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thebalancedmindfoundation.org Expert Chat with Dr. Mani Pavuluri, Author of "What Works for Bipolar Kids"

July 10th, 2008

Chat With Mani Pavuluri, M.D., Ph.D., FRANZCP
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Dr. Mani Pavuluri? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Summer. Watch your email for more details. 

                            Biography 

Mani Pavuluri

Dr. Pavuluri is an associate professor in Child Psychiatry and the Founding Director of the nationally recognized Pediatric Mood Disorders clinic and Pediatric Bipolar Research Program at the University of Illinois at Chicago. She is listed as one of the "Top Psychiatrists of America" by the Consumer's Research Council, and is a member of The Balanced Mind Parent Network's Scientific Advisory Council.                                     

 



Mani Pavuluri MD   
Dear Families, I am so thrilled to be with you, and what can be more fulfilling than to be of some use in my profession in this profound way! :)

Nanci - The Balanced Mind Parent Network   
Dr. Pavuluri recently published a book for parents "What Works for Bipolar Kids" that is an excellent resource. Dr. Pavuluri, would you like to start out by telling us a little about your new book? 

Mani Pavuluri MD   
Yes I hope you like it! I wanted the book “What Works for Bipolar Kids” to be most practical, and help you with day to day struggles, in a way that you can apply for yourself, and take care of yourself as parents, as you are in it for the long haul! I want to hold your hand through this book as I talk to you! 
And it tells you about school issues, home, marriage, kids, other kids, friendships and medication and treatment and so on!  

Davanna  
Hello Dr. Pavuluri. What is the recommended dosage of Risperdal for a 5 year old? Are there drugs that you feel would be more effective? 

Mani Pavuluri MD 
Second generation antipsychotics are very effective, predictable more often than not, and quick to see if they work. For example, Risperdal at .25 mg once a day or twice a day is a good start.  

Candy   
Could you comment on some of the complementary treatments such as Co-Q-10, or other supplements such as omega-3 oils? And, how do we determine the appropriate dosages? 

Mani Pavuluri MD   
I think it is variable as to how much kids like to take or tolerate. I have used Omega oils such as Omega Brite capsules up to 4g a day on average. I don’t usually use complementary meds a lot. But I do not discourage parents from trying. I do not like that mega vitamin therapy at all, too much money for not clear results in my opinion. But some swear by it. 

AZmom   
Are there any new meds out there that look promising in treating bipolar disorder? For instance, a one a day pill that does all (i.e., treat depression, racing thoughts, up & down moods)? 

Mani Pavuluri MD   
My answer to this is so twisted! I tell my kids to pretend it is all one pill in three parts as we don’t have a single pill! I wish. Sometimes, I would like to think second generation anti-psychotics are closest to it if any; but tolerance is very high unless you give mood stabilizer along with it.   

Candy   
What is your experience with using melatonin for sleep? 

Mani Pavuluri MD   
I like it a lot as it is tried in kids for primary insomnia and was found to be safe. I use it at 2 mg to 3 mg a night dose. But it works in some and not in others. But definitely a choice!  

Nanci - The Balanced Mind Parent Network   
Lets switch topics from medications to parenting. We have quite a few questions on that subject! 

cello   
What should be a parent's first response when your child is "on a mission" (mission mode)? 

Mani Pavuluri MD   
"Honey what is it that you want? Let us figure it out!" Use a non defensive approach to try to understand, get them on your side before trying to diffuse the behavior.

Waterlily9   
Are limits and boundaries really important for smart bipolar kids? I always promoted her independence before. . .  
Mani Pavuluri MD   
I think limits and boundaries are important but all of this is grey zone. If you can let her be the butterfly and let her realize the potential while you tolerate the exploration, I say go for it! But if you are falling off the center of gravity, then there is a problem and you gently state what is hard for you and negotiate the outcome! Limit setting for the sake of limit setting is not what I suggest! Children prefer to be treated with respect. If boundaries are pushed way too much, say ‘Yikes we need to think thru this’. I mean, let them know that we need to talk and what is hard if they push you over the top.  

desperate   
My 15 yr old son has difficulty stopping talking, arguing etc. I give him the cue that he is at the point at which he needs to stop, but he just doesn't do it. I feel bad about walking away from him when he won't shut down or gets verbally aggressive. Is this common with adolescents with BPD? Any suggestions on what I can do to help him (and ME!)? 

Mani Pavuluri MD   
Wow, put on a kind mom hat for a bit, if you know you paid your dues, put on the hat of 'satisfied mom of you have done what you need to do' hat. Move on after a statement that ‘you got the point and you both know what your son is talking about, and you need to do other stuff. If he follows you incessantly, then say 'STOP" and go ahead and be tough and look after yourself. I call these steps a, b, c.  

wrenae   
What do you recommend regarding how we react to issues of aggression? We give a short time-out, and try our best not to react with our emotions (that is sure tough at times!) We do know that our daughter (age 6) doesn't want to hurt people and that it only happens at most extreme mood states. What should we do in response to these incidents? 

