BEYOND ADHD AND ODD: BIPOLAR SPECTRUM DISORDERS IN CHILDREN AND ADOLESCENTS

1. BEYOND ADHD AND ODD: BIPOLAR SPECTRUMDISORDERS IN CHILDREN AND ADOLESCENTS Prepared for Indiana Deaf Educators’ Conference August 2 & 3, 2005 Julie T. Steck, Ph.D., HSPP Children’s Resource Group

2. CASE STUDIES TEDDY • Diagnosed with ADHD at age 4 • Early speech and language difficulties • Behavior manageable in kindergarten • Behavior very problematic in grade one • Superior non-verbal IQ • Struggles with reading and paper-pencil tasks • Difficulty with sleep, eating, anger

3. CASE STUDIES SUZANNE • Eighth grade • Extreme separation anxiety and school phobia • Four previous hospitalizations • Tried on numerous medications for anxiety and depression with no change or worsened symptoms • Numerous somatic symptoms • Does well in English, struggles in math

4. CASE STUDIES DAVID • Senior in high school • Difficulty with sleep and attention • History of substance abuse • Family history of suicide • No school problems of note • Introspective, creative • Unrealistic goals (be a model in LA)

5. EDUCATIONAL ISSUES • Excessive anxiety • School phobia/refusal • Runs out of classroom • Refuses to talk in class/do presentations • Frequent absences or trips to nurse’s office • Aggression • Intense hyperactivity

6. Autism Spectrum/Pervasive DevelopmentalDisorders AUTISM/ ASPERGER’S PDD/NOS

7. Bipolar Spectrum/Mood Disorder Spectrum Mood Disorder/NOS Bipolar II Bipolar I

8. Primary Symptom isMood Dysregulation

9. Mania Hypomania Mood Disorder, NOS Bipolar II Bipolar I

10. Secondary Symptom of Bipolar Spectrum Disordersis Cognitive Dysregulation • Working memory • Visual-spatial reasoning • Planning/organization • Attention • Most noticeable in math and written language

11. Bipolar Spectrum DisordersCause Family Dysregulation • Marital conflict • Financial strain • Difficulty with parents’ work schedules • Significant impact on siblings • Isolation from friends and extended family • Shame/fear/reliving old memories

12. Bipolar Disorder • Primary symptom is "mood dysregulation" • One of the most complicated & severe of all psychiatric disorders • Also one of the most treatable • Underrecognized & undertreated

13. Bipolar Disorder • Early, accurate diagnosis is a rarity • DMDA survey: 48% did not receive accurate diagnosis until they had seen 3 or more professionals • 34% suffered with bipolar disorder for 10 years or more before correct diagnosis & treatment

14. Bipolar Disorder • High level of morbidity = major public health problem • Mortality: suicide rate estimated between 23% & 41%. • Mortality can be reduced by 80% with appropriate treatment

15. Bipolar Disorder • Prevalence estimate: 5.7% of adolescents have bipolar spectrum disorder • Lifelong condition with early onset • DMDA survey: 31% experienced first bipolar symptoms before age 14; 28% between 15-19 years of age.

16. Bipolar Disorder • Strong genetic basis • Underlying biological basis not fully understood • Dysregulation of neurochemical and neuroendocrine pathways • Oversensitivity of limbic brain

17. Cingulate Cortex Cerebral Cortex HIGHER BRAIN Frontal Cortex Corpus Callosum Hippocampus Thalamus MIDDLE BRAIN Cerebellum Hypothalamus Pons Amygdala LOWER BRAIN Medulla

18. Smell Speaking Hearing Taste Conscious decision making Generating Speech Reading AUTISM/ ASPERGER’S SYNDROME Vision MOOD DISORDERS FUNCTIONAL ANATOMY

19. Common Symptoms of Early-Onset Bipolar Disorder(Papolos & Papolos, 1999) • Separation-anxiety • Rages and explosive temper tantrums lasting up to several hours • Marked irritability • Oppositional behavior • Rapid cycling or mood lability • Distractibility • Hyperactivity • Impulsivity

20. Diagnostic Challenges in Bipolar Disorder • Overlaps with many other disorders: ADHD, panic, generalized anxiety, OCD, Tourettes • Estimated that 1/3 children diagnosed with ADHD actually have bipolar disorder • 1/3 of children diagnosed with depression will eventually manifest bipolar disorder

21. Differences between adult & childhood bipolar disorder • Adults typically have episodes of either mania or depression with relatively normal functioning between episodes • Children with bipolar disorder often both manic & depressed at the same time • Younger children tend to be irritable, excitable & explosive • Children frequently have multiple daily cycles of highs & lows • Children often show a more severe, chronic course of illness

