Episode #14 of the Charged podcast
About the Episode
Bipolar disorder can be easily overlooked or misdiagnosed in children because it presents differently than adult bipolar disorder. Just 25 years ago, experts believed that bipolar disorder only affected adults—and to suggest otherwise was controversial. However, thanks to the work of child psychiatrist Janet Wozniak, MD, we now know that bipolar disorder also affects children. In this episode, she discusses her work with children struggling with bipolar disorder and why she believes early interventions to diagnose and treat psychiatric disorders in children can be such a powerful force to help her young patients and their families.
About the Guest
Janet Wozniak, MD, director of the Child and Adolescent Outpatient Service and director of the Pediatric Bipolar Disorder Clinical and Research Program at Mass General, is a pioneer in the field of pediatric bipolar disorder. Since the beginning of her career, her research has pushed the boundaries of knowledge and treatment in the field of child and adolescent psychiatry.
After graduating magna cum laude with a BA from Harvard College, Dr. Wozniak earned her MD from Cornell Medical University. She completed her residencies in adult, child and adolescent psychiatry at Mass General.
She is widely regarded as a global expert in pediatric bipolar disorder and has been at the forefront of a paradigm shift in the world of child psychiatry for two decades. Her 1995 paper on childhood mania is one of the ten most cited papers ever to be published in the Journal of the American Academy of Child and Adolescent Psychiatry. Her current research focuses on the course, characteristics and pharmacological treatment of juvenile onset bipolar disorder and how traumatic events affect the development of mood disturbances and other psychopathologies in children.
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Q: Prior to the mid-1990s bipolar disorder was understood to be a condition that exclusively affected adults. We now know, however, bipolar disorder also affects children, thanks in large part to Dr. Janet Wozniak. Janet has devoted her career to better understanding the characteristics, course, and treatment of pediatric bipolar disorder. She began her work at Mass General as a psychiatry resident working with her mentor, Dr. Joseph Biederman, a global expert in child psychiatry and psychopharmacology.
Once she joined the staff of Mass General’s child psychiatry practice this collaboration continued and Janet began examining a group of patients whose symptoms didn’t fit any existing pediatric diagnosis. That work resulted in a landmark 1995 paper on childhood mania. Today that work is one of the 10 most cited papers ever published in the Journal of the American Academy of Child and Adolescent Psychiatry. It also promoted a paradigm shift in the practice of psychiatry as bipolar disorder was accepted and codified as a pediatric disorder.
So, welcome, Janet.
A: Thank you. Glad to be here.
Q: People often hear the terms bipolar disorder and manic depression, but maybe not, maybe don’t know exactly what that entails, so can you talk a little bit about what the disorder is and what it looks like?
A: Sure. Well, maybe kind of a little bit of a step back. I would say that if a patient of any age is having a mood problem, a mood disorder in psychiatry we really have two large categories in which we might wonder about their diagnosis. One is called major depression and the other is called bipolar disorder.
bipolar disorder implies that you have had depression plus mania, but technically speaking it means you’ve ever had a manic episode. There are milder forms of mood disorders, and we do know that people can have mood reactions, there are difficult moods in response to life events, but if you’re starting to wonder about a serious mood disorder it’s going to be one or the other.
Depression is characterized by a sad or low mood, lack of pleasure and joy, and can often be associated with self-destructive or suicidal feelings. There are other ancillary symptoms as well involving sleep, energy, concentration, appetite. A manic episode is defined as seven days or longer of a mood that is characterized by either elation, euphoria, what people think of as the high mood, or severe disabling irritability. So the main mood disturbance in mania is either elation or irritability.
That is how we have always defined mania, and one of the lessons that I learned in studying children who have bipolar disorder who have manic episodes is that as psychiatrists and psychologists we have done a pretty poor job over the decades of understanding the spectrum of irritable mood states, because the type of irritability is key to the diagnosis of mania in children.
Q: And how do you tease out maybe what is regular irritability for a child and what is clinical irritability?
