Week 10 Pediatric bipolar Flashcards
Manic Episode: has to last for 7 days or they go to hospital
need 4 unless?
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
Excessive involvement in pleasureable activities that have a high potential for painful consequences (e.g., sexual behavior, shopping, gambling)
Pediatric Bipolar Disorder manifestations,
Also think rela. To CD odd. IT LOOK DIFFERENT THOUGH ON. PRESCHOOLERS
AS WITH DEPRESSION so what does bipolar disorder look like?
Different manifestations of the same underlying problem we see in adults
Fundamental debate in child psychology: How do we ensure that symptoms are developmentally appropriate
CD/ODD
Depression
Specifies:
Depressive Episode
Meets criteria for a major depressive episode
Hypomanic Episode
Same as manic episode except:
Lasting at least four days
No marked deterioration in functioning
Bipolar 1
do not need to have depression.
Need manic episode(s)
Manic episode or a mixed episode (mania and depression) lasting 7 days
(unless hospitalization is required)
May or may not show depression (note that textbook is mistaken)
Specifier – with mixed features
Person is experiencing episodes that include symptoms of both mania and depression (e.g., a manic episode in which some symptoms of depression are present)
Bipolar 2
Major depressive episodes and hypomanic episodes
Does not ever have a full manic episode or mixed episode Specifier – with mixed features
Cyclothymia (sim. To dysthymia) ?
Period lasting at least 1 year when there numerous hypomanic and depressive symptoms that do not meet full criteria for either a manic episode, mixed episode, or major depressive episode
Between 1990 and 2000 diagnoses of bipolar disorder in children quadrupled!
Why?
Epidemiology…
1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist
Argued that bipolar disorder in children was overlooked
Provided a vague and general list of behaviors
Poor handwriting
Complains of being bored
Is very intuitive or very creative
Excessively distressed when separated from family Has difficulty arising in the A.M
Elated or silly, giddy mood states
Curses viciously in anger
Intolerant of delays
But they are not specific! All children have this occasionally.
So
2001 field decided that bipolar disorder could be diagnosed in children
Noted that there can be differences in presentation of bipolar in children and adults
Adults have discrete episodes; have it, return to normal for a while, have it)
In children, may see changes in mood even within
the same day
Tend to have long episodes like this (1 to 4 years) (same day rips switches eg.)
How narrow or broad should the criteria be? For bipolar disorder in children?
Narrow phenotype
“Classic” adult symptoms
Mania, grandiosity
Some children/adolescents meet the full diagnostic criteria meant for adults
Broader phenotype
Irritability, mood lability
Irritability is much more common than mania
However, irritability occurs in other disorders as well
Depression
ODD
Is this actually bipolar disorder?
Diagnostic challenges pertaining to bipolar disorder in children?
Children may not show discrete episodes:
Children often show rapid mood changes (between depression and mania on the same day)
Also see youth with chronic mania
Irritability, rather than euphoria, can be the
predominant mood state
Differential diagnosis
Depression, ODD, CD, ADHD
Due to this overlap, some authors have argued that to be diagnosed with bipolar disorder, children must show core features of mania:
Grandiosity, elevated mood
These features do occur in a significant number of youth who have been identified as having bipolar disorder
Where we are now in diagnosis?
Practice Parameters of the American Academy of Child and Adolescent Psychiatry
DSM criteria for adults should be applied to children and adolescents
Mania, which may include irritability, must be present as a marked change in the individual’s state
Illness represents a departure from baseline functioning
Note that many children do not meet the duration criteria for a full manic episode, which is required for bipolar I, so bipolar 2 and cyclothymia are more common diagnoses
Diagnostic validity of bipolar disorder in preschool children has yet to be established
DSM-5
Concerns about over-diagnosing bipolar disorder in childhood
Frequent severe tantrums and chronic irritability
Irritability is included in many DSM diagnoses
ODD
Depression
To address this what was added?
inclusion of new disorder.
