BIPOLAR DISORDER AMONG THE PEDIATRIC POPULATION:

A COMPREHENSIVE REVIEW

Drs. Jane Petrillo, Ping Johnson, Kandice Porter

Department of Health, Physical Education & Sport Science

Kennesaw State UniversityKennesaw, GA

jpetrill@kennesaw.edu

Presentation Goals:

Identify early, accurate diagnostic strategies

Recognize the common and complex signs, symptoms behaviors

Distinguish among the various types Describe components of a

comprehensive treatment plan Examine factors that contribute to

effective outcomes and those that hinder treatment effectiveness

Bipolar Disorder A mood disorder in which feelings, thoughts,

behaviors, and perceptions are altered in the context of episodes of mania and depression.

5.7 million American adults are diagnosed yearly Large proportion of them experience their onset during

childhood (up to 20%) - “Early Onset” Bipolar Disorder At least half of all cases start before age 25 An under-recognized and difficult to diagnose, serious

mental health problem among children and adolescents

If left untreated, may result in: Higher rates of intentional and unintentional injuries Suicide Academic Problems Family, Peer, Social Problems Juvenile Imprisonment Substance Abuse

The Diagnostic and Statistical Manualof Mental Disorders, 4th edition,

text revision (DSM-IV-TR):

The DSM-IV describes four types of bipolar disorderBipolar I - manic or mixed episodes that last

at least seven days – or- manic symptoms that are so severe the person needs immediate hospital care. Usually, individual also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.

Types of Bipolar Disorder Bipolar II - pattern of depressive episodes shifting back

and forth with hypomanic episodes, but no full-blown manic or mixed episodes.

Bipolar Disorder NOS (Not Otherwise Specified) – presence of symptoms that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, symptoms are clearly out of the person's normal range of behavior.

Cyclothymia – a mild form of bipolar disorder. Have episodes of hypomania that shift back and forth with mild depression for at least two years (one year for children and adolescents). However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Diagnosis: A Major Challenge Bipolar disorder does not affect every child in the same

way. The frequency, intensity, and duration of a child’s symptoms and the child’s response to treatment vary dramatically.

Initial diagnostic criteria was based on adult symptoms.

In adults, bipolar disorder commonly involves separate episodes of major depression, alternating with separate episodes of mania.

In children, mixed states of cycling (mood swings) are more common.

When children have manic symptoms that last for less than four days, experts recommend that they be diagnosed with BP-NOS (Not Otherwise Specified). Some scientific evidence indicates that approximately one-third of these children will develop longer episodes within a few years. If so, they meet the criteria for bipolar I or II.

Diagnosis: A Major Challenge Some experts believe that children with severe

irritability, emotional instability, and severe temper outbursts are bipolar.

Others believe this view will lead to over diagnosis of children who are actually suffering from disorders other than bipolar disorder – and argue for a narrower definition of bipolar disorder which includes episodic mood swings, elevated or expansive mood - not just irritable mood - and grandiosity or inappropriate euphoria (extreme joyfulness).

Diagnosis: A Major Challenge Other factors further complicate the

diagnosis of bipolar disorder in children. 1) A history of severe emotional trauma and/or

physical trauma (physical, emotional, sexual abuse can lead to mood swings, emotional outbursts, hallucinations, and extremely severe behavioral problems.

2) AD/HD

*Improving our understanding and awareness of these “other” factors and related symptoms can lead to a more accurate diagnosis and effective multi-level treatment strategies.

AD/HD - Bipolar Disorder A significant overlap exists in the

symptoms of mania, and to a lesser extent depression, and the symptoms of AD/HD.

AD/HD, mania and depression involve inability to concentrate and problems with distractibility.

Mania and AD/HD may both involve hyperactivity and impulsivity.

AD/HD - Bipolar Disorder (Mania) AD/HD in children usually does not involve mood

symptoms such as depression and euphoria to the extent seen in bipolar disorder.

AD/HD symptoms usually first appear early in childhood while the onset of bipolar disorder appears to occur later in childhood or adolescence.

