By addressing her new book, Bipolar Disorders: A Guide to Helping Children & Adolescents, to the needs of bipolar children and adolescents, Mitzi Waltz fills a significant gap in the literature on this subject. And as a parent of a child with bipolar disorder herself, she follows the O'Reilly tradition of writers who share a hard-won expertise based on personal experience.

In this interview, Waltz discusses advances in treating bipolar disorder, talks about the unique personality traits--both positive and negative--of bipolar children, and tells why early and accurate diagnosis is especially important for children. She is frank about the lessons she learned as she raised a bipolar daughter: as she coped with a delayed diagnosis, with uninformed school staff, and with her own difficulty interpreting early warning signs. Finally, she cites the connection between untreated mental illness and school violence, and points out the crucial need for more accurate screening and treatment for children with mental disorders.

Allen:

First, what is the good news about bipolar disorders and what's on the horizon?

Waltz:

There's a lot of good news. Some very promising new medications are being developed. I didn't get to talk about them very much in the book, because they're not even in clinical trials yet. But knowledge gained about simple depression is yielding a lot of information about how to target medication better to avoid side effects.

There's also been some very interesting natural-medicine research on the role of essential fatty acids, which can be as effective as lithium for some patients. Unfortunately, the doses are kind of high and the stuff tastes awful. It's like cod liver oil. And the side effects, like diarrhea, can be unpleasant. They're working on that.

The natural medicine research is important, because people don't like giving medication to kids--it might affect their development. It's also good news for women in their reproductive years, because most of the medications for bipolar disorders are potentially dangerous during pregnancy. At the very least, taking fatty acids could let people take less medication so they can decrease the side effects.

Most exciting is an increased understanding that bipolar disorder, like depression, is a medical problem--not a personal failing. Recently, researchers found a biological marker for schizophrenia, something that can be measured in the blood for diagnostic purposes. And they may be close to finding a biological marker for bipolar disorders, too. We're also learning more about the possible role of viruses in bipolar disorder.

And we understand more about what bipolar disorder looks like in children, as opposed to adults.

Allen:

I was surprised to read that there seems to be some overlap between bipolar disorder and attention deficit disorder, autism, and other behaviors.

Waltz:

Well, all of them affect the basal ganglia, the part of the brain that controls automatic behaviors, and that has some influence on mood. You could look at it as being a lack of regulation in all sorts of brain activity. And that could come out in different ways in different people, depending sometimes on genetic inheritance and sometimes on life experiences.

There's a strong overlap with Attention Deficient Hyperactivity Disorder, or ADHD. The exact number is controversial, but many of the nation's foremost experts on childhood bipolar disorder believe that up to one-fourth of the kids who are diagnosed with ADHD actually have bipolar disorder, or have bipolar disorder and ADHD.

By intervening early and working within special education to make sure that their symptoms don't get in the way of getting a good education, and by providing nutritional support and, if necessary, appropriate medication, you increase the chances of a positive outcome. This is important for adults, too, because bipolar disorder can be devastating for an adult. It can destroy one's career and family life. But with good, early intervention and by harnessing their energy and avoiding mood swings (mania and depression), many of these people go on to be real achievers.

Allen:

Do you think there is some way in which bipolar disorder is adaptive? Did it provide an evolutionary advantage of some sort?

Waltz:

I think so. There are some mental illnesses that run in certain ethnic groups more than others, like a form of schizophrenia that is unique to the Pennsylvania Dutch. But bipolar disorder is found everywhere in the world and looks much the same everywhere. I think that indicates there's some evolutionary benefit to it. My guess is that it is the ability to work "outside the box," to use a current business term. People with bipolar disorder see the world with a unique perspective; they have lots of energy; they're funny and creative. They're also very quick and think up a million ideas in that stage of hypomania. It's when it goes beyond--to actual mania--that they're not able to maintain focus and accomplish things.

Allen:

Are there historical figures, especially young people, who are known to have been bipolar?

Waltz:

There are a lot. Dr. Kay Jamison is a medical researcher, and she has bipolar disorder herself. Read her work, Touched with Fire: Manic Depressive Illness in the Artistic Temperament. She mentions Virginia Woolf, Theodore Roethke, Lord Byron, William Blake, and lots of other fascinating people. She focused her study on bipolar disorder because there are so many artists who have been affected by it.

Allen:

And you are the parent of a child with bipolar disorder.

Waltz:

My daughter is an adult now; but yes, she has bipolar type II, which means she has mood swings between depression, normal moods, and hypomania. The only time she has been manic was because of an outside influence like medication. She was misdiagnosed with simple depression, as a lot of bipolar kids are. We didn't recognize the depression for a long time, because it looks so different in kids.

They're not necessarily sad and mopey; they're irritable and jumpy and uncomfortable. Kids often manifest their symptoms physically, and that makes it tough to recognize. If your kid has a stomach ache, you think of their stomach; you don't think of their brain, even though the two are connected. We had some real tough years with our daughter until she finally got an accurate diagnosis and, more importantly, some self-understanding.

