CEHL:

Q & A with Mary Ann McDonnell and Dr. Howard King

September, 2008

Below is an excerpt from a conversation between Dr. Howard King, CEHL founder, and Mary Ann McDonnell, APRN, BC.  Before reading these questions and answers, consider first reading Mary Ann's excellent article, The Meaning of “Bipolar”: Perspectives of a Parent and Health Professional.

Dr. King: “What could you have done earlier to prevent or minimize the severity of your children's illness if you had intervened earlier?” 

Mary Ann: Early identification of symptoms offers the possibility of earlier intervention, which can increase the likelihood of better outcomes and decreased burden over the person’s lifetime.

Dr. King: You stated you could have created “a protective environment to shield my children from stressors that contributed to the development of their psychiatric disorders.”  Could you elaborate upon this?

Mary Ann: Early life stress can influence the development and course of psychiatric disorders and children who experience stress during periods of development may have permanent changes which shape the brain regions that mediate stress and emotion.  The affected regions may, in turn, lead to an alteration in emotional processing and a heightened response to stress.  In an individual with a genetic predisposition, early stress could be a key determinant of the development of a psychiatric disorder.

Dr. King:  Your observation about “kindling” is fascinating.  Since most pediatricians may be unaware of how intervention may prevent progression of the illness, do you think it might be useful for you to elaborate a little more about this idea? 

Mary Ann:  The theory of kindling in mood suggests that the combination of psychosocial stress and genetic vulnerability may lead to a full mood episode and that once a full mood episode has occurred, future episodes are triggered more easily with a mild stimulus.  Over time, episodes begin to develop spontaneously with no stimulus at all.  Interventions during the early course of kindling may prevent progression of the illness.

Dr King: You also mention that if children are misdiagnosed, “they may be treated with medications that are harmful to them and may make their symptoms worse.”  Were you referring to some psychiatrists, not to mention pediatricians?  If so, how can we help families identify the right kind of psychiatrist for their child?  And what type of medications were you referring to? 

Mary Ann:  Misdiagnosis can occur in all areas of medicine and psychiatry.  Families who I work with have reported misdiagnosis from all different types of doctors and nurse practitioners.  The key to proper diagnosis is to find a specialist in the field of child psychiatry.  Pediatric Bipolar Disorder is complicated and not all clinicians are comfortable diagnosing and treating it.  Parents should ask their clinician about his or her level of experience and expertise in treating psychiatric disorders in children and adolescents. 

They can also contact local organizations who help families and ask for a referral in their area.  Some websites, for example, as associated with STEP Up for Kids, Inc. www.stepup4kids.com or the one associated with the Child and Adolescent Bipolar Foundation www.bpkids.org have information that will be useful as well.

Dr. King:  You suggest being “proactive and ask questions during routine visits to assess for risk and/or early symptoms of an emerging disorder.”  What questions did you have in mind and how do you find the time to incorporate such questions in the routine visit?

Mary Ann: It is important to ask about a family history of psychiatric disorders during the initial visit.  If psychiatric disorders are present or suspected in the family, it is important for the parents to educate themselves about those disorders so that they can recognize emerging symptoms in their child early on.  Pediatricians can provide them with fact sheets or hand outs about the disorder, and recommend helpful books to educate them. 

In the interest of time, it may be most effective for a pediatrician to use a questionnaire to assess for psychiatric symptoms in the child.  In my experience, parents are very receptive to filling out questionnaires while sitting in the waiting room prior to the visit or they can be mailed out in advance and brought with them to the visit.  The child behavior checklist is easy to use and helps to identify problem behaviors and symptoms in children and adolescents. 

Dr. King:  You suggest that “it is essential to ask parents about the home environment and refer them to programs and services for help if they are living in a stressful, chaotic or dangerous environment.”  But how do pediatricians find the time to do this in the routine “fifteen-minute visit?  Shouldn’t this encourage pediatricians to consider my suggestion of routinely “inviting parents back” when they are concerned about a particular family situation?