AD/HD usually have normal sleep patterns –once a child has settled down in bed and is ready for sleep. 

In contrast, mania, involves decreased need for sleep with the individual still "raring to go" the next day despite little sleep.

Also, family history is critical, as both disorders appear to run in families.

AD/HD - Bipolar Disorder (Depression) Children with depression more often

appear irritable than sad. Children and adolescents are naturally

prone to displays of unstable mood. Determining the cause(s) of the

moodiness (hormonal, social/peers, parent/child issues, stress, drug use…) is helpful.

Identifying the presence of other symptoms of mania or elevated mood, particularly the presence of euphoria or grandiosity at some point, is important in making this diagnostic distinction.

Depression - Bipolar Disorder The risk of depression turning into bipolar

disorder is 10 percent or less in adults. The risk increases to 20-40 percent for

children and adolescent. Risk factors for the eventual

development of bipolar disorder in addition to early onset of depression include: Psychosis; sudden onset, severely slowed or

retarded movement; antidepressant-induced mania or elevated mood; and family history of bipolar disorder

Diagnosis – Ruling out other Possible Health Problems

Other health concerns must first be ruled out to arrive at an accurate diagnosis.

A complete physical exam and medical work-up should be conducted for a child who is exhibiting significant variability in mood.

Physical conditions can manifest symptoms similar to bipolar disorder.

“Other” Possible Conditions AIDS Brain Tumor Diabetes Epilepsy Lupus Lyme Disease Multiple Sclerosis Neurosyphilis Sodium Imbalance Thyroid Disorder

DiagnosisNeed for a specific – accurate diagnostic tool

DSM-IV describes symptoms of 4 types

Young Mania Rating Scale (YMRS)(http://www.psych.uic.edu/csp/facilities/rating%20scales/YMRS.pdf)

Parent Version of the YMRS(http://www.healthyplace.com/images/stories/bipolar/p-ymrs.pdf)

Screening Tools-Bipolar Disorder/Mania Symptomshttp://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp

Screening Tool Rating Scale

For Ages (Years) Who Completes Checklist: Number of

Items

Time to Complete (Minutes)

Young Mania Rating Scale (YMRS)

Parent Version of the Young Mania Rating Scale (P-YMRS)

5-7 Clinician: 11

Parent, Teacher: 11

15-30

5

General Behavior Inventory (GBI) Parent Version,

General Behavior Inventory (P-GBI)

11+

5-17

Student: 73

Parent:

Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS)

6-18 Clinician 90-120

Weinberg Screening Affective Scale (WSAS)

7-17 Student: 56 5

Mood Disorder Questionnaire (MDQ)

12+ Student: 15 5-10

Diagnosis

A diagnosis should never be based on a symptom questionnaire alone. It is important for the individual to have a complete developmental, social, behavioral, educational and family history as well as information about previous interventions and their effectiveness.

Very Common Symptoms of Early-Onset Bipolar Disorder:

Separation anxiety

Rages & explosive temper tantrums (lasting up to several hours)

Marked irritability

Oppositional behavior

Frequent mood swings

Distractibility

Hyperactivity

Very Common Symptoms of Early-Onset Bipolar Disorder:

Impulsivity

Restlessness/fidgetiness

Silliness, goofiness, giddiness

Racing thoughts

Aggressive behavior

Grandiosity

Carbohydrate cravings

Very Common Symptoms of Early-Onset Bipolar Disorder:

Risk-taking behaviors

Depressed mood

Lethargy

Low self-esteem

Difficulty getting up in the morning

Social anxiety

Oversensitivity to emotional or environmental triggers

Common Symptoms of Early-Onset Bipolar Disorder

Bed-wetting (especially in boys)

