Transcript PEDIATRIC BIPOLAR DISORDER: A COMPLEX ISSUE

BIPOLAR DISORDER AMONG
THE PEDIATRIC POPULATION:
A COMPREHENSIVE REVIEW
Drs. Jane Petrillo, Ping Johnson,
Kandice Porter
Department of Health, Physical Education & Sport
Science
Kennesaw State University
Kennesaw, GA
[email protected]
Presentation Goals:
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Identify early, accurate diagnostic
strategies
Recognize the common and complex
signs, symptoms behaviors
Distinguish among the various types
Describe components of a
comprehensive treatment plan
Examine factors that contribute to
effective outcomes and those that
hinder treatment effectiveness
Bipolar Disorder
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A mood disorder in which feelings, thoughts,
behaviors, and perceptions are altered in the
context of episodes of mania and depression.
5.7 million American adults are diagnosed yearly
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Large proportion of them experience their onset during
childhood (up to 20%) - “Early Onset” Bipolar Disorder
At least half of all cases start before age 25
An under-recognized and difficult to diagnose, serious
mental health problem among children and adolescents
If left untreated, may result in:
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Higher rates of intentional and unintentional injuries
Suicide
Academic Problems
Family, Peer, Social Problems
Juvenile Imprisonment
Substance Abuse
The Diagnostic and Statistical Manual
of Mental Disorders, 4th edition,
text revision (DSM-IV-TR):
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The DSM-IV describes four types of bipolar
disorder
 Bipolar I - manic or mixed episodes that last
at least seven days – or- manic symptoms
that are so severe the person needs
immediate hospital care. Usually, individual
also has depressive episodes, typically
lasting at least two weeks. The symptoms of
mania or depression must be a major change
from the person's normal behavior.
Types of Bipolar Disorder
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Bipolar II - pattern of depressive episodes shifting back
and forth with hypomanic episodes, but no full-blown
manic or mixed episodes.
Bipolar Disorder NOS (Not Otherwise Specified) –
presence of symptoms that do not meet diagnostic criteria
for either bipolar I or II. The symptoms may not last long
enough, or the person may have too few symptoms,
to be diagnosed with bipolar I or II. However,
symptoms are clearly out of the person's normal range of
behavior.
Cyclothymia – a mild form of bipolar disorder. Have
episodes of hypomania that shift back and forth with
mild depression for at least two years (one year for
children and adolescents). However, the symptoms do
not meet the diagnostic requirements for any other type of
bipolar disorder.
Diagnosis: A Major Challenge
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Bipolar disorder does not affect every child in the same
way. The frequency, intensity, and duration of a child’s
symptoms and the child’s response to treatment vary
dramatically.
Initial diagnostic criteria was based on adult symptoms.
In adults, bipolar disorder commonly involves separate
episodes of major depression, alternating with separate
episodes of mania.
In children, mixed states of cycling (mood swings)
are more common.
When children have manic symptoms that last for
less than four days, experts recommend that they be
diagnosed with BP-NOS (Not Otherwise Specified). Some
scientific evidence indicates that approximately one-third
of these children will develop longer episodes within a few
years. If so, they meet the criteria for bipolar I or II.
Diagnosis: A Major Challenge
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Some experts believe that children with severe
irritability, emotional instability, and severe
temper outbursts are bipolar.
Others believe this view will lead to over diagnosis
of children who are actually suffering from
disorders other than bipolar disorder – and argue
for a narrower definition of bipolar disorder
which includes episodic mood swings,
elevated or expansive mood - not just
irritable mood - and grandiosity or
inappropriate euphoria (extreme
joyfulness).
Diagnosis: A Major Challenge
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Other factors further complicate the
diagnosis of bipolar disorder in children.
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1) A history of severe emotional trauma and/or
physical trauma (physical, emotional, sexual
abuse can lead to mood swings, emotional
outbursts, hallucinations, and extremely
severe behavioral problems.
2) AD/HD
*Improving our understanding and awareness of
these “other” factors and related symptoms can
lead to a more accurate diagnosis and effective
multi-level treatment strategies.
AD/HD - Bipolar Disorder
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A significant overlap exists in the
symptoms of mania, and to a lesser
extent depression, and the symptoms
of AD/HD.
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AD/HD, mania and depression involve
inability to concentrate and problems with
distractibility.
Mania and AD/HD may both involve
hyperactivity and impulsivity.