Mary Ann:  Absolutely.  If a pediatrician in concerned about a family situation, they should invite the family back for another visit so that they can better assess their concerns.

Dr. King:  You point out, “Given the heritability of bipolar disorder, offspring of adults with bipolar disorder at an increased risk.  Other than family history, there is no other risk factor that has been documented sufficiently to justify its integration in clinical decision-making regarding the diagnosis of pediatric bipolar disorder.  If so, isn’t it crucial we get a good family history from day one? 

Mary Ann:  Obtaining a good family history from day one is essential.  Having a section on pediatric bipolar disorder on your website is a great idea.

Dr. King:  You note, “If you are not familiar with the customs of patients, consult with someone who is, so you do not miss important symptoms or misinterpretation.  Do we need a paragraph on cultural competence including families who are “Afro-American” or “Hispanic?”

Mary Ann:  It might be helpful to gather and post more information for Afro-American and Hispanic families on your website.  Research has documented that ethnicity is significantly associated with misdiagnosis of bipolar patients. 

Findings from a study of youth, ages 5-17 years of age, reported that AA youth were less likely to receive the diagnosis of PBD than Euro-American youth of the same age, despite the fact that there were no differences found in the manic symptom presentation and overall depression scores between the two groups.

Dr. King:  You also wrote, “Children who are themselves experiencing symptoms of ADHD and/or depression or have early mood dysregulation, may be experiencing prodromal states of bipolar disorder.”  If so, how many such children are we missing by the too easy diagnosis of ADHD by pediatrician or teachers?

Mary Ann:  Many children with bipolar disorder are misdiagnosed with ADHD.  The problem with this is that if children with PBD are treated with stimulant medication, which is the most common treatment for ADHD, it can make them manic.  Before diagnosing a child with ADHD, it is important to rule out other psychiatric disorders.  Several rating scales are available for use in children and adolescents which may be helpful with differential diagnosis. 

It is also important to note that ADHD is NOT a mood disorder.  Rather, it is a disorder that encompasses three domains of symptoms which include inattention, impulsivity and hyperactivity.

Dr. King:  Later on, you write, about “the high rates of co-morbidity with ADHD, and oppositional defiant disorder.”  But, Mary Ann, if you interviewed twenty consecutive pediatricians regarding this idea, how many of them would be aware of this observation, and, particularly, would take the time to ascertain this?

Mary Ann:  I understand the time constraints in practice.  If a pediatrician does not have the time to do a full assessment of psychiatric disorders during their visit or if they are not well versed in assessing psychiatric disorders, then it is crucial for them to refer the child to a clinician who can make an accurate diagnosis and develop an appropriate treatment plan.  In some cases, the child may be able to receive a one time evaluation with a child psychiatrist or nurse practitioner who will provide them with a diagnosis and treatment plan and then consult with the pediatrician on an as needed basis with the pediatrician throughout the course of the child’s treatment.  

Dr. King:  When you wrote, under “core features of bipolar disorder in pre-pubertal and early-adolescent bipolar disorder phenotype,” that “hyper-sexuality” is one of the symptoms.  What is it that drives this hyper-sexuality? What is it in the service of?

Mary Ann:  Hyper-sexuality is seen in some children and adolescents during manic episodes.  It is most likely due to them being overstimulated.  When the mania is treated effectively, the hypersexuality usually resolves.

Dr. King:  Finally you write, “Sub-threshold PBD, sometimes referred to as bipolar spectrum disorder is common, clinically significant, and under-detected in treatment settings.”  You go on to suggest that there are screening instruments which are easy to use that pediatricians might find helpful in their practice. 

But how would you incorporate these into a routine busy pediatric practice, i.e. which ones, who would administer them, how would you or your practice find time to administer them, and how would you charge the insurer for doing so?

Mary Ann:  There are several parent rating scales that you can ask the parent to fill out in order to save time during a visit.   The most commonly used parent rating scales for pediatric bipolar disorder are: The Young Mania Rating Scale – Parent version (P-YMRS), The Parent General Behavior Inventory (P-GBI), The Child Mania Rating Scale-Parent Version (CMRS-P), and Parent Mood Disorder Questionnaire (P-MDQ).

