Transcript Juvenile Onset Bipolar Disorder: Identification & Treatment

Juvenile Onset Bipolar Disorder:
Identification & Treatment
©Carrie Cadwell PsyD HSPP
Cadwell Psychological Services, LLC
www.cpsllc.info
Why discuss the Bipolar Spectrum in
Youth?

Issue of myths versus realities

STEP-BD study “what age did you first
become bipolar?”
28% said before age 13
 37% said between 13 and 17
 35% said 18yo and above
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Why discuss the Bipolar Spectrum in
Youth?

Issue of reasonable diagnostic clarity

COBPD: mixed states common with significant
anxiety overlap;
restlessness/impulsivity/decreased
concentration present; dysphoria/irritability
present; behavioral dyscontrol
 Is it ADHD and depression?
 Is it depression and anxiety?
 Is it ADHD and ODD?
 Is it ADHD, depression, and anxiety?
 Is it PTSD? Complex Trauma? Develop
Trauma?
 Or is it COBPD? (get the picture)
What is the controversy?


Are these youth best characterized
as early onset Bipolar disorder or
multiply disordered?
Is early onset BPD the same
disorder as classic adult BPD

We do not know this yet
Bipolar Disorder
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Wolf and Wagner (2003):
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1% prevalence in American adolescents
Soutullo et al (2005):
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11% prevalence in young adults (Switzerland)
Holland 6 mo prevalence= 1.9% mania, .9%
hypomania (adol.)
Denmark= 1.2% prevalence in 15 yo or
younger whom were hospitalized
Finland= 1.7% adol.
University of Navarra data—4% prevalence of
5-8 yo
Bipolar Disorder
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Research Diagnostic Criteria
(Papolos, 2002)
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Marked variations in mood and energy
level that are characterized by abrupt,
rapidly alternating levels of arousal,
excitability, motor activity and mood (ie
mirthful, angry, depressed, anxious)
Diurnal cycles—low energy in am and
boost in afternoon ..buzzing by evening
 Seasonal affective impact
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Bipolar Disorder
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RDC (Papolos, 2002)
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Poor modulation of drives (anger, anxiety, SIB,
sexual, appetite, acquiring things)
Sleep-wake cycle disturbance including
dysomnias and parasomnias; nightmares
Low threshold for frustration---rage followed
with withdrawal and remorse
Poor self esteem regulation (abrupt
fluctuations in rejection sensitivity, LSE and
grandiosity/bravado)
Bipolar Disorder
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RDC (Papolos, 2002)
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Habituation deficit to situations--extreme, sustained overreaction to
repetitive stimuli/triggers
Possible mood/energy induction with
caffein. Corticosteroids,
antidepressants, stimulants
Executive function deficits (unrealistic
planning and others)
Bipolar Disorder
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RDC (Papolos, 2002)
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Motor overflow/fine motor problems
Common comorbids: enuresis, night
terrors, separation anxiety,
panic/phobic dx, ADHD, OCD, conduct
disorder, Tourette’s, Asperger’s, NVLD
Positive family history
Bipolar Disorder

