ADHD or Bipolar Disorder?
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Transcript of ADHD or Bipolar Disorder?
Copyright © 2011 The REACH Institute. All rights reserved.
ADHD or Bipolar Disorder?Assessment and Differential
Diagnosis ofBipolar Disorder in Children and
Adolescents
ADHD or Bipolar Disorder?Assessment and Differential
Diagnosis ofBipolar Disorder in Children and
Adolescents
Jointly sponsored by SUNY: Buffalo & NY State Office of Mental Health,
in conjunction with The REACH Institute. This activity is supported solely
by the joint sponsors, and received no commercial support of any kind.
Wanda Fremont MD 1/27/12
Special thanks:
The REACH Institute
Copyright © 2011 The REACH Institute. All rights reserved.
Prevalence in Community Samples of Pediatric Bipolar Disorder:
<1%
Prevalence in Community Samples of Pediatric Bipolar Disorder:
<1%
Author Measure Bipolar I Bipolar II Bipolar NOS
Carlson and Kashani (1988)
DICA 0.6% 7.0% 10.0%
Lewinsohn et al. (1996)
K-SADS 0.1% 0.06% 0.3%
Costello et al. (1996) CAPA 0.0% 0.1%
Shaffer/MECA DISC 1.2 0.6
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Criteria for Manic Episode (I)Criteria for Manic Episode (I)DSM criteria written with adults in mindA. Distinct period of abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) Inflated self-esteem or grandiosity
2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or subjective experience that thoughts are racing
5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7) Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
(Adapted from DSM-IV-TR, 2000)
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Bipolar Disorder in Children:The Broad Phenotype
Bipolar Disorder in Children:The Broad Phenotype
• There is a large group of children who show many manic symptoms
– Especially the affective storms & rages
– Don’t clearly cycle between mood states
– May not have bipolar in family pedigree
– Severe Mood Dysregulation (Leibenluft et al 2003)
• Are these bipolar cases? – Will they grow up to look more classic?
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Developmental Differences in the Expression of Manic and Depressive Symptoms
Developmental Differences in the Expression of Manic and Depressive Symptoms
Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.
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SYMPTOM ADULT CHILD
Racing thoughts
Jumping from one thought to another in an illogical manner
Describes mind is like a video on fast forward
Pressured speech
Hard to interrupt and not phased when you do
Child talks continuously and difficult to redirect
Developmental Differences in the Expression of Manic and Depressive Symptoms
Developmental Differences in the Expression of Manic and Depressive Symptoms
Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.
Copyright © 2011 The REACH Institute. All rights reserved.
ADHD vs. BipolarADHD vs. Bipolar
• Irritability is non-specific:
– Irritability does not = Bipolar
– Geller et al 2002 found irritability in 72% of Children with ADHD and 97.9% of Children with Bipolar Disorder
• Again elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep and hypersexuality provide the best discrimination between ADHD and BD in children and adolescents (Geller et al 2002)
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The Unipolar Depression vs.Bipolar Distinction
The Unipolar Depression vs.Bipolar Distinction
• First mood episode of pediatric bipolar disorder is often a depressive episode
• MDD in children often associated with high rates of irritability…i.e., children with depression can present with irritable mood, not depressed mood
• Children and adolescents with major depressive disorder can have very labile mood
• What do you mean by mood swings? – euthymia to depressed vs. depressed to manic or
hypomanic
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Substance Abuse vs.Pediatric Bipolar Disorder
Substance Abuse vs.Pediatric Bipolar Disorder
• The substance abuse may mimic a bipolar presentation– Check urine drug screens, educate patients and
families
• There are high rates of co-morbid substance abuse in adolescents with bipolar disorder– The substance abuse must be addressed
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Conduct Disorder vs.Pediatric Bipolar Disorder
Conduct Disorder vs.Pediatric Bipolar Disorder
• Conduct Disorder– The negative
behaviors areoften calculating and predatory
• Pediatric Bipolar– The negative
behaviors are secondary to grandiosity and risky, poor judgment
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With Pediatric Bipolar DisorderThere Are High Rates of
Co-occurring Psychiatric Conditions
With Pediatric Bipolar DisorderThere Are High Rates of