AD/HD - Bipolar Disorder (Mania)
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AD/HD in children usually does not involve mood
symptoms such as depression and euphoria to
the extent seen in bipolar disorder.
AD/HD symptoms usually first appear early in
childhood while the onset of bipolar disorder
appears to occur later in childhood or
adolescence.
AD/HD usually have normal sleep patterns –once
a child has settled down in bed and is ready for
sleep.
In contrast, mania, involves decreased need for
sleep with the individual still "raring to go" the next
day despite little sleep.
Also, family history is critical, as both disorders
appear to run in families.
AD/HD - Bipolar Disorder (Depression)
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Children with depression more often
appear irritable than sad.
Children and adolescents are naturally
prone to displays of unstable mood.
Determining the cause(s) of the
moodiness (hormonal, social/peers,
parent/child issues, stress, drug use…) is
helpful.
Identifying the presence of other
symptoms of mania or elevated mood,
particularly the presence of euphoria or
grandiosity at some point, is important
in making this diagnostic distinction.
Depression - Bipolar Disorder
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The risk of depression turning into bipolar
disorder is 10 percent or less in adults.
The risk increases to 20-40 percent for
children and adolescent.
Risk factors for the eventual development
of bipolar disorder in addition to early
onset of depression include:
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Psychosis; sudden onset, severely slowed or
retarded movement; antidepressant-induced
mania or elevated mood; and family history of
bipolar disorder
Diagnosis – Ruling out other Possible
Health Problems
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Other health concerns must first be ruled out
to arrive at an accurate diagnosis.
A complete physical exam and medical workup should be conducted for a child who is
exhibiting significant variability in mood.
Physical conditions can manifest symptoms
similar to bipolar disorder.
“Other” Possible Conditions
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AIDS
Brain Tumor
Diabetes
Epilepsy
Lupus
Lyme Disease
Multiple Sclerosis
Neurosyphilis
Sodium Imbalance
Thyroid Disorder
Diagnosis
Need for a specific – accurate diagnostic tool
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DSM-IV describes symptoms of 4 types
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Young Mania Rating Scale (YMRS)
(http://www.psych.uic.edu/csp/facilities/rating%20scales/YMRS.pdf)
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Parent Version of the YMRS
(http://www.healthyplace.com/images/stories/bipolar/p-ymrs.pdf)
Screening Tools-Bipolar Disorder/Mania Symptoms
http://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp
Screening Tool Rating
Scale
For Ages (Years)
Who Completes
Checklist: Number of
Time to Complete
(Minutes)
Items
Young Mania Rating
Scale (YMRS)
5-7
Parent Version of the
Young Mania Rating
Scale (P-YMRS)
Clinician: 11
15-30
Parent, Teacher: 11
5
General Behavior
Inventory (GBI)
Parent Version,
11+
Student: 73
General Behavior
Inventory (P-GBI)
5-17
Parent:
Kiddie Schedule for
Affective Disorders
and Schizophrenia
(Kiddie-SADS)
6-18
Clinician
90-120
Weinberg Screening
Affective Scale
(WSAS)
7-17
Student: 56
5
Mood Disorder
Questionnaire (MDQ)
12+
Student: 15
5-10
Diagnosis
A diagnosis should never be based on
a symptom questionnaire alone. It is
important for the individual to have a
complete developmental, social,
behavioral, educational and family
history as well as information about
previous interventions and their
effectiveness.
