Bipolar Disorder in Children and Adolescents

1. Bipolar Disorder in Children and Adolescents James H. Johnson, PhD, University of Florida *Some material for this presentation provided by NIMH Publication No. 00-4778 (2003)

2. Bipolar Disorder: General Introduction • Bipolar disorder is a biologically based disorder that causes unusual shifts in a person's mood, energy, and impairs their ability to function. • It causes dramatic mood swings - from overly "high" and/or irritable mood to sad and hopeless mood, and then back again. • In older adolescents and adults there are often periods of normal mood in between. • These mood related changes are accompanied by severe changes in energy and behavior. • The periods of highs and lows are called episodes of mania and depression.

3. Symptoms of Bipolar Disorder: Mania or Manic Episode • Increased energy, activity, and restlessness • Excessively "high,“ euphoric mood • Extreme irritability • Racing thoughts, talking very fast, jumping from one idea to another • Distractibility, inability to concentrate • Decreased need for sleep • Unrealistic beliefs in one's abilities and powers

4. Symptoms of Bipolar Disorder: Manic Episode • Poor judgment • Spending sprees • Increased sexual drive • Abuse of drugs, particularly cocaine, alcohol, and sleeping medications • Provocative, intrusive, or aggressive behavior • Denial that anything is wrong • A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present.

5. Symptoms of Bipolar Disorder: Hypomania • A mild to moderate level of mania is called “hypomania”. • Hypomania may feel good to the person who experiences it and may be associated with good functioning and enhanced productivity. • Without proper treatment, however, hypomania can become more severe in some people or can switch into depression.

6. Symptoms of Bipolar Disorder:Depressive Episode • Sad, anxious, or empty mood • Feelings of hopelessness or pessimism • Feelings of guilt, worthlessness, or helplessness • Loss of interest or pleasure in activities once enjoyed, including sex • Decreased energy, a feeling of fatigue or of being "slowed down" • Difficulty concentrating, remembering, making decisions • Restlessness or irritability

7. Symptoms of Bipolar Disorder:Depressive Episode • Sleeping too much, or can't sleep • Change in appetite and/or unintended weight loss or gain • Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury • Thoughts of death or suicide, or suicide attempts • A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

8. Mood Swings & Symptoms of Psychosis • Severe episodes of mania or depression can include symptoms of psychosis (or psychotic symptoms). • Common psychotic symptoms are hallucinations and delusions. • Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time (are mood congruent. • People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia.

9. Bipolar Disorder and Suicide • Bipolar disorder can result in an increased risk of suicide. • This increased risk seems to be higher earlier in the course of the illness. • Recognizing bipolar disorder early and learning how best to manage it may decrease the suicidal risk.

10. Suggestions of Suicidal Risk • talking about feeling suicidal or wanting to die • feeling hopeless - nothing will ever change or get better • feeling helpless - nothing I do makes any difference • feeling like a burden to family and friends • alcohol or drug abuse • putting affairs in order or giving away possessions to prepare for one's death • suicide note • putting oneself in situations where there is a danger of being killed

11. Bipolar Spectrum Disorders • It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. • At one end is severe depression, above which is moderate depression and then mild low mood. • This mild low mood is often short-lived (it is termed "dysthymia" when it is chronic. • Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

12. BipolarSpectrum Disorders

13. Bipolar Disorder: Mixed States • Symptoms of mania and depression may occur together in what is called a mixed state. • Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. • This may be accompanied by a sad, hopeless mood while feeling extremely energized.

14. Diagnosis of Bipolar Disorder Subtypes • The classic form of the disorder involves recurrent episodes of both mania and depression(Bipolar I). • In some cases the person never develops severe mania, but experiences milder episodes of hypomania that alternate with depression (Bipolar II). • When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. • Some people experience multiple episodes within a single week, or even within a single day. • Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

15. Child/Adolescent Bipolar Disorder • Until recently, the diagnosis of Bipolar Disorder was viewed as only appropriate for adults. • Indeed, few clinicians would have even considered using this diagnostic category with children. • Despite continuing controversy, it is increasingly common to find clinicians using this diagnosis with children displaying certain types of symptoms.

