Post on 22-Feb-2016
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Early Onset Bipolar DisorderEarly Onset Bipolar Disorderand the and the
Pediatric Behavior Rating Pediatric Behavior Rating ScaleScale™™ (PBRS (PBRS™™))
Children’s Mental HealthChildren’s Mental Health5,000,000 (the number of children and adolescents in the U.S.
suffer from a serious mental disorder resulting in significant functional impairments at home, at school, and with peers.)
80% (America’s youth with mental health needs who fail to be identified and to receive treatment and services.)
6-8 years – from onset to treatment for mood disorders
CONSEQUENCES (of untreated mental disorders include suicide, addictions, school failure, and criminal involvement).
Information obtained from National Alliance on Mental Illness web site Aug. 2007
Society benefits when Mental Health is addressed early
DIAGNOSIS DU JOUR?DIAGNOSIS DU JOUR?1980’S ADHD
1990’S DEPRESSION
2000’S EOBPD
RATES OF DIAGNOSISRATES OF DIAGNOSIS4,000% increase in rate of EOBPD
diagnoses in the past 10 years (Frontline, 2008)
At present, over 1 million American children have an EOBPD diagnosis, and the number is steadily increasing (Frontline, 2008)
PROBLEMS IDENTIFYING PROBLEMS IDENTIFYING BPD IN CHILDRENBPD IN CHILDREN
EOBPD is not in DSM IV.
EOPBD looks like other disorders.
EOBPD has high rates of comorbidity.
PROBLEM 1: EOBPD PROBLEM 1: EOBPD isn’t in DSM IVisn’t in DSM IV
BIPOLAR DISORDERS•Bipolar l Disorder
•Mania and major depression•Bipolar ll Disorder
•Hypomania & major depression•Cyclothymic Disorder
•Hypomania & depression/dysthymia
EOBPD vs. Adult BPDEOBPD vs. Adult BPD
(Birmaher et al, 2008; Danielyan et al, 2007; Kowatch et al, 2005)
EOBPD Adult BPDMixed Mood Episodes are typical
Discrete Mood Episodes are typical
Ultra-Rapid Cycling is common
Longer cycles
Symptomatic most of the time
Periods of no symptoms between cycles
PROBLEM 1: EOBPD PROBLEM 1: EOBPD isn’t in DSM IVisn’t in DSM IV
Bipolar Disorder-Not Otherwise Specified◦Rapid alternation between manic and
depressive symptoms that do not meet the duration criteria for manic, hypomanic, or major depression
◦Hypomanic without depression◦Infrequent episodes
PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders
Disruptive Behavior DisordersADHD60-93% meet diagnostic criteria for ADHD (Biederman,
et. al, 2003)Mania versus hyperactivityMore anger, irritability, aggressive temper tantrumsPresence of elation, grandiosity, racing
thoughts/flight of ideas, decreased need for sleep, hypersexuality
PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders
ODD77-88% have ODD (Wozniak et. al, 1995)
More intense irritability and severe emotional meltdowns
CD42-69% have CD (Biederman, et. al, 2003)
Violent and aggressive behavior lacks intent, planning, and premeditation
PROBLEM 2: EOBPD mimics PROBLEM 2: EOBPD mimics other disordersother disorders
Anxiety Disorders56-75% have anxiety disorder (Wozniak et. al, 1995;
Masi, et. al, 2001)
Tourette’s Disorder, Schizophrenia, Autism Spectrum Disorder
WHAT WE KNOW:WHAT WE KNOW:SYMPTOMS ASSOCIATED with SYMPTOMS ASSOCIATED with
EOBPDEOBPD Inflexible Oppositional Irritable Explosive rages Erratic sleep Difficult to soothe Separation anxiety Night terrors Fear of death and
annihilation Rapid cycling
Precociousness Sensitivity to stimuli Problems with peers Temperature
dysregulation Craving for carbs. and
sweets Bedwetting and soiling Hypersexuality Hallucinations Suicidal ideation
Frequency of EOBPD Frequency of EOBPD SymptomsSymptoms
Very Often(90%-97%)
Often(60%-80%)
Sometimes(20%-35%)
Infrequent(Less than
10%)Irritability Anxiety Hypersexuality Homicidal IdeasMood Lability Racing
ThoughtsPsychosis Suicidal Acts
Sleep Disorder Pressured Spch Suicidal IdeationAnger; Rage Euphoria,
GrandiositySelf-harm
ImpulsivityAgitationAggressionFrom: Faedda & Austin, 2006
Parenting a bipolar child p. 39.
