society of Clinical Psychopharmacology inappropriately lowered the bar, welcoming any physician (with or without psychiatric training) to be a prescriber of psychotropic medications and totally ignoring the dangers of misdiagnosis.

Second, psychiatrists trained solely in the tradition of developmental pathology and the psychoanalytic approach has a very difficult time accepting the reality of biological psychiatry. As a consultant for a special board of education, I frequently find myself in a difficult position when my diagnosis of bipolar disorder or psychotic disorder causes a furious reaction from my colleagues who had been treating the child for a couple of years for “ADHD” and ignoring the fact that their therapy and stimulants were, at best, not helpful. It is becoming a difficult moral dilemma for me: how to divulge the truth to parents without undermining the reputation of guild and at the same saving the face of the treating psychiatrist after his or her major diagnostic blunder.

The third part–and probably the most hopeless—concerns the lack of appropriate education for pediatric fellows: Who is to teach if the teachers themselves are not equipped with appropriate diagnostic tools and knowledge? I would like to share my experience with residents and fellows, but it is not possible in the conservative milieu in which we live. So, in the absence of a better solution, I can only continue to collect more and more knowledge about the interplay between ADHD and the great chameleon, bipolar disorder, and try to help as many of my patients as I can in the solitude of my private practice.

Irene Abramovich, MD, Ph.D.

This letter came as a healing balm for those who, at times, feel like we are fighting alone against an establishment that would never change. In fact, the reality is that truth always wins. Sometimes it takes decades or even centuries but, in the end, rightness would defeat wrongs.
(Drs. Mota and Abramovich letters reprinted with permission from Neuropsychiatry)

Everything You Wanted To Know About ADHD.

“I have been thinking all these years that he was not ADHD...I feel like I was the only one who believed it” (The mother of a bipolar child)

Attention Deficit Hyperactivity Disorder (ADHD) has become a household word, or as Mark Gluckman said, the “flu” of psychiatric diagnosis.
It was in 1902 when Sir George Still, in article published by The Lancet, described people with a defect of attention but for 35 years nothing really happened until Dr. Charles Bradley reported a “spectacular change in behavior” in children who took the stimulant Benzedrine for one week (1). Even though the results were quite striking, to confirm how slowly things move in psychiatry, it was in 1963 when the results of the first trial with methylphenidate (Ritalin) were published by Dr. Keith Conners and Leon Eisenberg.
Now ADHD is such a casual term that usually parents do not appear to be distressed by the realization that their child has this condition. For example, at a clinic in Arizona, 90% of the children were on Ritalin or some other type of stimulant medication when they were referred to me with the ADHD label. Half of them had been wrongly diagnosed but that is another story which I will present in detail throughout several chapters. I want to define ADHD and to look at its symptoms not only to contribute to the understanding of this condition but also to help you to figure out what ADHD is not. I actually look beyond mainstream’s conclusions and want to explain that hyperactivity can be more than just ADHD and to show several examples of “hyperactivity” as a symptom of a totally different problem.
In support of this idea, through the years I developed a list of multiple reasons that can explain hyperactivity in a child. This is how it looks on my office’s wall:

1- ADHD

2- Anxiety, as in Social Phobia or Generalized Anxiety

3- A medical condition (problems with thyroid, malnutrition, etc.)

4- Psychosis (hearing voices, paranoia, delusions)

5- Flashbacks from traumas

6- Obsessions

7- A racing mind, as in people with elevated mood

8- Explosive aggression as in Intermittent Explosive Disorder

9- Depression accompanied by anxiety

10- Low IQ

11- Learning disabilities

12- Tics (as in Tourette’s Disorder)

13- Absence seizures

Based on such possibility I keep repeating a very important fact: ADHD is a medical condition. This concept is accepted and disseminated even by the people who can benefit the most from the exaggerated (and false) prevalence of ADHD. One of them, the pharmaceutical company Alza Corporation, a subsidiary of McNeil Laboratories, maker of Concerta (a popular ADHD medication), distributed a pamphlet entitled “A Guide for Parents on Effective Management of ADHD.” It states:

“Establishing a diagnosis of ADHD is complex and requires information obtained from multiple sources, such as parents, physicians, and teachers. The diagnosis is dependent on the report of characteristic behaviors observed by parents and teachers and includes input from the child in addition to the physician’s examination of the child.”

As you can see, this is the same reasoning that we follow to bring a car to a mechanic instead of calling a plumber to fix it. In other words, psychiatrists, either on their own or following a provisional diagnosis formulated by a therapist, a pediatrician or Primary Care Physician (PCP), should do the final diagnosis of psychiatric conditions. Unfortunately, throughout the USA something very different is happening, as can be corroborated by the dramatic and sad examples presented here. They show the terrible consequences that prescribing stimulants for an aggressive or hyperactive child, misdiagnosed as ADHD can have.
This is not to say that a child afflicted with ADHD cannot be aggressive but it is the nature of his aggression that makes the difference. In the ADHD child the hostile behavior usually looks clearly impulsive and frustration-driven rather than deliberate, predatory aggression. Beyond this example of a practical fact, I want to share other basic concepts to help you to deal with a possible diagnostic confusion. For example, an important diagnostic criterion is the age of onset. If a child who did well in Pre-school or Kindergarten begins to have behavior and learning problems in first grade, chances are that ADHD is not the cause. This type of problem is present from the very beginning when caused by ADHD. The reason: ADHD is a genetic disorder of early childhood that becomes apparent when the child starts to perform tasks requiring attention and concentration. Unfortunately, it is common to see a child that was diagnosed ADHD, for the first time, while in third or 4th grade, despite a history of good school performance in first and second grade.

Supporting my view in this respect is the textbook of psychiatry by Kaplan & Sadock that describes some of the characteristics of the infant who’ll be identified later as ADHD. The authors say that these babies are very sensitive to stimuli and easily disturbed by noise and changes in the environment. They also affirm that these children are more active in the crib and require less sleep than the average baby. I find it interesting that parents of children and adolescents with bipolar disorder report similar experience.
Because it is usually the most important and most forgotten tip, I want to repeat it:

If the child did well in K and First Grade it is not ADHD.

Another hint: “ADHD is not an intermittent condition.” If, for example, a mother reports that her son “can be very good for one week and then out of control for 2-3 weeks,” we should take a meticulous look into the family history and search for conditions like a mood disorder, anxiety, explosive displays of rage, sexual abuse, psychosis, and etc.
To illustrate this idea here is comment from a foster mother:

“When she is by herself, you can’t ask for a better child.”

She was referring to a 6-year-old girl whose biological parents are both alcoholics and the father “extremely aggressive.”
The genetic link between that little girl and her father was neglected by her first evaluator who forgot that “maybe, the apple did not fall too far from the tree” and gave her an ADHD diagnosis which was treated without success.
Another relevant fact is that when Ritalin (or one of the amphetamines, i.e. Adderall) is given to an authentic ADHD patient, the usual response could sound like this:

“I have a new child… this is a miracle, a complete change.”

