Transcript bipolar-disorder-in-the-school-setting-naa

Bipolar Children in the School Setting
A Primer of Diagnosis and Treatment
Options for Special Education
Professionals
Gabriel Kaplan, M.D.
Bennett Silver, M.D.
Nadezhda Sexton, Ph.D.
NEW JERSEY CHILDREN'S
SYSTEM OF CARE
Nadezhda Sexton, Ph.D.
The History of mental health services for
NJ youth
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Get in line
Open a case
Confined care rules
Systemic fragmentation
Silencing of families and youth
System reform resulted in:
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Dramatic increase in community based services (needdriven, strength-based)
Separation of child welfare and mental health
systems (individualized)
Reduction in use of residential, detention, and hospital
stays (least restrictive)
Maximized funding for effective interventions
(outcomes-driven)
Empowerment and direct support of family members;
elevation of youth as consumers (youth and family
guided)
System of care agencies
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Care Management Organizations (CMO) are countybased, non-profit organizations that are responsible for
face-to-face care management and comprehensive
service planning for youth and their families with intense
complex needs.
Family Support Organizations (FSOs) are non-profit
organizations run by families of children in that county
with emotional and behavioral challenges..
Mobile Response & Stabilization Services (MRSS) are
provided to youth who exhibit emotional or behavioral
challenges that may jeopardize their current living
arrangements. They provide face-to-face crisis response
within 1 hour of notification.
Youth Case Management (YCM) offers face-to-face
services for moderate-risk youth.
About Us
Our Director's Message
A brighter, healthier future awaits those who care
In the late 90's, a dedicated group of parents approached the State of New Jersey with a plan to reform children's mental health.
These parents recognized that the system in place at that time was not meeting the needs of children with complex emotional,
mental health or behavioral challenges.
Under the direction of Governor Christie Whitman, New Jersey launched the Children's System of Care Initiative.
The vision was to create a system of care that focused on family strengths and community resources. Families and youth work in
partnership with public and private organizations to design mental health services and supports that are effective, that build on the
strengths of individuals, and that address each person's cultural and linguistic needs.
A system of care helps children, youth and families function better at home, in school, in the community and throughout life. System
of care is not a program — it is a philosophy of how care should be delivered. System of Care is an approach to services that
recognizes the importance of family, school and community, and seeks to promote the full potential of every child and youth by
addressing their physical, emotional, intellectual, cultural and social needs.
Madeline Lozowski
Executive Director
Family Support Organization
CSA Contract Service Administrator
Check it out:
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Toll-Free Access Line
1-877-652-7624
(Multi-lingual
Language Line available)
24 hours-a-day, 7 days a week
www.state.nj.us/dcf/behavioral
OVERVIEW OF BIPOLAR
DISORDER IN CHILDREN AND
ADOLESCENTS
Gabriel Kaplan, M.D.
Child’s Ordeal Shows
Risks of Psychosis Drugs for Young (9/1/10)
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At 18 months, Kyle started taking a daily antipsychotic
drug on the orders of a pediatrician trying to quell the
boy’s severe temper tantrums
Thus began a troubled toddler’s journey from one
doctor to another, from one diagnosis to another,
involving even more drugs. Autism, bipolar disorder,
hyperactivity, insomnia, oppositional defiant disorder
The boy’s daily pill regimen multiplied: the antipsychotic
Risperdal, the antidepressant Prozac, two sleeping
medicines and one for attention-deficit disorder. All by
the time he was 3. He gained Lb 49
Potentially Powerful Side Effects
(Published by NYT 9/1/10)
Kyle at 3 years old, he started taking
antipsychotics at 18 months due to severe
tantrums
Kyle at 6 years old, takes medication for ADHD,
doing well
Accurate Diagnosis a Must
(Published by NYT 9/1/10)
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“It’s a controversial diagnosis, I agree with that,” said Dr.
Concepcion. “But if you will commit yourself in giving these children
these medicines, you have to have a diagnosis that supports your
treatment plan. You can’t just give a nondiagnosis and give them the
atypical antipsychotic.”