Night terrors

Rapid or pressured speech

Obsessive behavior

Excessive daydreaming

Compulsive behavior

Common Symptoms of Early-Onset Bipolar Disorder

Motor & vocal tics

Learning disabilities

Poor short-term memory

Lack of organization

Fascination with gore or morbid topics

Hypersexuality

Common Symptoms of Early-Onset Bipolar Disorder

Manipulative behavior

Bossiness

Lying

Suicidal thoughts

Destruction of property

Paranoia

Hallucinations & delusions

Less Common Symptoms of Early-Onset Bipolar Disorder

Migraine headaches

Binging

Self-mutilating behaviors

Cruelty to animals

Treatment A child with bipolar disorder needs

medical treatment - but medication alone is only one component of an effective treatment plan

Patients must receive comprehensive treatment throughout life to maintain functionality

An effective treatment plan for bipolar disorder requires three essential elements:1) Medication 2) Lifestyle and Environmental Changes and Support3) School and Academic Accommodations

Medications help alleviate and reduce symptoms so they are less intrusive, smooth out mood fluctuations, reduce anxiety and distractibility, and increase frustration tolerance.

Because stress is a trigger that intensifies bipolar symptoms and causes a decline in overall level of functioning, lifestyle and school changes should be made to reduce stress.

Treatment – Medication and Psychotherapy Mood Stabilizers, Antipsychotics, and Atypical Antipsychotics

Agents (Lithium, lithium carbonate, Clozaril, Risperdal, Zyprexa, Seroquel )

Anticonvulsants (Depakote, Tegretol, Trileptal, Lamictal, Topamax, Gabatril)

Often, it is necessary to use 3-4 medications to effectively treat a child or adolescent with a bipolar disorder.

Regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist.

Cognitive behavioral therapy, interpersonal therapy, and multi-family support groups.

A support group for the child or adolescent with the disorder can also be beneficial.

Medication – Side Effects Nausea Increased or decreased appetite Excessive thirst Frequent urination Disinhibition Aggression (rare) Diarrhea or constipation Dry mouth Cognitive dulling Hyperactivity Muscle tremors Drowsiness Fidgeting or pacing Restlessness Chills or hot flashes (rare) Vision problems Weight gain

Lifestyle/Environmental Changes and Support Family must understand and accept bipolar

disorder as a chronic medical condition, participate in psychosocial therapies and create effective individual, family, and community support networks.

Counseling services and psychoeducation help the child deal with many effects of the illness and therapy for family members can help the family cope and reduce tensions at home.

In addition, research reveals that keeping a consistent sleep schedule, regular exercise, and maintaining a healthy diet is highly critical.

Lifestyle/Environmental Changes and Support A child with bipolar disorder needs a

supportive and caring, consistent, yet flexible environment providing predictability and emotional stability.

Parents should choose recreational and other activities for the child with these criteria in mind.

Parents should also ensure that the child is not burdened with more activities than he/she can comfortably handle/manage.

Also important to provide for sufficient time in the child's schedule to recover from the stresses that a child with bipolar illness endures during ordinary activities.

School and Academic Accommodations In school, a child with bipolar disorder needs a

consistent predictable schedule with advance notice of schedule changes and time and assistance to prepare for transitions throughout the school day. 

Teachers working with the parents to adjust homework requirements as needed to ensure that the child is able to get needed sleep, participate in psycho-educational programs and individual therapies as needed.

Children with bipolar disorder often feel overwhelmed by seemingly ordinary events and challenges - Provide designated "safe" adults to whom children can turn and "safe places" where they can seek refuge in times of emotional crisis – Goal is to defuse these crises.

School and Academic Accommodations Social skill and Conflict resolution training Anger management Problem-solving skill development Self-esteem development Modify school schedule and provide flexibility in

procedural rules: Unlimited bathroom use Access to water as needed Shortened schedule Late start as needed Consistent schedule Provide notice before any transition or change in

schedule Permission to move around when needed Naps as needed for primary education students Positive behavioral intervention plan

School and Academic Accommodations

Modified or shortened class assignments and homework

Testing in small groups or one-on-one

Extended deadlines for assignments

Regular home-school communication via assignment notebook and teacher-parent meetings/communications

Additional School/Academic Accommodations

Preschool special education testing and services

Small class size (with children of similar intelligence) or self-contained classroom with other emotionally fragile (not "behavior disorder") children for part or all of the day

