Comprehensive Quick Reference Handout on Pediatric Bipolar Disorder By Jessica Tomasula

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1 Comprehensive Quick Reference Handout on Pediatric Bipolar Disorder By Jessica Tomasula Official Name Bipolar Disorder; also referred to as Manic Depression Definitions (DSM-IV-TR, 2000) Bipolar I Disorder - characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes Separate criteria sets: Single Manic Episode Most Recent Episode Hypomanic Most Recent Episode Manic Most Recent Episode Mixed Most Recent Episode Depressed Most Recent Episode Unspecified Bipolar II Disorder characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode Cyclothymia characterized by by at least 2 years of numerous periods of hypomanic symptoms that do not meet criteria for a Manic Episode and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode Bipolar Disorder Not Otherwise Specified included for coding disorders with bipolar features that do not meet criteria for any of the specific Bipolar Disorders (or bipolar symptoms about which there is inadequate or contradictory information) Diagnostic Criteria (DSM-IV-TR, 2000) All types of episodes cannot be due to direct physiological effects of a substance or a general medical condition. The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Also, symptoms may be indicated by a subjective report or from the observation of others (e.g., parents). Major Depressive Episode - Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one symptom is either depressed mood or loss of interest or pleasure: (1) depressed or irritable mood, most of the day, nearly every day (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (3) failure to make expected weight gains 1

2 (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt nearly every day (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (9) recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Manic Episode - distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week - 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 (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (6) increase in goal-directed activity or psychomotor agitation (7) excessive involvement in pleasurable activities that have a high potential for painful consequences Mixed Episode - criteria are met both for a Manic Episode and for a Major Depressive Episode nearly every day during at least a 1-week period Hypomanic Episode - distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood - during the period of mood disturbance, three (or more) of the symptoms listed directly above have persisted (four if the mood is only irritable) and have been present to a significant degree Comorbidities (Leibenluft & Rich, 2008) - approximately 70% of Bipolar Disorder (BD) youths present with Attention- Deficit/Hyperactivity Disorder - high rates of comorbid anxiety, ranging from 45% to 78% - approximately 46% to over 80% of BD youths present with Oppositional Defiance Disorder - approximately 12% to 41% of BD youths present with Conduct Disorder 2

3 Prevalence Rates Due to the amount of diagnostic orphans (because of subsyndromal symptoms or confusion surrounding adult diagnostic criteria application to the pediatric population), disputes on the existence of the disorder in youths, high rates of comorbid disorders with overlapping symptoms, and the lack of longitudinal studies on pediatric populations, prevalence rates are most likely underestimates of the disorder (Birmaher, 2007). - up to 6% in outpatient clinical settings (Leibenluft & Rich, 2008) - up to 40% in U.S. community hospitals (Leibenluft & Rich, 2008) Possible Causes (Pavuluri, Birmaher, & Naylor, 2005) Genetics Heritability has not been established due to lack of studies in the pediatric population but two types of studies can be incorporated into the genetics discussion: 1. Familial Studies - compared to children of parents without psychiatric illness, offspring of parents with BD are: (1) at 2.7 times higher risk of developing any psychiatric disorder (2) at 4 times higher risk of developing a mood disorder (3) report significantly more psychopathology (60% vs. 25%) - earlier onset of BD is associated with greater familial loading of BD 2. Molecular Genetics Studies - research is focused on allelic associations but, at this time, there are no reliable indicators of genetic risk yet Psychosocial Risk Factors More than half of Parental and self-reports from BP youth indicated: - poor social skills (e.g., had no friends, were teased by others) - poor relationships with siblings - conflictual relationships with their parents which was indicated by: - high degree of hostility - minimal problem-solving skills - low warmth in maternal-child relationships - poor agreement between parents on child-rearing practices Prognosis (Birmaher et al., 2006) Recovery is defined as 8 consecutive weeks without meeting DSM-IV criteria for mania, hypomania, depression, or mixed affective state. - 68% of BP youth (diagnosed with all types: BP-I, BP-II, and BP-NOS) recovered from their most recent episode in 19 months, on average 3

4 - BP youth diagnosed with BP-NOS were 2 times less likely to recover than those youth diagnosed with BP-I and BP-II - recovery rates are significantly lower for the child-onset group (youth diagnosed with BP prior to age 12) who are under age 12 than for those older than age 12 in the child-onset group and for the adolescent-onset group (youth diagnosed with BP at 12 years or older) Recurrence is defined as two consecutive weeks of DSM-IV criteria for depression and one week of DSM-IV criteria for mania/hypomania. - 56% of BP youth (diagnosed with all types: BP-I, BP-II, and BP-NOS) had at least one recurrence roughly 15 months after recovery from their most recent episode - BP-II youth had higher rates of recurrences than BP-NOS youth - BP-NOS youth had significantly longer time to recurrence than those with BP-I and BP-II In general, children and adolescents diagnosed with any bipolar spectrum disorder have a worse prognosis when/if: - early-onset - BP-NOS - long duration - low SES - presence of psychosis - experience frequent changes in symptom status and polarity Treatment Interventions (Leibenluft & Rich, 2008) Psychopharmalogical Treatment 1. lithium or anticonvulsants/mood stabilizers Examples: valproate, divalproex, carbamazepine, topiramate, and lamotrigine 2. atypical antipsychotics Examples: olanzapine, quetiapine, risperidone, and aripiprazole - choice of medication: - should be based on the presence or absence of psychosis - with psychosis: combination of a mood stabilizer and atypical antipsychotic - without psychosis: mood stabilizer or atypical antipsychotic - considerations when selecting a medication: - BP youth s mood state - clinical variables (e.g., rapid cycling, comorbidities) - risk of side effects - prior response to medication - preferences of the patient and his/her family 4