In the presence of a minimal response, we should suspect that it’s because stimulants improve attention even in people who do not have a deficit or that the initial dose was insufficient. On the other hand, if a child is treated with a stimulant and his symptoms get worse, there is not a scientific reason to increase the dose. My experience with more than 2,000 children evaluated in the past nine years has demonstrated the validity of this equation:

Worsening of symptoms after a treatment= Wrong diagnosis

A mild improvement or no response could be a valid indication that an increase in the amount of medication is needed.
The above-mentioned textbook (Kaplan & Sadock) clearly states that, when used for ADHD, amphetamines do not induce tolerance (dependence or addiction to the drug).
By the way, a very popular myth is that amphetamine medications cause a predisposition for substance abuse to people with ADHD. Psychologists and psychiatrists from prestigious universities have written several papers stating that such risk does not exist.
The truth can actually be the opposite. Children with ADHD will never become addicted to stimulants for this simple reason: they don’t get a “high” with cocaine or amphetamines. On the other hand, many of those misdiagnosed, as ADHD will search for a “home remedy” (i.e. marijuana) in the street to appease their mind, especially after being bombarded with Ritalin or one of its partners. I use the word bombarded because I have seen the suffering of youths who are desperately needing something that could slow down their racing thoughts and, instead, they are prescribed with a substance that accelerate their fast-running mind even more.
At risk of sounding like somebody who tries to justify addictive behavior, it is fair to say that, when doctors fail or the individual refuses to ask for help his pervasive anxiety will find shelter in alcohol or marijuana. Depressed individuals can become addicted to the short lived happiness that cocaine or “crystal meth” can give to them. By the way, eating disorder patients know that they will lose appetite with these substances. Psychotic individuals can “normalize” their thoughts with heroin, and so forth.
Going back to the strategy of increasing the Ritalin dose when the symptoms get worse after the first trial, I remember the case of a 7-year-old boy who has ADHD in addition to being the victim of sexual abuse and neglect. When he was 5, one psychiatrist kept increasing the dose of Ritalin up to 45 mg (more than twice the maximum dose for his weight) until he finally realized that Ritalin was not helping this boy.
The reason for the “medication failure” was a simple one: besides his ADHD condition he also has severe anxiety and attachment problems. Since amphetamines are not a treatment for anxiety (in fact they worsen it) it is hard to understand what kind of expectations the treating physician had.
As you can see from stories like the one of that 7-year-old boy, I feel comfortable enough to say that a significant part of the research data on ADHD and other childhood disorders is questionable at best. However, that particular issue will be discussed in a separate chapter. At this point let’s continue to talk in a common language about ADHD.
Simple and practical observations help to avoid misdiagnosis; i.e., the child with ADHD cannot be quiet, but the one with Bipolar Disorder does not want to be quiet… his hyperactivity only disturb those around him. One manic individual told me once:

“I don’t suffer from mental illness…I enjoy every minute of it!

And never forget this fact: any person, including a child, can have more than one illness at a time. I have found several cases of children who have ADHD plus another psychiatric diagnosis. If you only treat one of them, the outcome is not going to be good.
As diagnostically challenging as the 7 year-old boy mentioned before were two siblings with the same parents but with different diagnoses: One has ADHD and the other a mood disorder, a situation that seems to be supported by several investigators who have postulated that the same set of genes accounts for several psychiatric illnesses. But it gets more complicated. One of them, after three years on Adderall (and doing well) began to show aggression, drastic mood changes insomnia and a decline in school performance. At 12 year-old she is now on mood stabilizers, like her brother and her parents.
Another aspect of the ADHD diagnostic confusion is the frequently attributed aggressive behavior. Many clinicians connect aggression with this illness even though the official classification (DSM-IV) does not include aggression as a diagnostic criterion for ADHD. Additionally, the “DSM-IV Handbook of Differential Diagnosis” (page 17) under “Decision Tree for Aggressive Behavior” does not even mention ADHD.
Nevertheless, frequently parents are led to believe that aggression is a component or a symptom of ADHD. “He strikes out when frustrated,” some clinicians will say. Though that makes sense, it also makes sense to realize that such “aggression” is not predatory or out of proportion as seen in other conditions.
With a very high frequency I see that other type of aggression and defiance (which it is typical of youth with mood problems) linked to an alleged ADHD diagnosis and then called Oppositional-Defiant Disorder (ODD) or, in the worse scenario, Conduct Disorder. In all the instances that I have observed a child with the ODD label, he was actually showing an elevated mood or was afflicted by anxiety or had been sexually or emotionally abused.
It seems clear to me that behaviors were a reaction to other identifiable explanations, that were missed by evaluators, but never a deliberate act of defiance.
This is why I encourage parents to do whatever it takes to get the ODD diagnosis deleted from their children’s record because such label implies a malicious intention to misbehave. Just think of how unfair that label is for a child who is refusing to attend school because he has Social Anxiety Disorder (also called Social Phobia).
But it can be even worse. I have seen cases of Mild Mental Retardation diagnosed as ODD because they “refused” to do the school work, however nobody considered the cognitive deficit. For more details you should read the chapter “There is not such thing as ODD.”
Another important concept to keep in mind is this: the ADHD diagnosis is a clinical one. What this means is that no test has been officially accepted as valid to corroborate or rule out the presence of ADHD. We determine that a child has this condition by using clinical skills and experience. Several investigators (James McCraken, MD at UCLA among them) are looking for that genetic test that can say, “beyond reasonable doubt, this is ADHD.” At the anatomic level, in 1995 Dr. Judith Rapoport reported that her group at the National Institute of Mental Health found a decreased volume in the brain structures known as the Caudate Nucleus and the Globus Pallidus. She compared 57 boys diagnosed as ADHD with 55 healthy control subjects.
At a more sophisticated level, in terms of neurotransmitter (chemicals involved in the regulation of moods and feelings) evidence points in the direction of the Dopamine and Nor-epinephrine receptors (a specialized chemical structure that receive the messages communicated by the neurotransmitters) but nothing is definitive yet. But, even if a test like this is available, it is so expensive that we still must rely on the clinical interview and observations reported by relatives and teachers. In most case we have do “detective work” and to pay attention to every word the child says or gestures displayed during the evaluation.
This is an illustrating example: During the interview of an 8-year-old girl, while talking about the speed of her mind, I asked if her mind was slow or fast upon awakening. This is what she said:

“My mind is slow in the morning…after I take my pill (Adderall) it goes fast.”

At this point I asked if with the increased speed of her thoughts if it was easier or more difficult to think and she responded:

“It is kind of hard to think.”

And then she proceeded to talk about the “good” side of her brain and the “bad” side and how each side tell her nice and nasty things, respectively. To my surprise, her brother, who was almost 10 years old and only 59 pounds, was not experiencing hallucinations despite being on 120 mg of Concerta (another brand name of Ritalin) which is the highest amount of this medication that I have seen prescribed to a child who weighed less than 60 pounds. That boy also was taking 60 mg of Strattera (a non-amphetamine drug for ADHD) and clonidine, a blood pressure-lowering drug that helps aid sleep.
In my experience, asking if the medication for ADHD “helps you to think better or not” can be helpful but only when the answer is understood in the context of the whole picture, which includes the symptoms that prompted the evaluation, family history, demeanor during interview, the presence or the absence of anxiety, psychotic symptoms, rapid mood changes, etc. All of this, complemented with the answers to clinical questionnaires such as the bipolar spectrum scale, the Incomplete Sentence List or the Conners Behavioral Scale.
When asking younger children about the speed of their thoughts, I usually move my hand at 3 different speeds and ask them to pick up the one that resembles how fast the brain is thinking. Other times I use a piece of paper to draw circles while applying increasing speeds to my hand, starting with the “slow mind” (numbered one) and continue with a “number two” that is going medium speed. “Number three” “goes” really fast.
It should be said that normality usually goes unnoticed and that the opposite applies to abnormal situations. For example, if we are asked “how fast is your heart going?” we will have a hard time figuring that out. But if we have been jogging we become aware of the heart rhythm. Something similar happens with the speed of our thoughts. If they are going at normal pace we are not even aware of the thinking process; but if it is too slow, i.e. alcohol-intoxication with slurred speech, or too fast, as in the case of one person with elevated mood who declared:

“I am trying to fall sleep and my brain keeps going... I wish I could shut it off and fall sleep,”

That awareness immediately becomes a painful reality.
I became a believer of children’s ability to accurately report racing thoughts because I had the fortune of witnessing the following: “A five-and-a-half-year-old Caucasian boy was admitted to an inpatient psychiatric hospital due to out-of control behavior at home and at his Day Care Center. He had been on 20 mgs of Adderall (a medication that combines four types of amphetamines) until a few weeks before his hospitalization. He was hitting children and adults, masturbating constantly, speaking about “a man that was talking to him in his head” and addressing authority figures with an adult-like demeanor.
I asked him this simple question: “How fast is your mind going” and he gave me this amazing answer:

“Fast, really fast, so fast that I don’t even know what I’m thinking”.