22. Bipolar disorder in adolescents • May resemble classical adult presentation with periods of wellness between episodes • Puberty is a time of risk for onset • In girls, onset of menses may trigger the illness • Alcohol and drug abuse common

23. The Many Moods of Bipolar Disorder • Manic episode • Hypomanic episode • Major depressive episode • Mixed episode

25. Symptoms of Mania • Euphoria or irritability • Needing little sleep yet having great amounts of energy • Racing thoughts and rapid speech • Easily distracted • Grandiosity: inflated feeling of power, greatness or importance • Reckless behaviors: spending, promiscuity

26. Symptoms of Hypomania • Symptoms similar to mania, but less severe • No marked impairment in functioning • Psychotic features never present • Pleasurable • Seldom recognized by the patient as problematic

28. Symptoms of depression • Criteria same for childhood & adult depression • Physical symptoms: disturbances in sleep, appetite, energy, somatic complaints • Mental symptoms: problems with concentration, memory • Emotional symptoms: tearfulness, sadness, irritability, suicidal thoughts, hopelessness, pessimism

29. Symptoms of a mixed episode • Criteria for both mania and depression experienced nearly every day for at least one week • Mood alternates rapidly between euphoria, sadness, and irritability • Agitation, appetite disturbance, insomnia, psychosis, suicidal ideation are common

30. Subtypes of Bipolar Disorder • Bipolar I: at least one manic or mixed episode • Bipolar II: one or more episodes of both major depression and hypomania, but no manic or mixed episodes • Bipolar NOS: partial criteria • Cyclothymia: numerous episodes of hypomania and depression that do not meet criteria for mania or major depression

31. Bipolar Disorder: Summary • Mood dysregulation disorder • Early onset, but challenging to diagnose given comorbidities & developmental issues • Illness causes significant impairment in interpersonal, academic, and emotional functioning • Very treatable

32. INTERVENTIONS • Intervention starts with diagnosis • Education about the disorder for the parent/child/educators • Appropriate and closely monitored medication management • Therapy (Diagnositic, educational, family, cognitive-behavioral, supportive) • School programming

33. Treatment Planning

34. SCHOOL CONSIDERATIONS • Little learning will take place until mood is stabilized • Goals should proceed from attendance to participation to production • Reading comprehension, speed and accuracy of math and written expression most affected

35. SCHOOL CONSIDERATIONS • Student cannot complete as much work in same amount of time as other students with same ability • Student has difficulty with flexibility so teachers/staff must be flexible • Performance will be variable • Fatigue, hunger, illness, “mild” life issues will have major impact on functioning

36. SCHOOL CONSIDERATIONS • Environmental issues are important (lighting, seating, noise/distractions) • Periods of transition are taxing • Communication among those involved with the student is critical • Student needs a “safe place” and a “confidante” at school

37. SCHOOL CONSIDERATIONS • Behavior should not be interpreted at face value—important to look at the underlying emotions • Writing assignments and math will be the most threatening for these students • Students may need more than the “four year plan” for high school”

38. PEARLS . . . Treat a Bipolar Spectrum Disorder as a chronic illness . . . it will wax and wane but not be cured. “Children do well if they can.” Ross Greene, 2001.

39. Reading List • The Bipolar Child, Papolos and Papolos, Broadway Books, 2002. • The Bipolar Disorder Survival Guide, Miklowitz DJ., The Guilford Press, 2002. • An Unquiet Mind, Jamison KR, Knopf, 1995. • Touched with Fire: Manic-depressive Illness and the Artistic Temperament, Jamison KR, Maxwell Macmilllan International • The Explosive Child, Greene R, Harper Collins, 2001.

40. Reading List • His Bright Light, Steel D, Delacorte Press, 1998. • Survival Strategies for Parenting Children with Bipolar Disorder, Lynn GT, Jessica Kingsley Publishing, 2000. • Straight Talk About Psychiatric Medication for Kids, Wilens TE, Guilford Press, 1998. • Geller, B. & DelBello, M.P. (2003). Bipolar Disorder in Childhood and Early Adolescence. New York: Guilford Press.

41. Reading List • It’s Nobody’s Fault: New Hope for Difficult Children. Harold S. Koplewicz. Three Rivers Press, 1996. • When You Worry About the Child You Love: Emotional and Learning Problems in Children. Edward Hallowell. DIANE Publishing, 1999. • Firstad, M.A., & Goldberg Arnold, J.S. (2004). Raising a Moody Child: how to cope with depression and bipolar disorder. New York: Guilford Press.

42. Julie T. Steck, Ph.D., HSP Children’s Resource Group 9106 North Meridian, Suite 100 Indianapolis, IN 46260 317/575-9111 www.childrensresourcegroup.com