Dr. Charles H. Zeanah, a Tulane medical professor, who disagreed
with both the diagnosis and the treatment. “I have never seen a
preschool child with bipolar disorder in 30 years as a child
psychiatrist specializing in early childhood mental health,”
Kyle’s new doctors point to his remarkable progress — and a more
common diagnosis for children of attention-deficit hyperactivity
disorder — as proof that he should have never been prescribed
such powerful drugs in the first place.
DSM-IV Mood Disorders
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Unipolar Disorders
 Major
Depression
 Dysthymic Disorder
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Bipolar Disorders
 Bipolar
I
 Bipolar II
 Cyclothymic Disorder
DSM-IV Bipolar Disorders
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Bipolar I
 One
or more Manic episodes (or Mixed
Mania/Depression) usually accompanied by episodes
of Depression (but may not)
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Bipolar II
 Major
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Depressive episodes with Hypomania
Cyclothymic Disorder
 Less
than full episodes of Mania and Depression
Bipolar Stats
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1% of population will develop
One parent with Bipolar
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Both parents
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15-30% risk to offspring
50-75% risk
Risk in siblings: 20%
Risk in identical twin: 70%
60% of adults report onset before age of 20
Bipolar Epidemic ?
40-fold increase in outpatient diagnosis
1994-2003
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Moreno C, Laje G, Blanco C et al. National trends in the outpatient diagnosis and treatment of bipolar
disorder in youth. Arch Gen Psychiatry. 2007;64:1032–1039
6-fold increase in hospital diagnosis 1996-2004
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Blader JC, Carlson G. Increased rates of bipolar disorder diagnoses among US child, adolescent, and
adult inpatients, 1996–2004. Biol Psychiatry. 2007;62:107–114.
Increase in Outpatient Diagnosis
DSM-IV Manic Episode
A distinct period of abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week (or any duration if hospitalization is necessary).
During the period of mood disturbance, 3 (or more) of the following symptoms have
persisted (4 if the mood is only irritable) and have been present to a significant
degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility
(6) increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
Are DSM IV Criteria Applicable to
Pediatric BP?
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Criteria were established from adult research at a time
when PBP was not fully accepted
Main problem is criterion A “Distinct Period”, often not
present in children
In youth, BP shows mainly as
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ongoing mood lability and increased energy,
Irritability/aggression,
reckless behavior,
short lived mood shifts
However, DSM is Recommended
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The “presence” of mood episode –mania- must be
determined (elevated, expansive, or irritable)
Although its “precise” onset may not be ascertained,
in order to meet Bipolar criteria, a mood episode
MUST be distinguished from persistent other kinds
of presentations, i.e. either normal personality style
or pathological (ADHD)
“B” (developmentally reviewed) symptoms must be
present during the mood episode and be of an
impairing nature
Frequency of Pediatric Bipolar
Symptoms
Kowatch RA et al. Review and meta-analysis of the phenomenology and clinical characteristics of mania in
children and adolescents. Bipolar Disord 2005;7:483–496.
Normal or a Symptom?
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Children might present with seemingly manic
symptoms for a variety of reasons
Clinicians use the FIND (Frequency, Intensity,
Number, and Duration) strategy to make this
determination.