A: So, in fact irritability, if that were the chief complaint of a parent or a child, somebody that they were quite irritable, or even an adult as well, you could imagine a whole spectrum of explanations or understandings of it. There is expected irritability that anybody might have, if you’re stuck in traffic or walking through a rainstorm. It could be just a temporary mood that is grouchy or cranky. Then depression in children is often characterized by a more persistent irritable mood. The children are sad, they’re joyless, but more often than not they’re cranky, whiny, complain-y, difficult to please in a way that seems rather persistent, and that is associated with the other symptoms.
People who are anxious could become irritable, even. If you’re compelled to do something that makes you afraid or that you think is going to humiliate you you might react with anger and say, “No I’m not going to do it” and become quite irritable or defiant, but it’s not the main part of anxiety. Anxiety is more of a fearful state.
Kids who have ADHD can also be grouchy, like if you ask them to do things that are hard for them to do. If you ask anybody to do something that is hard for them to do, if you have a sprained ankle and I ask you to hop on it you’re going to be irritable about it. But what distinguishes the irritability of mania is the severity of it. So, I say it’s kind of like all capital letters bold-faced irritability, maybe in bright red. And it involves really significant and severe states of rage. So it could be threatening, swearing, destructive behaviors. I often will ask parents about kicking, hitting, biting, spitting, breaking, throwing, attacking. So, violence and aggression can often characterize these irritable states.
When children are younger or even as they become school age or adolescent sometimes people will use the word tantrum to describe it. But we don’t like that idea, because a tantrum is a normal phase of, that very young children go through. And tantrums are short lived, they’re usually in response to something, and don’t have the same level of severity as the outburst.
So, the irritability, as you can hear, it’s like talking about different shades of a color. You know, I’ve heard like in Ireland there is many shades of green, and the Inuits have many words for snow. And we need more ways of understanding how to describe irritable states and irritability, because we think it’s key in cleaving apart these different diagnoses.
Q: And when you are talking about children what is the range? How young or how old are we talking?
A: Well, in pediatrics we generally serve individuals who are under age 18, and when we started to talk about childhood mania we were specifically looking at the under age 12 group, because that was really the most controversial question. Could a child who was pre-pubertal, under age 12 have such a severe disturbance of mood that was already causing disruption problems and needed treatment. So the first paper we wrote focused only on the children in our clinic under the age of 12 who had all of the symptoms of mania as we describe it in adults.
Now some interesting facts about that is when we start to look at the under age 12 group, the average age of those children was about eight. So it’s a fairly common age where parents will bring children in to a specialist. When you ask the parents in retrospect when the mood symptoms started for these children 75% of them say that prior to age five. And there was 25% of the parents who said to us, “I can’t give you an age of onset. My child has had a mood disorder from birth.” Sometimes they even say in utero--this was a child that was more violent and moving around a lot and seemed very uncomfortable. And then when born didn’t soothe easy, was crying a lot, didn’t sleep, was constantly irritable. And then as they could toddle around and pick things up would start to use their hands to break and throw things and hit and kick, acting in ways that are very disruptive and not compatible with regular life, preschools. These are children who have often been kicked out of preschools.
And of that group that we started to look at, the under age 12 group, 20% of them had already been psychiatrically hospitalized. So for such a young group that is an extraordinary statistic and it speaks to just how disruptive and disabling the symptoms were, usually with violence towards self or others, putting people in harm’s way in a very severe way that would require hospitalization.
So, while the parents talk about their children as having this mood disorder from the very early age, we know very little about how to diagnose preschoolers themselves, because if we were sitting in a room right now full of five-year-olds it would be a quite different room. We wouldn’t be sitting kind of quietly and politely, and there might be a lot of noise and interrupting. There could be crying and hitting and breaking and throwing, but we would think that that was cute, because it was just all preschoolers behaving the way they do.
But with brain development we expect greater emotional regulation and control. So, the question remains certainly in a preschooler where we already know that emotional regulation hasn’t fully developed where do you make the cut-off and say, “Ah this is a mood disorder ?”
In some of the children it is quite obvious, as I said they don’t sleep, they’re not, they can’t attend any regular type of daycare or preschool, the symptoms can appear to be so dramatic that we feel compelled to intervene.