Dysruptive Mood Dysregulation Disorder (DMDD) Very controversial
No published data using these criteria
DMDD definition
8 items
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers)
E. Symptoms are present for 12 months or more
F. Not diagnosed before age 6 or after age 18
G. Age at onset of the outbursts and irritable mood is before age 10
H. Child has never met criteria (except duration) for a manic episode (even lasting one day)
DMDD
Is not diagnosed concurrently with:
ODD
As DMDD is more severe
Also:
Bipolar disorder
Research on DMDD is very limited
More research has focused on related on construct –
severe mood dysregulation (SMD)
Also includes symptoms of hyperarousal (e.g., flight of ideas, agitation, insomnia)
Work has been done primarily on one sample
Phenotypic contiur amity of mood disorders?
Children diagnosed with bipolar disorder much more likely to have future manic episodes than children with SMD
Children who meet criteria for SMD more likely to go on to develop major depression
Suggests that SMD and bipolar disorder are distinct
Research team worked retrospectively by applying new criteria to data already collected, looking at DMDD and found?
Found that DMDD was not well-differentiated from CD or ODD
58% of youth with ODD and 62% of youth with CD met criteria for DMDD
No difference between youth with and without DMDD diagnosis in symptom severity or functional impairment
Showed poor stability, might not meet it later iow
Second study using retrospectively applied criteria related to DMDD found
that the frequency and duration criteria are very important
Half of the sample was reported to have severe temper outbursts
When frequency criteria (3 x week) applied, number drops to 6% to 7%
Irritability present in 8-13% of children
When duration criteria (1 year) applied drops to 1.5-2.8%
All criteria yields a prevalence of about 1%, not common
Validity is not established, odd and cd similarity an issue, as is possibility over diagnosis.
DMDD considerations?
DMDD
Validity of this diagnosis not firmly established
Risk of over-diagnosis
Irritability is an important construct in child psychopathology!
DMDD highlights this.
Prevalence of Bipolar Disorder
Lifetime prevalence of bipolar disorder in children and adolescence is about 0.4% to 1.2%
Very rare prior to puberty Rates rises in adolescence
Presentation of bd in Dolescents?
Adolescents
About 60% of people with bipolar disorder experience their
first episode in adolescence (i.e., prior to 19-years-of-age)
Peak age of onset between 15 and 19
Most people report first episode was major depression
Mania in adolescence associated with psychosis, mixed episodes (mania/depression), extreme mood lability
Recovery course of bd
Recovery
8 consecutive weeks in which an individual does not meet the DSM criteria for manic episode, hypomanic episode, or depressive episode
40% to 100% of children and adolescents with bipolar disorder will recover within a year
60% to 70% of the children who recover will show recurrence within a year
Children with pre-pubertal onset bipolar disorder are two times less likely to recover than those with adolescent onset
Suggestion of homotypic continutioy of bd
Rate of mania in adults who had Bipolar I as a child are 13 to 44 times higher than population prevalences
Suggests homotypic continuity
Taken together then, the evidence suggests a chronic course
Recurrence quickly is likely
Clinical Correlates: Comorbidity of BD with
Adhd, disruptive Behaviour disorders like CD
ADHD
60% to 90% of children, 30% of adolescents with bipolar meet
criteria for ADHD
Note similarity in symptoms
This is a challenging and critical differential diagnosis
Possible that stimulant medications may exacerbate bipolar symptoms
Disruptive behavior disorders
20% of children with bipolar disorder meet criteria for conduct
disorder
Again, note overlap in symptoms
Conduct symptoms may be a consequence of bipolar presentation
Risk-taking activities associated with mania
Remember no inhibit actions in manic episodes.
Clinical Correlates: Social Functioning of BD
Marked social impairment, interpsonal skills issues.
Peers
Poor social skills
Frequently teased and victimized by peers
Few friends, instability of trust?
Families
Poor relationships with siblings
Frequent hostility and conflict with parents
Hard for child too!
