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Pediatric Bipolar Disorder

Pediatric Bipolar Disorder. Mani N Pavuluri, MD, PhD Berger Colbeth Chair in Child Psychiatry Pediatric Brain Research and Intervention Center University of Illinois at Chicago @ copy righted. Overview of the presentation. How does it look? Measurement

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Pediatric Bipolar Disorder

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  1. Pediatric Bipolar Disorder Mani N Pavuluri, MD, PhD Berger Colbeth Chair in Child Psychiatry Pediatric Brain Research and Intervention Center University of Illinois at Chicago @ copy righted

  2. Overview of the presentation • How does it look? • Measurement • How to differentiate from ADHD • Prevalence • Onset • Follow up • Assessment: Big picture Pavuluri, 2012

  3. Pavuluri, 2012

  4. What is a Pediatric Bipolar Disorder? Central feature: Elevated, expansive mood or Irritable mood Pavuluri, 2012

  5. Excited Giggly Silly Giddy constantly on the go laughing fits joking and feels invincible “ overwhelming” “ like wanting to jump on the bed” Equivalent description in a child Mood • Constantly irritable • Aggressive • throwing pot plants • slamming doors • hard to transition • Acidic • Abrasive • hostile in words • Kicking • screaming • intense & inconsolable • out of proportion to the psychosocial stresses around them Pavuluri, 2012

  6. Feeling good about myself 1) Generous gave money to the school’s mission collection 2) Friendly to everyone 3) Share my lunch with my friends getting up every morning at the regular time not tired I eat breakfast, lunch and dinner Pavuluri, 2012

  7. Pavuluri, 2012

  8. Timeline • Ultra Rapid Cycling: Complex Cycling • “Mini cycles within a big cycle” • Frequency: most days in a week • Intensity: severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains • Number: three or four times a day • Duration: four or more hours a day Pavuluri, 2012

  9. Specific to PBD Irritability 77-98% Rapid Cycling 46-87% ComorbidADHD 75-98% Mixed Mania 20-84% Chronicity 4229 months; 84% Pavuluri, 2012

  10. Normal Mood Spectrum: Elevated Mood Depressed Mood Time Pavuluri, 2012

  11. Major Depressive Disorder Mood Spectrum: Elevated Mood Normal Depressed Mood Time Pavuluri, 2012

  12. Mania Mood Spectrum: Elevated Mood Normal Major Depressive Disorder Depressed Mood Time Pavuluri, 2012

  13. Dysthymia Mood Spectrum: Elevated Mood Mania Normal Major Depressive Disorder Depressed Mood Time Pavuluri, 2012

  14. Hypomania Mood Spectrum: Elevated Mood Mania Normal Major Depressive Disorder Depressed Mood Dysthymia Time Pavuluri, 2012

  15. Bipolar Disorder Mood Spectrum: Elevated Mood Mania Hypomania Normal Major Depressive Disorder Depressed Mood Dysthymia Time Pavuluri, 2012

  16. Pediatric Bipolar Disorder Mood Spectrum: Elevated Mood Depressed Mood Time Pavuluri, 2012

  17. Mood Spectrum Mania PBD Elevated Mood Hypomania Normal Major Depressive Disorder Depressed Mood Dysthymia Bipolar Time Pavuluri, 2012

  18. Distribution of Bipolar Subjects Pavuluri, 2005

  19. BP-NOS at Intake – Convert to BP-I Mania Hypomania BP-NOS Euthymia Dep-NOS Major Depression Birmaher et al, AACAP, 2003 Pavuluri, 2012

  20. BP-II at Intake – Convert to BP-I Mania Hypomania BP-NOS Euthymia Dep-NOS Major Depression Birmaher et al, AACAP, 2003 Pavuluri, 2012