Allen:

What was the time lag between when she started having difficulties and when she was accurately diagnosed?

Waltz:

At least six years passed between the time my daughter's illness started to manifest itself and the time she was accurately diagnosed. The first things I can really point to were around age seven or eight. She had some hallucinations and we just blew it off. She was very insistent that these were real experiences, but we didn't want to hear that and we didn't do anything about it medically. Her differences weren't a big problem for her at that age. She was a little disorganized but very bright and creative.

Although she had done very well in school, around sixth grade we started noticing more severe mood swings and more moping. When she got into middle school, things really began to go badly: a lot of defiant behavior. We thought, okay, it's early puberty, we'll just weather it and it'll be okay. But her grades started to slip and she started cutting class.

The school was concerned, so they encouraged us to send her to a counselor, and all the counselor did was talk about her childhood and blame her parents. We thought, "Oh, gosh, this is our fault." But my daughter felt we had nothing to do with how she felt. She was right. Something physical was going on, and they were looking for problems in her life. We actually had a pretty good relationship with our daughter.

Events at school led to a downward spiral, and my daughter's eventual hospitalization for a suicide attempt, which resulted in a misdiagnosis of simple depression.

For insurance reasons, as is often the case, the hospital didn't keep her long enough to really see what was going on. If I had only known what to look for, I think we could have avoided a lot of trouble. She was only accurately diagnosed a couple years later, when a doctor really took the time to talk with her about her symptoms and inner experiences.

Allen:

The trouble you're describing must be shared by many others.

Waltz:

Yes, these problems are quite common. For example, we weren't able to get our daughter any help at school. We were refused special education. This is a common problem. They don't have a category for serious mental illness. They have what they call "emotional disturbance," but just having a mental-health diagnosis doesn't get you services under that. And even if you're qualified, the services you get don't tend to be very good.

I've been really upset about what has come out over the past year about violent kids in school. In almost every case, you have a kid with a serious mental illness who was denied services, or who was given such incredibly poor services that they might as well have been denied services.

Allen:

When I read about these kids, I always think, gee, somebody really dropped the ball here.

Waltz:

Eric Harris in Colorado is a great example. [Editor's Note: Eric Harris was one of the two boys at Columbine High School who murdered his fellow students.] He had a serious mental disorder (probably more than one), and all they ever did was give him some limited anger counseling and a prescription, which he didn't take. There are a lot of these kids, and the families don't know this. They feel like they're the only ones. They'll get on an Internet list and they'll be really quiet for a couple of days, and then they'll say things like, "I had no idea other people have had these experiences," or "We were made to feel such shame." They were told, "You're terrible parents…." or "This is a bad kid." Then they discover all of these other concerned and caring people who are experiencing the same things with their children.

Allen:

One of the really liberating effects of the Internet, I think, is the way it brings people with similar conditions together and helps them realize they are not alone.

Waltz:

Oh, the Internet was a life saver for us. I got on BPParents, and I can't say enough great things about that list; they helped me a lot with this book. When I had a question about the side effects of my daughter's medication, I got a personal response from the top expert in the country.

Allen:

What did you learn about a bipolar child that you wish you had known at the outset?

Waltz:

I wish I'd known more about better parenting techniques. I was going to a parenting class during this period. The things that they were telling me to do didn't work, and I kept thinking, I must not be doing this right.

I've since learned from Ross Greene's book, The Explosive Child--which I strongly recommend to parents--you need to focus on the things that really aren't negotiable, like health and safety issues.

The other thing I learned is that it does get better. Some literature on bipolar disorders, written about adults who got poor treatment and didn't have the tools to keep themselves safe and healthy, gives you a feeling it's an inevitable downward slide. As a parent, you can do a lot for your child that some adults with bipolar disorder can't do for themselves. You have more of an opportunity not only to save children from bad consequences now but to give them the tools they need to be really good self-managers and self-advocates as adults. To see where my daughter is now, compared to where she was as a child, is the thing that really convinced me that treatment does work.

Allen:

In closing, what would you say is the most important thing for parents of a bipolar child to keep in mind, based on your experience and research?

Waltz:

That there is hope--that early, consistent intervention increases the likelihood of a positive outcome for young patients.

I'd also like to stress the importance of teaching self-management skills to children with bipolar disorders, especially to adolescents. These skills, coupled with age-appropriate information about the disorder and how to use medications and therapy, can help young people take charge of their lives. The main problem that parents face as their kids get into the teen years is non-compliance: refusing to go to therapy, refusing to take meds, trying to "wish away" the disorder.

My feeling is that most of this is due to the unfortunate intersection of normal teenage rebellion and a serious medical condition. If kids have learned self-management skills and are given both information and an appropriate level of control, they will more likely see therapy and meds not as something they do for their parents or doctor but as something they do for themselves.