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The Bipolar Child Miriam E. Halpern, MD 10/27/2009 What is it? • Bipolar Disorder • condition characterized by periods of high mood and low moods • Studies show that 1.5% of the population will have at least one hypomanic or manic episode in their adult lives Hypomanic • When a person is hypomanic • Feels unusually good and competent, or simply irritable • Thoughts race, speech is often pressured • Distractible and flit from topic to topic • Sleep seems less necessary • Drive for pleasurable activities with uncharacteristic disregard for risk Depression • the other pole of Bipolar Disorder • may vary in severity from a relative decrease in enjoyment and interest, to a painful lack of pleasure in anything • disturbances in concentration, sleep, appetite and energy as well as paralysis of decision making • guilt and low self-esteem are common Definition • The thought that a child can be too happy, too cocky, too exuberant, is an anathema to many people. But when we're talking about childhood bipolar I disorder, we are talking about children who are so silly and giddy that families are asked not to bring them to church; who are so cocky, expansive, and grandiose that they go to the principal's office and tell them to fire teachers they don't like; bright kids who fail classes because they are fully convinced they know it all and don't study," . Recent Changes • Brady Case and Anthony Russo, researchers at New York University, reported that the number of children under 18 who had been diagnosed with bipolar disorder increased fourfold between 1999 and 2000 (Groopman, 2007). Another report shows up to a 600% increase in children under the age of 13 diagnosed with bipolar disorder in the past 10 years (Groopman, 2007) New understanding • The authors presented a groundbreaking premise that not only do children and adolescents actually develop bipolar disorder in childhood, but much more commonly than anyone had conceived. They also strongly supported the hypothesis that the symptoms of bipolar disorder in children are different than those seen in adults. Renewed concept • study contributes to a growing awareness that serious mental illnesses do not emerge de novo when individuals reach adulthood but rather reflect early developmental processes. New awareness • it is important that physicians are aware that mania in children does exist and that they know, at least at this time, that outcomes are poor, so that they can appropriately counsel families. Arch Gen Psychiatry. 2008;162:1125-3113 In addition • Childhood sexual and physical abuse are associated with mental health problems and psychiatric disorders in adulthood (MacMillian et al. 2001; Molnar et al. 2001). Among adults with SMI, childhood abuse is associated with greater psychiatric symptoms, including depression, psychosis, dissociation, and posttraumatic stress (Craine et al. 1988; Malow et al. 2006 The Risk • A conservative estimate of an individual's risk of having full-blown bipolar disorder is 1 percent. Disorders in the bipolar spectrum may affect 4-6%. • When one parent has bipolar disorder, the risk to each child is l5-30%. • When both parents have bipolar disorder, the risk increases to 50-75%. • The risk in siblings and fraternal twins is 15-25%. • The risk in identical twins is approximately 70%. What????? • In every generation since World War II, there is a higher incidence and an earlier age of onset of bipolar disorder and depression. On average, children with bipolar disorder experience their first episode of illness 10 years earlier than their parents' generation did. The reason for this is unknown. Keep in mind • The family trees of many children who develop earlyonset bipolar disorder include individuals who suffered from substance abuse and/or mood disorders (often undiagnosed). Common Symptoms • • • • • • • • • • Separation anxiety Rages & explosive temper tantrums Marked irritability Oppositional behavior Frequent mood swing Distractibility Hyperactivity Impulsivity Restlessness/ fidgetiness Silliness, goofiness, giddiness Common Symptoms • • • • • • • • • • • Racing thoughts Aggressive behavior Grandiosity Carbohydrate cravings 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 • • • • • • • • Bed-wetting (especially in boys) Night terrors Rapid or pressured speech Obsessive, perseverative behaviors Excessive daydreaming Compulsive behavior Motor & vocal tics Learning disabilities (especially nonverbal) • Poor short-term memory Common Symptoms • • • • • • • • • • Lack of organization Fascination with gore or morbid topics Hyper-sexuality Manipulative behavior Bossiness Lying Suicidal thoughts Destruction of property Paranoia