A real FIND
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Frequency
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Intensity
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Symptoms are severe enough to cause extreme disturbance
in one domain or moderate disturbance in two or more
domains
Number
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Symptoms occur most days in a week
Symptoms occur three or four times a day
Duration
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Symptoms occur 4 or more hours a day, total, not
necessarily contiguous
FIND Qualifies Symptoms
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A child who becomes silly and giggly to a noticeable and
bothersome degree for 30 minutes twice per week in school and
home
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Frequency (twice per week),
Intensity (mild interference in two domains),
Number (one episode per day),
Duration (30 minutes)
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Does not qualify for a BPD
A child described as ‘‘too cheerful’’
 F: during school days and every day after school
 I: to the point that relations with teachers, parents, siblings, and peers are
disrupted
 N: several times per day
 D: ‘‘high’’ times last several hours
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Has crossed the FIND threshold
Euphoric/Expansive Mood
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NORMAL
25th
 Very happy, giggling
 Got latest Wii model
 Dec
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MANIA
25th
 Laughing hysterically in
Church
 Says people dress
funny
 Parental disapproval
does not stop laugh
 Dec
Irritable Mood
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NORMAL
 After
a long car trip in
the summer
 Hot and hungry
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MANIA
 Asked
to tie shoes
 Two hour tantrum
Grandiosity
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NORMAL
I
am Superman
 Pretend play, stops
when its time for
supper
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MANIA
I
am Superman
 Attempts to jump out
the window to prove
can fly
Decreased Need for Sleep
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NORMAL
 Anxious
about test
tomorrow
 Up till 1 AM, stays in
bed
 Difficult to get up in
the morning and tired
all day
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MANIA
 No
identifiable stressor
 Up till 1 am running
around throughout
house
 Sleeps only 4 hours
and full of energy next
morning
Pressured Speech
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NORMAL
 Running
back home to
tell mom got lead part
in school play
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MANIA
 No
identifiable reason
for broken up fast
speech that lasts for
hours
Young Mania Rating Scale
Young Mania Rating Scale
Functional Impairment
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aggressive behavior,
attention problems
anxious and depressed symptoms
delinquent behavior,
social problems
withdrawal,
poor social skills, no friends, and teased by other children.
Substance abuse 39% which when present greatly worsens
severity and prognosis
Sala R et al Phenomenology, longitudinal course, and outcome of
children and adolescents with bipolar spectrum disorders. Child Adolesc
Psychiatr Clin N Am. 2009 Apr;18(2):273-89
Suicidal Ideas and Psychosis
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NORMAL
 Not
present
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MANIA
 May
be present
Suicide Attempts Various Conditions
0-18 years
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Mania
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Major Depression
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44%
18%
No Disorder
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1%
Lewinsohn, PM.; Seeley, JR.; Klein, DN. Bipolar disorder in adolescents: epidemiology and
suicidal behavior. In: Geller, B.; DelBello, MP., editors. Bipolar Disorder in Childhood and
Early Adolescence. New York: Guilford; 2003. p. 7-24.
DIFFERENTIAL DIAGNOSIS:
IS IT BIPOLAR OR ADHD?
Gabriel Kaplan, M.D.
ADHD Criteria
ADHD Bipolar Overlap
Distractibility
Manic Specific Symptoms
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Elated Mood
Grandiosity
Flight of Ideas
Racing thoughts
Decreased need for sleep
Hypersexuality
Geller et al, Journal of Child and Adolescent
Psychopharmacology 2002; 12:11–25
Common Diagnostic Dilemma
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A child with impairing distractibility and
aggression
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it mild Bipolar?
 Is it severe ADHD?
 Are both conditions present? (Co-morbidity)
ADHD vs Bipolar
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ADHD
 Child
has always been distractible
 Family history of ADHD
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Bipolar
 Distractibility
only occurs in the context of a change of
mood that is different from the patient’s usual mood.
 Hypersexual, grandiose, elated, suicidal
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Co-Moribidity
 Distractibility
persists when mood episode remits
TREATMENT OF MANIA IN
BIPOLAR DISORDER
Bennett Silver, M.D.
What Are Mood Stabilizers?
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Medications with both antimanic and antidepressant
actions
Medications that decrease vulnerability to
subsequent episodes of mania or depression and do
not exacerbate the current episode or maintenance
phase of treatment.
Mood Stabilizers Used for Bipolar
Disorder
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LITHIUM:
 Lithium Carbonate
(Eskalith,Lithobid)
ANTICONVULSANTS:
 Valproic Acid (Depakote)
 Carbamazepine (Tegretol)
 Lamotrigine (Lamictal)
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ATYPICAL ANTIPSYCHOTICS:
 Risperidone (Risperdal)
 Quetiapine (Seroquel)
 Aripiprazole (Abilify)
 Olanzapine (Zyprexa)
 Ziprasidone (Geodon)
 Asenapine (Saphris)
 Paliperidone (Invega)
 Clozapine (Clozaril)
How Do Mood Stabilizer Medications
Work?
