UNTREATED PAIN

Schools can often overlook bipolar disorder in children

By CINDY HORSWELL
Copyright 2002 Houston Chronicle

Three years ago, Helen Smith found her grandson locked in an empty 4-foot-by-4-foot closet, deprived of food.

She then learned that the 11-year-old, Paul Daniel Kilgore, was being routinely confined in the so-called "quiet room" at Harlem Elementary in Baytown in response to his bad behavior.

Paul Daniel's family put an end to his confinement that day, but the mystery surrounding his erratic conduct continued. It would take two more years and a half-dozen hospital stays before he was finally diagnosed with bipolar disorder -- a brain disorder affecting mood regulation.

Psychiatrists now believe Paul Daniel is only one of many children and adolescents who are going untreated for the disorder they say is so often misunderstood, mishandled and misdiagnosed. Between 1 percent and 4 percent of adults have been diagnosed as bipolar, and researchers are beginning to think a similar percentage of children and adolescents may also suffer from it.

Texas schools were barred by state lawmakers in April from keeping students behind locked doors, but they have not been told how they should handle an uncontrollable child who has a disorder such as bipolar.

Many area school districts complain that the boundaries aren't clear on the extent to which educational or medical communities should be responsible for helping a bipolar child. The issue has forced school districts to scrap for more funding and training to handle increasing numbers of these children who walk through their doors.

"It's been dramatic ... the increase that we are seeing in the diagnosis," said Kay Pickett of the Conroe school district's special education department.

When Paul Daniel's behavior initially became disruptive, nobody understood why his moods would swing wildly from giddy mischievousness to angry aggression within the same day. School authorities thought he was bent on being a troublemaker, such as when he trashed the files and desk of his counselor, his family said.

"I stayed in that closet most of the time," Paul Daniel, now 14, recalled in a recent interview. "There was nothing to do but sleep on the tile floor. I'd get an apple or a half sandwich for lunch. I didn't like it. I was bad all the time then, but I'm not bad anymore."

Shelley Swedlaw, special education director for Baytown schools, confirmed that the lock has been removed from the closet. However, she said since his teacher is no longer with the district she could not comment further on the use of the room.

The boy's mother, Melissa Buchan, decided this past week to begin home-schooling her son.

For years, the medical community assumed the onset of bipolar disorder (also called manic-depression) came in early adulthood. Authorities now are increasingly convinced that the disorder can begin in childhood.

"There is no question that the bipolar disorder is very frequent in children and adolescents and usually missed," said Dr. Robert Hirschfield, head of psychiatry at the University of Texas Medical Branch in Galveston.

The diagnosis can often be overlooked because adults usually switch from the manic to depressive phase over a period of months while children can flit back and forth within the same day, authorities said.

"In the last few years, more authorities are starting to recognize that the bipolar disorder can exist in children. Just as they have had to recognize children can be depressed, instead of thinking childhood is this idyllic, trouble-free period of life," said Dr. Karen Wagner, who heads UTMB's Mood and Anxiety Center for Children and Adolescents in Nassau Bay.

The American Academy of Child and Adolescent Psychiatry estimates a third of the 3.4 million children and adolescents in the United States diagnosed with depression may actually be experiencing the early onset of bipolar disorder.

Adults diagnosed with serious bipolar symptoms often report first noticing mood swings when they were children, Wagner said.

DePelchin Children's Center in Houston, which finally diagnosed Paul Daniel as bipolar, provided crisis intervention for 38 children and adolescents diagnosed with the illness last year. Half of those were under age 14.

"You must carefully distinguish between children with the illness and those who may be having normal mood swings for their age or be in a home situation that makes them depressed," said Arlene Fisher, DePelchin's director of behavior and health.

Bipolar symptoms can include lengthy rages or tantrums, pervasive sadness or thoughts of suicide, impulsive or reckless behaviors, trouble sleeping or concentrating, and racing speech and hyperactivity.

Researchers are delving into possible causes of the illness, from chemical imbalances to the brain's wiring. Studies indicate a genetic link: If one parent has the disorder, the child has as much as a 30 percent risk of having it. If both parents have the disorder, the risk increases to as much as 70 percent.