Fergus, 1999—American Psychiatric
Assoc meeting

Look at
Grandiosity
 Suicidal gestures
 Irritability
 Decreased attn span
 Racing thoughts
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If all 5- 91% prediction
If 3- 80% prediction
Bipolar Disorder
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Consensus Guidelines:
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(Kowatch et al, 2005)
July 2003; 20 clinicians and CABF
members developed guidelines over 2
days
Three sections: diagnosis, comorbities,
treatment
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We will cover diagnosis only
Bipolar Disorder
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Kowatch, 2005
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1% prevalence in adolescents (BPD I, BPD II,
cyclothymic)—Lewinsohn 1995 study
5.7% BPD nos (some core sx but not full
threshold for dx)—Lewinsohn 1995 study
 In practice BP NOS and BPD II more likely to
be seen, BP I more likely in inpatient settings
 BPD II 5x more common than BPD I in teens
Rule of thirds—onset before 13, 13-18, 19+
(STEP-BD study)
Bipolar Disorder
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Why difficult per DSM criteria
(Kowatch et al, 2005)
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Issue of childhood equivalents---mania
and hypomania---does the DSM
present constructs that generalize
down?
No clear stop/start to mood episodes
Child presentation often more mixed
states---which can create a confusing
diagnostic picture
Bipolar Disorder
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Gellar et al 2004:
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4 yr prospective study of 86 children/teens
with bipolar symptoms
Inclusion in bipolar sx group required presence
of grandiosity and elated mood (ie to
differentiate ADHD)
Results 10% ultrarapid cycling; 77% ultradian cycling
 On average 3.5 (+/- 2) cycles per day
 Average onset—7.4 y.o (+/-3.5)
 Average episode length 3.5 yrs (+/- 2.5)
Bipolar Disorder
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Kowatch et al, 2005
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Euphoric/Expansive Mood
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excessive silliness, giddiness, excitability—look at
congruence to context/triggers
Irritable Mood
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“irritability” as sx is common to childhood-onset--depression, dysthymia, ODD, ASD, anxiety, ADHD
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Disruptive behavior dx often show limited irritability with
limit setting
Medication wear off for ADHD and side effect of SSRIs
can create “whiny” irritability
ASD and Anxiety may show situational irritability or
transition irritability
Key to all above irritability---limited in severity,
frequency, and duration
Bipolar Disorder
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Kowatch et al, 2005
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Irritability cont.
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MANIC IRRITABILITY= “frequently have
rages or meltdowns over trivial matters (e.g.
a 1- to 2- hour tantrum after being asked to
tie their shoes). Aggressive and/or selfinjurious behavior often accopmanies..”
(p216)
This is qualitatively different from an 10-15
minute screaming match and slamming of
doors after a parents says “no”
Bipolar Disorder
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Kowatch et al, 2005
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Grandiosity
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Look at whether child can differentiate pretend play
from reality
If hearing “I know…; I am the best…; I can take
anyone down; I have special powers like
(superhero)”—make sure to ask how they know
this
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“because I know” may indicate impaired reality testing or
of acts on belief---”because my dad/mom told me so” =
env’t
Decreased need for sleep
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“a child’s sleep should be decreased by two or
more hours per night for his or her age without
evidence of daytime fatigue” (p216)
4-5 hours sleep but still like the Energizer Bunny--heightened energy in evening, waking up during
the night and engaging in goal directed activities)
Bipolar Disorder
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Kowatch et al, 2005
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Pressured Speech
 It is normal to speak fast for children in
carious emotional states
 ADHD= incessant talking at fast rate
 BPD= rapid speech that is loud, intrusive, and
often hard to interpret
Racing Thoughts
 My mind is going a million miles a minute
 Observer---how easy is it to follow topic(s);
baseline fx
Bipolar Disorder
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Kowatch et al, 2005
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Distractibility
 Ask caregiver to think of a time when child
was “even mood” or “doing fairly well” and
question ADHD sx during this period
 To what extent does it worsen during mood
episodes? Is it present only in the course of
the mood episode? What functional impact
does this have? (ie poorer school perf.)
Increased Goal-Directed Activity/Psychomotor
Agitation
 Psychomotor agitation is non-specific (ie equal
opportunity disorder sx)
 Mania-look at heightened goal directed
activity---excessive drawing, writing, building,
creating, etc
Bipolar Disorder
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Kowatch et al, 2005
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Goal-Directed Act cont