Very Common Symptoms of Early-Onset
Bipolar Disorder:
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Separation anxiety
Rages & explosive temper tantrums
(lasting up to several hours)
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Marked irritability
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Oppositional behavior
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Frequent mood swings
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Distractibility
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Hyperactivity
Very Common Symptoms of EarlyOnset Bipolar Disorder:
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Impulsivity
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Restlessness/fidgetiness
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Silliness, goofiness, giddiness
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Racing thoughts
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Aggressive behavior
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Grandiosity
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Carbohydrate cravings
Very Common Symptoms of Early-Onset
Bipolar Disorder:
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Risk-taking behaviors
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Depressed mood
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Lethargy
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Low self-esteem
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Difficulty getting up in the morning
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Social anxiety
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Oversensitivity to emotional or
environmental triggers
Common Symptoms of Early-Onset Bipolar
Disorder
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Bed-wetting (especially in boys)
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Night terrors
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Rapid or pressured speech
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Obsessive behavior
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Excessive daydreaming
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Compulsive behavior
Common Symptoms of Early-Onset
Bipolar Disorder
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Motor & vocal tics
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Learning disabilities
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Poor short-term memory
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Lack of organization
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Fascination with gore or morbid topics
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Hypersexuality
Common Symptoms of Early-Onset
Bipolar Disorder
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Manipulative behavior
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Bossiness
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Lying
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Suicidal thoughts
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Destruction of property
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Paranoia
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Hallucinations & delusions
Less Common Symptoms of Early-Onset
Bipolar Disorder
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Migraine headaches
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Binging
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Self-mutilating behaviors
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Cruelty to animals
Treatment
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A child with bipolar disorder needs
medical treatment - but medication
alone is only one component of an
effective treatment plan
Patients must receive comprehensive
treatment throughout life to maintain
functionality
An effective treatment plan for bipolar
disorder requires three essential elements:
1) Medication
2) Lifestyle and Environmental Changes and
Support
3) School and Academic Accommodations
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Medications help alleviate and reduce symptoms
so they are less intrusive, smooth out mood
fluctuations, reduce anxiety and distractibility,
and increase frustration tolerance.
Because stress is a trigger that intensifies
bipolar symptoms and causes a decline in
overall level of functioning, lifestyle and school
changes should be made to reduce stress.
Treatment – Medication and Psychotherapy
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Mood Stabilizers, Antipsychotics, and Atypical Antipsychotics
Agents (Lithium, lithium carbonate, Clozaril, Risperdal, Zyprexa,
Seroquel )
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Anticonvulsants (Depakote, Tegretol, Trileptal, Lamictal, Topamax,
Gabatril)
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Often, it is necessary to use 3-4 medications to effectively treat
a child or adolescent with a bipolar disorder.
Regular therapy sessions with a licensed clinical
social worker, a licensed psychologist, or a
psychiatrist.
Cognitive behavioral therapy, interpersonal therapy,
and multi-family support groups.
A support group for the child or adolescent with the
disorder can also be beneficial.
Medication – Side Effects
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Nausea
Increased or decreased appetite
Excessive thirst
Frequent urination
Disinhibition
Aggression (rare)
Diarrhea or constipation
Dry mouth
Cognitive dulling
Hyperactivity
Muscle tremors
Drowsiness
Fidgeting or pacing
Restlessness
Chills or hot flashes (rare)
Vision problems
Weight gain
Lifestyle/Environmental Changes and Support
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Family must understand and accept bipolar
disorder as a chronic medical condition,
participate in psychosocial therapies and
create effective individual, family, and
community support networks.
Counseling services and psychoeducation
help the child deal with many effects of the
illness and therapy for family members can
help the family cope and reduce tensions at
home.
In addition, research reveals that keeping a
consistent sleep schedule, regular
exercise, and maintaining a healthy
diet is highly critical.
Lifestyle/Environmental Changes and Support
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A child with bipolar disorder needs a
supportive and caring, consistent, yet
flexible environment providing
predictability and emotional stability.
Parents should choose recreational and
other activities for the child with these
criteria in mind.
Parents should also ensure that the child
is not burdened with more activities than
he/she can comfortably handle/manage.
Also important to provide for sufficient
time in the child's schedule to recover
from the stresses that a child with bipolar
illness endures during ordinary activities.
School and Academic Accommodations
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In school, a child with bipolar disorder needs a
consistent predictable schedule with advance
notice of schedule changes and time and
assistance to prepare for transitions throughout
the school day.
Teachers working with the parents to adjust
homework requirements as needed to ensure that
the child is able to get needed sleep, participate in
psycho-educational programs and individual
therapies as needed.
Children with bipolar disorder often feel
overwhelmed by seemingly ordinary events
and challenges - Provide designated "safe"
adults to whom children can turn and "safe
places" where they can seek refuge in times of
emotional crisis – Goal is to defuse these crises.