Hallucinations & delusions Less Common • Migraine headaches • Binging • Self-mutilating behaviors • Cruelty to animals Children, more than adults • experience faster mood swings, often cycling (changing from mania to depression) many times within a day • exhibit a "mixed" state that is a mix of mania and depression Children • with bipolar disorder are at risk for school failure, substance abuse, and suicide. • The lifetime mortality rate for bipolar disorder (from suicide) is higher than some childhood cancers. ADHD • Since hyperactivity can be seen in both bipolar disorder and ADHD, many children who are diagnosed with “severe ADHD” may actually have undiagnosed bipolar disorder. Academic issues • The disorder affects learning • • • • • • difficulties with sleep energy school attendance concentration executive function cognition Co-occurring Learning Disorders • Many of these children are bright or creative but they often have co-occurring learning disabilities. • Non verbal learning disorders • Autobiographical narrative issues Difficulties in • Paying attention • Remembering and recalling information • Thinking critically, categorizing, and organizing information • Employing problem-solving skills • Coordinating eye-hand movements Needs • • • • Consistent scheduling Planned and unplanned breaks Seating with few distractions Providing buffer space and model children Needs • Shortened assignments • Homework focusing on quality, not quantity • Prior notice of transitions or changes in routine • Minimizing surprises Needs • Scheduling the student’s most challenging tasks at a time of day when the child is best able to perform • allowing for medication-related tiredness, hunger, etc. Needs - continued • Reduce exposure to stressors • Help build coping skills • Structure and predictability Discipline • Experts recommend some praise for all children at least once every 5 minutes, or 12 positive comments for every negative statement. Suggestions • Focus on facts and solving problems (rather than blame). • Inform parents regularly about how the student is performing. • via a notebook that goes back and forth to school with the child, or a daily chart or e-mail that records successes, progress, difficulties, and mood information. More Suggestions • Provide opportunities for the student to move around during class. • Work on computers, or use manipulatives. • Encourage him/her to get involved in other interactive activities. Don’t forget • Children in a depressed state find it extremely hard to wake up in time for school. • They should not be penalized for tardiness that is biologically based. • Any talk of suicide must be taken seriously and reported to the child’s parents. “No tolerance” • Defiance and aggression are the most challenging moods to manage. • The best strategy: • • • • • Do not take it personally Keep your composure Do not get involved in power struggles. Remain a positive model. Prompt children who are rude to rephrase statements politely and try again. • Be firm and consistent. Remember • Try to ignore inappropriate, attention-getting behaviors as much as possible. • Use “bossiness” to everyone’s advantage by making the child a leader or teacher. Use Social Stories • Guidelines for writing your own social stories: • • • • Picture the goal Gather information Tailor the text Teach with the title • Additional Resources • www.thegraycenter.org/socialstories .cfm Think Education! • Build the child’s skills that lead to appropriate reactions and behavior, including emotion labeling, empathy, anger management, social rules, nonverbal communication and making amends Safe place • Students with bipolar disorder need an established “safe” person—an adult to go to when feeling overwhelmed—and a safe place. Accommodations • • • • modified time constraints altered or simpler instructions oral testing or the use of a scribe an altered environment (such as a room with few or no other students) • multiple-choice or matching rather than open-ended questions • tools such as a calculator or word bank • offering an alternative type of assignment to reduce the stress of testing Classification • An OHI classification clearly defines the child’s heightened levels of impulsivity, distractibility, sensory integration deficiencies, and poor decision-making skills as being due to this neurological disorder. Medications • On June 9, 2004, the task force of experts and stakeholders, established in 2003 by NAMI’s Policy Research Institute (NPRI), released a report addressing issues related to the use of psychotropic medications for children and adolescents. The Bad News • About 1 in 10 children in the U.S. suffers from a mental illness severe enough to cause impairment. Treatment