But if we’re really committed to early intervention, as I know we are, we need a lot more studies looking at preschoolers and how to discern the earliest symptoms of these serious disorders as they emerge.
Q: How did you develop the skill to recognize, what can be nuanced differences between normal and abnormal?
A: This skill is really the main focus of child and adolescent psychiatry training. That is what we do in the midst of that training is we understand typical development and then we understand the deviations from typical development and how to recognize them and how to categorize them into these different diagnostic categories with the goal of making a treatment plan. The diagnoses help us make a treatment plan. That’s why they’re useful.
And making a good treatment plan, intervening early, we believe in child and adolescent psychiatry that you could change the course of someone’s life if you start very close to when things start to go wrong.
I think it’s often astounding for people that we have so many youngsters who have such severe problems that they would need medications and hospitalization, because when you think about a pediatric practice you’re mostly seeing healthy children in for well visits. Their hearts, their lungs, their kidneys. These things are all functioning well. They’re healthy.
But the brain is so complex it’s possible for things to go very wrong with it from the very earliest stages of life, especially when you’re talking about thinking, feeling, and behavior. So, part of recognizing these severe syndromes in children is first of all to realize and acknowledge that things can go astray from typical development.
Q: I know when you first published that paper in 1995 and proposed or sort of identified this disorder within children it was fairly controversial, correct?
Q: And can you talk about why that was?
A: Well, at that point there had been some previous papers written about childhood mania, because we reviewed the literature and looked at any other studies that involved this diagnosis in youngsters, and most of them started with the phrase “I know this is extremely rare, but we want to describe a few children in our practice who have childhood mania.” And so we learned quite a bit from those papers, which were purporting to identify and describe a very rare condition.
So, at the time I was doing my training, a clinician would say or a childhood psychiatrist would say, “Well, this is a disorder that might exist, but it’s so rare maybe you’ll see one in your entire lifetime of practice.” And because that was the general outlook most psychiatrists didn’t even think about it. It was a blind spot in their diagnostic interviews. Researchers who would go through a battery of questions wouldn’t ask the questions about mania to save time-- “Children don’t have this; let’s not include it.”
And so one of the areas of pushback that was really most dramatic when we published the paper, it wasn’t so much from parents or even clinicians who had “aha moments,” like oh finally somebody is describing what we’re seeing in our practice or what a parent is seeing in their child, the biggest pushback was from the researchers who said, “I don’t have this in my sample,” to which we would say, “Have you specifically asked about mania? And when the parent said yes were you open to the idea that yes meant yes?”
And what it indicates is that the children were there in plain sight. It all had to do with this paradigm shift of considering their symptoms in the context of bipolar disorder. Once that happens I would say that it’s not such a mysterious disorder to diagnose at all. We use the same criteria, the same questions that we use for adults, although we have some developmental distinguishing pieces to those questions, so I’ll give you an example.
We might, one of the questions for an adult with mania has to do with hyper sexuality, so acting in impulsive ways that involve sexual encounters, many sexual partners, or sexual behavior that is regrettable, and/or immodest. And in children it’s you’re not going to ask them about how many times they have been married or how many times they have had sex. And so the questions have to be different. Are they preoccupied with sex or sexual matters? Do they talk about it, do they make references to it? Do they seek it out on the internet? Do they touch themselves or other people inappropriately in ways that get them into trouble?
And so when we start to ask those questions, parents will start to say, “Oh yeah, my child does say and do these things and it’s an embarrassment to all of us, but they seem to be unable to stop in an impulsive way.”
Adults with bipolar disorder may spend too much money, spend up a credit card, take out loans, go into debt. Well, what do children do? Well, they beg, they’re shopaholics, they beg for more, and when they get old enough the clever ones actually do take their parents’ credit cards and buy things online. I’ve had many parents for whom I’ve had to try to write letters to help them return the things their parents, their children had bought impulsively.