Agitation/activity exceeds ADHD
 Nervous agitation or trauma related
hypervigilance/disorganized
tension/agitation different
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Bipolar Disorder
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Kowatch et al, 2005
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Excessive pleasurable/risky activities
 Hypersexuality
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Traumatized youth often have anxious/compulsive
qualities to hypersexuality
BPD---pleasure seeking; teens may engage in
sexual behaviors several times in a day
Psychosis
 Hallucinations/delusions often present in BPD
 Differentiate these from alert perceptual
distortions and sleep onset or awakening
phenomena
Bipolar Disorder
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Kowatch et al, 2005
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ADHD issue—is it comorbid, is it a
prodrome?
Co-morbid ADHD 70-90% of CO-BPD
 Comorbid ADHD 30-40% of AO-BOD
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(Chang, 2005)—comorbid—children (9095%), teens 50-60%)
Family History—if a child has a parent
diagnosed with BPD that child has 2-3x
increased risk
Bipolar Disorder
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Does it work the other way around?
NO
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While youth diagnosed with COBPD
have a high likelihood of additional
ADHD diagnosis…..in youth diagnosed
with ADHD there is only a 10-22%
comorbidity rate (Faraone & Kunwar,
2007)
Bipolar Disorder
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Kowatch et al”
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FIND criteria
Frequency—sx present most days in a
week
 Intensity--- severe impairment in 1
domain, moderate impairment in 2+
domains
 Number--- sx occur 3-4x in a day
 Duration---sx present 4+ hours in a day
(does not have to be consecutive
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Risk Factors
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AACAP guidelines (2007)
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Family history (4-6x increased risk of BPD in
first degree relatives of affected persons)
Hyperarousal, disruptive beh, irritability,
behavioral dyscontrol, anxiety/dysphoria
20% of youth with MDD go on to experience
manic episodes
Predicting mania conversion in depression
children (same as adults)
 Rapid onset depression with psychomotor
retardation/psychotic features
 Family hx of affective dx
 Antidepressant induced cycling
Bipolar Disorder
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Screening Measures:
Note: Parent report tend to be superior to
teacher and self-report for identifying BPD
in youth
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Mood Disorder Questionnaire (MDQ)
90% specific to BPD, 70% sensitive (adults)
MDQ-adol version (self report, parent report)
(JCP, 2006)
 Using a cut-off of 5
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Parent report 81% specific, 72% sensitive
Self report 73% specific, 38% sensitive
Bipolar Disorder
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MDQ cont..
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Best at screening BPD I not as sensitive to
BPDII and BPDNOS (Hirschfeld et al 200,
2002, 2005; Miller et al 2004)
 Outpatient mood disorder clinic
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General population
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Sensitivity .28, specificity .97
Bipolar/Unipolar population
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Sensitivity .73, specificity .90
Sensitivity .58 (BPDI .58, BPDII/BPDNOS .30)
Specificity .67
PCP tx for depression
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Sensitivity .58, specificity .93
Bipolar Disorder
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Screening cont.
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Parent Young Mania Rating Scale
General Behavior Inventory
Child Mania Rating Scale (Pavulari et al 2006)
 Core characteristics: elevated mood,
grandiosity, and irritability
 5-17yo
 Cut off of 20 differentiated BPD from ADHD
and no BPD (94% specific, 82% sensitive)
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This translates into a youth having a score equal
to or above 20 almost 14x more likely to have
BPD than ADHD—scores for BPD+ADHD vs BPD
alone pretty similar
Bipolar Disorder
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Screening cont.
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Child Bipolar Questionnaire-2 (Papolos &
Papolos)
 65 item parent rating scale
 Ages 5-17yo
 Scales: mania, depression, dysregulation of
aggressive impulses, dysregulation of sexual
impulses, sleep/wake cycle disturbance, low
threshold for arousal, anergia, low frustration
tolerance, attention deficits/executive
functions, fear of harm to self or others
 Promising measure in terms of psychometrics
Bipolar Disorder
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Other instruments:
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JBRF: Diagnostic Assessment Package
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Includes:
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CBQ-2
Jeannie/Jeffrey Questionnaire for Children
(4-11yo)
Child Bipolar Screening Interview
Optional:
 Overt Aggression Scale
 Yale-Brown Obsessive-Compulsive Scale
Bipolar Disorder
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Jeannie and Jeffrey Interview (9-12
yo)
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Basically it is the child bipolar