Mani Pavululuri MD
This is common. If it is occasional and as these kids in general are good sweet kids anyways, I would let it go. Influencing by discussing good and bad and correcting is more important than time outs. You can start fresh again after you have sorted it out i.e. usually thru dialogue and maybe taking a break after some time away from each other to think for a bit! We need to move on from bad spots and celebrate good spots! We can’t mop, mop, mop. (Like mopping the floor AFTER spilling).  

Candy 
  
I have had family members say that if the child can control his behavior for a definite time period that it is not really bipolar, for instance why can they go to grandpa' house for a week and not have any rages the whole week. How do we as parents respond to this? 

Mani Pavuluri MD   

Smile and accept the parents view. Take care of your own adolescent sense of inner self to not react and be a grown up with your parents! Kids tend to be intense with parents and not others, especially with mom. Explain a bit and then let it go. And yes, kids can be very good for example in summer camps etc. and the minute they come home, it is hell again!

AZmom   

How common are eating disorders in teens with bipolar disorder? Also, do you see more instances of low self-esteem and problems with handling parental authority in teens with BP than in teens without BP? 

Mani Pavuluri MD  
 
I see eating disorders with type 2 bipolar, associated with substance abuse and cutting arms etc. There is severe affect dysregulation with low self esteem to the extent of major depression at times. The mistake people make is treating this like depression. You need to start with mood stabilizer combination along with an antipsychotic and that seems to work better!   

Nanci - The Balanced Mind Parent Network 
  
Lets talk about diagnosis and symptoms. 

cnphess   

Chronic irritability seems to be a frequent symptom. Is this a sign of mania or depression or both? 

Mani Pavuluri MD  

Both. But it is bothersome regardless. It is sign of affect dysregulation compounded by stress whether perceived or real.  

cbrduo 
  
Do you believe there is such a condition as "medication resistant" bipolar? And if so, what other options are there to stabilize moods? 

Mani Pavuluri MD  
 
Just as in Tuberculosis treatment that involves triple therapy and quadruple therapy. It is that way, but we need to know the symptoms, types of drugs, doses, combinations to carefully orchestrate treatment and then we offer rainbow therapy to bring normalcy to life for parents and kids alike by fostering strengths.   

AZmom   

If bipolar symptoms didn't appear in a child until the early teen years, and the child has been stable on meds for a few years, do you think it's possible a child can outgrow bipolar disorder? Maybe not need the meds as an adult as they mature? Have you seen young adults able to stop the meds? 

Mani Pavuluri MD  
 
A great deal depends on parents modeling and nurturing and fostering.  Some teens can reduce meds and others have stopped and returned to taking meds. I also like to give hope and say yes! 

cnphess  
 
Does a manic response to antidepressants or stimulants indicate bipolar disorder? 

Mani Pavuluri MD   
It indicates a pathophysiologic process that could potentially be bipolar disorder, but basing the diagnosis solely on it is not correct. Having said that, a great deal of families give that history while the florid symptomatology is in full swing. So it is easy to understand the potential role of such chemical triggering accentuating the underlying process.   

garyfakhoury   
Dr. Pavuluri, does the medical-scientific community yet know what causes bipolar disorder? 

Mani Pavuluri MD   
Adult studies of typically manifesting bipolar disorder is shown to be genetic, but the pediatric variant is yet to be explained as to what causes it. All I know is that there are clear brain based changes in these kids. That tells me it is brain disorder. 

Davanna   
Does diet affect BP in any way? Do you have recommendations on diet? 

Mani Pavuluri MD   

Well people talk about carbohydrate craving. I do not know much about that specifically. But one thing I noticed is: if they are hungry, boy they are irritable! Keeping them fed to the extent that they do not become hypoglycemic especially after school is all I can say regarding the diet! Keeping up with the golden rule of everything in moderation is a good one right?!  

judy   
Dr. Pavuluri, some of your research involves the functional MRI. What are you hoping to learn from these studies and can it help prove the bp diagnosis? 

Mani Pavuluri MD   
Well I do not know about proving and for sure diagnosing based on this foot print of brain activation patterns. But what we found is that it is solidly useful in understanding these kids. Negative emotions lead to excessive activation of amygdala like a fountain of emotions hitting at you; for example a small criticism they perceive as a large one and they will hit the roof! They cannot think clearly with their frontal part of the brain that gets switched off in problem solving if they are way too excited! They cannot process facial emotions as effectively to tune in or stop where they need to stop in conversations etc! So the wiring is affected in general. Emotionally affected regions are also negatively influencing the thinking regions. That connection between feeling and thinking is critical in understanding how these kids function and use therapy for that matter or manage class rooms and teachers! 

rainbow   
How many of these children have social skills issues? I have been searching for social skills classes but can not find one that is geared towards children with emotional dsyregulation. Most classes seem to be geared towards kids with Aspergers. 