16. Child/Adolescent Bipolar Disorder • It is now believed that symptoms of bipolar disorder can emerge in early childhood. • Mothers often report that children, later diagnosed with early-onset bipolar disorder, were extremely difficult to soothe and slept erratically. • They seemed extraordinarily clingy and, from a very young age, often displayed uncontrollable, seizure-like tantrums or rages out of proportion to any event. • These severe tantrums often appear to be without provocation.

17. Frequency of Child Bipolar Disorder • Prevalence is largely unknown as there are no well accepted criteria for the diagnosis of Child Bipolar disorder. • This is because DSM IV criteria are generally viewed as inadequate for use with younger children. • The best guess is that the disorder occurs at least as often as adult bipolar disorder (e.g., about 1%) • However, many believe that this disorder is significantly under diagnosed in children (Youngstrom, 2007).

18. Frequency of Child Bipolar Disorder • It is suspected that a significant number of children diagnosed with ADHD at an early age actually have early-onset bipolar disorder instead of (or along with) ADHD. • According to the American Academy of Child and Adolescent Psychiatry, up to one-third of children and adolescents with depressive disorders may actually have early onset of bipolar disorder. • 20 to 40 % of adults with Bipolar Disorder report a childhood onset of symptoms.

19. Child/Adolescent Bipolar Disorder: Clinical Presentation • As with adults, Bipolar disorder in children is viewed a serious mental disorder • Characterized by recurrent episodes of depression, mania, and/or mixed symptom states. • Some evidence suggests that child bipolar disorder may be a different and possibly more severe form of the illness than older adolescent and adult-onset bipolar disorder.

20. Child/Adolescent Bipolar Disorder: Clinical Presentation • While older adolescents often have a clinical presentation that is somewhat similar to that seen with adults. • The clinical presentation of early-onset bipolar disorder in children can look quite different than that seen in older individuals. • Clinicians may fail to diagnose this disorder when using DSM IV criteria for the diagnosis of this condition.

21. Child/Adolescent Bipolar Disorder: Clinical Presentation • Most cases of child bipolar disorder do not present with the sudden or acute onset often found with adults. • Most do not show the improvement between episodes, often found with adult bipolar disorder. • With children the symptom onset may be more insidious.

22. Child/Adolescent Bipolar Disorder: Clinical Presentation • With children, • initial symptoms of the disorder can be depressive in nature • With these being confused with and treated as MDD. • In other cases, ADHD like symptoms appear first • with these symptoms being followed later by a full manic episode. • Unlike adults - children in a manic state are more likely to be irritable and prone to destructiveoutbursts than to be elated or euphoric.

23. Child/Adolescent Bipolar Disorder: Clinical Presentation • Children, more often show • rapid cyclingand mixed statesrather than clear manic or clear depressive episodes, and • an “ongoing and continuous mood disturbance that is a mix of mania (or hypomania) and depression”. • The rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes.

24. Child/Adolescent Bipolar Disorder: Clinical Presentation • Depression and dysphoria are an almost constant part of pediatric bipolar disorder. • As noted earlier, hyperactivity is often the first manifestation of early-onset bipolar disorder. • When children are initially seen because of bipolar symptoms, • approximately 90% of early-onset, and • 30 % of adolescents with bipolar disorder meet criteria for a diagnosis of ADHD. • Comorbid conduct disorder is also quite common.

25. Bipolar Disorder vs. ADHD Bipolar Disorder (Mania) • More talkative than usual, or pressure to keep talking • Distractibility • Increase in goal directed activity or psychomotor agitation ADHD • Often talks excessively • Is often easily distracted by extraneous stimuli • Is often “on the go” or often acts as if “driven by a motor” Differentiation: Elated mood, Grandiosity, Decreased need for sleep, Hypersexuality, and Irritable mood. Hart (2005)

26. Child Bipolar Disorder: Comorbidity • Attention Deficit Hyperactivity Disorder (ADHD) • Between 60 - 80% display symptoms • Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) • 70 - 75% • Substance Abuse (adolescents) • 40 - 50% • Anxiety Disorders • 35- 40%

27. Child Bipolar Disorder: Genetics • Bipolar Disorder has a heavy genetic loading • More than two-thirds of those with bipolar disorder have at least one close relative with the disorder or with unipolar major depression • When one parent has bipolar disorder, the risk to each child is about 15 – 30 % • When both parents have bipolar disorder, the risk increases to 50 – 75 %

28. Child Bipolar Disorder: Genetics • The risk to siblings and fraternal twins is 15 – 27 % • The risk in identical twins is approximately 70 % • Note. Despite these figures only about 5% of children with a parent with Bipolar disorder would be expected to develop the disorder in childhood.