Co-occurring Psychiatric Conditions
• ADHD
• ODD
• Conduct Disorder
• Learning Disabilities
• Substance Abuse
• Anxiety Disorders
Individually orin combination
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A Family History ofBipolar Disorder
A Family History ofBipolar Disorder
• Take a careful family psychiatric history
– Bipolar disorder in one parent = 5x odds of bipolar disorder in child (but still only ~5% prevalence; LaPalme et al., 1997), still less than likelihood of ADHD
– Bipolar disorder in parents, grandparents, and siblings is clinically meaningful but doesn’t rule out “bad” ADHD
– The presence of bipolar disorder in more distant relatives may not confer greater genetic risk
– No clear family history doesn’t rule out pediatric bipolar disorder
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Pediatric Bipolar Rating ScalesPediatric Bipolar Rating Scales
• Young Mania Rating Scale for Parents P-YMRS (Gracious et al. JAACAP,2002) – the scale can be found at www.healthyplace.com/bipolar/p-ymrs.asp
• General Behavioral Inventory, GBI (Findling et al. Bipolar Disorder, 2002)– Self and parent report ages 5-17– Very long tool 73 mood items
• Life Mood Charts– Asking about mood symptoms throughout the patient’s life– Can be found at www.dballiance.org
• These rating scales do a better job of ruling out pediatric bipolar disorder then ruling it in
• Still very helpful to follow symptoms to assist with diagnosis and to follow symptoms
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SummarySummary• In evaluating pediatric bipolar disorder look for classic
criteria– elevated mood, grandiosity, decreased need for sleep,
racing thoughts
• High rates of psychiatric co-morbidity– Especially ADHD, ODD, Conduct Disorder and Learning
disabilities
• Careful family history– Focus on first and second degree relatives
• Rating scales do a better job of ruling out pediatric bipolar disorder then ruling it in
• If significantly concerned get a child psychiatry consultation
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Bipolar DisorderTreatment Options
Bipolar DisorderTreatment Options
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FDA Pediatric Labeling for BDFDA Pediatric Labeling for BD
Brand name Generic Name Indicated Age
Cibalith-S Lithium citrate 12 and older
Eskalith Lithium CO312 and older
Lithobid Lithium CO3 12 and older
Risperdal Risperidone 10 and older
Abilify Aripiprazole 10 and older
Zyprexa Olanzapine 10 and older
Seroquel Quetiapine 10 and older
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Updated Treatment Algorithm for Mania/
Hypomania in Children
& Adolescents
Updated Treatment Algorithm for Mania/
Hypomania in Children
& Adolescents
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Depression Switching toBipolar Disorder
Depression Switching toBipolar Disorder
• Prepubertal depression BD
– Limited outcome studies
– 24/72 (33%) MDD children BD-I at age 20, 11/72 (11%) BD-II or hypomania (Geller et al., 2001)
• Adolescent depression BD
– Limited studies
– 58 MDD inpatients followed up in 24 months Overall: 5/58 (8.6%) BD; 0/40 without psychotic symptoms, 5/18 (28%) with psychotic
symptoms (Strober et al., 1992)
– Epidemiological sample; 275 teens with MDD, < 1% BD by age 24 (Lewinsohn et al., 2000)
– 5/26 (19%) of MDD adolescents had BD after ~7 year follow-up (compared to 0% of controls) (Rao et al.,1995)
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Switching to Bipolar Disorder with Antidepressants:
Switching to Bipolar Disorder with Antidepressants:
• Antidepressants may induce mania in children with a bipolar diathesis
– In a survey of child and adolescent psychiatrists: 10/228 (4.4%) of children under 13 y/o treated by psychiatrists switched to BD (Reichart & Nolen, 2004)
– Treatment for Adolescent Depression Study (TADS), of 439 12-17 year olds: 0 switches to BD after 12-week follow-up (2004)
– large private insurance database, 5.4% switch rates, increased risk for youth on antidepressants and risk greatest for age group of 10-14 y/o (San Martin et al., 2004)
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Switching to Bipolar Disorder with Stimulants:
Switching to Bipolar Disorder with Stimulants:
• Concerns that stimulants may precipitate mania or destabilize children with bipolar who are not stabilized on other medications
– However…
– In the Multimodal Treatment Study of Children with ADHD (MTA), children with ADHD and some manic symptoms responded well to stimulants with decrease in ADHD symptoms and without increased rates of developing bipolar disorder (Galanter et al 2003, 2005)
– “Follow-back” study of children originally diagnosed and treated for “minimal brain dysfunction.”