Mani Pavuluri MD   
Well maybe your therapists can read my book and start similar techniques in your area! Rainbow therapy is all about building self esteem and being a good friend and tuning in! I think you can directly teach these skills as I suggest in my book as well. I believe in generalizing to real life experience, so you will get tons of tips to foster the peer relations thru the book.  

007   
Do you have any advice on how to heal the rift between siblings who have been traumatized by the violent episodes of their sibling? Or to get them to accept the need of their own taking of medication, even vitamins, which they can't because then it makes them feel as if they are the same as their out of control sibling? 

Mani Pavuluri MD   
Well, tell each kid that they have their own story and help them gently understand what each problem is and the answer for each one which is different. Beyond that, again I explain in my book: 
1. Get siblings to understand and empathize with affected kid with bipolar disorder who is suffering. 
2. Get them to realize that they can help that person by using empathic statements. 
3. Try and spend time with each sib separately with you but then realize that BP kid may need more time as they are indeed affected; it is not all bad as sibs learn thru this tough process that growth, i.e. emotional development, is rich, continuous and stretched in their lives.  

Nanci - The Balanced Mind Parent Network   
We are almost out of time, I'd like to put through one last question and I apologize that we couldn't get to everyone's questions. We had a tremendous turnout for today's chat. 

exmish   

Given the relative newness of pediatric BP as a diagnosis, etc., and all of the negative outlooks (e.g. high mortality rate due to suicide), what would you say are reasons for parents of bp kids to have hope? 

Mani Pavuluri MD   
Well this is easy! I truly believe that these kids are smart, funny, caring, loving, not incapable of bonding which is harder in autism, they are "teach-able," have committed parents, sibs will be nurtured as a team within family, and if you break the day and times in schedule into bits and enjoy the moments you can enjoy, and build one piece at a time and preserve yourself as a parent while you do it, your kid will grow tall, big and wonderful before you know it and you can all talk about these in toasting ceremonies as  jokes! and listen, you will be saving for tuition and not trust fund ok?! Now you all look after yourself. Promise?? 

Nanci - The Balanced Mind Parent Network   
If you are interested in Dr. Pavuluri's book you can order it through our online bookstore. The forward was written by The Balanced Mind Parent Network's Executive Director, Susan Resko, and many of the parent quotes came from The Balanced Mind Parent Network members. Dr. Pavuluri, thank you so much for sharing your time, experience and encouragement with all of us today. 

wrenae   
This is all fabulous stuff! Great questions and answers! I can't wait to get Dr. Pavuluri's book... thanks so much for the chat session! 

Mani Pavuluri MD   
It is my pleasure and this is very rewarding for me you know! :) 

desperate  
 
Thank you for setting up this chat! I've been jotting down notes for the past hour. 

bm   

My friend goes to Dr. P and worship's her. She bought be the book and says it's perfect for us. 

rainbow   

Your book is amazing. I love it! I have bought it for my friend and I am going to buy it for my son’s new teacher next year 

judy   
Dr. Pavuluri has so much heart. I love her! 

cello   
I am so glad to be reminded of the role of empathy in communicating, in discipline and all of its problems... 

rainbow   
She is amazing Her book is incredible I wish the chat was longer I have so many more questions 

Mani Pavuluri MD   

I am excited that I am part of this wonderful group of people. What a way to live, lucky me, please feel free to ask me if there is burning question, I am here!

Waterlily9   
With a kid who had a plan to run away, and says they won't again, how can you trust them when they lie sometimes? 

Mani Pavuluri MD   
Each day is fresh day right? We can only influence them one day at a time with no crystal ball. I think not having that expectation of knowing definite answers and leave it to God if you believe in him/her, then that is it! 

rainbow  
 
Can you tell me how much of these issues are learned behaviors between siblings My 9 yr old son has bp and ADHD, my 8 yr old has been diagnosed ADHD not bp. I truly think he has bp also but the doctors do not agree. 

Mani Pavuluri MD  
 
Well regardless of diagnosis, there is affect dysregulation let us say! Learned behavior is not to be ruled out! But the answer is the same if you are not medicating, help them through Rainbow therapy principles of appropriate behavior. It is focused on parenting these difficult kids regardless! 

Nanci - The Balanced Mind Parent Network
Dr. Pavuluri, thank you again for being such a tremendous resource to our families. I'm going to have to close the chat room now so that I can copy over the transcript. I know that many of our members are looking forward to reading the chat session. 

Mani Pavuluri MD   
Bye now, take care!!!! Thanks for this wonderful opportunity!




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