Early Onset Bipolar Disorder and the Pediatric Behavior Rating Scale™ (PBRS™) Children’s Mental Health 5,000,000 80% (America’s youth with mental health needs who fail (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.) 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? 1980’S ADHD 1990’S DEPRESSION 2000’S EOBPD RATES OF DIAGNOSIS 4,000% 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 BPD IN CHILDREN EOBPD is not in DSM IV. EOPBD looks like other disorders. EOBPD has high rates of comorbidity. PROBLEM 1: EOBPD isn’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 BPD EOBPD Adult BPD Mixed Mood Episodes are typical Discrete Mood Episodes are typical Ultra-Rapid Cycling is common Longer cycles Symptomatic most of the Periods of no symptoms time between cycles (Birmaher et al, 2008; Danielyan et al, 2007; Kowatch et al, 2005) PROBLEM 1: EOBPD isn’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 other disorders Disruptive Behavior Disorders ADHD 60-93% meet diagnostic criteria for ADHD (Biederman, et. al, 2003) Mania versus hyperactivity More anger, irritability, aggressive temper tantrums Presence of elation, grandiosity, racing thoughts/flight of ideas, decreased need for sleep, hypersexuality PROBLEM 2: EOBPD mimics other disorders ODD 77-88% have ODD (Wozniak et. al, 1995) More intense irritability and severe emotional meltdowns CD 42-69% have CD (Biederman, et. al, 2003) Violent and aggressive behavior lacks intent, planning, and premeditation PROBLEM 2: EOBPD mimics other disorders Anxiety Disorders 56-75% have anxiety disorder (Wozniak et. al, 1995; Masi, et. al, 2001) Tourette’s Disorder, Schizophrenia, Autism Spectrum Disorder WHAT WE KNOW: SYMPTOMS ASSOCIATED with EOBPD 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 Symptoms Very Often (90%-97%) Often (60%-80%) Sometimes (20%-35%) Infrequent (Less than 10%) Irritability Anxiety Hypersexuality Homicidal Ideas Mood Lability Racing Thoughts Psychosis Suicidal Acts Sleep Disorder Pressured Spch Suicidal Ideation Anger; Rage Euphoria, Grandiosity Self-harm Parenting a bipolar child p. 39. Impulsivity Agitation Aggression From: Faedda & Austin, 2006 Psychosis Tillman et al (2008), 257 EOBPD participants, ages 6-16, funded by NIMH Psychosis 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 DEVIANCE VOLUNTARY - 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 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 AGGRESSION IS BEING 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 approaches serve mainly to provoke and escalate. GOALS OF INTERVENTIONS Stabilize Reduce Symptoms Opposition Defiance Irritability Aggression Improve Functioning (academic, social) TWO WAYS TO ACHIEVE THESE GOALS Medications (to make the child “available”) Psychotherapies (coping & managing) General Rule for Interventions Behavioral approaches tend to focus on consequences. There are two problems with this… TWO PROBLEMS 1. By definition, children and adolescents with deficits in impulse control and selfregulation do not consider consequences before they act. 2. Behavioral consequences (especially if they are aversive) introduce provocation, confrontation…and escalation. INTERVENTION TARGETS CHILD medications sleep self-regulation PARENTS psychoeducation medication compliance ENVIRONMENT (control the pace) home school DRUG TREATMENTS EOBPD FOUR MAJOR CLASSES of MOOD STABILIZERS Lithium Antiepileptics (Mood Stabilizers) Antidepressants Antipsychotics CHARACTERISTIC DIAGNOSIS AGGRESSION TYPE MEDI Impulse Control ADHD Accidents/ Injuries STIMU S ANTIPS MOOD S Affective Instability Bipolar, Borderline, IED Reactive, affective attack ANTISP MOOD S S Irritability Depression, Dysthymia Acting Out, Suicide S OT ANTIDEP Anxiety/Low Frustration Tolerance Anxiety, PTSD, ASD Reactive striking out OT ANTIDPE S TE CLON Impaired Judgment Substance Abuse, Psychosis Inadvertent Aggression ANTIPS Stimulation Seeking CD, ODD Predatory Aggression MOOD S NONDRUG INTERVENTIONS THERE ARE 550 PSYCHOTHERAPIES (NONMEDICAL INTERVENTIONS) FOR TREATING CHILDREN AND ADULTS BEYOND BEHAVIORISM Parent Management Training Cognitive Behavioral Therapy Dialectal Behavior Therapy Choice Theory Problem-Solving Skills Health Promoting Environments RACT STIC DIAGNOSIS AGGRESSION TYPE PSYCHOTHERAPY pulse ntrol ADHD Accidents/ Injuries CBT; DBT PROBLEM-SOLVING Parent Training ctive ability Bipolar, Borderline, IED Reactive, affective attack CBT; DBT PROBLEM-SOLVING Parent Training