Depression and Bipolar Disorder in Children

Excerpted from
Acquainted with the Night : A Parent's Quest to Understand Depression and Bipolar Disorder in His Children
By Paul Raeburn

On his third day in the hospital, Alex became agitated. He spent the morning in the "quiet room," a small room used to confine patients who become angry or agitated and cannot be soothed, to ensure that they don't hurt themselves. A quiet room is empty except for a mattress on the floor. Left alone there, some children are able to calm themselves. Some require sedation. Alex was released after lunch, protesting that he had not done anything to deserve confinement. During one of the three, hour-long periods each day during which patients were allowed to call home, Alex called his mother to complain about his treatment. He got angry with her and hung up. He was again sent to the quiet room. He banged on the door, demanding to be let out. The staff tried to work with him, to find out what was wrong. But he refused to talk to them.

The next day was a good day, and we all knew that was important, because good behavior counted toward getting him out of there. The cause of his "recovery" was as mysterious as the cause of his outbursts the day before. He was cooperative and remorseful. The hospital staff said he'd taken an interest in some of the younger patients, and was helping them adjust to the hospital. He was doing so well on this, his fourth day in the hospital, that the staff began to plan for his discharge. They had made no progress in diagnosing Alex's condition. The hospital was having some sort of scheduling problem, and he still had not had the EEC or the CT scan that had been ordered the first day but could not be done on the weekend. I was afraid that he would be discharged without those tests, and that we might miss a critical clue about the cause of his distress. I was afraid that his behavior might be the result of some sort of atypical seizure disorder or, worse, a brain tumor, and that he would be discharged before it was found. Maybe it was something that could be cured if dealt with quickly. I was assured that the tests would be done. Alex's social worker scheduled a family therapy session for the next day.

I left work early for the two-hour train trip to the Boonton Township station, near the hospital but too far to walk. Liz was supposed to pick me up at the station on her way to the hospital. Somehow, we had crossed signals, and she went directly to the hospital. While I was standing on the platform, fretting over the time and wondering what had happened, the social worker canceled the family therapy session, because I wasn't there. Liz found me at the train station an hour later. We argued about who had been responsible for the missed connection. The family therapy session was not rescheduled. Alex had had his sleep-deprived EEC and CT scan, and both were normal. He was scheduled to be discharged on Friday, April 26, one week after being admitted.

Alex beamed when he was told he would be leaving. It was easy to forget the state he'd been in only a week earlier. He looked much stronger. The dark circles were gone from his eyes, and he was eager to see his brother and sister. He wanted to see Reggie, our Scottish Terrier. He told the staff that he had learned a lot about himself during his stay, and they were pleased with his improvement. He said the hospital stay had helped him and he expected to do much better at home and at school after his discharge. We drove him home, bought him pizza, and celebrated his return. It was like welcoming him home from summer camp. I was relieved, and happy to have him home, and I set my worries aside for the evening.

But they returned the next day. Alex still had no diagnosis. He had had only minimal therapy, a session or two a day for less than a week. When he was discharged, he had been on Tegretol for three days, far too little time to determine whether it was helping. It was tempting to believe that the problem had been solved. But I was skeptical. I couldn't see how such a short stay in the hospital could do much of anything. The hospital had kept Alex safe, when he needed to be kept safe, and Liz and I had had a chance to talk about Alex with Psychiatrist No. 2 and a social worker. But they didn't have any answers. We had a long, thoughtful conversation with the neurologist, who said he didn't think Alex had a seizure disorder or a brain tumor, but that he would need more tests if we wanted to be certain.

The hospital discharged Alex on the condition that he continue to receive psychiatric treatment, but didn't direct us to anyone who could provide that treatment. Psychiatrist No. 2 had undone the work of the first psychiatrist Alex had seen, dropping the Zoloft in favor of Tegretol. I started to keep score: this was Alex's third drug, after a total of three visits to two psychiatrists. Each visit seemed to generate a new hypothesis and a new treatment. I didn't know anything about how psychiatric diagnoses or treatment decisions were made, but this seemed wrong. I wanted to get Alex set up with a good child psychiatrist who could spend some time with him. get to know him, and make a treatment decision based on more than twenty or thirty minutes of conversation. The hospital staff agreed. But when I asked whether they could recommend a good psychiatrist for us, they said, Sorry, we don't know any in your area. So what now? I asked the hospital staff. Where will we go for help? We really wish we could help you, the kindly social worker said; Alex is such a bright boy. Best of luck.

With no child psychiatrists on the insurance company's preferred-provider list, we had to abandon the list. We asked Alex's school psychologist to help. He recommended that we take Alex to see a local psychiatrist who knew our community and its children. We made an appointment. Psychiatrist No. 3.

Alex seemed fine during the first weekend after his discharge, except for an episode of uncontrollable laughter. On Monday morning, however, he refused to go to school. "I'm not going. Get away from me!" he shouted at his mother. He pulled his hair, thrashed around on the bed, and eventually calmed down and fell into a deep sleep. He spent most of the day in bed. His outbursts were often followed by a deep, trancelike sleep, after which he couldn't recall what had happened.

Psychiatrist No. 3 had a large number of patients with attention-deficit/hyperactivity disorder, or ADHD, one of the most common brain disorders in children. He was treating many of them with Ritalin. After his visit with Alex, Psychiatrist No. 3 concluded that Alex, too, was suffering from ADHD. He stopped the Tegretol and started Alex on Ritalin. He added Ativan, an antianxiety drug that he thought might help with the more ferocious emotional swings. But Alex's condition began to deteriorate as soon as he started taking the medication. His outbursts became more frequent and more severe. It seemed to me that these psychiatrists were diagnosing a complex emotional problem and dispensing medication with no more care or deliberation than if they were swabbing Alex's throat for strep and sending him away with penicillin. I updated my tally: three psychiatrists, four visits, four drugs. All within less than two months.

I'm not sure why it seemed so crucial to get Alex a proper diagnosis. Partly, I suppose, it was because I wanted to get him the right treatment, and I wanted to know what his prognosis was. Would he get better? Would he struggle with this for the rest of his life? Without a diagnosis, it was hard to know what to think.