juvenile onset bipolar disorder: identification & treatment ©carrie cadwell psyd hspp cadwell...

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


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


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


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


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


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


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


Session 10 & 11—Child & parents together Discuss life stressors and problem

solving Discuss how to avoid knee jerk

responses but to “react smart”


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


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


Elements of Interpersonal Therapy Unresolved grief/loss issues Interpersonal Disputes Role Transitions Other Interpersonal Challenges **”Grief for the lost healthy self”


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)

juvenile onset bipolar disorder: identification & treatment ©carrie cadwell psyd hspp cadwell...

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