PsychosisPsychosisTillman et al (2008), 257 EOBPD participants, ages
6-16, funded by NIMHPsychosis was present in 76.3% of subjects
◦38.9% with delusions Grandiose was most common
◦5.1% with pathological hallucinations Visual hallucinations were most common
◦32.3% with both
DEVIANCEDEVIANCEVOLUNTARY - we have a tendency
to attribute misbehavior—especially noncompliance and disobedience--to willful disobedience.
INVOLUNTARY - we tend to minimize this even when it explains the child’s behavior.
EOBPD and AROUSAL EOBPD and AROUSAL
Children with EOBPD are less able to modulate arousal live in fear are “on alert” for danger are primed for “fight/flight” response
And when aroused, aggression is more likely.
WHAT KIND OF WHAT KIND OF AGGRESSION IS BEING AGGRESSION IS BEING
EXPRESSED?EXPRESSED?
Predatory-controlled (instrumental)
Defensive-impulsive, reactive (not for gain)
CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE
Impulse Control ADHD Accidents/ Injuries
Emotional Instability Bipolar, Borderline, IED
Reactive, affective attack
Irritability Depression, Dysthymia
Acting Out, Suicide
Anxiety/Low Frustration Tolerance
Anxiety, PTSD, ASD Reactive striking out
Impaired Judgment Substance Abuse, Psychosis
Inadvertent Aggression
Stimulation Seeking CD, ODD Predatory Aggression
REACTIONARY and CONFRONTATIONAL REACTIONARY and CONFRONTATIONAL approaches serve mainly to provoke and approaches serve mainly to provoke and
escalate.escalate.
GOALS OF GOALS OF INTERVENTIONSINTERVENTIONS
StabilizeReduce Symptoms
OppositionDefianceIrritabilityAggression
Improve Functioning (academic, social)
TWO WAYS TO ACHIEVE TWO WAYS TO ACHIEVE THESE GOALSTHESE GOALS
Medications (to make the child “available”)
Psychotherapies (coping & managing)
General Rule for InterventionsGeneral Rule for InterventionsBehavioral approaches tend to focus on
consequences.
There are two problems with this…
TWO PROBLEMSTWO PROBLEMS
1. By definition, children and adolescents with deficits in impulse control and self- regulation do not consider consequences before they act.
2. Behavioral consequences (especially if they are aversive) introduce provocation, confrontation…and escalation.
INTERVENTION TARGETSINTERVENTION TARGETSCHILD
medicationssleepself-regulation
PARENTSpsychoeducation medication compliance
ENVIRONMENT (control the pace)homeschool
DRUG TREATMENTS EOBPDDRUG TREATMENTS EOBPD
FOUR MAJOR CLASSES of MOOD STABILIZERS
LithiumAntiepileptics (Mood Stabilizers)AntidepressantsAntipsychotics
CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE
MEDICATION
Impulse Control ADHD Accidents/ Injuries
STIMULANTSSSRI
ANTIPSYCHOTICMOOD STABILIZERS
Affective Instability
Bipolar, Borderline, IED
Reactive, affective attack
ANTISPYCHOTICSMOOD STABILIZERS
SSRI
Irritability Depression, Dysthymia
Acting Out, Suicide
SSRIOTHER
ANTIDEPRESSANTSAnxiety/Low Frustration Tolerance
Anxiety, PTSD, ASD
Reactive striking out
OTHER ANTIDPERESSANTS
SSRITENEX
CLONODINEImpaired Judgment Substance Abuse,
PsychosisInadvertent Aggression
ANTIPSYCHOTICS
Stimulation Seeking
CD, ODD Predatory Aggression
MOOD STABILIZER
NONDRUG INTERVENTIONSNONDRUG INTERVENTIONSTHERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS
BEYOND BEHAVIORISMBEYOND BEHAVIORISM
Parent Management TrainingCognitive Behavioral TherapyDialectal Behavior TherapyChoice TheoryProblem-Solving SkillsHealth Promoting Environments
CHARACT-ERISTIC
DIAGNOSIS AGGRESSION TYPE PSYCHOTHERAPY
Impulse Control
ADHD Accidents/ Injuries CBT; DBTPROBLEM-SOLVING
Parent Training
Affective Instability
Bipolar, Borderline, IED
Reactive, affective attack
CBT; DBTPROBLEM-SOLVING
Parent Training
Irritability
Depression, Dysthymia
Acting Out, Suicide CBT
Anxiety/Low
Frustration
Tolerance
Anxiety, PTSD, ASD Reactive striking out CBT; DBTPROBLEM-SOLVING
Parent Training
Impaired Judgment
Substance Abuse, Psychosis
Inadvertent Aggression
Cognitive Enhancement Therapy
Stimulation Seeking
CD, ODD Predatory Aggression Parent Training
PSYCHOEDUCATIONPSYCHOEDUCATION•The Bipolar Child (3rd Edition) by Papolos and Papolos (2006)•Understanding the Mind of Your Bipolar Child by Lombardo (2006)•The Bipolar Disorder Survival Guide by Miklowitz (2002)•The Bipolar Teen by Miklowitz and George (2008)•www.bpchildren.com•www.bipolarhelpcenter.com•www.bipolarkids.org•www.cabf.org•www.jbrf.org/juv_bipolar/faq.html
80 - 90%
10 - 15%
1 - 5%
Three-Tier Model of Behavioral Intervention/Support
Tier III: Intensive, Individual Interventions
Tier II: Targeted Group Interventions
Tier I: Universal Interventions/Supports
80 - 90%
10-15%
1-5%
Tier III: Individual InterventionsTier III: Individual Interventions
Goal: To develop and implement interventions for student behaviors that can not be addressed or remedied via Tier I or Tier II interventions.