One-on-one or shared special education aide to assist child in class

Recorded books as alternative to self-reading when concentration is low

Art therapy and music therapy

Additional School/Academic Accommodations Extended time on tests Use of calculator for math Extra set of books/resources at home Use of keyboard or dictation for writing assignments Regular sessions with a social worker or school

psychologist Social skills groups and peer support groups Annual in-service training for teachers by child's

treatment professionals (sponsored by school) Enriched art, music, recreation, or other areas of

particular strength Curriculum that engages creativity and reduces

boredom (for highly creative children) Tutoring during extended absences Goals set each week with rewards for achievement

Additional School/Academic Accommodations Summer services such as day camps and special

education summer school Placement in a day hospital treatment program

for periods of acute illness that can be managed without inpatient hospitalization

Placement in a therapeutic day school during extended relapses or to provide a period of extra support after hospitalization and before returning to regular school

Placement in a residential treatment center during extended periods of illness if a therapeutic day school near the family's home is not available or is unable to meet the child's needs

Resources for parents about bipolar disorders

School and Academic Accommodations Student Management Plan = Academic and

Behavioral Success Expectations (rules) should be simple, clear, and

phrased in positive or neutral language. (Keep hands to self; please raise hand to speak)

Issue only one specific direction at a time and modify assignments. (Complete 10 math problems instead of the entire assignment)

Tailor/individualize the identified target behaviors Accommodate the child's fluctuating level of stability

with a menu of behavioral and academic expectations. Administrative support is critical

Reward the child for positive behavior

Student Management Plan = Academic and Behavioral Success

Continue to expect the best from the child and though the student may have behaved poorly in the past - Must remove lingering bias from prior misbehaviors which will assist the child in demonstrating new social skills.

Ignore minor issues as it is impossible to change everything at once. Focus on the big picture and goal-setting. Set realistic expectations.

Consistently create opportunities for the child to be successful and share unique talents and strengths to help foster development of positive relationships with self, teachers, and peers.

Prevention/Early Detection Early Detection

Proactive universal screening Evaluating at-risk students in primary grades for

emerging antisocial behavior patternsdifficulties with peer and teacher

relationshipsaggressive and disruptive behaviorinternalizing behaviors: e.g., anxiety,

inattentionwithdrawn behavior in the classroom

Diagnosis and Treatment is critical: Prior to condition progresses; or If child is disciplined for an unknown/uncontrollable disorder or condition

Prevention/Early Detection

Bipolar can be genetic:Parents should be tested for psychological disorders Be aware of signs and symptoms of other conditions – (ADHD, behavioral disorder, anxiety disorders and depression) Behavioral signs in children can be key signs in discovering bipolar disorderKnowing/being aware of the signs See a doctor immediately if any of the signs appear

References/Resources

Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J,Iyengar S, Keller M. “Clinical course of children and adolescents with bipolar spectrum disorders.” Archives of General Psychiatry. 2006 Feb;63(2):175-83.

Child and Adolescent Bipolar Foundation (CABF) www.bpkids.org

Cincinnati Children's Hospital Medical Center, Resource Center on Mental Health Wellness. (2010). http://www.cincinnatichildrens.org

Juvenile Bipolar Research Foundation (2010) http://www.jbrf.org/index.html

Kowatch, R.A., Fristad, M., Birmaher,B., Wagner, K.D., Findling, R.L., Hellander, M. (2005).“Treatment Guidelines for Children and Adolescents With Bipolar Disorder: Child PsychiatricWorkgroup on Bipolar Disorder.” J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 44:3, 213.

Massachusetts General Hospital, School Psychiatry Program and MADI Resource Center (2010) http://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp

National Alliance for the Mentally Ill (NAMI) http://www.nami.org/

National Institute of Mental Health (2010). “Bipolar Disorder in Children and Teens.” Science Writing and Dissemination Branch. Bethesda, MD

The Depression and Bipolar Support Alliance (DBBSA) http://www.dbsalliance.org/index.html