John Moses of Dallas, who a year ago founded Texas Parents of Bipolar Children, believes schools tend to be reluctant to recognize a child with bipolar condition, choosing instead to see the child as "undisciplined."

His 11-year-old son, Justin, was not diagnosed until he was hospitalized with the disorder two years ago. By then, his moods were so erratic that he sometimes slept less than three hours a night, had extreme temper tantrums, and experienced giddy moods during which he set fires and hunted lizards with a flashlight while his family was asleep.

Justin now takes mood-stabilizing drugs that have allowed him to move from special education to regular classes, his father said. But not everyone is that lucky.

Ben Davidson of Nassau Bay fell into such a depressed state of hopelessness that he began writing suicidal letters.

In March, not long after penning the letters, the 17-year-old hanged himself.

His grandmother, Barbara Sewell, who moved from California to care for him after his mother's death from cancer, says she feels "like a complete failure." But she is also angry with the Clear Creek school district for what she called its failure to acknowledge her grandson's bipolar condition.

Lynn Slaughter of Clear Creek's special education program said she could not comment on the grandmother's complaints because student privacy rules prevent it. She would say only that each student's problems are handled on an individual basis.

Beginning in elementary school, Sewell said, her grandson showed signs of an inability to control his emotions. His frustrations escalated to the point that he once threw a desk across a classroom, but he wasn't officially diagnosed with the disorder until 1998, when he threatened his family with a knife.

Juvenile authorities sent him to a residential treatment center in Corpus Christi where the diagnosis was finally made.

She said Clear Creek never questioned why he was truant during the six months he received classroom instruction and medical help at the center, except to "ask him to return his school books." When released from the center, he registered at Clear Creek again, but the district was not interested in the diagnosis, his grandmother said.

He ended up quitting school and eventually took his life.

An estimated 20 percent of adults and children diagnosed with bipolar disorder will attempt suicide over a five-year period, and others will become substance abusers to "self-medicate," said Wagner with UTMB's mood and anxiety center. She is the lead investigator on a National Institute of Mental Health study looking into the treatment of bipolar children and adolescents.

In a recent address to Congress about the disorder, fiction writer Danielle Steel said her son began writing in his journal about thoughts of taking his life when he was 11. Eight years later, he did.

Steel testified in support of early diagnosis: "It is no longer good enough to diagnose them in their 20s; they are sick long before that."

Many educators and parents agree that more training is needed to help teachers recognize common symptoms and possible strategies in dealing with the disorder.

That's because students are often mainstreamed into regular classes where teachers have no specialized psychological training.

"It would be wonderful to get more training, but finding time to do it can be difficult," said Peg Sherwood, director of instructional support services in the Fort Bend school district.

Parents think educators particularly need to be trained to recognize the difference between a bipolar child's willful behavior and manifestations of the illness.

For instance, Linda Lamb of West University Place would like to see a suspension for "making a terroristic threat" to blow up the high school expunged from the record of her 15-year-old bipolar son.

When his career teacher asked him what he wanted to do, he replied, "Blow up a building" -- but only because he had recently seen one being imploded on the news, Lamb said.

Pauline Clansy, manager of psychological services for the Houston school district, said she sympathized with Lamb but that privacy rules prevented her from discussing the case.

Another problem for parents is obtaining residential treatment for extremely ill bipolar children who may need round-the-clock care. The cost runs from $85,000 to $200,000 a year, state officials estimate.

"I don't think you should have to have your kids arrested if they are mentally ill, but I resorted to that to get residential care for my son," said Allene Smith of Sheldon.

Medicaid and her private insurance would cover only a short hospital stay for stabilization, Smith said.

"The police did not want to arrest my teenage son because he was sick. But I insisted," she said. Police found a straight razor on him that he had threatened to use on his sister.

He was sent to juvenile detention, which then placed him in a residential treatment center. When he was released last year, his mother asked the Sheldon school district to pay for his continued placement at the center, but the district balked.

However, schools are required by law to educate all students, which means that if a child cannot be taught in a regular school, districts sometimes pay for residential care that offers educational services.

"I hired an attorney and won," she said. "I don't think school districts should have full responsibility for the high cost, but that's the way it ends up."