The past few months have been busy as we readied the revision of The Bipolar Child for its September publication date, and as we continue to launch the first programs of the Juvenile Bipolar Research Foundation. Last week JBRF launched its professional listserv for physicians. This is the first online forum for physicians from around the world who treat or supervise the treatment of children and adolescents diagnosed with bipolar disorder. The board of JBRF is extremely concerned that there are only 6300 child psychiatrists throughout this country (most residing in more urban areas) and we hear from parents everyday who cannot find a doctor to evaluate, diagnose and treat their children. JBRF envisions that this listserv, a rapid peer consultation service for those on the front lines, will provide an efficient vehicle for members to learn and communicate about clinical experience, differential diagnosis, treatment outcomes, and adverse effects to medications. It is also the JBRF’s hope that pediatricians and family practitioners will join this forum as they are the ones who first see these children and, in many rural areas, they will have to oversee their treatment as there are no child psychiatrists to whom they can refer.
In the next few weeks, JBRF will begin subscribing psychologists, neuropsychologists, social workers and therapists to a second professional listserv so that professionals seeing these children can share information and ideas as to what works best for the children and their families. Discussions about neuropsychological testing and remediation techniques will also take place in this forum.
If you know child or adult psychiatrists, pediatric neurologists, family practitioners and pediatricians and other mental health professionals who would like to join an important and informative online discussion group, please have them contact Sandra Norelli at firstname.lastname@example.org and visit www.bpchildresearch.org. Please feel free to forward this newsletter to doctors and therapists and pediatricians who work with your children.
Past issues of this newsletter have focused on aggression, night terrors, separation anxiety, sensory integration problems, and other symptoms of early-onset bipolar disorder, but we feel it’s time to discuss a very common symptom of the illness -- one that particularly affects and disturbs the families of the children, one that is rarely talked about, and one that leaves us all uncomfortable: hypersexuality.
Hypersexuality in children is rarely discussed about for two reasons: one is that (bipolar or not) sexuality in children is simply not spoken about in public; and the other, sadly, is that parents of hypersexual children are afraid to mention the subject -- even over email. They are petrified that Child Protective Services will find out and wrongly assume that a hypersexual child is an overstimulated child, and that that overstimulation stems from sexual abuse in the home. Few people -- even the professionals at the Departments of Child and Families (DCF) or Child Protective Services (CPS) realize that hypersexuality is so common during the manic or hypomanic stages of bipolar disorder (in adults and in children) -- and so it is rarely if ever factored into the equation. Parents of bipolar children fear losing custody of their children based on these suspicions of abuse.
In the pages below, we’ll discuss the subject forthrightly -- what it is, why it is, and how to deal with sensuous demands or behaviors in ways that are not punitive and shameful for the child. Hopefully, some of the things you’ll read here will also help a child gain more control.
What Is the Definition of Hypersexuality?
Webster’s New Collegiate Dictionary describes “hypersexual” as “unusually or excessively interested in or concerned with sexual activity.” It is an accepted fact that hypersexuality is a symptom of hypomania or mania in an adult who has bipolar disorder. In Overcoming Depression, 3rd Edition, we wrote about the increased sociability that accompanies an upswing in mood and stated that “often accompanying this increased sociability is an increased sexual drive (hypersexuality). It is not uncommon for the person to ‘fall in love’ and impetuously pursue a love affair or a string of affairs, possibly jeopardizing an established relationship or marriage.” In another section, a man describes some of the sensations he felt early in a manic phase: “Sexually I felt awakened, competent, responsive...” Hypersexuality is a very common symptom of mania.
In children, the symptom may manifest as a fascination with private parts and an increase in self-stimulatory behaviors, a precocious interest in things of a sexual nature, and language laced with highly sexual words or phrases.
If aggression is difficult to explain to the neighbors, what do you do with little ones who always have their hands down their pants, whose language may be filled with sexual jargon, or who are constantly trying to rub their bodies up against an adult?