ability Depression, Dysthymia Acting Out, Suicide CBT ty/Low ration rance Anxiety, PTSD, ASD Reactive striking out CBT; DBT PROBLEM-SOLVING Parent Training aired ment Substance Abuse, Psychosis Inadvertent Aggression Cognitive Enhancement Therapy ulation eking CD, ODD Predatory Aggression Parent Training PSYCHOEDUCATION •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 Three-Tier Model of Behavioral Intervention/Support Tier III: Intensive, Individual Interventions 1 - 5% 1-5% 10-15% Tier II: Targeted Group Interventions 80 - 90% Tier I: Universal Interventions/Supports 80 10- -90% 15% Tier 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 ASSESSMENT Modified from: Santilli, Nancy, Dodson, W.E., Walton, A.V. (1991) INTERVENTIONS FOR SIMPLE Monopharmacy Mildly intrusive therapy individual therapy group therapy parent training Regular classroom placement Favorable RTI INTERVENTIONS FOR COMPROMISED Polypharmacy (aggression, irritability, comorbidity) Intensive child and family therapies individual therapy group therapy family therapy/parent training May require Spec. Ed. (EH, SED, OHI) Variable RTI INTERVENTIONS FOR COMPLEX Polypharmacy Intensive Interventions individual therapy intensive parent training alternative educational placements Acute hospitalization Self-contained to RTC Law Enforcement Very poor prognosis Predictors of Outcome Worse outcomes are associated with: ◦ Younger age of onset ◦ Long duration of mood symptoms ◦ Low socioeconomic status ◦ Lifetime psychosis (Birmaher et al, 2006) PEDIATRIC BEHAVIOR RATING SCALE WHY A NEW RATING SCALE? • Existing scales came out normal • Item analysis told us why • The need for differential diagnosis OTHER 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]) • PURPOSE • 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 FEATURES Sufficient items to identify core features of EOBPD, such as: Mood swings Irritability Grandiosity Easily provoked Explosive outbursts • Syndromal differentiation (e.g., ADHD vs. EOBPD) • Identifies areas of concern rather than providing diagnoses • PBRS APPLICATIONS • • • Clinical Distinguish between EOBPD and its mimics Symptom identification and profile analysis Areas of concern Educational Clarify diagnosis using IDEA More complete symptom profile (intervention) Research Defining the disorder in children Handling comorbidity Intervention efficacy COMPONENTS • • Parent Form PBRS Parent Item Booklet (102 items) PBRS Parent Response Booklet PBRS Parent Score Summary/Profile Form Teacher Form PBRS Teacher Item Booklet (95 items) PBRS Teacher Response Booklet PBRS Teacher Score Summary/Profile Form SCORES 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 ITEMS These 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 SCALES Eight 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) Scale Bizarre beliefs Auditory hallucinations Delusions Self-harm behaviors Excessive fears Irritability (IRR) Scale Emotional dysregulation Behavioral/emotional outbursts Demandingness Grandiosity (GRAND) Scale Elevated sense of self and mood Not taking responsibility for actions Exaggerating Stealing Hyperactivity/Impulsivity (HYPER) Scale Classic description of overactivity and impulsivity Difficulty sitting still Acts without thinking about consequences Always on the go Aggression (AGG) Scale Aggression targeting other people, animals, or objects Inattention (INATT) Scale Traditional scale for inattention and distractibility Difficulty focusing Difficulty sustaining attention Affect (AFF) Scale Mood disturbances Suicidal ideation Cognitive distortions Social Interactions (SOC) Scale Ability to interact with peers Ability to make friends Relating to others Engaging in social interactions TOTAL 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) • POPULATION • Normative sample Parents n = 541 Teachers n = 610 • Clinical sample (clinical groups included BPD, ADHD, CD, ODD, and autism spectrum disorders [ASD]) Parents n = 224 Teachers n = 194 RELIABILITY Internal 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 • RELIABILITY • • Parent-teacher interrater reliability Coefficient α = .77 to .86 Coefficient α for TBX = .88 Parent-parent interrater reliability Coefficient α = .67 to .86 Coefficient α for TBX = .85 VALIDITY Convergent 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 VALIDITY Convergent 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) VALIDITY Clinical 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).