questionnaire and adapted to use with
children
Pictures that depict various symptoms
and a statement about the picture
 Client answers never, sometimes, often,
always
 Upwards of 40 items
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Bipolar Disorder
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Cardinal Symptoms (Chang, 2005)
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Look at
Grandiosity
 Decreased need for sleep
 Racing thoughts
 hypersexuality
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Bipolar Disorder
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Understanding Phenotype (Papolos et al,
Pavulari et al 2002, Leibenluft et al 2003)
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Narrow: cardinal features—grandiosity, elated
mood etc= more specific to DSM criterion
Broad: explosive rages, aggression,
hyperarousal, chronic mood disturbance
Intermediate:
 Irritable hypomania
 Shorter duration episodes
Core (Papolos)—adds the dimensions of
anxiety sensitivity, fear of harm, and overt
aggression (hence the OAS and YB-OCS)
Bipolar Disorder
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Other measures:
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WASH-U-KSADS (Kiddie Schedule for
Affective Disorders and Schizophrenia)
KSADS Mania Rating Scale
Behavioral Inhibition Scale/Behavioral
Activation Scale (supplemental)
Bipolar Disorder
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NPQ: Neuropsych Questionnaire
(Gualtieri, 2007)
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www.ncneuropsych.com
Online asst->start online asst->
administrator name: doctor,
password:doctor
Ratings of various symptom areas—not
diagnostic in and of itself but helpful in
gathering information about patient
status
Bipolar Disorder
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Kowatch, 2005
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% comorbids
CD/ODD—30-76%
 Substance use 40% (also Chang, 2005)
 Anxiety dx---36%
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Resources
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Depression & Bipolar Support Alliance
(www.dbsalliance.org)
Juvenile Bipolar Research Foundation
(www.jbrf.org)
Child Adolescent Bipolar
Foundation(www.bpkids.org)
The Bipolar Child (www.bipolarchild.com)
www.schoolpsychiatry.com
Bipolar Significant Others (www.bpso.org)
Intervention
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Medications
Child & Family Focused Cognitive
Behavioral Treatment
Interpersonal Social Rhythm
Therapy
Educational Interventions
Issue of Medication
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AACAP Practice Parameters (2007)
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They note that the issue of medicating
children with aggressive medication is
a serious choice and there needs to be
healthy caution about it
CABF survey found that of 854
caregiver respondents that 24% of
affected children fell between 1 and
8yo
Issue of Medication
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AACAP Rec 6: “for mania in well defined
DSM-IV TR Bipolar I Disorder
pharmacotherapy is the primary
treatment”
“Treatment should begin with an agent
that is approved by the FDA for bipolar
disorder in adults recognizing that the
evidence of the efficacy for these agents
in children & adolescents is sparse at
best”
Issue of Medication
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Medication lifelong?
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Comes back to answering the
controversy of whether this is the same
as adult BPD
AACAP recommends 12-24 mos
continuation tx an some will need
longer or lifelong maintenance tx
For adults we know that the relapse
rate is high and that maintenance tx is
typically needed
Issue of Medication
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CABF guidelines suggest stabilizing
mood before addressing
comorbidity (Correll 2008)
AACAP and CABF guidelines
“advocate monotherapy with a
mood stabilizer or atypical
antipsychotic agent as a first line tx
of BPD without psychotic features”
Issue of Medication
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Several available tx algorithms
Currently FDA approved for juvenile
BPD:
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Lithium down to age 12
Risperdal and Aripiprazole
Range of meds get used though
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Keep side effects in mind!
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Principles to live by…
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Sleep: 7-8 hours restful
sleep/developmentally appropriate
No drugs/alcohol
Medication adherence
48 hour rule/pacing
Mood monitoring—what are my 3 warning
signs
“EE” reduce negative expressed emotion
How do I solve the problem?
Psychosocial Treatment
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Should Address (AACAP, 2007)
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Psychoeducation
Relapse Prevention
Individual Therapy
Social & Family Functioning
Academic & Occupational functioning
Child & Family Focused CBT (Pavuluri
et al 2004)
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Derived for MultiFamily
Psychoeducation Groups & Family
Focused Tx BPD adults
Consider 3 things:
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Characteristics of COBPD
Neurcircuitry dysfunction
Environmental stressors in family &
school
Child & Family Focused CBT (Pavuluri
et al 2004)
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Routine
Affect regulation
I can do it!
No negative thoughts & live in the Now
