SUNDAY TIMES MAGAZINE: Can a child as young as four have bipolar?

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Rory jabs a blue brick at me, grinning. “Will you make me a Lego tower?” he asks, Chocolate Button eyes peering up from under baby-soft hair. Together, Rory — who’s four and a half — and I are going to make the absolute biggest, best Lego tower in the whole world. He jabbers away, darting around his room picking up books and toys to show me. He is very cute and charismatic, just like his mother, Jayne, said he’d be. “He looks angelic,” she’d said, looking tired, “that’s why it’s so hard to get anyone to believe us.”

Dave and Jayne were both 29 when they had Rory, their first child. As a toddler, he began displaying behaviour associated with autism: slapping, spinning, walking on his toes. His play was strange, repetitive, hyper-focused. Then he began performing “little acts of aggression”, Jayne says. He was urinating and defecating all over the house. He was angry, yet afraid. He suffered from extreme anxiety and panic attacks. When Jayne tried to take him to nursery he’d experience acute separation anxiety; locking his little body rigid, screaming, refusing to go.

Oddly, for a young child, he was highly self-conscious; acutely embarrassed if someone smiled at him — he’d start screaming at them “not to look”. He became paranoid, catastrophising events, and dangerously erratic: when Jayne tried walking him to school, suddenly he’d run into the road on a whim. He was highly impatient, and oddly manipulative. Jayne recalls walking him to a pantomime one Christmas, when Rory was three: “He was misbehaving, hitting me. I said, ‘If you hit me again we won’t go.’ He turned to me and said, ‘after the pantomime, when we get home, I’m going to hit you then.’”

But it was “the rage”, says Jayne, “the anger, the outbursts, the violence, that’s the worst part. He’s angry all the time, and it’s out of proportion.” If they refused to give Rory some chocolate he’d slam doors, take his parents’ iPads or laptops and throw them. He’d lie red-faced on the floor, spitting and screaming. In supermarkets, he’d explode so violently they’d have to restrain him. In the car he began unclipping his seatbelt. “Once,” says Dave, “as I was driving he got out of his seat, punched me in the face and grabbed hold of me by the neck.” In the end they were forced to move Rory’s booster seat to the boot, behind a dog grate. “It’s scary how aggressive he is. When he has a meltdown it can go on for over an hour. He attacks you — biting, spitting, kicking. I’d lock myself in a room with him and he’d trash the room and attack me. It was off the scale in terms of normal child’s behaviour.” Dave, a large man, and a former police officer, sighs: “The prisoners aren’t as difficult as him.”

When Rory’s baby sister, Joy, was born, he began attacking her, too.

Rory has seen a succession of mental-health workers in his short life. They’ve sent Jayne and Dave on parenting courses. “Nothing helps,” says Dave, “it’s like he can’t control himself.” One psychologist suggested Rory had anxiety disorder; another said it was behavioural problems. A psychiatrist diagnosed attention-deficit hyperactivity disorder (ADHD), and prescribed Rory the anti-hyperactivity drug Ritalin. “It’s taken the edge off his anger,” says Jayne, “but none of the psychiatrists seem able to agree. He’s a complex character. Nothing ever quite fits.” Jayne and Dave have their own explanation for Rory’s behaviour. They believe he has bipolar disorder.

For a long time the psychiatric community didn’t believe children could be diagnosed with bipolar before their mid-teens. Before 1995, pre-adolescent bipolar was considered so rare that “you might see one case in your entire career”, says the American child psychiatrist Janet Wozniak. But in 1995 she published a study with her mentor, Dr Joseph Biederman — one of the world’s most influential child psychiatrists and chief of paediatric psychopharmacology at the Massachusetts General Hospital in Boston — which dramatically changed that.

Wozniak and Biederman assessed 262 under-12s who had been referred to them from 1991 to 1993 and found, unexpectedly, that 16% of them met the diagnostic criteria for mania — episodes that form the “highs” of bipolar disorder. It was a phenomenal discovery. What it suggested was that bipolar had been missed in children, simply because psychiatrists weren’t considering it. “When I first presented my work, a lot of researchers would say to me, ‘I’ve got studies of ADHD kids and I’ve got studies of kids with depression but I don’t have any bipolar kids,’” Wozniak tells me, “and I would say to them, ‘Which instrument did you use to assess? What questions did you ask to rule it in or out? And I discovered that most of these clinics had never asked the questions associated with bipolar at all.”

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In 1999, the American psychiatrist Demitri Papolos and his wife, Janice, published a book called The Bipolar Child. It was met by a media storm in the US, and featured on Oprah. It attracted such interest, the US National Institute of Mental Health began funding nationwide research into paediatric bipolar. In the decade that followed, pre-adolescent bipolar became the greatest phenomenon in American child psychiatry. Between 1994 and 2003 the number of outpatient visits for children and adolescents with bipolar disorder increased from 20,000 to 800,000. “What I’ve lived through, and been part of, in the last few years has been a paradigm shift,” says Wozniak.

Yet the boom in diagnoses of paediatric bipolar in the US has not been seen in Britain at all. Dr Anthony James, a child psychiatrist at Highfield Adolescent Unit in Oxford, has conducted a study that suggests the rates of diagnosis were 60 times higher in America than in Britain from 2000 to 2010. “Sixty times!” James shakes his head emphatically. “In any other illness that would be a public-health crisis.”

Are British child psychiatrists missing this condition? Or are American clinicians too quick to diagnose it?

READ THE FULL ARTICLE HERE: http://www.thesundaytimes.co.uk/sto/Magazine/article1371135.ece

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