In the same way that children with bipolar disorder have difficulty modulating aggressive impulses, so do they sometimes have problems reigning in sexual impulses that may overtake them and cause them to overreach the boundaries of what is appropriate in a social context --particularly in hypomanic or manic states where all systems rev up. They seem on a different time clock than other children, as though certain behaviors set to go off in the adolescent years happen well before. Yet doctors, nurses and social workers in this country are taught routinely that any sign of increased sexual behavior in children is a result of overstimulation in the home environment.
But is this so? When Dr. Barbara Geller and her colleagues at Washington University in St. Louis looked at a group of 93 children and adolescents diagnosed with bipolar disorder as a part of an ongoing NIMH-supported phenomenology study, they found that 43% of this group who were manic were also hypersexual. In order to rule out any overstimulation or sexual abuse in the environment, each child and family was examined first with the Psychosocial Schedule for School-age Children Revised (PSS-R).
Dr. Geller explained:
This is a comprehensive semi-structured interview that was given by the research nurses separately to mothers about their children and to children about themselves. It has a section with items on sexual abuse. In addition, pediatric and other medical records were obtained and examined for any possible clues to abuse (e.g., multiple visits for accidents, unusual urinary problems etc.). Teachers and after school caretakers also supplied information.
Dr. Geller and her colleagues found that less than 1% of these hypersexual bipolar children had evidence of overstimulation or sexual abuse in the home environment. The conclusion of one of the journal articles published about this on-going study of children and adolescents with bipolar disorder was that “the 43.0% rate of hypersexuality in the prepubertal and early adolescent subjects strongly supports hypersexuality as a symptom of mania.”
What Does Hypersexuality in a Child Look Like? How Early Does It Begin?
Danielle Steele, in her book His Bright Light, describes her son Nick’s intense interest in women at the age of two (italics ours).
She wrote that:
He was absolutely enamored of women. And just as I had thought early on, he often seemed to me like a grown man in a toddler’s body. ....He groped, he hugged, he caressed, and who would expect a two-year-old of anything other than being cuddly? I did. I knew him better. Even at two, Nick was a Don Juan in the making.
He used to sneak up behind my housekeeper, creep under her skirt and pat her bottom, and then laugh outrageously. When I took him to our neighborhood ice cream store for an ice cream cone, he would invariably stand in line with a look of innocence, and reach up to a comfortable height for him and pat some woman’s bottom.....And when we went to a beach house we still rented then, he would cheerfully suggest we go down to the beach and “hug the ladies.”
While most children possess some curiosity and interest in their body orifices, many of the parents we interviewed for this article described their children as intently keyed into body parts and talking about them all the time, especially during periods of instability. A little girl talked endlessly about her “butt,” and a three-year-old boy asked his mother to “rub his penis”. When in a silly, giddy mood one boy screams “Tickle me penis” over and over and breaks up laughing about it. Another little boy told his mother “It feels really good to stick my finger up my butt.”
Almost every mother described some variation of the child’s hugging or kissing her in an extremely sensual way. A mother emailed us that: “He loves to smash his face into my breasts when he hugs me and he constantly begs to ‘squish my big, fat tummy’ (this woman is very slim and trim). He usually has his hands on me before I can pry him off.”
We heard many stories of both boys and girls watching TV with their hands down their pants or little boys holding onto their penises for hours of the day or evening. One mother wrote about her 6-year-old son:
Hypersexuality is the most disturbing symptom for Matthew after the aggression and rages are gone, and it’s one of the last behaviors to go away as treatment is effective for him. For instance, today, despite a lithium increase, he’s had his hand on his penis all night. I told him over and over again to put his hands somewhere else, but to no avail. Now, granted this is minor compared to two nights ago when he threatened to hit our privates so hard it hurt (as revenge for a simple “no”). If this lithium increase works as others have, tomorrow night or the next, Matthew should not exhibit hypersexuality unless he needs a higher lithium level for the umpteenth time. Sometimes, we see minor signs of the hypersexuality right before the needed lithium dose.