At the same time, he jumped from one chair to the other and said:

“I’m half monkey”.

This happened in Arizona where his father was raising this child by himself. The boy’s mother left the family, during an episode of mania, when they were living in a southern state and she never came back. A psychiatrist in his native state started him on Ritalin before the father moved to Phoenix where a pediatrician switched him to Adderal. He ended up admitted to Charter Hospital in Glendale, AZ as a “bad case of ADHD.” In less than a week he was able to sit quietly after Valproic Acid and Risperdal (mood stabilizers) completely controlled his misdiagnosed “ADHD.” His mind was no longer going fast.
As you can see the key to a good diagnosis is still based on good history and a complete mental status examination. Unfortunately, many professionals chose to “shoot from the hip” and rush into fast diagnosis. Others do not even bother to make a diagnostic evaluation and take as valid what a non-physician allied professional suggested, “after testing for ADHD,” which as I already said, is not possible because there is not a valid written test for this illness.
Considering the scenario presented in the preceding lines we can understand the surprise of a mother who stated:

“I am amazed that you are actually taking notes and expending time talking about my son…These other doctors scare me…They handled me a Ritalin prescription without asking half of the questions that you have today.”

Her twin boys were on Ritalin during 4 painful years and another 6 months on Adderall. She stopped the second medication after a very smart case manager suggested having the boys free of medication until the appointment already scheduled with me. They showed clear improvement in aggressive behavior and decreased clowning just by being without the stimulant. As in many other cases, that mother was in treatment for bipolar disorder and she described the children’s biological father as “the most hyperactive person I have seen in my whole life” and said that he also was a class clown.
In the following pages I am going to present several real-life stories that illustrate how pervasive these diagnostic confusions are. They also provide living proof of the actual age when mood disorders can begin.

The Half Milligram Miracle
“Ashley” was a beautiful 27- month- old girl referred to a child psychiatrist by a Glendale, AZ, psychologist. Her mother is very assertive lady, who divorced the girl’s father soon after her daughter was born, due to his persistent spousal abuse and refusal to get treatment for his well-established diagnosis of Bipolar Disorder. The psychologist’s diagnosis was confirmed by my assessment and I started the little toddler on Depakene (a mood stabilizer a seizure medication) that made the girl less aggressive toward other children but she still would not go to sleep until midnight, even without taking naps. During follow up visits she exhibited destructive/aggressive play in my office and the aggression toward other children re-emerged.
After being on therapeutic levels of Depakene for several weeks and having tried Vistaril (an anti-allergic drug), without good results, I prescribed 0.25 mg of Risperdal, another mood stabilizer. There were no side effects but no improvement was observed. After 4 weeks the dose was raised to 0.5 mgs with only a minimal decrease in her aggression.
She was the blond and smaller version of Melissa, another girl mentioned in several chapters; because when she came to office’s reception area she would shout “Dr. Mota!!” and run toward me like a tornado.
In April 2000 during a regular follow up appointment something extraordinary happened. That day, the first voice I heard came from the mother:

“Doctor, what a miracle half a milligram can make!”

Not understanding the meaning of her statement, I asked for her daughter and she responded:

“This is the miracle I am talking about. She is behind me”

In an act of desperation, the mother had increased the Risperdal to one milligram the week before (something that parents shouldn’t do without consulting the doctor) and, fortunately in this case, there was no harm. In fact, the little girl was a “completely different child,” as her mother would describe her later in the conversation. For the first time since starting medication treatment, she sat quietly to play with the Legos and there was no disruption in the office or aggressive destruction of toys.
Five years after that experience the public opinion is more open to the idea of medicating children but not a two-year old. I do not share the fear but, as a father of six children, I understand how it feels to give medication to a little girl. Nevertheless, from a more objective point of view, when it comes to preserving the brain of that precious child, and I am 100% certain of the diagnosis, I don’t hesitate to offer medication to a toddler in need of treatment. Besides, pediatricians use Depakote for children the same age with seizures and nobody even blinks. I have to continue discussing ADHD but I will take a few more lines to disperse the fears around medications in children. To start, given the wrong medication for a wrong diagnosis is bad for anybody but given a necessary medication should never be denied on the sole base of age. We should keep in mind that, Risperdal (the medication I prescribed to the little girl mentioned above) decreases the amount of dopamine in the brain, which is exactly the opposite of what Ritalin, Concerta and Adderall do. When psychiatrists modify the levels of that substance with psychotropic drugs many eyebrows are raised but when a pediatrician actually administer pure dopamine to a three pound baby who is fighting for his life everybody welcomes that treatment. In the Neonatal Intensive Care Unit it is common practice to give intravenous dopamine to babies in septicemic shock (a severe generalized infection that overcomes the body’s natural defenses) without concern for the safety of the “developing brain” the anti-psychiatry groups love to present as threatened by our treatments.
One last question: have the objectors ever asked a parent like the mother of “A” how she feels about the opposition against the professionals that returned happiness to her home?
I would love to hear the answers.

A Whole Family with Social Phobia
Can you imagine a safari guide mistaking an elephant for a zebra? Hard to believe but something like that happened in a town in the outskirts of Phoenix, Arizona. A 10-year old boy was diagnosed with ADHD and ODD because he was refusing to attend school. The child was being very nervous in the classroom (“hyperactive” was the description of his behavior) but he ended up completely unable to stay in the school for more than one hour. When he came to the clinic for a psychiatric evaluation, his mother had to drag him into the office. He was avoiding eye contact and kept asking “when are we going to be done with this?” A few minutes later his mother explained that I should take no offense for his behavior because he always felt uneasy around any stranger.

“He never goes to shopping malls or restaurants. That’s why we live in the desert; his father is just like him, or maybe worse. I am here because somebody had to get out but I am uncomfortable too.”

A diagnosis of Social Anxiety Disorder was made and he was started on 5 mgs of Paxil. In the second visit, 2 weeks later, he still had pretty much the same nervousness. The medication was increased to just 10 mgs to avoid possible side effects that could sabotage the tenuous alliance being started. That day I also had the chance to evaluate his 12-year-old sister who presented with similar symptoms. In the 6th week of treatment this boy walked into the office without arguing or pestering his mother in the reception area. He made normal eye contact and exchanged a brief conversation about his experiences of being back in school for half/day, which was a drastic change from his “Yes” or “No” answers on his first two visits. At this point I began to plant the idea in his mother of getting treatment for herself because she was very pleased with the changes she was observing in her son and I increased his medication to 15 mgs.
To make the story short, after three months of combining medication (20 mgs now) and cognitive-behavioral therapy for him, plus “in home” Family Therapy provided by a skillful and dedicated therapist, the boy was ready to start his full time school attendance. His sister was also doing better and his mother had gone on Paxil too, prescribed by her PCP. Just a few months after the beginning of treatment, both brother and sister were attending school like any regular child their age. Their mother was doing better with her symptoms. It was a success story but how scary it is to think that this child was diagnosed ADHD and prescribed Ritalin, a medication that, as should be expected, worsened his anxiety.
To conclude this story, and as this is not a soap opera but real life, I should clarify there was not a completely “happy ending.” The father refused to go into treatment because he does not believe in medications. He is also the one with the most severe symptoms in the family. His wife explained how they met when she was told about the idea of including her story in a book and in a Case Report, she smiled and explained:

“We met through mutual friends… He can stay inside the house for 3-4 days. I don’t care for going out… In the supermarket I feel uncomfortable with so many people.”

