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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?”

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Juvenile Onset Bipolar Disorder: Identification & Treatment

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  1. Juvenile Onset Bipolar Disorder: Identification & Treatment ©Carrie Cadwell PsyD HSPP Cadwell Psychological Services, LLC www.cpsllc.info

  2. 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

  3. 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)

  4. 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

  5. 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

  6. 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

  7. 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)

  8. 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)

  9. 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

  10. 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

  11. 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

  12. 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)

  13. 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

  14. 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)

  15. 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

  16. 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”

  17. 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)

  18. 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

  19. 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

  20. Bipolar Disorder • Kowatch et al, 2005 • Goal-Directed Act cont • Agitation/activity exceeds ADHD • Nervous agitation or trauma related hypervigilance/disorganized tension/agitation different

  21. 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

  22. 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

  23. 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)

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Bipolar Disorder • Cardinal Symptoms (Chang, 2005) • Look at • Grandiosity • Decreased need for sleep • Racing thoughts • hypersexuality

  33. 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)

  34. 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)

  35. 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

  36. Bipolar Disorder • Kowatch, 2005 • % comorbids • CD/ODD—30-76% • Substance use 40% (also Chang, 2005) • Anxiety dx---36%

  37. 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)

  38. Intervention • Medications • Child & Family Focused Cognitive Behavioral Treatment • Interpersonal Social Rhythm Therapy • Educational Interventions

  39. 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

  40. 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”

  41. 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

  42. 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”

  43. 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!

  44. 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?

  45. Psychosocial Treatment • Should Address (AACAP, 2007) • Psychoeducation • Relapse Prevention • Individual Therapy • Social & Family Functioning • Academic & Occupational functioning

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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

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