Problems • • • • • Not as effective in children Inadequately studied Off label use Medical malpractice Informed consent Diagnostic Confusion • Diagnoses that mimic, mask, or co-occur with pediatric bipolar disorder include: • Attention-deficit hyperactivity disorder (ADHD)* • Depression • Oppositional-defiant disorder (ODD) • • • • • • • • Conduct disorder (CD) Pervasive developmental disorder (PDD) Generalized anxiety disorder (GAD) Panic disorder Obsessive-compulsive disorder (OCD) Tourette syndrome (TS) Seizure disorders Reactive attachment disorder (RAD) The Dilemma • It is estimated that 85% of children with bipolar disorder also have ADHD and up to 22% of children with ADHD have bipolar disorder. Gold Standard • Lithium Carbonate • Eskalith, Lithobid • Lithium alters sodium transport in nerve and muscle cells and effects a shift toward intraneuronal metabolism of catecholamines • Excellent anti-manic agent • Not anti-depressant Target Symptoms • pressure of speech, motor hyperactivity, reduced need for sleep, flight of ideas, grandiosity, elation, poor judgment, aggressiveness, and possibly hostility The Other Side • Lithium toxicity is closely related to serum lithium levels, and can occur at doses close to therapeutic levels • FREQUENT BLOOD MONITORING • Diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination may be early signs of lithium intoxication Common Side Effects • • • • • Thirst Tremor Sleepiness Gastrointestinal upset Cognitive slowing Other Mood Stabilizers • Anti-epileptics • Anti-psychotics • Nicotine Anti-epileptic • Depakote (divalproex) • • • • Most studied Moderately effective in studies Blood monitoring Side effects include sedation, gastrointestinal effects, hepatic effects (especially young children) Depakote • No correlation with therapeutic range (sometimes have to push up high) • Hair loss or thinning • PCOS in females • Weight gain • Osteoporosis Tegretol, Trileptal • Not well studied in adolescents • Well tolerated • Effectiveness may not relate to drug levels • Some evidence of use for ADHD in Europe Other AEDs • • • • Keppra Neurontin Lamictal Topamax Anti-psychotics • Atypical neuroleptics • • • • • Risperdal (Risperidone) Zyprexa (Olanzepine) Abilify (Aripiprazole) Geodon (Ziprasidone) Seroquel (Quetiapine) Anti-psychotics • Essentially off label use in children under age 13 years • Long term side effects (metabolic syndrome) • Efficacy not well studied in children Nicotinic Receptor • Comorbid bipolar disorder in Tourette’s syndrome responds to the nicotinic receptor antagonist mecamylamine (Inversine) Omega Fatty Acids • recognized to have intracellular effects similar to lithium and valproate • well tolerated and improved the short-term course of illness in a preliminary study of adults with bipolar disorder Co-morbidity • • • • • • • ADHD Tic Disorders Depression Personality Disorder Self harming Mental Retardation Autism ADHD • Controversial usage of stimulants • Limited effectiveness over time of stimulants • Worsening of symptoms vs. delayed diagnosis Tic Disorders • Co-morbidity between TS and BD does not appear to be due to chance co-occurrence of the two disorders. • Family history, gene theories Depression • Agitated depression is more common in children and teens than in adults. Personality Disorder • Need a good developmental model for borderline personality disorder in children • Present classification system not helpful Self harming • When present, what medications are indicated? • Obsessive compulsive characteristic? • Social construct/ group activity Mental Retardation • According to the DSM-IV, all types of disorders are found in mentally retarded persons, with an incidence at least 3-4x higher than in the general population. Rutter, Graham, and Yule (1970), in their epidemiological study on the Isle of Wight, found psychiatric problems in 30% to 42% of retarded children and adolescents, as opposed to 7% of the children with normal intelligence levels. Autism and Familial Major Mood Disorder: Are They Related? Robert DeLong, M.D., D.S. • Medications that proved to be beneficial are the same as those used for mood disorder in the nonautistic population, atypical antipsychotics, and mood stabilizers (lithium or antiepileptic agents). This does not prove that autism and mood disorder are the same, but strongly suggests that their neurotransmitter and receptor characteristics must be similar. Conclusion • Childhood Bipolar Disorder is real and in a school near you • Medications are not yet the answer • CBD has an effect on academic performance of the child References • The Bipolar Child, by Papolos and Papolos • www.bipolarchild.com/ • bipolar.about.com/cs/ • www.nimh.nih.gov/health • www.nami.org