The grandiosity of mania we think of in childhood as involving a lot of the defiance. A real disdainful in your face rude defiance of “Why should I do what you tell me?” An above the rules quality that is overconfident and self-focused and quite disabling, because not following rules gets children into a lot of trouble in all of their different settings and may cause them to do things that are harmful to themselves and others. Driving a car before they have a license, that would be an example of a grandiose moment in one of the kids who I was treating, making plans to quit school and start their movie career, buying tickets to go to Hollywood. And the parents discover it at the last minute and disrupt the plan.
Children will do these things. Sometimes the stories are cute, like I’ve had a lot of kids who show me their business cards, because they’re starting businesses. And you have to admire that, but it’s a bit unusual for children to do that. And it was even more unusual when one of the children under my care had 10 desks and chairs delivered to his house, because he knew he was going to be hiring employees. And his mother had to turn the truck back and say, “No, no, we’re not taking this delivery.”
Q: Wow, I can’t even imagine.
A: Yeah. So, it’s interesting though, the grandiose stories and the kind of high elated stories often make us smile, and we find them amazing, kind of cute and astounding. But that’s not why parents are bringing them into the office. They don’t come to Mass General Hospital, they don’t go to a child psychiatrist because of the stories that make them smile or laugh or that just cause a little bit of disruption. They’re usually coming because of the really severely disruptive rages and outbursts which are so dangerous, and then coupled with the depression as well, the self-destructive thoughts and suicidal thinking and self-harm.
Q: And so it sounds like it can manifest differently on different days.
A: Yes. So, one of the features of bipolar disorder is that it’s a cycling disorder, and there are some famous people who have talked about their bipolar disorder, which I sometimes call celebrity bipolar disorder, because this is where we hear about it. Maybe it’s even like TV bipolar disorder. If you kind of had to think of a sort of iconic presentation this would be it. And it would be like weeks or a month of mania with elation and high and super energy, taking on lots of projects, talking fast, maybe making a lot of bad decisions, dressing in flamboyant ways, making decisions that later on have to be reversed.
Then there is a month of depression and the depression can be very melancholy and low energy and staying in bed and not leaving the house, dressing in black and dark colors, thinking about death and dying, maybe suicide attempts. And then many people with bipolar disorder , this subgroup come out of it and they have this inter-morbid period of high functioning it’s called. Well, I say many people, it’s not the majority of people with bipolar disorder who have this type. This is a more rare form of bipolar disorder, and yet it captures our imagination not only in the public but also as psychiatrists. Many psychiatrists are looking for that form of bipolar disorder.
And for many years that is why adults often went unrecognized. There is a lot of papers written about how adults with bipolar disorder can go 10 years going, seeing different doctors before someone finally says, “Aha, this is bipolar disorder you have.” Because doctors may be looking for this classic form.
What many adults have and most of the children have who we see is often more of a chronic course. It’s children who are never fully well, because they’re either cycling through mania, Depression, or more often than not mixed state, where you have both mania and depression within one day, minute to minute.
One of the parents who I interviewed talked to me about his daughter who he said was like a five pointed star. And he said she would just circle around this star of these different mood states. One just the regular kid, but then there was the melancholy of depression, the grouchiness of depression, the rage of mania, and the elation of mania. So, sometimes I give like a clinical example when I’m teaching and I’ll talk about a little girl.
So, she is a 10 year old and she is a grouchy and cranky and complain-y and whiny, and her mom tries to get her to do things. And she doesn’t want to and she doesn’t like it and it’s no fun and it’s no good and I hate my life and nothing goes my way. And then she gets a call about a party and she starts to become super happy. She bounces literally, parents will say, bounces around, jumping from furniture to furniture, talking about how exciting the party is, that she is so popular and so many friends and what can she wear and trying on lots of clothes. Demanding they go shopping, demanding now a new cell phone, even though she is only 10, to text everyone about this party.
And when told no, a limit set, triggers the next mood which is an explosion--screaming, yelling, hitting, kicking, breaking, throwing, angry, swearing at her mother for ruining her life.
Finally that will settle down and she dissolves in tears. “How could I be like this? I am so sorry. Look what I broke. You must hate me, Mom. Why am I like this? I should just die.”
