Welcome to Max’s World

By 18 months, the day-care facility was threatening to throw Max out, and the Blakes were desperate. Richie, the drill sergeant, tried the strict discipline he'd grown up with—he said no, he withheld TV and dessert, he spanked. It didn't work. Amy, the lawyer, tried bargaining with her toddler. That didn't work either. Amy and Richie started to fight about how to raise their son. The family's pediatrician had been treating kids for decades—he had once been Amy's doctor—but he had no answers. All he could say was that this wasn't the terrible twos come early. It was bigger than anything he could fix, and if the Blakes wanted help, they would have to look for it 20 miles down the road.

The Blakes started calling doctors in Boston. After three months of trying, they got through to Joseph Jankowski, chief of child psychiatry at Tufts-New England Medical Center, and scheduled an appointment for Nov. 18, just after Max's 2nd birthday. Jankowski ran several lab tests, but they showed little except for slightly high levels of a metabolic enzyme. He ordered a brain scan and sat down with his interns to watch his new patient. Max behaved as usual: he screamed and bit Amy, then gathered up pieces of paper to draw on, only to rip them to shreds. After an hour, Jankowski said he thought Max might have bipolar disorder. He told the Blakes little else.

To the Blakes, bipolar disorder was as foreign as dengue fever. Amy had heard of "manic-depression," but that was a serious illness, one that didn't strike children. Although the National Institute of Mental Health (NIMH) estimates that 5.7 million American adults are affected by the disorder, most doctors, then as now, consider it impossible to diagnose in toddlers. There are still those who joke that every child is "bipolar": up, down, at the mercy of emotion. Amy had her doubts as well. She sat in Jankowski's office and wondered if she should get a second opinion. Worn down, she looked at the degrees on his wall, at the name embroidered on his white coat. "Well," she thought, "I hope he knows what he's talking about."

Jankowski wanted to put Max on a low dose of Depakote, a drug used for seizures, migraines and bipolar disorder. Amy was used to migraine medications—she'd had the headaches for years—and she and some of her family members had taken antidepressants. Richie was more wary. Like many people, he didn't think children should be on powerful psychoactive meds. He worried about side effects, a concern that would dog him and Amy for years to come. Max lasted on Depakote for just three weeks. He wasn't eating and couldn't sleep. Jankowski tried Zyprexa, an antipsychotic. Within days, Max started eating again. For the first time Amy could remember, he slept like the baby he was. "Good," Amy thought. "We'll keep him on this for a few weeks, like an antibiotic. Then he'll get well and we'll move on."

On Feb. 4, Jankowski said he had a diagnosis. Amy was hoping for something with a cure—"something like a brain tumor, even, something we could read about and understand and fix." Most likely, she thought, it would be attention-deficit/hyperactivity disorder; her friends' kids all had that. Richie thought that whatever Max had, he might grow out of it, the way the hole in his heart had healed on its own. But Jankowski had little comfort for the Blakes. Their son's problem was serious and incurable: a life sentence. Jankowski's first impression had been borne out. Max was bipolar. Amy and Richie took their son home, and Amy started writing in a notebook that would become a complete log of Max's medical history: "dx: Bipolar Disorder, Hyperactivity." Then she closed the notebook. Max was screaming again. There was one good thing about this strange diagnosis, she thought: at least it meant she wasn't a bad mother.

At the time, pediatric bipolar disorder was obscure, even within child psychiatry. Doctors at Massachusetts General Hospital (MGH) fully described the disorder just four years before Max's diagnosis. In 1995, child psychiatrist Joseph Biederman and his protégée Janet Wozniak reported that 16 percent of the kids in their clinic had a form of the illness. "Back then it was considered so rare in children that you might see one in your entire career," says Wozniak. "But we'd been blind to children who were right in front of us." Doctors had missed the fact that their young patients were bouncing between pathological highs and lows, she says: if they saw kids on the upswing, they diagnosed hyperactivity, and if they saw the down side, they diagnosed depression. The MGH team's ideas left many doctors skeptical, but other psychiatrists followed them closely.