Those diagnosed with bipolar spectrum disorders as young adults had responded well to stimulants as children
Those children with more comorbidities did not develop higher rates of bipolar as compared to those with uncomplicated ADHD (Carlson et al 2000)
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CAP PC: Child and Adolescent Psychiatry for Primary Care
Providers: Consultation, Education and
Linkage/Referral Support:Wanda Fremont MD
1/27/12
Special thanks to David Kaye MD
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OMH EFFORTS TO ADDRESS THE NEEDS OF PCPs FOR INCREASED SUPPORT
FROM CAPsProject TEACH (Training and Education for
the Advancement of Children’s Health)
Two Project TEACH programs covering NYS:
1. CAPES (Child and Adolescent Psychiatry Education and Support)
Northeastern NY State – Jeff Daly MD
2. CAP PC: (Child and Adolescent Psychiatry for Primary Care)
Rest of NY State – David Kaye MD , (5 Medical Univ)
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CAP PC:The program’s intent is to
provide support for PCPs to manage children and
adolescents with mild-moderate mental health problems and to
assist with linkage/referral services for those patients
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CAP PC Collaboration:$2.6 million 3 yr grant
NY State Office of Mental Health American Academy of Pediatrics
American Academy of Family Medicine (AAFP)
NY State Conference of Local Mental Hygiene Directors
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5 Academic University Centers:
Columbia UniversityLong Island Jewish /Northshore
SUNY BuffaloSUNY Upstate
University of Rochester
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CAP PC SERVICES
1. Phone consultation/Linkage Referral
2. Website
3. Face to Face Consultation
4. REACH training
5. Outcomes Evaluation
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Most Common Childhood Problems:
1. ADHD
2. Anxiety
3. Depression
4. Behavioral Problems
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What CAPPC Grant Does Not Cover:
• Childhood Schizophrenia• Bipolar Disorder• Moderate or Greater Intellectual Disability• Substance Abuse• Persons who have had their 22nd birthday• Persons seriously and persistently
mentally ill, whatever the diagnosis (es)
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1. Phone Consultation and Linkage/referral
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ANY PCP in the State of New York is eligible to call the
1-855-CAP-PC72 line
1-855-227=7272
(9-5 M-F, excluding holidays)
For child psychiatric consultations by phone.
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Coverage is provided :Coverage is provided :
Monday: Upstate SyracuseTuesday: LIJ/NSU
Wednesday: ColumbiaThursday: Buffalo ChildrensFriday: Rochester (Strong)
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Regional Site Teams
Each site team consists of a:
1. Child/adolescent Psychiatrist
2. Liaison Coordinator (MSW/PhD)
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Work Flow for Phone Consultations
The Liaison Coordinator will take the initial phone call and will
respond to all calls within their scope of training and expertise.
If a child psychiatrist is appropriate or requested then
the covering CAP will return the phone call within 2 hours.
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HIPPA IHIPPA IPhone calls are considered
educational consultations to the PCP about patient management, not a clinical service to patients. It is
critical that PCPs maintain patient confidentiality and that
communications are HIPPA-compliant in these phone calls.
Identifying health information will NOT be requested and should not
be provided! De-identified demographic information about you and the patient will be requested to provide feedback and evaluation of
the project.