School and Academic Accommodations
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Social skill and Conflict resolution training
Anger management
Problem-solving skill development
Self-esteem development
Modify school schedule and provide flexibility in
procedural rules:
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Unlimited bathroom use
Access to water as needed
Shortened schedule
Late start as needed
Consistent schedule
Provide notice before any transition or change in
schedule
Permission to move around when needed
Naps as needed for primary education students
Positive behavioral intervention plan
School and Academic Accommodations
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Modified or shortened class assignments
and homework
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Testing in small groups or one-on-one
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Extended deadlines for assignments
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Regular home-school communication via
assignment notebook and teacher-parent
meetings/communications
Additional School/Academic
Accommodations
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Preschool special education testing and
services
Small class size (with children of similar
intelligence) or self-contained classroom
with other emotionally fragile (not
"behavior disorder") children for part or all
of the day
One-on-one or shared special education
aide to assist child in class
Recorded books as alternative to selfreading when concentration is low
Art therapy and music therapy
Additional School/Academic Accommodations
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Extended time on tests
Use of calculator for math
Extra set of books/resources at home
Use of keyboard or dictation for writing assignments
Regular sessions with a social worker or school
psychologist
Social skills groups and peer support groups
Annual in-service training for teachers by child's
treatment professionals (sponsored by school)
Enriched art, music, recreation, or other areas of
particular strength
Curriculum that engages creativity and reduces
boredom (for highly creative children)
Tutoring during extended absences
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Goals set each week with rewards for achievement
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Additional School/Academic Accommodations
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Summer services such as day camps and special
education summer school
Placement in a day hospital treatment program
for periods of acute illness that can be managed
without inpatient hospitalization
Placement in a therapeutic day school during
extended relapses or to provide a period of extra
support after hospitalization and before returning
to regular school
Placement in a residential treatment center
during extended periods of illness if a therapeutic
day school near the family's home is not
available or is unable to meet the child's needs
Resources for parents about bipolar disorders
School and Academic Accommodations
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Student Management Plan = Academic and
Behavioral Success
Expectations (rules) should be simple, clear, and
phrased in positive or neutral language. (Keep
hands to self; please raise hand to speak)
Issue only one specific direction at a time and
modify assignments. (Complete 10 math problems
instead of the entire assignment)
Tailor/individualize the identified target behaviors
Accommodate the child's fluctuating level of stability
with a menu of behavioral and academic
expectations. Administrative support is critical
Reward the child for positive behavior
Student Management Plan = Academic
and Behavioral Success
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Continue to expect the best from the child and
though the student may have behaved poorly in
the past - Must remove lingering bias from prior
misbehaviors which will assist the child in
demonstrating new social skills.
Ignore minor issues as it is impossible to change
everything at once. Focus on the big picture and
goal-setting. Set realistic expectations.
Consistently create opportunities for the child to
be successful and share unique talents and
strengths to help foster development of positive
relationships with self, teachers, and peers.
Prevention/Early Detection
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Early Detection
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Proactive universal screening
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Evaluating at-risk students in primary grades for
emerging antisocial behavior patterns
difficulties with peer and teacher
relationships
 aggressive and disruptive behavior
 internalizing behaviors: e.g., anxiety,
inattention
 withdrawn behavior in the classroom
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Prior to condition progresses; or
If child is disciplined for an unknown/uncontrollable
disorder or condition
Prevention/Early Detection
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Bipolar can be genetic:
Parents should be tested for psychological
disorders
Be aware of signs and symptoms of other
conditions – (ADHD, behavioral disorder,
anxiety disorders and depression)
Behavioral signs in children can be key
signs in discovering bipolar disorder
Knowing/being aware of the signs
See a doctor immediately if any of the signs
appear
References/Resources
Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J,
Iyengar S, Keller M. “Clinical course of children and adolescents with bipolar spectrum
disorders.” Archives of General Psychiatry. 2006 Feb;63(2):175-83.
Child and Adolescent Bipolar Foundation (CABF) www.bpkids.org
Cincinnati Children's Hospital Medical Center, Resource Center on Mental Health Wellness.
(2010). http://www.cincinnatichildrens.org
Juvenile Bipolar Research Foundation (2010) http://www.jbrf.org/index.html
Kowatch, R.A., Fristad, M., Birmaher,B., Wagner, K.D., Findling, R.L., Hellander, M. (2005).
“Treatment Guidelines for Children and Adolescents With Bipolar Disorder: Child Psychiatric
Workgroup on Bipolar Disorder.” J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 44:3, 213.
Massachusetts General Hospital, School Psychiatry Program and MADI Resource Center (2010)
http://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp
National Alliance for the Mentally Ill (NAMI) http://www.nami.org/
National Institute of Mental Health (2010). “Bipolar Disorder in Children and Teens.” Science
Writing and Dissemination Branch. Bethesda, MD
The Depression and Bipolar Support Alliance (DBBSA) http://www.dbsalliance.org/index.html