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Nobody really knows for sure but our understanding is growing
rapidly
Effect “first messenger” brain neurotransmitters that act at the
synapse between nerve cells, such as dopamine, serotonin,
norepinephrine, glutamate, and GABA
Effect “second messenger” systems within the nerve cell such as
cAMP (cyclic AMP) and BDNF (Brain-Derived Neurotrophic
Factor) which can turn on genes within the nerve cell promoting
nerve growth (neurogenesis) or nerve atrophy
Lithium
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Oldest mood stabilizer
Improves depression and mania
Helps prevent future episodes
Narrow dosage range (blood levels required)
Very dangerous in overdose
Side – effects
 drowsiness,
weakness, nausea
 fatigue, hand tremor, increased thirst
 increased urination, thyroid underactivity,
 weight gain, decreased kidney function (rarely)
Anticonvulsants
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Improve depression and mania
Lamictal especially good for depressive episodes
Help prevent future episodes
Narrow dosage range (blood levels required)
Work better than Lithium for rapid cyclers and mixed
states
Side effects:
Nausea, headache, double vision, sedation,
 liver enzyme elevation,weight gain,
 hormone changes in women (Depakote, e.g., polycystic
ovary syndrome, absence of menstruation)
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Atypical Antipsychotics
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Improve depression and mania
Help prevent future episodes
Control delusions & hallucinations (psychosis)
No blood levels required
Side – effects: sedation; metabolic syndrome (some) - weight
gain,elevated blood sugar, blood pressure, diabetes, elevated
cholesterol; neuromuscular - restlessness, muscle spasms
(dystonia), involuntary movements (tardive dyskinesia) - rarely
Monitor: weight, blood pressure, blood sugar, cholesterol
Commonly Used Antipsychotic Medications (SecondGeneration antipsychotics, “Atypicals”)
*All of the atypical antipsychotics are serotonin and dopamine antagonists
*In 2009, Seroquel and Abilify were numbers 5 and 6 respectively amongst the
top ten drugs in the U.S. based on sales (over $4 billion each)
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Abilify –weight neutral, less sedating
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Risperdal – Moderate weight gain, increases prolactin
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Seroquel – Moderate weight gain, sedating, may have antidepressant properties
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Zyprexa – Very effective, but significant weight gain, metabolic effects (blood sugar,
cholesterol)
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Geodon – Weight neutral, less sedating
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Saphris – Recently released, sublingual pill
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Invega – Recently released
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Clozaril – Most effective, weight gain, metabolic effects, risk for severe white blood cell
suppression requires regular blood tests. Used when other medications fail.
Treatment Considerations
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Choice of medication depends on an individual’s
Bipolar symptoms and pattern of illness (psychosis,
rapid cycling, etc.)
Side-effect profile may affect choice of medication
Psychotherapy along with medication improves
outcome
Principles of Medication Treatment
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Bipolar Disorder is a chronic, recurring illness and
requires chronic, long-term maintenance
medication
Treatment targets acute episodes and prevention
of episodes with maintenance medication
Sometimes a single medication is inadequate
and a combination of medications is required
Principles of Medication Treatment
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In fact, research indicates that there is a large
group of Bipolar patients who require very
complex psychopharmacologic regimens in
order to achieve and sustain a good to
excellent response *
Periodic monitoring of blood levels confirms
adequate dosing and compliance
Periodic monitoring for metabolic effects
(weight, blood sugar, cholesterol), thyroid,
kidney & liver function
*Post, R , Altshuler, L, et al. Complexity of pharmacologic treatment required for sustained improvement in
outpatients with bipolar disorder. J. Clin Psychiatry. 2010:71(9):1176-1186.
Accurate Diagnosis and Early
Intervention
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Bipolar Disorder is often difficult to diagnose in
adolescence, because of the nature of adolescent
moodiness, and similarities with other conditions
such as ADHD, Schizophrenia, and Addiction to
drugs and alcohol
Bipolar Disorder can have a spectrum of severity
and milder forms are often missed or
misdiagnosed (eg., subthreshold or subsyndromal
mania)
Misdiagnosis leads to delayed or incorrect
treatment
Early Aggressive Intervention Improves
Long Term Outcome
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Research shows that very often there are long lags
from the onset of Bipolar illness to first treatment *
This delay is longest in those with the earliest onset
in childhood and adolescence *
Early onset Bipolar Disorder and delay to first
treatment are independent risk factors for poor
outcome in adulthood **
*Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolar disorder. J
Pediatr. 2007;150(5):485-490.