Etiology and Maintenance of BD
Environmental factors likely play a role
Diathesis-stress model
Genetic risk and environmental stressor
Problematic family interactions
Hostility, conflict
Contributes to expression of bipolar symptoms
As research in genes shows?
Very little work done on this topic
Work with adults suggests that bipolar is highly heritable
If one or both parents have bipolar, chances are 5 x greater that child will develop bipolar or another mood disorder (e.g., depression)
However, twin studies suggest that variability is not entirely due to genetics
If one identical twin has bipolar disorder, 65% chance that the other twin will have it as well
Genetics appear to play a bigger role in early onset cases
Multiple gene problem (again)
Medications most often used with bd
Mood stabilizer lithium: approved by fda but
Or antipsychotic or
Combination
Mood Stabilizers: lithium for bd considerations?
Common treatment for adult bipolar disorder
Approved for use in children aged 12 and older
Serious side effects Toxicity
Difference between an effective dose of lithium and a toxic dose is very small
Renal and thyroid problems Weight gain
Compliance with instructions VERY important
Have to visit physician regularly to monitor side effects
Need to take drug in appropriate dose
Open-label trials have also shown that lithium is
Open-label trials have also shown that lithium is effective for treating mania in adolescents, not blind to condition!
One RCT demonstrated lithium was efficacious at reducing bipolar symptoms, compared to placebo, in adolescents
A second did not demonstrate a positive effect of lithium, relative to placebo
Atypical antipsychotics used for bd?
Wide-ranging class of antipsychotics
Some evidence from RCTs that these are effective in
Two of these have been approved for treating mania in youth aged 10 and older
Practice recommendations for using medication to treat bipolar disorder in children and adolescents?
Start with monotherapy with either a mood stabilizer or an
atypical antipsychotic
For patients who do not fully respond, add a second mood stabilizer or atypical antipsychotic (augmentation)
If no response, change primary agent
Again, may need to augment
For youth who do not respond to two medications, recommendation is to add a third
Note that limited data is available for combination therapy
For patients presenting with psychosis, start with a combination of a mood stabilizer and an atypical antipsychotic
SSRIs for BD
May exacerbate symptoms of mania
Note that many people will present with a major depressive episode at the outset of bipolar disorder
Have to monitor children and adolescents receiving SSRIs for a first depressive episode carefully because of this
Psychosocial Treatments for bd considerations?
Medication is first line treatment, unlike anx!
Family Education:
Help Understanding disorder and symptoms
Help Reducing conflict in the family
Help Medication management
Poor compliance to medication regimes is a major source of
relapse
Medications can be toxic
Important for family to be educated about the medications
Evidence for Psychosocial Treatment
Two RCTs have shown support for two family treatments
(1) Multifamily Psychoeducational Psychotherapy (Fristad et al., 2009)
(2) Family-focused therapy (Miklowitz et al., 2014)
Education, communication, problem-solving skills
Child- and Family-Focused CBT for BD
RAINBOW
Routine
Establish a predictable routine that will reduce tantrums, negativity, conflict
Affect regulation
Parents taught behavior management techniques Children taught to monitor and recognize moods
Icandoit!
Increase childrens’ and parents’ beliefs that they can manage bipolar symptoms
No negative thoughts
Retraining cognitive distortions associated with depression
Be a good friend and balanced lifestyle
Taught skills necessary to be a good friend and given opportunities to practice
Help parents learn to develop a balanced lifestyle
Oh, how can we solve this problem?
Help parents and children learn to problem-solve together
Ways to get support
Help parents learn how to seek help, as well as advocate for their child at school
Pre treatment post
Overall functioning went up.
Booster sessions helped maintenance maintained.
Limitations,
Treatment shows promise but did not have a control group.
Time, age confound,
Rather were also NOT blind. Needs an rct which has been done!
Evidence cbt was effective.
Below cutoff
Similar to parent reported depression
Adjunc to meds, promising.
Parent report for mania
More reliable