  21. “Diagnostic fashion runs in cycles!” Pavuluri, 2012

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  23. The following questions concern your child’s mood and behavior in the past month. Please place a check mark or an ‘x’ in a box for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. For example, check ‘never' if the behavior is not causing trouble. 1. Have periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling "on top of the world" 2. Feel irritable, cranky, or mad for hours or days at a time 3. Think that he or she can be anything or do anything (e.g., leader, best basketball player, rap singer, millionaire, princess) beyond what is usual for that age 4. Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble Never Sometimes Often Very Often /Rarely 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 Child Mania Rating Scale, Parent Version Pavuluri et al, aacap 2004 Pavuluri, 2012

  24. How to use it? • Have the parent focus on the child’s behavior in the past month. • “Never/Rarely” and “Sometimes” = behavior that is causing minimal or no difficulty • “Often” and “Very Often” = behavior that is causing trouble. • The child’s score is the sum of all item scores. Pavuluri, 2012

  25. Interpreting the results • A cut off score of 15 screens for the manic spectrum • A cut off score of 20 is highly specific for mania Pavuluri, 2012

  26. Reliability • Internal Consistency: 0.96 • Test Re-test Reliability: 0.96 Pavuluri, 2005

  27. CMRS-P Total Score Pavuluri, 2012

  28. PROS DSM IV basis Singular item focus Integrated functionality Age specific items Timing of symptoms Language Linked examples Why should I choose it? Pavuluri, 2012

  29. Diagnosis Precipitating Factor Outcome Family Friends Teacher Interpersonal Relationships Functioning Other… Why now? DD 1. (w/3 main symptoms) 2. 3. Home School Background Maturity Work Psychopathology Mother - Dev. Hx Personality Father Personal Resources (knowledge, skills, attitude, motivation) M-F (partnership) Child Siblings Family Attachment/Goodness of Fit Parenting Capacity Context Temperament and Personality Style Strengths Coping Mechanisms/Defenses - Support - stresses *Central Issue *EMIC vs. ITIC *Find the Person/s Structural (roles, relationships) C – C, M – C, F – C, etc. Strategic (problem solving, family beliefs) Systemic (theme) Formulation

  30. Mania vs. ADHD • ADHD • Primarily a disorder of attention, not mood • Onset before age 7 • Persistent, not episodic • Problem of Comorbidity Pavuluri, 2012

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  35. Study n Mean Age ADHD West et al., 1995 14 15.1 57% Wozniack et al., 1995 43 7.9 98% Faraone et al., 1997 68 6.1 93% Geller et al., 2000 60 11 98% / 72% Kafantaris et al., 1998 48 16 29% Kowatch et al., 2000 42 11 71% DelBello et al., 2001 34 15.7 65% Comorbidity of ADHD In Pediatric Bipolars Pavuluri, 2005

  36. Distinguishing Between Bipolar and ADHD Geller & Zimerman 2002.

  37. Prepubertal & Early Adolescent Onset Bipolar Disorder (PEA - BD) Juvenile BD Atypical BD Childhood Onset BD Adolescent Onset Bipolar Disorder (AO-BD) Pediatric Bipolar Disorder  12 yr. > 12 yr. Pavuluri, 2012

  38. Pavuluri, 2012

  39. Prevalence of BP in Adolescents Diagnostic interviews with 1709high school students, ages 14-18 years Findings 1.0% prevalence of BP (primarily BP II and cyclothymia) 5.7% prevalence of BP NOS Lewinsohn 1995

  40. Age of Symptom OnsetNDMDA Survey N=500 Lag to Diagnosis = 8 Years 30% 28% 20% 59% 16% 15% 14% 10% 12% 9% 5% < 5 5-9 10-14 15-19 20-24 25-29 30+ Years of Age Pavuluri, 2012 Lish 1994

  41. Recovery and Relapse Pavuluri, 2012

  42. Symptom List FIND Brain Disorder Invisible Fist Signature Developing the language Pavuluri, 2012

  43. R A I N B O W R A I N B O W OUTINE FFECT CONTROL CAN DO IT O NEGATIVE THOUGHTS; LIVE IN THE NOW E A GOOD FRIEND: BALANCED LIFESTYLE H! HOW CAN WE SOLVE IT?! AYS TO GET SUPPORT Pavuluri, 2012

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