Dr. King: In summary, for pediatricians who are motivated, here is a list of challenges for the pediatrician to incorporate these tasks into their practice.

1. It will require a conscious desire on the part of the pediatrician to pick up such problems and educate parents so they can play a key role in bringing them to a doctor’s attention.

2. When should we begin to orient all parents to the aforementioned statistics and develop an alliance with parents in the early detection? [Mary Ann: at the first visit, the earlier the better]]

3. Should there be a handout for parents to be given at the first visit for new families? [Mary Ann:  I think handouts are a great way to introduce new concepts that parents need to be thinking about.  The pediatrician could give them the handout, briefly discuss its content, and encourage parents to be alert to early signs and symptoms of psychiatric disorders.]

4. Should pediatricians mention that parents should be sometimes be offered the opportunity to be “invited back” to elaborate a vaguely described set of symptoms so we can be more precise in our diagnosis? [Mary Ann:  It is appropriate for a pediatrician to express his or her concerns to the family and explain that they have a limited amount of time during this visit so they would like to invite them back to gather more information and properly assess the situation. Unless of course there is a safety concern for the child, then it would need to be dealt with immediately.  If the pediatrician isn’t well versed in the assessment of psychiatric disorders, they may opt to send the child to the emergency room in a crisis situation. 

5. Parents know from day one that their child requires a set of immunizations throughout their pediatric experience.  How do we educate all parents that we need to be equally vigilant about pediatric bipolar disorder? [Mary Ann:  If psychiatric disorders are talked about during the first visit as part of the assessment and explained as having a biological basis, families may be more open to discussing them.] 

6. Most families have had some level of experience with a psychiatric disorder such as anxiety, depression or ADHD but they do not know much about bipolar disorder in children.  It is important to educate parents that prevention and early intervention are far superior to treating a full blown disorder once it has developed. 

7. Given the short duration of most pediatric visits, shouldn’t the orientation in terms of educating pediatricians to these situations be as follows:

  • Increased awareness of the presence of such symptoms? [Mary Ann:  yes.]
  • Be ready to “invite parents back?” [Mary Ann:  yes.]
  • Focus on timely referral rather than providing opportunity to just “treat with medication? [Mary Ann:  yes].

8. If I was going to ask you to evaluate such children or family situations, should I have a printed form describing questions the parent and I should answer together for me to help, you (as a consultant) take my concern, seriously? [Mary Ann:  It doesn’t have to be a printed form.  Verbal or written communication with a brief description of your concerns would be helpful.]

9. How can I help parents be reassured of the likelihood of a positive outcome by having some kind of a handout explaining the value of early referrals? [Mary Ann:  The handout could provide research based findings about prevention and early detection of psychiatric disorders.  These messages are pretty powerful, especially if you use some case examples of those treated early and those who have been treated after many years of untreated illness]]

10. What parental issues do I need to be vigilant about in order to increase parents’ early cooperation? [Mary Ann:  It is important to be nonjudgmental in your approach to sensitive issues such as psychiatric illness.  Let the family know that is your job to assess and promote good health in children and adolescents and that includes assessing for any symptoms of psychiatric disorders.

Explain that a high percentage of children and adolescents will experience symptoms of a psychiatric disorder at some point in their development and that early identification and treatment, as is true with most illnesses, is essential to improving outcomes.]   

11. Finally, how do we overcome provider resistance to developing this kind of approach on their part?  [Mary Ann:  Educate the providers about the devastating results of untreated mental illness and help them understand that they may be the only one who is seeing this child and is able to recognize symptoms early enough to prevent poor outcomes.

I would emphasize that as medical professionals, we have the responsibility to assess and treat the child as a whole person and to promote good health.  Our responsibility is not limited to medical issues only in general pediatric practices.  We have to be aware of psychiatric disorders and their devastating impact on the lives of children, adolescents and their families if they are left undiagnosed and untreated.]

 


 

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Support

I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.


- Dr. Howard King, M.D.