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HIPPA II HIPPA II
While informed consent is not required for HIPPA -compliant
discussion of patient care issues by telephone, CAP PC
encourages PCPs to inform families and obtain verbal consent about these phone
consultations
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PCP Cheat Sheet
• Contact information for you
• Patient grade in school; support services?
• Global assessment of function score
• Screens completed: ?Vanderbilt; ?PSC
• Insurance
• Current mental health treatment
• Psychotropic med history
• Medical history
• Family history of mental illness
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2. WEBSITE
Cappcny.org
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Website Contents:
• Screening Tools: e.g. Vanderbilt, SCARED, PHQ9, MOAS, PSC17 and 35
• Links: AAP Bright Futures, AACAP Practice
• References
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3. FACE TO FACE CONSULTS
OPENto ALL PCPs
in NEW YORK STATE(Direct or Telepsych)
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Face to Face ConsultationsSelected cases will be seen for a
one time only face-to-face (or telepsychiatric if the patient is
geographically distant from one of the program sites) consultation
with a program child psychiatrist. Face to face (FTF) evaluations will be scheduled within a few weeks
with the local child/adolescent psychiatrist (CAP).
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Selection of Face to Face Consultations
FTF evaluation will be offered for cases which are
diagnostically confusing or complex, or it is unclear
whether it is appropriate for PCP management.
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Face to Face Evaluations are Consultations Only
Face to face evaluations are consultations only; patients cannot
be picked up by the child psychiatrist for ongoing treatment
and medication management. Please be sure to educate your
patients/families about this.
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Our Promise
Following completion of the FTF evaluation, verbal feedback and
a written report will be provided by the evaluating CAP to the
referring PCP.
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Emergency Cases
In urgent situations PCPs may call
the 1-855 line for assistance with
referral to an appropriate emergency service in the
region. Face to face evaluations will not be scheduled on an
urgent basis and should NOT be looked to for emergency cases!
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Jumping the Queue for Linkage/Referral
AssistancePlease note that CAP PC can not
provide assistance with referral and linkage services for routine cases. These cases should be referred to
local mental health agencies or child mental health professionals in private practice. The same is true
for patients/families who have been dismissed from mental health agencies or clinics because of
noncompliance or poor attendance.
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4. Education:REACH TRAINING
Copyright © 2011 The REACH Institute. All rights reserved.
About REACH
• Yearly three day continuing education workshop
• Developed by Peter Jensen, Child Psychiatrist
• Interactive dynamic innovative
• Open to 20-25 PCPs in each of the 5 sites
• Biweekly conference calls for the next 6 months
• Up to 32 hours FREE CME
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5. Outcomes Assessment
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Important requirements for the use of the CAP-PC service
• Necessity of Evaluation– Required by New York State as part of this
program• What is involved- details are still being
worked out– Clinician practice questionnaire-
• Before this training• End of this training• After phone call meetings• At some future time
Copyright © 2011 The REACH Institute. All rights reserved.
Important requirements for the use of the CAP-PC service
• Evaluation of phone consultations and face-to-face consultations–Brief questionnaire follow-up about
ease of access and usefulness of consultations
–Brief questionnaire follow-up about further contacts with the child, the implementation of recommendations, and the functioning of the child.
Copyright © 2011 The REACH Institute. All rights reserved.
Direction for the Future
• With regard to moderately to severely intellectually disabled patients, we recommend that this group be the subject of discussion between OMH and OMRDD with the goal of coming up with a pilot project similar to CAP-PC to serve this chronically underserved population.
Copyright © 2011 The REACH Institute. All rights reserved.
Summary 1-855-CAP-PC72www.cappcny.org
• Phone consultation/Linkage Referral
• Website
• One time Face-to-Face Consults
• REACH training• Outcomes Evaluation
Copyright © 2011 The REACH Institute. All rights reserved.
Copyright © 2011 The REACH Institute. All rights reserved.
Thank you!Thank you!
QUESTIONS?QUESTIONS?