So, you see this rollercoaster of moods, grouchy, cranky, rageful, elated, melancholy, so parents describe really having their head spin with a kind of rollercoaster of different mood states. Sometimes there is just the regular 10 year old in there too, which makes them think, “Maybe we’re done with this. Maybe she has grown out of it” until it all starts again.
Q: I’m curious to ask you, Janet, how did you end up in the field of pediatric psychiatry to begin with?
A: Well, I guess to take a further step back, why does anyone go into psychiatry at all? And in medical school it’s fascinating. I loved medical school. But the focus on heart and lung and kidneys and surgery and internal medicine really eclipses psychiatry in many instances. And the decision to go into psychiatry is met with enthusiasm by other psychiatrists, but usually that’s about it. So, you have to have a compelling reason for that to begin with, something that captures your imagination.
I happened to go to med school at Cornell, so I had terrific mentors. I also realized that when I rotated through psychiatry, I acknowledged really for the first time that it was the specialty I was going to choose, because my mother was so psychiatrically ill. And I had put it aside, because the stigma associated with her illness was so profound. And the message I received from the years I was growing up, her illness started when I was four, was, “Don’t tell anybody about this. Don’t talk about this ever.” Her own personal sense of stigma and shame was profound, and some of her illness involved paranoia which further caused her to be inhibited about talking about her illness.
So by the time I became a doctor, I realized that for years I had already been trying to be a psychiatrist. Trying to figure out what she was thinking, what was wrong with her, what went wrong with her, and seeing how it impacted everyone in my family all in different ways. So, from the beginning a lot of my focus was thinking about that, thinking about my mother, and having a curiosity about her illness. And in that way when I went into psychiatry I was drawn to understanding the more serious disturbances associated with thinking, feeling and behavior.
Child psychiatry came as a total surprise. I was the youngest in my family. I wasn’t a camp counselor or a babysitter, like a lot of child psychiatrists are pediatricians. But I came at it at the time through an idea of looking at the brain as something that can go wrong in its functioning and development and realizing that that happened at very, very early stages of life. I was fascinated with the idea of intervening at the earliest stages of life.
Probably I was also thinking about my own childhood and how to understand what I had gone through as a child, still processing it even as an adult. So, my curiosity about how children think and how they become resilient and how they meet things with challenge or how they become ill or, and why, what triggers it, what events, what genetics, that became my focus.
By serendipity, I was working with Dr. Biederman and he asked me what I was interested in, and at the time I said I was interested in a lot of things. And he said, “Well, but I have one problem and maybe you could work on it. And one of my problems right now has to do with this diagnosis of mania. We have got a group of kids who are scoring positive on this mania questionnaire and I don’t know exactly what to make of it. Let’s look at it closely to see if it seems like a bonafide diagnosis of mania. Because if it is it’s important for the field to know. And if it isn’t we need to fix our questions so that we’re not diagnosing it inappropriately.”
Well, as you can imagine it was really the former that we wanted to let the field know that we had identified a subgroup of children in our clinic who had, what appeared to us, a valid form of bipolar disorder that was onsetting in the very early years of life.
Q: You mentioned a few times the importance of intervening early. Can you talk a little bit more about why that is such an important piece of the puzzle?
A: Well, we do know from the outset that every single disorder in medicine, benefits from early identification and early intervention. It’s why we all get mammograms and do breast screening. We do all kinds of checkup things to find problems before they have caused serious problems in our lives and before they’re harder to treat. I mean I guess cancer is a good analogy, if you catch it early you could treat it, and if not it spreads so profoundly that you may never be able to treat it.
But you can imagine the same is true of so many things in psychiatry, certainly substance use disorders. If we find children at an early stage who are misusing these substances it’s going to be much easier to intervene with them then than it is once they have been addicted to something for decades.
So, we do think that with these mood disorders that if you intervene early that we could set the brain on a better developmental trajectory. At the very least you free someone up from the symptoms while they have them. And if you can imagine, at my age of 57 if I had a bad year, even bad five years I’ve got a long, a whole lifetime of self and identity and I could put it in a type of context.