29. Etiology :What is Inherited? • A significant question is What is Inherited?? • The answer is not entirely clear, but … • It's believed this condition is caused by an imbalance in neurotransmitters. • a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the likely cause. • Others have suggested that it is an imbalance of these substances that may be the problem • Here, a specific level of a neurotransmitter may not as important as its amount in relation to the other neurotransmitters. • Still other studies have found evidence that a change in the sensitivity of the receptors may be the issue. • It seems likely that the neurotransmitter system is at least part of the cause of bipolar disorder, but further research is still needed to define its exact role.

30. Etiology of Bipolar DisorderEnvironmental Factors • That more than hereditary is involved in Bipolar Disorder is indicated by the fact that in studies involving identical twins, raised in the same home, one twin sometimes develops bipolar disorder while one does not . • Here it is suggested that environmental factors may play a role in bipolar disorder. • For some, stresses such as a death in the family, divorce, or other traumatic events seem to trigger a first episode of mania or depression.

31. Etiology of Bipolar DisorderEnvironmental Factors • Puberty may trigger the disorder in adolescent females. • Stressful life events can lead to the onset • Once the disorder is triggered and progresses, it seems to develop a life of its own. • Once the cycle begins, a psychological or pathophysiological process takes over and ensures that the disorder will continue. • The best explanation for this disorder seems to be reflected in the "Diathesis-Stress Model." • Genetics PLUS environmental percipients.

32. Treatment of Child Bipolar Disorder • Treatment of children and adults with bipolar disorder is generally similar to adults with this disorder. • Less is known about the effectiveness & safety of the medications used. • Lithium appears to frequently have a strong prophylactic effect against mania, and is sometimes used with children. • However, in very early onset bipolar disorder, with a heavy family loading, children may not respond as well to lithium as do adults.

33. Treatment of Child Bipolar Disorder • As with adults, anti-convulsants are often used to control rapid cycling and aggressive behavior. • Depakote – an anti-convulsant – used to control rapid cycling. • Tergetol – an anti-convulsant – has anti-manic and anti-aggressive qualities. • Other anti-convulsants (Neurontin, Lamictal, Topamax) Sometimes these are used in combination with Lithium.

34. Treatment of Child Bipolar Disorder • As with adults, certain antipsychotic drugs may also be used to control symptoms. Included here are atypical antipsychotic medications such as Clozaril®, Zyprexa®, Risperdal®, and Seroquel®. • Such drugs have been shown to sometimes function as mood stabilizers in cases were drugs like lithium and anticonvulsants may not work • They are used to deal with acute mania, and/or to treat psychotic depression.

35. Issues in the Pharmacological Treatment of Child Bipolar Disorder • Bipolar youth often require multiple medications for mood stabilization, treatment of attention problems, depression, and sometimes psychotic symptoms. • There can, however, be risks with drug treatments • Problems can arise in cases of misdiagnosis. • Sometimes children with undiagnosed bipolar disorder are mistakenly treated for MDD with antidepressants.

36. Issues in the Pharmacological Treatment of Child Bipolar Disorder • Treating such children with antidepressants (in the absence of a mood stabilizer) can actually precipitate or exacerbate manic symptoms. • In children with ADHD symptoms, treatment with stimulant drugs (in the absence of a mood stabilizer) can result in manic symptoms and/or worsen symptoms.

37. Issues in Pharmacological Treatment of Child Bipolar Disorder • It is difficult to determine which children will become manic or experience a worsening of symptoms • There is a greater likelihood among children with a strong family history of bipolar disorder. • It has been suggested that • if manic symptoms develop or markedly worsen during antidepressant or stimulant use, the diagnosis and treatment for bipolar disorder should be considered. • Proper diagnosis of Child Bipolar Disorder is necessary to avoid these problems.

38. Additional Treatment Approaches • As with adults, treatments in addition to medication are often necessary to assist children with bipolar disorder and their families. • These interventions may involve • Educating the family about the nature of childhood bipolar disorder and involving the family in treatment. • Insuring that children receive the special educational servicesnecessary to prevent them from falling behind academically • Appropriate classroom accommodations to help them function effectively in the academic environment. • Family and individual approaches to therapy should be provided as necessary.