Here is another description of a very hypomanic, hypersexual seven-year-old boy:
He got very silly after dinner -- very affectionate with me, and hypersexual at bath time. He said: “I love you Mommy,” trying to kiss me. “Will you lay on top of me. I’m going to rub my penis, can you do it?” After his bath he jumped on top of me trying to give me “long kisses” and telling my husband he knows a girl who would rub his penis.
How Can a Parent Effectively Deal with Hypersexuality?
Almost all the parents we interviewed said the hypersexual symptoms disappeared with proper stabilization, but until that day arrives, a parent whose child is hypersexual is going to have to contend with the conversations and behaviors and, embarrassed or not, model appropriate social behavior for the child -- without making the child feel shame.
We were very impressed by the handling of such delicate, uncomfortable material by the very wise women we spoke to and we would like to pass on their statements. Because it’s extremely difficult to think through appropriate responses to language and actions that happen almost out of the blue and that leave a parent gasping with shock and embarrassment, we thought these “fall-back lines” could help other parents address these behaviors and utterances simply and cogently.
Scenario: The child is running naked around the house. One mother described it and dealt with it this way:
He loves his body, loves how it feels and doesn’t have any impulse control. At 8 1/2 he’ll still run around the house naked, dancing to a rock song. I calmly say: ‘Come on sweetie, put some clothes on.’ I don’t over discuss it or give it too much attention, but he is definitely ‘Naked King of the Moment.’ It goes along with everything about them -- they’re just out there and I understand that.
In response to his nakedness she said: “Your penis and testicles and butt are very special and will be throughout your life. But you notice that even in the pool, this is the one area people cover up and still keep private. Why? Because it’s so special.”
Scenario: The child is trying to kiss a parent on the mouth in a sensuous manner. His mother replied: “Honey, this is a special kiss; something a Mommy and a Daddy do, and you will do it as an adult when you feel very close to someone. But it’s not a Mommy-son kiss. We have a special kiss.” (She demonstrates kissing him on both cheeks and then giving him a big hug.)
This same mother also had to respond to her three-year-old sticking his finger up his anus all the time and when she told him not to do that in public he responded: “But it feels so good.” She said:
That’s great. It should feel good, but look around you, do you see anyone else in this house doing that? Do you see anyone at school doing that?” So, you have to figure out what is private and what is not. (This mother wanted her little boy to start looking around and seeing what’s normal or acceptable.)
She then had a very frank discussion with him:
Honey, what comes out of your body is meant to come out (mucus, urine, feces) it’s your body’s natural way of letting go of what is no longer needed and shouldn’t be there, and you could get germs if you do that. It makes sense to do that in the bathtub if you want to because you’re using soap and you can clean your hands immediately and they will get clean and smell clean. But, anywhere else and you will smell like poop and you don’t want the kids to think you smell like poop. (This made sense to him.)
Scenario: Your child asks you to lay down with him or her at night because she or he is afraid (whether it be separation anxiety or fear of night terrors). One mother explained her system to avoid their bodies touching and any overarousal taking place:
I never get under the blanket with him . It would be too stimulating. I wrap him in a cotton blanket and turn the air conditioner on or open the window (he is always hot) and once he’s papoosed like this, I may lie down on the bed across from him or sit there awhile. The blanket gives him a physical, hugged feeling, and separates our bodies.
She concluded our interview by stating: “Now that he’s treated, it’s not such a problem anymore.”
Hypersexuality in the Dreaded Teenage Years
Since over 50% of American teenagers are having sex, adolescence becomes even more loaded for parents of a teenager who may be unstable at times and exhibit periods of hypersexuality. As we wrote in The Bipolar Child:
So many parents have described watching with horror as their daughters get “dressed” in the skimpiest of outfits and attempt to go out flaunting their bodies to cadres of boys in the neighborhood and school. One girl we knew was so hypersexual that she and her boyfriend were practicing heavy petting in the school library for all to see. We have heard of many boys making calls to 1-900 numbers.