But if I see an eight year old who has been ill from the age of four what kind of sense of identity does that person develop and what does it do to their relationships with their family? It becomes quite strained. The family who loves them, often at their wit’s end trying to help them contain their emotions. It leads to a lot of conflict, arguing, fighting. So these children grow up feeling like they’re being yelled at a lot, not really fully recognizing how they may be pulling for it or stimulating it in those around them.
Q: Yeah and they’re so young I imagine they put it all on themselves.
A: Yeah, there can be, there can be a lot of self-blame and a lot of guilt, and in fact one of the features of bipolar disorder we see is that as time goes on people spend less time in their manic states and more time in their depressive states.
So, one of the, another reason why bipolar disorder may be difficult to diagnose in adults is that the adult may be experiencing mostly depression, and it takes a skilled clinician to recognize that there had been previous episodes of mania that may change the way in which the person should be treated. And in fact, by the way this is very important differential diagnosis, because the treatments for depression can make bipolar disorder much, much worse.
Q: I’m wondering you talked a little bit about the parents, so when you’re treating the pediatric patient how do you bring the family into it and what is it like to really almost treat not just one patient but a whole family?
A: Well, one of the fascinating parts of child psychiatry is that every child comes with family. Parents are with them. And you know I always look to the parents as the main stability factors for the child. Doctors may come and go, teachers come and go, the parents are going to be with that child for their whole life. And so strengthening that relationship, helping the parents understand what their child is going through. And building a greater sense of support and rapport within the family is very, very important for all of them.
So, the treatment usually involves many discussions with the parents. Having the parents involved in understanding all the different skills and all the different interventions is very important. Parents also act like as the “case manager” for their children. They have to pick the right camp. They have to help them cultivate friendships. They have to communicate with teachers year after year after year to help their child find a good match educationally. So, helping parents become advocates for their child and for what their child needs is part of all of our jobs in child and adolescent psychiatry.
But one of the best ways to help a parent in this situation is to diminish the symptoms that the child is presented with. If the child is less irritable, more ability to say, “Sure, Mom, no problem” when asked to do something, well that is worth its weight in gold in a family, and dramatically improves the relationships. That is when the emotional and social development can really flower and blossom and grow.
So, taking away the symptoms allows someone to be free so that they can go through all of the normal developmental stages. If you’re constantly in a state of grouchy, cranky, irritable, rageful, out of touch with reality, there is no way that you can develop the social skills and the emotional regulation skills that your age matched peers are going to be doing.
Q: I imagine too if you’re a parent there may be a sense of guilt or anxiety. Did we do something? Could we have prevented this? How do we stop it?. How do you help parents work through those emotions?
A: Well, I would say, I would say parents are guilty creatures. Just being a parent, that new, that fact brings out a tremendous amount of wondering what should I do, have I done something wrong, did I do something that is irrevocable? But on any given day I would say that when I see these kids one set of parents will come in and say, “I’m sure it’s all my fault. I’m too strict.” And then the next set of parents will come in and say, “I’m sure it’s all our fault. We’re too lenient.”
And within a certain range there doesn’t seem to be a specific type of parenting that is causative for this disorder. And so part of, part of my approach in thinking about the child from more of this perspective of their brain structure and functioning and what medications they can use or complementary and alternative treatments to help improve that functioning and their emotional regulation, in and of itself I think helps parents understand that it wasn’t a matter of them buying too many presents or not enough presents or letting them stay up late or letting them watch TV too much. These questions wrack parents’ brains, because you want control.
What we do know from a family study that we have done, and my group has done the largest family study of Pediatric bipolar disorder, looking at what disorders occur in the first degree relatives of the child we are diagnosing with mania. And what we found in that study is that the rate of bipolar disorder is much higher among the families of the children we diagnose with mania than it is among children who have say ADHD without of mood disorder or control children who don’t have any serious psychiatric syndromes, indicating that there seems to be a powerful genetic component to this.