Be a good friend & Balanced lifestyle for
parents
Oh how can we solve the problem
Ways to get support
Child & Family Focused CBT (Pavuluri
et al 2004)
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Sessions 1 and 2---Parent & Child
together
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Psychoeducation
Develop common language—externalize the
illness, give it a name
Mood charting/tracking for one month
Calling bipolar “wiring dysfunction” or “brain
disorder”
Medications overview
RAINBOW overview
Discuss routine & relaxation
Child & Family Focused CBT (Pavuluri
et al 2004)
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Sessions 3- Parents only
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Discuss specifics of affective regulation
Encourage “I can do it” self statements
and “no negative thoughts”
Train parents to coach their children to
use the above
Discuss how to reorient grandiose,
paranoid, devaluing thoughts in
children
Child & Family Focused CBT (Pavuluri
et al 2004)
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Sessions 4-7—child only
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Introduce RAINBOW
Techniques of mood monitoring
Self talk for mood regulation
Identify “triggers”
Teach ABC model (antecedent-behaviorconseq)
“I can do it”, “No negative thoughts”
Write a “happy story” about self
Rewrite sad story to happy story
Child & Family Focused CBT (Pavuluri
et al 2004)
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Session 8- Parents only
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Joint problem-solving
Walking their child through ABC model
Effective communication strategies
Creating opportunities for healthy
conversations
Active listening & validation of child
Offering choices
Use of metaphor to understand rage as
unintentional fire
Child & Family Focused CBT (Pavuluri
et al 2004)
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Session 9—Parents & siblings
together
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Allow siblings to vent and receive
validation
Educate siblings about COBPD and help
them develop empathy
Teach siblings assertiveness and
disengage from direct confrontation
Child & Family Focused CBT (Pavuluri
et al 2004)
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Session 10 & 11—Child & parents
together
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Discuss life stressors and problem
solving
Discuss how to avoid knee jerk
responses but to “react smart”
Child & Family Focused CBT (Pavuluri
et al 2004)
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Session 12—Parents and child
together
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Reinforce strengths
Ways to get support
Have a child draw a support tree
Role play how to ask for help
Reinforce seeking support as a strength
Child & Family Focused CBT (Pavuluri
et al 2004)
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School Component of RAINBOW
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Educate school personnel about COBPD
Provide educators with specific
strategies (ie RAINBOW)
Consider letter of support for 504 plan
or special education
Consider providing ideas for
accommodations/modifications
Consider attending case conference
Interpersonal Social Rhythm Therapy
(Frank et al 2005)
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“social zeitgeber hypothesis”—
”regularity of social routines and
stability of interpersonal
relationships have a protective
effect in recurrent mood disorders”
2 components:
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Social behavioral routines
Interpersonal therapy
Interpersonal Social Rhythm Therapy
(Frank et al 2005)
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Elements of Interpersonal Therapy
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Unresolved grief/loss issues
Interpersonal Disputes
Role Transitions
Other Interpersonal Challenges
**”Grief for the lost healthy self”
Interpersonal Social Rhythm Therapy
(Frank et al 2005)
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Social Rhythm
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Behavioral routines
Mood monitoring
Triggers of rhythm disruptions and how
these are addressed
Other…
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Collaborative Problem Solving
approach (Greene & Ablon)
Positive Behavior Support
DBT for Teens
Many therapy options—the question
is:

How are you addressing the core
elements of AACAP guidelines for
psychosocial treatment
Educational Services (JBRF)

Advocating for youth in the school
systems:
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504 plan
 “individuals with impairment that substantially
limit a major life activity such as learning are
entitled to academic adjustments and
auxillary aids and services so that courses,
examinations, and services will be accessible
to them”
Special education
 Not enough that there is a diagnosis need
“evidence that your child’s disability adversely
affects his educational performance”
 Category: Emotional Disability
Educational Services

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Re-authorization of IDEA
Changes in Indiana Article 7

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Response to Intervention
Functional Behavior
Assessment/Behavior Intervention plan
Educational Services (JBRF)

Accommodations/Modifications

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For specific symptom expression
For side effects
For comorbid concerns
**Find a list at JBRF website**
In conclusion…
“Children do well if they
can”
(Greene & Ablon)