39. Examples of Educational Accommodations • Provide student with a safe place and person to go to when feeling overwhelmed or stressed • Shortened day (permit late start as needed) • Prior notice of transitions • Consistent schedule • Scheduling the student’s most challenging tasks at a time of day when the child is best able to perform • Modified or shortened assignments • Adjust for medication needs, dispensing, as well as plans for addressing side effects (e.g., sedation) Hart (2005)

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41. Childhood SchizophreniaLite* James H. Johnson, PhD, ABPP University of Florida *Some material for this presentation provided by NIMH Publication No. 00-5124,(2003)

42. Child Schizophrenia: Symptoms • Childhood Schizophrenia is a severe neurodevelopmental disorder of childhood that is usually manifest in a range of symptoms including: • Disturbed though processes • psychotic symptoms (hallucinations, delusions) • social withdrawal • flattened emotions • loss of social and personal care skills • increased risk of suicide • Schizophrenia in children is rare, affecting only about 1 in 40,000 compared to 1 in 100 in adults.

43. Child Schizophrenia: Symptoms • Children with schizophrenia often see or hear things that do not exist. and harbor paranoid and bizarre beliefs. • They may think people are plotting against them or can read their minds. • Other symptoms of the disorder include • problems paying attention, • impaired memory and reasoning, • speech impairments, • inappropriate or flattened expression of emotion, • poor social skills, and • depressed mood. • Such children may laugh at a sad event, make poor eye contact, and show little body language or facial expression.

44. Child Schizophrenia: Overview • While schizophrenia sometimes begins as an acute psychotic episode in young adults, it emerges gradually in children. • It is often preceded by developmental disturbances, such as lags in motor and speech/language development. • The diagnostic criteria for childhood schizophrenia are the same as for adults, except that symptoms appear prior to age 12, instead of in the late teens or early 20s.. • It is seldom diagnosed before the age of 7.

45. Child Schizophrenia: Differential Diagnoses • Misdiagnosis of schizophrenia in children is common. • It is distinguished from autism by the persistence of hallucinations and delusions for at least 6 months, and a later age of onset - 7 years or older. • Autism is usually diagnosed by age 3.

46. Child Schizophrenia: Differential Diagnoses • Some children who later develop schizophrenia may have a history of some Pervasive Development Disorder symptoms. • In adolescents, schizophrenia is also to be distinguished from bipolar disorder.

47. Child Schizophrenia: Differential Diagnoses • Sometimes an acute onset manic episode may be mistaken for schizophrenia, as hallucinations and delusions may be present (usually mood congruent). • Symptoms of schizophrenia characteristically pervade the child's life, and are not limited to specific situations. • Since impairment in social relationships are central, if the child shows a strong interest in friendships (even if they fail at maintaining them) it is unlikely that they have schizophrenia.

48. Child Schizophrenia: Presumed Etiology • Evidence suggests that Childhood Schizophrenia is a neurodevelopmental disorder likely involving; • a genetic predisposition, • a prenatal insult to the developing brain, and • stressful life events. • The role of genetics has long been established; • the risk of schizophrenia rises from 1 percent with no family history of the illness, • to 10 percent if a first degree relative has it, • to 50 percent if an identical twin has it.. • Prenatal insults may include viral infections, such as maternal influenza in the second trimester, starvation, lack of oxygen at birth, and untreated blood type incompatibility

49. Child Schizophrenia: Etiology • Studies find that children with schizophrenia display many of the same abnormal brain features (structural, physiological, and neuropsychological) that are found in adults. • The children seem to have more severe symptoms than adults, with more pronounced neurological abnormalities. • Unlike most adult-onset patients, children who become psychotic prior to puberty show conspicuous evidence of progressively abnormal brain development.

50. Child Schizophrenia: Neurology • “In the first longitudinal brain imaging study of adolescents (Giedd, et al 1999; Rapoport, et al, 1999), MRI scans revealed fluid filled cavities in the middle of the brain, enlarging abnormally between ages 14 and 18, in teens with early-onset schizophrenia, suggesting a shrinkage in brain tissue volume. • These children lost four times as much gray matter, neurons and their branchlike extensions, in their frontal lobes as normally occurs in teens.