In fact, I mentioned breast cancer, I think every woman knows that if you have a family history of breast cancer you’re at higher risk. But most people don’t realize that the psychiatric disorders we treat are even more genetically determined than something like breast cancer. Bipolar disorder is a strongly genetic diagnosis. So is ADHD, attention deficit hyperactivity disorder.
Q: So, how are you, the genetic piece and brain function piece, how is that changing the outlook and the practice around pediatric bipolar disorder ?
A: Psychiatry is in a very exciting time right now, because we have many more, maybe you would call probes, ways of understanding how the brain functions with the novel neuroimaging techniques. So, we have much greater sense of which parts of the brain may be malfunctioning for children who have serious mood disorders and other disorders as well. We’re not at the point yet where we can use these brain scans in our clinic setting.
So, although in a study of 20 children with bipolar disorder versus 20 children without, we may be able to see some dysfunction in the limbic areas, these deepest areas of the brain, no one brain scan is obviously bipolar or non- bipolar. The differences we find are very small, and so they can’t be used for diagnostic purposes--yet. But we hold the hope that in the future as our brain imaging techniques become even more sophisticated--so, we’re getting better and better pictures of the brain and we’re getting pictures of the brain while it’s functioning and while it’s doing tasks, what we call functional MRI. As we get better technologies we will be better able to understand what has gone wrong in the brain. We don’t even know what has gone right in the brain when everything seems to go according to plan. So, those questions will increasingly be unraveled.
It also will intersect with what we know about genetics. And many genes have been identified which are associated with a variety of different disorders in psychiatry, as well as medication reactions. So far there is no genetic test.
Parents will say, “Give me the test for pediatric bipolar disorder.” And I have to say, “I’m very sorry to tell you that the test is that we’re going to sit here and I’m going to ask you a series of questions that you’re going to answer, and then I’m going to tell you whether your child has the diagnosis or not.” There is not any big mystery to it.
But I wish I could give them brain scan. I wish I could show them a picture of, “Here it is where something has gone wrong.” We know something has gone wrong in the brain, but if I did the scans I would do on any of the children in my clinic are normal. We don’t usually do brain scans for these psychiatric disorders for that reason.
The genetic tests though maybe coupled with brain scans and maybe coupled with symptom profiles could come together to help us have a test which would allow us more definitively make our diagnosis, especially at earlier stages of life so that we could be certain that we need to be more cautious and maybe even intervene with medications. The genetic tests that we have now that have become so popular can tell how a person metabolizes medication. And so the report can generate a list of medications that seem to be metabolized typically or too quickly or too slowly to be of use.
It’s something that we kind of already can tell in clinical practice though, because we start with low doses and advance gradually, and we know that some people, no matter what their symptoms or what size they are, might need only a tiny amount to be better, and maybe a little tiny amount causes side effects, and then sometimes the littlest people I treat need the highest doses in order to control their symptoms and don’t suffer from side effects, even at medicine doses which you think would be rather high for anybody.
Q: I’m struck as you’re talking, these disorders when they occur in children, these very serious psychiatric disorders, it can be scary for parents or society, but you seem to have such a sense of hope and optimism. So I’m wondering when you’re looking forward and you’re looking to the future what is it that brings you that hope?
A: I see children who get better all the time and who are very grateful. Just this past week I saw a little boy and I had gone through, I don’t know how many different medicines, five, six medicines until I finally had given him lithium, which is a great medication for bipolar disorder , but we don’t start with that, because it doesn’t tend to get as many children better as the other mood stabilizers we use, the what are called the second generation anti-psychotics.
But at any rate, I had prescribed him lithium in March and then he came back to see me in August, and I was wondering why it had been so long since I had seen him. He was so well. I was astounded and pleased and thrilled. And I said to his mother, “Had I only known when I first met him years ago that Lithium was the medicine he was going to respond to I would have started with it.”
But unfortunately the state of the art is that we tick through these different trials until we find the one that works well. But I have seen enough children for whom I have hit upon the medicine or combination of medicines that works really well that I love my work and I feel like I add a lot of value to people’s treatment plans and to their lives because of my devotion towards the psychopharmacologic part of their treatment plan.