With a big and sincere smile she stated:

“I still get nervous when I talk to people.”

They live on a 10-acre farm and the closest house has been vacant for many years. Until they got into treatment, their way of life was interpreted by the family as “just the way we are.” They did not suspect that “enjoying” isolation was their way of coping with a mental disorder.
Even though many people know about Social Phobia because Paxil and Zoloft have been advertised on TV and magazines, I should explain why an antidepressant medication works for this condition and that not only Paroxetine (Paxil’s generic name) but also all of the “SSRIs” can improve the symptoms of anxiety, OCD, Social Phobia, Panic Disorder or Generalized Anxiety Disorder. “SSRI” stands for “Selective Serotonin Re-uptake Inhibitor.”

The following drawing is the graphic expression of a 10 year old girl who was diagnosed ADHD because she was “restless and inattentive” in class. In fact, she was only nervous about leaving home.


The word selective was included in the name of this category because other antidepressants, like imipramine, also work on the serotonin receptors, but not exclusively. The first SSRI was Prozac (Flouxetine) released in 1988. Paxil was the second, soon followed by Zoloft (Sertraline) and Luvox (fluvoxamine). More recently, Celexa (citalopram) was added to the list and 2 years later its manufacturer developed an improved form of citalopram and named it Lexapro (estacilopram). It should be said that several organs, including the brain naturally produce serotonin. A deficit, or an excess, of serotonin in the brain affects mood and aggressive behavior but in other parts of the body it can be responsible for skin reactions and diarrhea, to mention just a few of its other actions. The various SSRIs have almost similar effects but the side effect profile (unintended reactions) can be different. They differ in terms of their “half life,” which is the number of hours the active substance and its derivatives remain in the blood after ingesting one dose of it.
Until three or four years ago investigators thoughts that Paxil could be the least likely to induce mania in a person with a family history of bipolar disorder or actually having the condition but the pasges of time has proved all antidepressant are equally guilty of aggravating and/or triggering mania. Once again, this is not a book aimed to educate psychiatrists and clinicians, but parents, patients and the teachers that have to deal with emotionally disturbed children. By including this type of information I intend to provide you with the technical jargon commonly use by doctors.

The Youngest Case of Mania
C K was 25 months old when he was referred to me by Dr. Alicia Torruellas, a clinical psychologist practicing in Phoenix, AZ. Dr. Torruellas’s skillful clinical knowledge made her realize that the little boy had more than ADHD, as the day care center suggested.
C K’s parents noticed that something was wrong, when he began to display unprovoked aggression at home and at several day care centers. Within months he’d been expelled from five of those centers, and a baby sitter quit the job and his mother was covered with bite marks and bruises. Both mother and father are non-aggressive people and very loving parents, but the father has Bipolar Disorder and the mother suffers from depression. When he entered the office he was elated, hardly re-directedable, very restless and hyperactive, but with a clearly elevated mood. After gathering all the history, parents were presented with the possibility of using a mood stabilizer. It was easy for them to make the decision, not only because the father was taking lithium but also because I told the parents that children younger than her son take valproic acid for seizures, without any major problem. She was also reassured that I would monitor his liver function and white blood cell count as recommended by the drug manufacturer.
His case and several others were reported in the Journal of Affective Disorders, March 2002 issue. The following is a compendium of what was reported in the scientific journal: I started him on 125 mg of the liquid valproic acid (brand name Depakene) and there was an immediate improvement in his behavior but the amount was later raised to 250 mgs. He never had a side effect during the one and a half years that I treated him. But he is not the only one. In less than a year I evaluated several two and three-year-old children with a variety of symptoms which, I suspect should bring this question to your mind: Why do these cases come to Dr. Mota and not the other professionals? The answer is a simple one: The referring insurance company could not find another psychiatrist that would accept a child younger than 4 years old. That was true in 1999 in Arizona and, six years later, the same was happening in Orlando, Florida. Maybe I should explain what seems to be a “never talked about” big misconception about mental illness. Apparently there is a “secret agreement” (or a huge denial?) to believe that early childhood is a shield or immunization against mental illnesses. Very few people will entertain the idea that a two-year-old can have OCD or anxiety, not to say a Mood Disorder. Paradoxically, the majority of professionals do not have any problem in giving a serious diagnosis, like autism or leukemia, to a child of the same age.
Here are several enlightening stories about small children:
The Gatorade Boy
Francisco was a three-and-a-half-year-old Hispanic boy referred by the counselor that was working with him. His pediatrician had diagnosed him with autism, a year before because he was not talking, and the only food that he would eat was Gatorade and soda crackers. He was even hospitalized to search for a physical condition but nothing was found.
When I met him he was engaging, had normal eye contact: he would not speak but indicated what he wanted using his hands. He did not have a history of ritualistic behavior and willing to participate in normal playing with siblings and other children, although he didn’t talk.
I explained to his mother that Francisco was missing the basic element in autism, lack of relatedness to other people. My diagnostic impression was something in the realm of OCD and I started him on the smallest amount of liquid Prozac that can be measured to gradually increase it to 2.5 mgs/day in a four weeks interval.
At the 2.5 mg dose, two months later, he grasped a piece of hamburger from his older sister. He ate the whole portion, and after that he added another element to his diet. Twelve months after his first visit he was saying several words, eating tortillas and drinking milk.
I do not know what happened after that because the family moved to another state and I lost contact with them but I have no doubts he was not autistic.

The Batman Boy
“Tommy” was a 3-year-old when he was referred by his day care center because he was refusing to take off his Batman costume and would throw a fit if somebody called him by his real name. He demanded to be called Batman at home, he would not let his cape be removed to take a bath, and his parent also had to call him Batman.
His mother was a smart and sophisticated Caucasian lady who was familiar with the diagnosis of OCD because of personal experience with several relatives and her own readings. She agreed to start him on liquid Prozac and continue it, even after the day care staff asked her to report me to the Board of Medicine for giving such a strong drug to a little child.
In less than a month, Tommy was allowing people to call him by his name and by the 3rd month he completely forgot about the Batman costume. At that time, 1997, I was not aware of any study of Prozac in small children, but I knew that several studies did not find any harm to fetuses when pregnant women took the medication.
The rationale was that at the fetal stage the brain is undergoing more significant development than at age three, and if it did not do harm to a fetus, it should be safe for a three-year-old. At the last follow up, three years later Tommy was just fine.
One more time grandmother’s knowledge would explain the establishment’s apathy:

“The blindest man is that one that refuses to see.”

There is perhaps nothing we can do to change the willing blind but we can refuse to be restricted by their wrong beliefs.

The Runaway Boy

“He is very smart and will do well in class, if he wants to... He can be loving and caring but it will be hell if he does not get his way...He always thinks that he is the man of the house.”

With these words an African-American grandfather in Central Florida described his 13-year-old grandson. The boy came into his care after his drug addicted mother lost custody due to neglect. Even though she abused cocaine and alcohol when pregnant with him, his intellect appears to be above average.
At the time of evaluation he appeared to be a happy boy but also very defiant to authority figures to the point of leaving home to spend the night with friends if he was frustrated with household rules.
Not surprisingly, he was on a high dose of Adderall (amphetamines) in combination with two mood stabilizers (Depakote and Risperdal) because he was diagnosed, not only with the “evil triad” of Oppositional-Defiant, Conduct Disorder and ADHD, but also with Bipolar Disorder. A psychiatrist who gathered a family history of mood disorders and substance abuse added that last diagnosis, instead of deleting the wrong one. I felt compelled to fix the diagnostic confusion and to discontinue the Adderall because, even if the boy actually had ADHD, it is nonsense to prescribe together two drugs that antagonize each other as is the case with Adderall and Risperdal: One increases dopamine and the other reduces the level of this substance in the brain.
A year after our first meeting, the grandfather reported that his grandson’s behavior had improved and there were no more episodes of running away or defiance. In school he was getting excellent grades which confirms he was never ADHD but bipolar from the very beginning.

