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Juvenile Onset Bipolar Disorder: Identification & Treatment
©Carrie Cadwell PsyD HSPPCadwell Psychological Services, LLCwww.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
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
Wolf and Wagner (2003): 1% prevalence in American adolescents
Soutullo et al (2005): 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
Research Diagnostic Criteria (Papolos, 2002) 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
Bipolar Disorder
RDC (Papolos, 2002) 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
RDC (Papolos, 2002) 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
RDC (Papolos, 2002) 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
If all 5- 91% prediction If 3- 80% prediction
Bipolar Disorder
Consensus Guidelines: (Kowatch et al, 2005) July 2003; 20 clinicians and CABF
members developed guidelines over 2 days
Three sections: diagnosis, comorbities, treatment
We will cover diagnosis only
Bipolar Disorder
Kowatch, 2005 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
Why difficult per DSM criteria (Kowatch et al, 2005) 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
Gellar et al 2004: 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
Kowatch et al, 2005 Euphoric/Expansive Mood
excessive silliness, giddiness, excitability—look at congruence to context/triggers
Irritable Mood “irritability” as sx is common to childhood-onset---
depression, dysthymia, ODD, ASD, anxiety, ADHD 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
Kowatch et al, 2005 Irritability cont.
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 self-injurious 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
Kowatch et al, 2005 Grandiosity
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
“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 “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
Kowatch et al, 2005 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
Kowatch et al, 2005 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
Kowatch et al, 2005 Goal-Directed Act cont
Agitation/activity exceeds ADHD Nervous agitation or trauma related
hypervigilance/disorganized tension/agitation different
Bipolar Disorder
Kowatch et al, 2005 Excessive pleasurable/risky activities
Hypersexuality 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
Kowatch et al, 2005 ADHD issue—is it comorbid, is it a
prodrome? Co-morbid ADHD 70-90% of CO-BPD Comorbid ADHD 30-40% of AO-BOD
(Chang, 2005)—comorbid—children (90-95%), teens 50-60%)
Family History—if a child has a parent diagnosed with BPD that child has 2-3x increased risk
Bipolar Disorder
Does it work the other way around? NO 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
Kowatch et al” 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
Risk Factors
AACAP guidelines (2007) 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
Screening Measures: Note: Parent report tend to be superior to
teacher and self-report for identifying BPD in youth 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
Parent report 81% specific, 72% sensitive Self report 73% specific, 38% sensitive
Bipolar Disorder
MDQ cont.. 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 Sensitivity .73, specificity .90
General population Sensitivity .28, specificity .97
Bipolar/Unipolar population Sensitivity .58 (BPDI .58, BPDII/BPDNOS .30) Specificity .67
PCP tx for depression Sensitivity .58, specificity .93
Bipolar Disorder
Screening cont. 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) 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
Screening cont. 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
Other instruments: JBRF: Diagnostic Assessment Package
Includes: CBQ-2 Jeannie/Jeffrey Questionnaire for Children (4-
11yo) Child Bipolar Screening Interview Optional:
Overt Aggression Scale Yale-Brown Obsessive-Compulsive Scale
Bipolar Disorder
Jeannie and Jeffrey Interview (9-12 yo) 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
Bipolar Disorder
Cardinal Symptoms (Chang, 2005) Look at
Grandiosity Decreased need for sleep Racing thoughts hypersexuality
Bipolar Disorder
Understanding Phenotype (Papolos et al, Pavulari et al 2002, Leibenluft et al 2003) 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
Other measures: WASH-U-KSADS (Kiddie Schedule for
Affective Disorders and Schizophrenia) KSADS Mania Rating Scale Behavioral Inhibition Scale/Behavioral
Activation Scale (supplemental)
Bipolar Disorder
NPQ: Neuropsych Questionnaire (Gualtieri, 2007) 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
Kowatch, 2005 % comorbids
CD/ODD—30-76% Substance use 40% (also Chang, 2005) Anxiety dx---36%
Resources
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
Medications Child & Family Focused Cognitive
Behavioral Treatment Interpersonal Social Rhythm
Therapy Educational Interventions
Issue of Medication
AACAP Practice Parameters (2007) 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
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
Medication lifelong? 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
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
Several available tx algorithms Currently FDA approved for juvenile
BPD: Lithium down to age 12 Risperdal and Aripiprazole Range of meds get used though
Keep side effects in mind!
Principles to live by…
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
Should Address (AACAP, 2007) Psychoeducation Relapse Prevention Individual Therapy Social & Family Functioning Academic & Occupational functioning
Child & Family Focused CBT (Pavuluri et al 2004)
Derived for MultiFamily Psychoeducation Groups & Family Focused Tx BPD adults
Consider 3 things: Characteristics of COBPD Neurcircuitry dysfunction Environmental stressors in family &
school
Child & Family Focused CBT (Pavuluri et al 2004)
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)
Sessions 1 and 2---Parent & Child together 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)
Sessions 3- Parents only 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)
Sessions 4-7—child only Introduce RAINBOW Techniques of mood monitoring Self talk for mood regulation Identify “triggers” Teach ABC model (antecedent-behavior-
conseq) “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)
Session 8- Parents only 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)
Session 9—Parents & siblings together 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)
Session 10 & 11—Child & parents together 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)
Session 12—Parents and child together 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)
School Component of RAINBOW 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)
“social zeitgeber hypothesis”—”regularity of social routines and stability of interpersonal relationships have a protective effect in recurrent mood disorders”
2 components: Social behavioral routines Interpersonal therapy
Interpersonal Social Rhythm Therapy (Frank et al 2005)
Elements of Interpersonal Therapy 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)
Social Rhythm Behavioral routines Mood monitoring Triggers of rhythm disruptions and how
these are addressed
Other…
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: 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
Re-authorization of IDEA Changes in Indiana Article 7
Response to Intervention Functional Behavior
Assessment/Behavior Intervention plan
Educational Services (JBRF)
Accommodations/Modifications 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)
Recommended