FUNCTIONAL ASSESSMENTFUNCTIONAL ASSESSMENT
Modified from: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991)
INTERVENTIONS FOR SIMPLEINTERVENTIONS FOR SIMPLE Monopharmacy Mildly intrusive therapy individual therapygroup therapyparent training
Regular classroom placement Favorable RTI
INTERVENTIONS FOR COMPROMISEDINTERVENTIONS FOR COMPROMISED
Polypharmacy (aggression, irritability, co-morbidity)
Intensive child and family therapiesindividual therapygroup therapyfamily therapy/parent training
May require Spec. Ed. (EH, SED, OHI) Variable RTI
INTERVENTIONS FOR COMPLEXINTERVENTIONS FOR COMPLEX Polypharmacy Intensive Interventions
individual therapyintensive parent trainingalternative educational placements
Acute hospitalizationSelf-contained to RTCLaw Enforcement
Very poor prognosis
Predictors of OutcomePredictors of OutcomeWorse outcomes are associated with:
◦Younger age of onset◦Long duration of mood symptoms◦Low socioeconomic status◦Lifetime psychosis
(Birmaher et al, 2006)
PEDIATRIC BEHAVIOR PEDIATRIC BEHAVIOR RATING SCALERATING SCALE
WHY A NEW RATING SCALE?WHY A NEW RATING SCALE?
• Existing scales came out normal
• Item analysis told us why
• The need for differential diagnosis
OTHER SCALESOTHER SCALES• Young Mania Rating Scale–Parent Version (P-YMRS; 11 items)
• General Behavior Inventory (GBI; 73 items; age 11; self-report accuracy)
• Child Mania Rating Scale (CMRS; mania only)
• Conners’ Abbreviated Symptom Questionnaire (ASQ; 10 mania items from the Conners’ Parent Rating Scales [CPRS])
• Omnibus rating scales (e.g., Clinical Assessment of Behavior [CAB], Achenbach System of Empirically Based Assessment [ASEBA], Behavior Assessment System for Children [BASC])
PURPOSEPURPOSE• For children and adolescents ages 3-18 years
• Primary function: To assist in the identification of emotional dysregulation and related disorders, specifically early onset bipolar disorder (EOBPD)
• Secondary function: To aid in differential diagnosis, leading to differential interventions
FEATURESFEATURES• Sufficient items to identify core features of EOBPD, such as:
Mood swingsIrritabilityGrandiosityEasily provokedExplosive outbursts
• Syndromal differentiation (e.g., ADHD vs. EOBPD)• Identifies areas of concern rather than providing diagnoses
PBRS APPLICATIONS PBRS APPLICATIONS • Clinical
Distinguish between EOBPD and its mimicsSymptom identification and profile analysisAreas of concern
• EducationalClarify diagnosis using IDEAMore complete symptom profile (intervention)
• ResearchDefining the disorder in childrenHandling comorbidityIntervention efficacy
COMPONENTSCOMPONENTS• Parent Form
PBRS Parent Item Booklet (102 items)PBRS Parent Response BookletPBRS Parent Score Summary/Profile Form
• Teacher FormPBRS Teacher Item Booklet (95 items)PBRS Teacher Response BookletPBRS Teacher Score Summary/Profile Form
SCORES PRODUCEDSCORES PRODUCED• Inconsistency Score
Can I trust the responses?• Critical Items
No matter what, these are clinically important• Symptom Scales
Each is important, as is the profile• Total Bipolar Index
Composite of all 8 symptom scales
CRITICAL ITEMSCRITICAL ITEMSThese items have special clinical significance and
should be given special attention. Any item with a score greater than zero should be investigated further as this suggests a serious problem that must be addressed or ruled out.