The Child Who Reads Charles Dickens

“A giant stream of air is trying to lift up my head.”

This was B.D.’s description of his racing thoughts at the time of his evaluation. He presented as a very healthy and handsome 13-year-old boy, described by his father as having a superior intelligence, even though he was born, in 1989, weighing only 4 lb., and needed a medication to help his lungs mature enough for normal breathing.
He was referred to me by a hospital in Florida after he received a few days of involuntary inpatient treatment prompted by a comment he made to his teacher. B.D. said: “I am going to blow my head off.”
The interesting part of this story is that this happy and very articulate boy was not depressed or suicidal but very distressed by the discomfort of a fast-firing brain and auditory hallucinations. Reading was like torture for him because his thinking could not state focused on the book’s subject and his mind wandered while his eyes were looking at the lines of words. He also admitted to losing his temper easily and described “trance-like episodes” when he gets angry.

“I want to get everything right on the first try or I will explode… I hear my name being called.”

“He believes he is an adult,” father said. And B.D. admitted to feeling that he knew better than his teachers do.

After two weeks on 300 mgs twice/day of lithium and 0.25 mgs of Risperdal he reported a mild decrease in his racing thoughts but stated:

“I still can’t really catch up with anything I am thinking.”

He had no more auditory hallucinations but sleep was still difficult due to his racing mind. The lithium level was 0.5 (effective levels should be around 0.8 to 1.1) and all his blood tests were within normal range, which supported an increase of Lithium dose to 900 mgs/day and Risperdal to half milligram/day.
A month after that, a very relaxed B.D. walked into the office with the Charles Dickens book “A Tale of Two Cities” which prompted this comment from his mother:

“He eats books.”

Then he gave the most impressive description of going back to normal brain function a child his age could ever state:

“My mind has been going on so fast for years that now it is catching up with its breath.”

No wonder this boy scored 600 just in the math component of the SAT, even thought he was only in the 7th grade. He does not have racing thoughts anymore and his attitude toward his teachers now is very different:

“I just sit down and learn whatever they have to teach me ...No, I don’t think I know more than them.”

His weight, after two months on medications was two pounds less than his starting 102 lb. (a surprising finding because his medications are known to increase appetite) while the only reported or detected side effect was a mild tiredness that it is not interfering with school performance.

There is Not Such Thing as “Terrible Twos”
Another popular myth that interferes with proper diagnosis of small children with behavior problems is the misconception about alleged “normal” aggressive behavior around 24 months of age. Prominent pediatricians, such as Alan Greene (not to confuse with the outstanding Harvard professor of psychiatry Alan Green) has written books and comments about it in his popular website. Again, it is another by-product of the same problem that we address throughout this book: The best pediatrician in the world still is not a psychiatrist and the best psychiatrist is not a pediatrician, unless your last name is Rubin, Dana in Boston and Mark in Phoenix, and you trained in both pediatrics and psychiatry.
If you talk to the parents of children with a psychiatric diagnosis and ask about the beginning of first symptoms, in many cases they will tell you that it was around the age of two or even before.
I believe that it is important to burst this mythical bubble because it deprives children of prompt diagnosis and treatment, which in many cases can hurt the self-esteem of those children that are disliked because of unruly behavior. Of course, it is less painful to take the ostrich’s strategy and hide away from the problems, pretending it is just a faze, but we need to remember that it is not a solution to the problem.
If you take that route, the Internet can become your house of dreams because an abundance of dreamers maintain shelters where they can escape from reality. They are not excellent pediatricians, like Dr. Greene, but individuals without a real knowledge of what constitute normal development in children. For example, one of them claims that it is part of the normal development of a child to kick, bite and hit.
That would be a bad news for me because then I have 6 very abnormal children.

From “The Worst” to the “Most Improved”
A 10-year-old Florida boy and his very determined mother did everything possible to prove the psychiatric/educational establishment wrong. His pediatrician prescribed him Ritalin in 1st grade, even though the child’s father has been diagnosed with bipolar disorder, and was described as a violent person.
When I first met him, his mother was extremely frustrated because she was convinced her son was afflicted with the same condition his father had but his previous doctor stated repeatedly that he was too young to be bipolar. Describing his behavior, the mother said: ‘there is no reasoning with my son.” In school he had been suspended several times while taking 30 mgs/day of Dextrostat (a brand of amphetamine) that was making him angrier, according to mother.
I discontinued the stimulant medication and started him on 2.5 mgs of Zyprexa, a mood stabilizer that yielded a remarkable improvement. In a matter of days his whole demeanor started to become “the child he used to be,” his mother said, but he was sedated in the morning when the dose was increased to 5 mgs. Then he was switched to Risperdal with continued positive results, without the sleepiness.
After 4 months of corrected treatment and diagnosis, he came to proudly show me his ROTC award as “the most improved”, wearing a smile, full of pride. He was oppositional-defiant no more.
The only sad part of this outcome is that the establishment may choose to ignore stories like this, which make me wonder what could be a different explanation for such a transformation? …why should this boy labeled oppositional-defiant if the bipolar diagnosis (inherited from his father) could explain his behavior?

Two plus Two= Five?
The story of Pablito is another one that you will find hard to believe. He was born in the same psychiatric hospital where his mother met his father and at the age of 18 months a nice and caring Puerto Rican lady adopted him.
Hyperactive from the beginning, he would jump from his cradle to the floor; his mother told me 11 years later. By the time he was four-years-old, it was necessary to have him evaluated by a psychiatrist at a major teaching hospital in New York City.
Despite the adoptive mother’s report about Pablito’s biological parents (both schizophrenic) he was diagnosed ADHD and prescribed Ritalin. That was the beginning of a painful ordeal that ended when I diagnosed him with a psychotic disorder and switched his medications from Adderall and Clonidine to Zyprexa and Depakote. That was in August of 2003 and he did so well that his follow up appointments were scheduled every 3-4 months. Unfortunately, after two years he stopped taking medications and deceived his mother about his compliance with treatment.
When I hospitalizing him my thoughts were that the possibilities of schizophrenic parents having an ADHD child are similar to Japanese parents having a Navajo or Apache boy… or 2 + 2 being equal to five

An Adult Conspiracy?
In 1994 Frankie was 3 year old when he began to show sexualized behavior and severe temper tantrums. His aunt (and foster mother) took him to a pediatrician who told her that nothing was wrong with the boy. A year later his behavior escalated to the point that he was “terrorizing” the classroom in Pre-K.
His teacher, in Phoenix, AZ, told Frankie’s mother:

“Either you put him on Ritalin or we are not going to take him in Kindergarten.”

He was taken to his pediatrician with a behavioral questionnaire and a note from the school with the boy’s diagnosis, as determined by the educator. The doctor wrote a prescription for the drug and he was accepted in school.
A few weeks later he began to exhibit more aggression and was staying up late during the night. His mother took him back to his doctor and he was given clonidine to help him to sleep and Ritalin was replaced with Dexedrine which is another amphetamine. As could be expected (because he was still on the same type of medication) nothing changed except for an improvement in his sleep.
Multiple medication adjustments and combinations characterized two years of serious behavior problems at home and school. Because he was not getting any better, his pediatrician requested a psychiatric evaluation for “this severe case of ADHD and ODD.” The poor boy was “upgraded” to oppositional-defiant because, according with the teacher and the doctor “he didn’t want to change his behavior even with appropriate treatment for ADHD.”
When I was faced with this “defiant” boy (in fact showing an elevated mood) and I heard the family history of mood problems, violent behavior and substance abuse, Frankie left the office with a prescription for Depakote and the advice to stop the Adderall (combination of 4 amphetamines) he was taking.
There was an immediate improvement in his behavior, but still his mother only heard a negative comment from the pediatrician:

“This medication is only going to make him gain weight.”