The first thing parents of such a teenager should do is call the treating psychiatrist and get the teen’s blood levels checked. The hypersexuality may be a sign that the levels have dropped or the teen is being noncompliant. (In an adolescent with no history of the disorder, the hypersexuality may be a symptom of the impending illness, not an indication that the teen is amoral.) We then go on to suggest that perhaps the teen should be kept home from school for a few days while the meds are adjusted and to keep him or her out of trouble. Again, stability seems to be the key to all things good.
How Does a Parent Feel About This Hpersexuality?
No parent rejoices in dealing with a child’s sexual life, and no parent ever imagines that he or she will be confronted with this aspect of a child’s behavior or interest so early in the game. It catches parents unprepared. Parents can become overwrought about how it will affect siblings -- older or younger -- and the outside world who will somehow think they are “doing something.” How strictly the subject of sexuality was dealt with in their families of origin will account for many of the feelings that may flood parents when they witness (or are the object of) such behavior. All parents have heard stories of children being taken out of the homes by CPS and so not only do they feel embarrassment and confusion, but profound threat. They also fear that neighbors or other family members will see this going on and not allow their kids to play with their own child.
There are other feelings. One mother, whose eight-year-old son became very manic this spring, leaned over to get something from the refrigerator and felt him stick a hairbrush up her skirt. This kind of impulsive, unexplainable action, and his early interest in women’s breasts and body parts leave her in a tumult of guilt and confusion. She’s constantly asking herself: Did I do something wrong? Where does he get this from?
She told us: “I find the hypersexuality directed at me disgusting. I’m not a prudish person, but I find it so awkward and scary. It goes against all of society’s norms and dictates.”
Most of the parents were especially surprised by their children’s precocious knowledge as they know how sensitive these children are and prone to night terrors and bad dreams and so they screen all television, movies, and popular media that might expose the children to anything scary, overstimulating, or sexual. Eric’s mother wrote of her own confusion about her son’s knowledge:
I am shocked that embarrassing hypersexual behavior shows up in bp kids despite the fact that most of our kids have NOT been exposed to sexually explicit media images But my point is, not only are our kids not sexually abused, they also tend to have LESS exposure to any sexual images than other kids, because we parents of bp kids are hypervigilant about what they see, and we screen everything. Eric, for example, does not watch any network or cable TV, does not see any sexually explicit materials, does not know any descriptive sexual words, other than basic boys' and girls' anatomy, and he has a couple of rather conservative (my sister would say "nerdy") parents. Yet, he displays blatant hypersexuality when unstable. WHERE does it come from?
It may be that these children are so exquisitely attuned to things that they hear -- snatches of lyrics in a parking lot as they walk to a store with a parent, or see a television commercial at a friend’s or relative’s house, or they overhear something at school and it simply makes a bigger impression on them. We can’t say for sure.
What Should A Parent Do to Protect the Child and the Family?
Many parents expressed their concerns that the child’s “out-there” flaunting of his or her body and suggestive talk could open the door to a sick outsider taking advantage of the situation, and they realize that they need to educate the child from a young age about any possible consequences of such talk and behavior. One mother, whose very young son became hypersexual during a period of instability and asked her: “Could you rub my penis?” told him: “If anyone ever tries to touch your body in any way, you tell Mommy and Daddy right away. No matter what you say, no one should ever be touching you anywhere near your private parts. She is worried sick about his being so inviting and open about himself sexually. (As though there isn’t enough to worry about with a child with bipolar disorder...)
Siblings may be pulled into games of “Doctor” and a few parents reported that, understanding there might be periods of hypersexuality, they watch their children like hawks. Most understood that the children should not bathe, shower or sleep together (or with a parent) and that separation was something to be imposed if signs of hypomania and hypersexuality were seen. One mother said: We’re buying a new house and I want each of the kids to have his own room. Next year I’m sending the two boys to opposite days of preschool so that they aren’t together as much.”