•Self-abuse•Hallucinations•Bizarre beliefs•Expresses violent themes•Suicidal thoughts•Aggression
SYMPTOM SCALESSYMPTOM SCALESEight clinical scales and one index• Atypical (psychotic symptoms)• Irritability (persistent and chronic)• Grandiosity (exaggerated sense of self)• Hyperactivity/Impulsivity (as in ADHD)• Aggression (toward others, animals, objects)• Inattention (as in ADHD)• Affect (mood disturbances, cognitive distortion)• Social Interactions (interacting with peers)• Total Bipolar Index
Atypical (ATY) ScaleAtypical (ATY) ScaleBizarre beliefsAuditory hallucinationsDelusionsSelf-harm behaviorsExcessive fears
Irritability (IRR) ScaleIrritability (IRR) ScaleEmotional dysregulationBehavioral/emotional outburstsDemandingness
Grandiosity (GRAND) ScaleGrandiosity (GRAND) ScaleElevated sense of self and moodNot taking responsibility for actionsExaggeratingStealing
Hyperactivity/Impulsivity (HYPER) ScaleHyperactivity/Impulsivity (HYPER) Scale
Classic description of overactivity and impulsivity
Difficulty sitting stillActs without thinking about consequencesAlways on the go
Aggression (AGG) ScaleAggression (AGG) ScaleAggression targeting other people, animals, or
objects
Inattention (INATT) ScaleInattention (INATT) ScaleTraditional scale for inattention and
distractibilityDifficulty focusingDifficulty sustaining attention
Affect (AFF) ScaleAffect (AFF) ScaleMood disturbancesSuicidal ideationCognitive distortions
Social Interactions (SOC) ScaleSocial Interactions (SOC) ScaleAbility to interact with peersAbility to make friendsRelating to othersEngaging in social interactions
TOTAL BIPOLAR INDEXTOTAL BIPOLAR INDEX• TBI is a composite of the 8 scales
• The most robust PBRS score (like g on IQ tests)
• T scores >70 are a significant concern for disorders of emotional dysregulation; T scores >80 suggest EOBPD
• The most effective way to differentiate EOBPD from other diagnoses (especially ADHD)
POPULATIONPOPULATION• Normative sample
Parents n = 541Teachers n = 610
• Clinical sample (clinical groups included BPD, ADHD, CD, ODD, and autism spectrum disorders [ASD])
Parents n = 224Teachers n = 194
RELIABILITYRELIABILITYInternal consistency• Coefficient α for PBRS-P = .60 to .89• Coefficient α for PBRS-T = .75 to .93
• Coefficient α for PBRS-P TBX = .95• Coefficient α for PBRS-T TBX = .97
RELIABILITYRELIABILITY• Parent-teacher interrater reliability
Coefficient α = .77 to .86Coefficient α for TBX = .88
• Parent-parent interrater reliability
Coefficient α = .67 to .86Coefficient α for TBX = .85
VALIDITYVALIDITYConvergent validity: Omnibus rating scales for similar behaviors
• PBRS-P with CAB ≈ .50-.80• PBRS-T with CAB ≈ .30-.80
• PBRS-P with BASC-2 ≈ .60-.80• PBRS-T with BASC-2 ≈ .70-.80
VALIDITYVALIDITYConvergent validity: Domain-specific rating scales•PBRS-P with CMRS = .07 (Affect) to .63 (Aggression)•PBRS-T with CMRS = -.23 (Affect) to .70 (Hyperactivity/Impulsivity)•PBRS-T with Conduct Disorder Scale (CDS) = .52 to.74 on four similar scales•PBRS-T with Conners’ Teacher Rating Scales (CTRS) = .16 (Cognitive Problems/Inattention with Atypical) to .69 (Hyperactivity with Hyperactivity/Impulsivity)
VALIDITYVALIDITYClinical validity•Normative group compared to clinical groups (BPD, ADHD, ODD, CD, ASD) on the 8 scales and the TBX were significant at p < .001.•The 8 scales and the TBX differentiated the five clinical groups on all scales except Atypical and Inattention (Parent) and Irritability and Inattention (Teacher).