“Good” said the mother, referring to the fact that he was underweight. But the big surprise came from the school Principal. In a clear disregard for the psychiatrist’s expertise, he said:

“There is no way that an eight year old can be bipolar.”

Despite all the negativism around him, and with the help of that wonderful aunt and foster mother that stood with him, even when he was being labeled as a “bad boy,”
Frankie was able to survive that “adult conspiracy.” He is another example of a child who became “non oppositional-defiant” with the right treatment for a correct diagnosis. To conclude I want to share with you this letter that was published by the dynamic and informative journal “Current Psychiatry”:

Vol. 4, No. 7 / July 2005
ADHD or bipolar, but not both
“What’s the best treatment for comorbid ADHD/bipolar mania?” by Drs. Nick C. Patel and Floyd R. Sallee (Current Psychiatry, April 2005) was well-written and offers excellent treatment guidelines. However, the idea that patients can have comorbid bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) is a fallacy.
I challenge any colleague, from the leading expert to the most recent graduate, to present a bona fide case of “comorbid” ADHD/bipolar disorder. I can prove that only one diagnosis is correct because:
· Bipolar disorder is more heritable than other psychiatric illnesses. Many patients labeled as having “comorbid” bipolar disorder and ADHD have parents with bipolar disorder or schizophrenia or are in foster care and their biological parents’ histories are unknown.
· I’ve seen hundreds of patients enter full-blown psychosis after another clinician put them on amphetamines or antidepressants while being treated for ADHD.
· Bipolar disorder can explain any so-called ADHD symptom.
· ADHD does not include moodiness or predatory aggression.
Over 10 years, I have diagnosed three or four patients as having comorbid bipolar disorder and ADHD. After a few years and inpatient treatments, these patients proved the second diagnosis wrong. We can decrease costs and avoid patients’ suffering by refining diagnostic criteria.
Manuel Mota-Castillo, MD, medical director The Grove Academy, Sanford, FLand Lake Mary Psychiatric ServicesLake Mary, FL

References:
1- Am J Psychiatry 155:968, July 1998

What Is BIPOLAR Disorder?

“From the brain and from the brain only arise our pleasures, joys, laughter and jests, as well as sorrows, pains, grieves and tears... It is the same thing which makes us mad or delirious, inspires us with dread, or fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absence-mindedness, and acts that are contrary to habit.” (Hippocrates)

We could answer the title question by saying that bipolar disorder is the new name for Manic-Depressive Illness. That old name was actually more objective and descriptive of this disease’s nature because “manic-depressive” can be easily associated with the concepts of mania and depression. Its downside is that mania could sound derogatory and phonetically close to maniac. Bipolar, on the other, brings some dose of mystery to name, that I can infer by noticing how frequently patients and parents ask me for the meaning of the word bipolar.

But how did the name evolve from “manic-depressive” to “bipolar”? Dr. Charles Bowden, a world authority in this area, attributes the coining of the term “bipolar” to Dr. Robert Kendell. Dr. Bowden stated that in the mid-1970s, the new name was introduced as an attempt to minimize the confusion between manic-depressive illness and schizophrenia. In 1987 the APA officially accepted the name in its DSM-III-R, possibly because it is more politically correct.

Why the word “bipolar”? One possible explanation for this name is that it came about as an inference from the “follie circulaire” (circular madness), described by the French psychiatrist Jules Falret. I like this theory because the earth is almost a circle and “bipolar” could be a metaphor for the “emotional journey from the North Pole to the South Pole,” from one state of mind to the opposite...Switching from being “high” to feeling “down.”
If I could give a nickname to bipolar disorder I will probably chose something like “The Silent Killer,” a label given to high blood pressure in the1970s, but I am afraid that it could sound like the headlines from one of the supermarket tabloid newspapers. Unfortunately the statistics about this illness are very scary. Fifty per cent of the people with bipolar disorder will attempt suicide in their life span and 10% of those without treatment will kill themselves.
This trend continues even with the modern treatments now available, probably due to multiple reasons. One of them could be the refusal by many of the people afflicted by this condition to accept the existence of a problem and to seek treatment. Sadly, a significant amount of those in active treatment can flip out of a stable mood due to stress, lack of sleep, a concomitant illness or other reasons. Other triggers of suicidal thoughts include substance abuse, less than optimal drug treatment combinations and impulsivity. In every case I encourage family involvement because it could be the only source of reality check and support when the patient’s stability is falling apart.
Because this book’s goal is to empower families and patients I am going to offer ready-to-use information about the bipolar spectrum, undoubtedly one of the most common psychiatric diagnoses in the world, second only to anxiety disorders.

Maybe I should start by explaining that the knowledge of its existence is as old as the practice of medicine. It goes back to the “father of medicine,” Hippocrates (c. 460-c. 377 B.B.) describing “mania and melancholia” in one of his writings. Ironically, in those ancient times he used only clinical observations to diagnose mood problems, whereas now, with modern medicine’s technology clinicians are having problems diagnosing similar conditions.
Closer to our times, Emil Kraepelin (1856-1926) one of the fathers of psychiatry described a “Manic-Depressive Insanity and Paranoia.” I suggest to those who are skeptical about the validity of childhood mania to pay attention to this information:

He even described mood swings in pre-pubertal children, back in 1921. But long before Kraepelin, the French psychiatrist Jean Etienne Dominique Esquirol published a book in 1845 that included a report of several cases of manic-depressive illness in school-age children. 158 years ago he thought that this disease could start in childhood but the good Sigmund Freud came with his revolutionary ideas and children were “instructed” not to get depressed. That Freudian influence can still be perceived in some of our colleagues who believe children are unable to suffer from the bipolar spectrum disorders.

To give the benefit of the doubt to those professionals, I should say that a frequent source of confusion comes from having a restrictive view of the original description of manic-depressive illness. Kraepelin, and even the APA in its DSM-IV manual of diagnosis, describe a cyclical condition with well-defined stages of mood. In the real world that clear differentiation between depressed and elevated mood only happens in a limited number of individuals.
Most commonly, we see people with a more subtle separation of moods (and frequently a mixture) in their presentation. This is what Dr. Hagop Akiskal refers to as Bipolar Spectrum Disorder.
In a commentary included in the Journal of Bipolar Disorders of which he is the Editor in Chief, he said:

“The patients seen today in psychiatric practice deviate considerably from such a classical prototype. The rubric classical bipolar disorder it is generally reserved for non-mixed euphoric mania that alternates with depression in a cyclical, episodic fashion. I haven’t seen such patients in this strict sense for a long time. Most patients have rather subtle presentation.”