5 - duration of treatment: - 6- to 8-week trial is required before a change or addition - chronic medication treatment may be required to prevent relapse in BP youths - noncompliance with lithium treatment was associated with a 90% relapse rate in adolescents Psychotherapeutic Treatment - psychotherapeutic interventions with BD youths should aim to improve: (1) the child and parent s understanding of the causes, symptoms, and treatment options of BD (psychoeducation) (2) symptom management (3) coping skills (4) social and family relationships (5) academic and occupational functioning (6) the prevention of relapse - possible treatment programs: (1) include child- and family focused cognitive-behavioral therapy (CFFCBT) - emphasizes individual psychotherapy with children and parents, parent training and support, and family therapy (2) multifamily psychoeducation groups (MFPG) - uses child and parent group therapy (3) family-focused psychoeducational therapy (FFT) - adopts a family-therapy format Annotated Bibliography Faraone, S., Glatt, S. & Tsuang, M. (2003). The Genetics of Pediatric-Onset Bipolar Disorder. Biological Psychiatry, 53, For more information on the genetics of pediatric BD, Faraone, Glatt, and Tsuang provide an in-depth description and discussion. Geller, B., Tillman, R., Bolhofner, K., & Zimmerman, B. (2008). Child Bipolar I Disorder: Prospective Continuity with Adult Bipolar I Disorder; Characteristics of Second and Third Episodes; Predictors of 8-Year Outcome. Archives of General Psychiatry, 65, This article supports the notion of continuity for child and adult Bipolar Disorder 1 and discusses the similarities between substance use disorder rates for grown-up BP youth and adults diagnosed with BD I. 5

6 Geller, B., Tillman, R., Craney, J., & Bolhofner, K. (2004). Four-Year Prospective Outcome and Natural History of Mania in Children with a Prepubertal and Early Adolescent Bipolar Disorder Phenotype. Archives of General Psychiatry, 61, This article discusses the controversy surrounding unspecified mania in diagnosing BD in children. Irritability is the common descriptor for mania which this article suggests is too general and should specify the presence or absence of grandiosity or elation. Leibenluft, E. (2008). Pediatric Bipolar Disorder Comes of Age. Archives of General Psychiatry, 65, Leibenluft gives an astute commentary on the field of pediatric bipolar disorder and implications for future research. Pavuluri, M., Birmaher, B., & Naylor, M. (2005). Pediatric Bipolar Disorder: A Review of the Past 10 Years. Journal of the American Academy of Child & Adolescent Psychiatry, 44, Pavuluri, Birmaher, and Naylor provide a comprehensive, but concise, review of the past 10 years of research in the field of pediatric bipolar disorder. Resources This website was created by the Child and Adolescent Bipolar Foundation (CABF) and provides a public health perspective. Membership indicates two groups for families and professionals. For families, informative podcasts, forums, support groups, an online directory for professional services, and a learning center are available. For professionals, links to current research, clinical trials, and news pertaining to pediatric BD are also available through the website. This website s strength draws from the wide variety of contributors. Authors, educators, psychologists, doctors, BD youth, and parents of BD youth provide information to the website. Age-appropriate information and activities are provided for BD youth, such as mood charts, a talent showcase, and a forum for questions and advice for kids authored by kids. The well-known authors, Dr. Demitri Papolos and Mrs. Janice Papolos, provide information geared toward parents and educators. Access to a model Individualized Education Plan (IEP) for BP youth and the Juvenile Bipolar Research Foundation s Child Bipolar Questionnaire (CBQ) are just a few resources that are provided for those interested in this website. 6

7 References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4 th ed., Text Rev.). Washington, DC: American Psychiatric Association. Birmaher, B. (2007). Longitudinal Course of Pediatric Bipolar Disorder. American Journal of Psychiatry, 164, Birmaher, B., Axelson, D., Strober, M., Gill, M.K., Valeri, S., Chiapetta, L., et al. (2006). Clinical Course of Children and Adolescents with Bipolar Spectrum Disorders. Archives of General Pscyhiatry, 63, Leibenluft, E., & Rich, B. (2008). Pediatric Bipolar Disorder. Annual Review of Clinical Psychology, 4, Pavuluri, M., Birmaher, B., & Naylor, M. (2005). Pediatric Bipolar Disorder: A Review of the Past 10 Years. Journal of the American Academy of Child & Adolescent Psychiatry, 44,