These children have other needs. There is their educational needs, there is therapy, there is family therapy, there is cognitive behavioral and dialectical behavioral therapy, there are many non-medication interventions. But one of the things that is so wonderful about the pharmacologic interventions is that children can get better rather quickly in a short period of time.
An entirely different child responded when he was very young to the very first medicine I gave him, and he has been well ever since for seven or eight years.
And so these children who are able to articulate it have said to me things like, “Well finally you’ve given me something that makes me feel better” or “I’m so glad I don’t have those angry outbursts, because I didn’t really want to hurt my teacher. I don’t know what made me do it.”
Sometimes children will say, “My brain is making me do it,” which I think is pretty insightful, because they feel astounded at their own behaviors. They are unable to control it. Sometimes I’ll liken it to like a seizure, but maybe a better example is like a sneezing fit, because you’re awake and alert during your sneezing fit. You just can’t stop, no matter how much I tell you to stop.
And so these poor kids, to see them feel relief and be able to have their own sense of self and identity and agency in the world is tremendously gratifying. I see a lot of kids get better. I think that is, that is very, very gratifying. And when I have kids under my care who don’t, well we still hang in there and we do the best we can, and that is one of the great reasons to also do research.
So, I, my time is divided, I do clinical practice, but I also have a research career, and being able to go to take these vexing questions into a study and then provide information that is useful for a child I’m going to see in the clinic in the next days or weeks, that is really super. That’s an exciting thing to do. And I talk to a lot of the young doctors to consider a career in clinical research for that very reason.
Q: Well, wonderful. That brings us to the end of our discussion. Janet, before you go, I have my final five questions. What is the best advice you have ever received?
A: Follow your heart. Do what makes you excited and passionate. It’s important to be pragmatic, but not at the expense of what you really love.
Q: The name of this podcast is Charged, so what does that word mean to you?
A: I kind of picture sort of energy, energy and excitement and sparks. And sparks of inspiration and flow of energy from place to place and person to person. So, disseminating ideas and having excitement about what you do.
Q: Great. How do you recharge?
A: Well, I would say something that I have come to more recently in life is hiking. How much I really enjoy hiking, being out in nature where it’s quiet and the scene is neverending. And your vision is like an expansive vision looking out over a horizon. I spend so much time kind of looking just a few inches away from my nose most days, so to be able to have that opportunity, I think it does, I would like to do a brain scan and see what is happening in my brain when I look out at a beautiful horizon.
I would say that that recharges me more than anything.
Q: When and where are you happiest?
A: Well, I’m happiest in my home with my kids, my husband, my two dogs. You know, the weekends are awesome, because there is more time for that. And it’s so much fun to be with them all, even if we’re apart. It’s one of the great things about the cellphone and texting is you could have these group texts and all feel like you’re connected.
So, I think one of the reasons maybe I’m so passionate about helping families by helping children with these illnesses is because I know how much joy my family brings to me. And I guess the corollary to that is I know how unhappy I was when I was a child when there was so much misery in my family.
Q: And what rituals help you have a successful day?
A: Well, I’m probably a pretty ritual-driven person. I think of myself as kind of obsessive compulsive. In many ways it’s a useful trait in medicine. But I guess maybe part, one of the rituals that I kind of am trying to increasingly incorporate is physical movement. So, getting up, moving around, walking, and if I can getting on a bicycle or getting on a treadmill or going for a run or just even going for a long walk is something that I would like to be more of a regular ritual and part of every single day.
Q: Thank you, Janet, for coming and talking with us about bipolar disorder. It’s been such a pleasure.
A: Thank you for having me.
- Storybook Ball 2018 - featuring Dr. Wozniak's work with Jett, a young patient with bipolar disorder
- Pediatric Psychiatry
- Mass General for Children
- Mania-Like Symptoms Suggestive of Childhood-Onset Bipolar Disorder in Clinically Referred Children, Journal of the American Academy of Child and Adolescent Psychiatry (subscription may be needed to view)