His findings have been replicated by several investigators; among them Giovanni B. Cassano et al. who published a special article in the Journal of Affective Disorders in 1999.
In their paper “The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology” they affirm that failing to identify “sub-threshold” manifestations of mania could be a reason for the under-diagnosis of bipolar disorder. These authors also presented several explanations for the lower rate of recognition of sub-syndromal (those no meeting the full diagnostic criteria) cases of manic-depressive illness. Four years later, Dr. Mark Frye in a poster presentation at the APA Annual Meeting in San Francisco displayed data indicating that 61% of patients who sought help for their mood problems from a primary care physician received a wrong diagnosis. When they visited a psychiatrist, the margin of error was 44%. Our data (collected in three states: Arizona, Tennessee and Florida) shows an even higher percentage of failure to identify a bipolar spectrum disorder.
In the November 2000 issue of its official journal the APA sent a positive sign of flexibility when 13 world-renowned researchers published “Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire.”
It is relevant that, even though the authors started by endorsing the doubtful 1 % prevalence for Bipolar I Disorder, in the same paragraph they assigned 2.6 to 6.5 % lifetime prevalence to the Bipolar Spectrum.
I say that 1 % is inexact because this number is, in part, the consequence of the inflated percentages attributed to other diagnoses like Conduct Disorder (CD), Attention-Deficit Hyperactivity Disorder (ADHD), and the disastrous Oppositional-defiant Disorder (ODD). If they are reported with its real prevalence the percentage for mood disorders would be much higher and the victimization of children (by the mental health and the legal systems) less common.
A main contributor to such diagnostic confusion is the way that many clinicians interpret the illness of individuals whose mood fluctuates from happy to angry, instead of happiness to depression and vice-versa. They rarely are classified as bipolar.
In Dr, Cassano’s paper, and most articles on mood disorders, you will find the terms “manic” and “hypo-manic”. If you wonder about the difference between these two categories, the manual of diagnoses (DSM-IV) offers a set of clear criteria to make the diagnosis. The most important factor distinguishing hypomania is that the person with this state of mind does not require hospitalization if no significant social impairment is present. Importantly, psychotic symptoms are not part of its presentation.
In simple words, the “manic” individual is usually lacking insight (unaware of how his disruptive/erratic behavior is affecting others) and his judgment is seriously impaired. The “hypo-manic,” on the other hand, is generally functioning fairly well (or even being more productive and creative) and enjoying his natural “high.” A common feature in both situations is a decreased need for sleep and a feeling of “racing” thoughts, when the mind is “going too fast.” Friends and relatives perceive that fast-paced mind, as “he can’t keep his mouth shut” or “it is hard to understand what he is trying to say.” One clear example is this description from the mother of a 9- year- old boy:

“He doesn’t know when it is time to make jokes…He will ask the silliest questions.”

I have seen this child behave like this even though he has superior intelligence.
Another example comes from a 45- year-old lady who described her sudden mood change with these words:

“All of the sudden I felt like I went to hell in a hand basket.”

What probably puzzles some professional who follow the rigid diagnostic concepts spelled out in the official classification, is this well-known fact: The “classic” bipolar cycling described by Kraepelin at the beginning of the 20th century is the least common presentation of this illness. Most frequently in clinical practice, we encounter a very wide spectrum of mood disorders that can range from “one to ten” in terms of severity. A clear example of a severe episode would be a patient who asked me to call the Secret Service to notify them of his hospitalization because “his name was Bill Clinton.” Do you want to guess the name of his wife? He said: Hillary Clinton, of course.
Ten days later cleared of his delusions with his mood stabilized, he laughed when he was told what he had said. After his release home, he returned to his career as a successful Realtor. In milder cases, of course the individual never has to be hospitalized. He may go through divorces and business failures, or bankruptcy related to impulsive behavior or gambling, but he manages to stay afloat. Between the severe and mild cases, there are many forms of presentations that could fill this book entirely.
A composite of the bipolar symptoms could be like this:

Ø Very fast speech
Ø Can’t stop talking
Ø Grandiose & histrionic, theatrical
Ø Too Funny
Ø Angry w/o a clear reason
Ø Racing thoughts “I would think better if my mind would slow down a little”
Ø Dresses provocatively
Ø Craving for attention
Ø Sexualized behavior and language
Ø Asking staff for a date

Another question that it is frequently asked is this:
How do you get bipolar disorder?

The available evidence from experts in the field points to a genetic problem. Social, psychological stressors and drugs like prednisone, amphetamines and antidepressants can function as precipitating factors. Several chromosomes are “prime suspects” but as of November 2005, nothing concrete and final has been found.
The statistical evidence proving the hereditary nature of mood disorders is conclusive. It could be even more overwhelming if every patient has had a thorough psychiatric evaluation, including a detailed family history yielding more accurate diagnoses. By true I mean the opposite of perfunctory questions. It implies asking with the intent of gaining deeper discovery about this person, not just using the routine “is there a history of mental illness in your family?” The usual interviewer will take a “no” for a good answer and continue to the next question. An investigative clinician, for example, will make sure that the person being evaluated is talking about his biological family and not about an adoptive one. In other cases, after having said that there is no history of mental illness in his or her family, a parent will say:

“Well, in fact, my father was never diagnosed and he didn’t believe in doctors, but I swear there was something wrong with his mood.”

We should also search for the possibility of a very common scenario: the patient is certainly a biological son but one of his parents being an adopted child. That would open a big window of possibilities with grandparents.
At times we need to talk with each parent separately and apart from the child. In many instances I have read the embarrassment on faces as the interview progresses. I usually change the subject then, and a few minutes later, I ask to talk alone with that person. That was the case with a violent adolescent that belonged to a family where everybody was laid back and calm. During a follow-up visit, his mother (European emigrant), opened up and said:

“I was pregnant when I got married. His real father is a very crazy man.”

On the other hand, with divorced parents, we never ask about the other parent in front of the child. It is not uncommon to get an answer like this:

“Oh my God, he is carbon copy of his real father. It is amazing, they never spent time together, and I feel like I am going through that hell again.”

Sometimes it is revealing to ask with the child out of the room:
“Who in your family does your child act like, or remind you of?”

Getting more scientific, in terms of pinpointing specific areas in the brain that are implicated in the development of this condition, significant advances have been made. Investigators all over the world have found these locations within the brain as well as the substances and chemical reactions responsible for the elevation or depression of the mood.
Some researchers like Dr. Husseini K. Manji (National Institute of Mental Health) have even described how the medications used to treat Bipolar Disorder affect the gene expression. I should emphasize the important of this concept because it could explain why there is a “waiting period” between initiation of treatment and therapeutic results. By the way, that delay is a confusing element for many educators and counselors who are accustomed to seeing immediate results in children treated with stimulants for ADHD. They usually perceive as a failure what it is the expected waiting time to obtain a therapeutic response from a mood stabilizer in a person previously exposed to stimulants or antidepressants.
That delayed response it is even worse when the child has been on stimulants with an incorrect diagnosis of ADHD which is due to the destabilizing effect that amphetamines have on the mood.
Dr. Frederick K. Goodwin of George Washington University and Dr. Manji (National Institute of Mental Health) have explained in detail how giving stimulants to a person with bipolar disorder can make the illness more difficult to manage or even treatment resistant. The clinical picture of a child being switched from ADHD medications to mood stabilizers can also be complicated by a withdrawal reaction from the amphetamines.
As you will see in the following chapters, the so-called symptoms of hyperactivity and poor concentration are misleading. To prevent can confusion sometimes it can be productive to ask:

“What do you mean by hyper”.

The answers can be surprising. For example, the mother of one of my patients described her father as hyper but, with further questioning, she stated that he was “always on the go, never will stop talking, was very impulsive and funny, very creative and smart”.
To me, that portrait of a “hyper” father looks closer to an elevated mood than to usual presentation of person with ADHD.
Going back to the informative part of this fast walk through the puzzling world of mood problems I could list here the official diagnostic criteria for Bipolar Disorder, but this information is widely available. It can be resumed as:

Significant mood changes that create emotional
discomfort and/or interfere with social functioning.

If you want to expand your information on the diagnostic criteria, the following are several good websites:

ü http://www.psych.org/
ü http://www.currentpsychiatry.com/
ü www.nami.org (National Alliance for the Mentally Ill)
ü http://www.chadd.org/ (Children & Adults with AD/HD)
ü www.mhsource.com/bipolar/ (sponsored by the Psychiatric Times journal)
ü http://www.infinitemind.com/
ü http://www.goaskalice.columbia.ed/

Instead it seems to be more practical to use this space to remind you of some important facts, like this one:

Many other conditions can imitate Bipolar Disorders.