**Post R, Leverich G, Kupka R, et al. Early onset bipolar disorder and treatment delay are risk factors
for poor outcome in adulthood. J Clin Psychiatry. 2010; 71(7):864-872.
Diagnostic Ambiguity and Co-Occurring
Disorders
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Correct diagnosis guides treatment and prevents a child from being placed on
medications that can worsen the course of the disorder
Rarely does bipolar disorder in children occur as a pure entity
It is often accompanied by symptoms that suggest other psychiatric disorders,
such as ADHD, Depression, Anxiety Disorders, Addiction
For example, 61% of individuals with Bipolar Disorder also have a substance
abuse disorder – a higher co-occurrence than with any other psychiatric
disorder *
1/3 of children who first present with depression will eventually go on to
manifest a Bipolar Disorder (risk of misdiagnosis as unipolar depression) **
As a result, a child with Bipolar Disorder may be prescribed antidepressants
such as Prozac or Zoloft to treat depressive or anxiety symptoms, or stimulants
such as Ritalin or Adderall to treat ADHD
* NIMH
** American Academy of Child and Adolescent Psychiatry
Diagnostic Complexity and Choosing the Right
Medication
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Treating a Bipolar child suffering from depression,
anxiety or ADHD with an antidepressant or a stimulant
alone can cause negative reactions such as rapid cycling,
manic, violent, aggressive, or agitated behavior
Often such patients seem to do well at first, but after
weeks or months of treatment their behavior deteriorates
Proper diagnosis prevents the child from being placed on
medications that may worsen the course of the disorder
Therefore, in a Bipolar child with such co-occurring
conditions it is prudent to stabilize the patient first on a
mood stabilizer(s) alone, prior to initiating other
medications
When Medication Does Not Yield the
Expected Improvement
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Is patient taking the medication as instructed?
Re-assess the accuracy of the diagnosis
Look for and treat co-occurring conditions such as:
substance abuse, anxiety disorders, ADHD,
personality disorders, etc.
Maximize use of non-pharmacologic treatment
modalities such as cognitive, behavioral therapies
The Problem of Non-Compliance (NonAdherence) with Medication Treatment
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Non-compliance is the most common
reason for failure of medication, relapse
and re-admission to the hospital
Rates of poor compliance may reach 64%
for Bipolar Disorders *
* J Clin Psychiatry, 2000 Aug, 61 (8): 549-55
Why Don’t Patients Take Their
Medication?
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Failure to understand the diagnosis, the chronic nature
of Bipolar illness, the prophylactic function of medication
& its positive effect on long term outcome
A desire to recapture the elevated mood, energy and
lack of inhibition associated with hypomanic and manic
states
Side-effects, especially weight gain and sedation
Underestimating the long-term consequences of Bipolar
Disorder on school, social and occupational functioning
Stigma associated with psychiatric illness & medication
Poor relationship between psychiatrist and patient or
parents
Countering Non-Compliance
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Psycho-education regarding medication and Bipolar
Disorder
Create a treatment partnership between physician,
patient and parent(s)
Listen and be flexible & responsive to patient
complaints about side-effects
Group interaction with peers who are at different
stages of their treatment experience
Traditional Treatment Model
Psychiatrist
student
Child study
team
Family
peers
therapist
teachers
(Office-based)
Therapeutic School: Integrated Treatment Model for
Bipolar Disorder
Psychiatrist
(In-school consultant)
Accurate diagnosis, Education
about diagnosis and use of
medication
Teachers/Therapists
(In-school)
Education, IEP
Address psychiatric disorders, social,
family, peer issues
Peers
Group Therapy, Social Skills
Student
Family
Integration of school and
therapeutic environment
Family Therapy