One woman was in the middle of typing an email to us when she wrote:
As a matter of fact, I just had to stop typing in order to separate him from his eight-year-old sister. He was sucking her toes and told me that he was “shaking my booty “ (he was provocatively swinging around while gyrating at the hips and sticking his derriere out). I have no clue where he heard that one. Whenever the hypomania starts, so starts the sexually-related jargon and actions. It is one of our "Oh no, here he goes" signs. I try not to think too long about what the teenage years could hold if this continues. We are hopeful that through time he will be in better control and be aware of the dangers of such sexually-oriented behaviors and recognize them as warning signs.
She told us what she says to him about his behavior and language:
We have had one-on-one conversations stating that our actions can make others uncomfortable and that some actions are OK in one place but not another. I referred to church. It is not OK to be loud and run around in that situation, however, at home playing that way is all right. So, when he is doing something like sucking his sister's toes I gently guide his shoulders the other way, look him in the eyes and say: "Uncomfortable." Then I get him into a different activity.
When we asked her how her daughter deals with all this. She said:
As far as our daughter is concerned, she recoils and says, "Stop it! I don't like that". By this time, I'm usually on the scene. I've also explained to her that her brother has trouble thinking before acting and that is usually when his mood is hyped up. She kind of lumps this into the same category as his outbursts. She understands that such behavior is not acceptable and we are to know when it happens. Each of the kids has his or her own "private" place in our living room. Only Mom and Dad can interrupt that space. This is to give her some place to go.
Several mothers were having this discussion on a listserv we’re on, and one woman advised the group to have the treating psychiatrist document the hypersexual behaviors or language in the child’s medical records and to keep a copy of these in a binder at home. This way if that knock on the door from CPS ever comes, a medical document exists, detailing exactly what’s been happening -- that the child when manic tends to exhibit sexual behaviors or language. Medical documentation can help explain the situation before suspicions outpace knowledge.
The mothers also warned each other against telling anyone who doesn’t need to know. It's just something that neighbors, teachers, or even relatives cannot easily understand, and may in fact misinterpret.
Some days, in dark moments, we wonder if the Powers Above decided to experiment to see just how much these earth beings called parents could withstand. If the aggression and mood swings of the unstable child don’t get to them, than maybe the hypersexuality will. However, these children do gain control as they become stable and more mature, and -- as we see in the stories above -- there is much that parents can teach. No doubt the sensuality and sensitivity of these children will make them highly attentive partners when they become adults.
All we can say is that we salute these brave parents who have so much to contend with and do it with such grace and wisdom. We thank them for sharing their thoughts and phrasing about this sensitive subject, and to Dr. Barbara Geller for her pioneering research in this area and for contributing to this article.
We’ll write again soon, but, as always, we wish you and your children healthy and stable summer days and nights.
Janice Papolos and Demitri Papolos, M.D.
Geller, Barbara, Kristine Bolhofner, et al. “Psychosocial Functioning in a Preputeral and Early Adolescent Bipolar Disorder Phenotype.” Journal of the American Academy of Child and Adolescent Psychiatry 39 (December 2000):1543-48.
Geller, Barbara, Betsey Zimmerman, et al. “Diagnostic Characteristics of 93 Cases of a Prepubertal and Early Adolescent Bipolar Disorder Phenotype by Gender, Puberty, and Comorbid Attention Deficit Hyperactivity Disorder.” Journal of Child and Adolescent Psychopharmacology 10 (2000): 157-164.
Geller, Barbara, Betsey Zimmerman, et al. "DSM-IV Mania Symptoms in a Prepubertal and Early Adolescent Bipolar Disorder Phenotype Compared to Attention-deficit Hyperactive and Normal Controls." Journal of Child and Adolescent Psychopharmacology 12 (2002): 11-25.
Geller Barbara, Marlene Williams, Betsey Zimmerman, Jeanne Frazier. Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). Washington University, St. Louis, MO, 1996
Papolos, Demitri, and Janice Papolos. Overcoming Depression, 3rd Edition. New York: HarperCollins, 1997.
Papolos, Demitri, and Janice Papolos. The Bipolar Child. New York: Broadway Books, 1999.
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