One of the more common is substance abuse. In fact, many clinicians believe that unmedicated individuals use alcohol as a “home remedy” to control a racing mind and be able to think straight and to sleep.
Another category to remember is the personality disorders. Individuals diagnosed with a character problem might be very sensitive and feel hurt so easily, that to be around them becomes an unpleasant task. Such is the case of Borderline and Narcissistic Personality Disorders. Many books and treatment strategies aim to treat this type of problem but several outstanding psychiatrists believe that these personality disorders are in fact cases of bipolar spectrum disorder in disguise. If this theory is correct that could explain why these individuals “never get better.”
My take is that antidepressants, officially blessed as the standard of treatment for the “borderline” patients, could actually worsen their mental functioning. For that reason Dr. Robert Molpus and I are working with a team of therapists to gather the cases of a number of patients admitted by us to a hospital with a diagnosis of Borderline Personality Disorder. We plan to present data showing that those patients got significantly better by just stopping the antidepressant medication and prescribing a therapeutic amount of a mood stabilizer. Even though this issue is an academic discussion, I bring it here because it could assist some readers (or their friends and relatives) going trough unnecessary suffering.
Going back to the list of facts about bipolar to keep in mind, a relevant one is this:

A person can have more than one condition at the same time.

A beloved professor of Pediatrics, Héctor Cruz (currently retired in Arecibo, Puerto Rico) used to tell his residents “there is no a Federal Law that prohibits having more than one illness at the same time.” This is the equivalent to an expression frequently use by a famous psychiatrist, Dr. Ronald Pies:

“The body can have as many illnesses as it pleased.”

Dr. Cruz was talking about Pediatrics and Pies is thinking of Psychiatry and medical conditions that can mimic psychological problems but the fact is that we find bipolar disorder in a person that also can have drug addiction, anxiety, Obsessive-compulsive Disorder, Post Traumatic Stress Disorder, sexual abuse history, and etc.
Another condition that could be mistaken as bipolarity, if we do not take a good history, is the Pre-menstrual Syndrome (PMS). Many women actually go through obvious mood changes every month to the point that, in severe cases, partners and friends can describe the changes in the person’s demeanor as a “180 degrees shift for the worse.” Curiously, I have observed that close relatives of bipolar individuals, who do not have bipolar spectrum disorder, are the one who have severe PMS.
Another clue: excessively flirtatious manners and an extroverted personality may lead you to suspect a mood disorder. Fortunately most of the time it is very easy to separate socially acceptable behavior from “out of line” interactions. In children it is even more obvious. Here is one example:

Molly Duran is a very attractive and tall Texan lady who was the receptionist at the Goodyear office of Comcare, in Arizona. She has a very likeable personality but she is also the mother of grown up children; she inspires respect in most children. Being friendly is a plus for a receptionist but also a magnet for flirtatious men.

I would not be surprising if a visiting case manager or a therapist tries to start a conversation with her. What was really amazing is that a 5-year-old boy with an adult-like demeanor approached this 6 foot-tall woman, and flirted with her as a grown up would do. This happened one morning in the spring of 1997. The child was in a full-blown state of mania but still taking the amphetamine medication Dexedrine, prescribed by his pediatrician, against my advice.
This five-year-old had a severe elevation of mood that drove him to behave like an adult, losing the normal shyness a child his age would have with a woman that could be his mother. His case should remind us that in childhood and adolescence, mood instability is often expressed as irritability, hypersensitivity, anger and acting out behaviors, or lack of inhibitions.
The mother of an eight-year old boy in Florida described her son’s impulsivity with these words:

“The said to a teacher “you better brush your teeth… At the supermarket he approaches women and said “you have beautiful eyes and he starts conversations with strangers at the Mall.”

In adults, mood disorders may present in many different ways. If they are afflicted by mania or hypomania, we could see the classic “party clown” that throws spicy jokes to strangers or people in a position of authority. These individuals can also lose jobs after jobs (and relationships) because of their lack of boundaries, non-stop talking, gambling away the mortgage money, impulsively buying a car they cannot afford, and etc.
Mania can also present as unprovoked aggression, very poor frustration tolerance, and an overtly inappropriate short temper. We might also see intolerant, inappropriate and grandiose demeanor. That was the case of a 53-year-old man at an Emergency Department, waiting to be evaluated for a possible hospitalization due to suicidal thoughts. He had the following answer to my usual courteous introduction:

“What do you me want to do? Give you a dollar? “

This type of attitude can be understood by reading the brilliant explanation given by Dr. Peter Whybrow during the Annual Neuropsychiatric Review (1999). This distinguished professor and Chairman of the Department of Psychiatry of the University of California at Los Angeles (UCLA) said:

“A manic person, for example, who is very intrusive-socially-as you know, will not take the usual “code” coming back saying, “please, stay out of this”. They will continue to move forward, telling you that your tie is outrageous that you possibly shouldn’t wear a paisley shirt with that particular pattern, etc., etc. The memory acquisition and storage system, the Hippocampus is also disturbed and deregulated. People can’t decide what tie to put on. That’s why they put on paisley ties with checked shirt. They can’t make decisions very well. Body homeostostasis: They wake up early in the morning or they sleep too long.”

To conclude this brief discussion of bipolar spectrum disorders I want to mention that I use to tell my patients and parents that bipolar disorder can presents very differently from one person to the other and that the severity of the illness could fluctuate from mild to severe. In fact this characteristic is one of the validations to the concept of bipolar spectrum disorder coined by Dr. Akiskal. Sometimes I talk of two famous actors and call the two most common presentations of bipolar illness the “Robin Williams type” and the “Jean-Claude Van-Damme type”. One always happy and making jokes, the other one, mostly irritated and aggressive in their on-screen characters.
I find this separation relevant because the majority of those adolescents with the angry type are usually labeled with the unfortunate Oppositional-Defiant Disorder diagnosis. On the other hand, adults with this type of bipolar spectrum disorder are, more than 50% of the time, labeled as being just depressed and prescribed with anti-depressive medications, which only worsen their anger and agitation. Sadly, in children too the happy type, hardly ever get a right diagnosis. They contribute to inflate the percentages of the misleading ADHD statistics, because they are “hyper.”
Finally, if you wonder why the bipolar individual has poor attention span and can be wrongly diagnosed as having ADHD, this is what the eminent Dr. Husseini Manji said to an academic publication:
An errant enzyme linked to bipolar disorder, in the brain's prefrontal cortex, impairs cognition under stress, an animal study shows. The disturbed thinking, impaired judgment, impulsivity, and distractibility seen in mania, a destructive phase of bipolar disorder, may be traceable to over activity of protein kinase C (PKC), suggests the study, funded by the National Institutes of Health (NIH) National Institute of Mental Health (NIMH) and National Institute on Aging (NIA), and the Stanley Foundation. It explains how even mild stress can worsen cognitive symptoms, as occurs in bipolar disorder, which affects 2 million Americans.
Abnormalities in the cascade of events that trigger PKC have also been implicated in schizophrenia. Amy Arnsten, Ph.D., and Shari Birnbaum, Ph.D., of Yale University, and Husseini Manji, M.D., of NIMH, and colleagues, report on their discovery in the October 29, 2004 issue of Science. Either direct or indirect activation of PKC dramatically impaired the cognitive functions of the prefrontal cortex, a higher brain region that allows us to appropriately guide our behavior, thoughts and emotions, explained Arnsten. PKC activation led to a reduction in memory-related cell firing, the code cells use to hold information in mind from moment-to-moment. Exposure to mild stress activated PKC and resulted in prefrontal dysfunction, while inhibiting PKC protected cognitive function.

In the future, drugs that inhibit PKC could become the preferred emergency room treatments for mania, added Manji, currently Director of NIM's Mood and Anxiety Disorders Program, who heads a search for a fast-acting anti-manic agent.



Excess of ornaments in this vehicle resembles the colorful makeup and/or clothes that people tend to wear during a “manic” episode.