Pediatric Bipolar Disorder 11.02.10
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Millions of Americans are affected by bipolar disorder. The American Academy of Child and Adolescent Psychiatry (1997) give further details that up to one-third of 3.4 million American children and adolescents with depression may actually be experiencing the early onset of bipolar disorder. In the last 15 years, pediatric bipolar disorder (PBPD) is gradually becoming more recognized as a distinctive disorder for persons under the age of 18 years. A psychosocial consequence of PBPD is that children and adolescents may struggle with academics and interpersonal relationships (Hamrin & Pachler, 2007) during critical stages of emotional development. Additionally, children and adolescents are at a higher risk for legal problems, substance abuse, increased suicidal behavior, and hospitalizations (Hamrin & Pachler, 2007). Recent advancements in psychotherapy have shown that the recovery rate in treating patients with PBPD is remarkably high, which is a promising prognosis for relapse prevention. For treating PBPD, several empirically-based articles point to four methods of psychotherapy, which include: cognitive-behavioral therapy, family-focused therapy, psychoeducation, and interpersonal and social rhythm therapy. When considering the best treatment interventions, many pieces of literature also point to both pharmacologic and psychotherapeutic interventions that are needed to adequately treat PBPD (Fristad et al., 2007). Nevertheless, the best support that a clinician can provide is to separate the child from the symptoms – the symptoms of PBPD do not define the personality of individuals seeking treatment. This awareness is paramount in helping to remind parents that their child is not “bad,” and that there is hope in successfully managing pathological symptoms to achieve an enhanced quality of life. References: 1. American Academy of Child and Adolescent Psychiatry. (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. J. Am. Acad. Child Adolesc. Psychiatry, 46(1): 107-125. 2. Fristad, M.A., Davidson, K.H., and Leffler, J.M. (2007). Thinking-feeling-doing: A therapeutic technique for children with bipolar disorder and their parents. Journal of Family Psychotherapy; 18(4): 81-103. 3. Hamrin, V., and Pachler, M. (2007). Pediatric bipolar disorder: Evidence-based psychopharmacological treatments. Journal of Child and Adolescent Psychiatric Nursing; 20(1): 40-58.
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Pediatric Bipolar Disorder 11.02.10
- 1. Pediatric Bipolar Disorder PBPD Kulky Nakai
- 2. The American Academy of Child and Adolescent Psychiatry (1997) • Up to one-third of 3.4 million American children and adolescents with depression may actually be experiencing the early onset of bipolar disorder
- 3. Prevalence • 0.3-0.5% of adults with bipolar disorder reported the onset of symptoms before the age of 10 years • 15-28% of bipolar adults experienced onset before the age of 13 years • 50-66% experienced onset before the age of 19 years
- 4. High Risks for PBPD • A risk for children of parents with bipolar disorder to develop a mood disorder is quadrupled o Rates of these offspring for developing bipolar disorder is 14-50% • Higher risk for legal problems, substance abuse, increased suicidal behavior, and hospitalizations
- 5. Diagnosis • Commonly placed in the category of bipolar NOS • Child’s developmental stage has an influence on how mania is presented
- 6. Bipolar I • At least one manic or mixed episode, characterized by irritable mood, in at least one week duration • Functional impairment and 3 or 4 more symptoms: 1. 2. 3. 4. 5. 6. 7. grandiosity decreased need for sleep flight of ideas distractibility pressured speech increased activity risk-taking behavior
- 7. Depressive Episode persistent sad or irritable mood loss of interest in activities once enjoyed significant change in appetite or body weight difficulty sleeping or oversleeping physical agitation or slowing loss of energy feelings of worthlessness or inappropriate guilt • difficulty concentrating • recurrent thoughts of death or suicide • • • • • • •
- 8. Bipolar II • At least one hypomanic and one depressive episode • No functional impairment or hospitalization is a characteristic of hypomania
- 9. Differential Diagnosis • attention-deficit/hyperactivity disorder • unipolar depression • conduct disorder or oppositional defiant disorder • substance abuse and dependence • post-traumatic stress disorder • schizophrenia • bulimia nervosa • Tourette syndrome • borderline personality disorder
- 10. Co-Morbidity • 69% co-morbidity rate of conduct disorder in children with bipolar disorder • 60-90% of adolescents who are bipolar also have ADHD • Overlapping symptoms in both PBPD and ADHD include excessive talking, increased activity, and distractibility
- 11. Cognitive-Behavioral Therapy (CBT) • Focuses on monitoring negative automatic thoughts • 77% of their clients who received CBT had a significant reduction in the number of episodes o experience difficulty recognizing the pattern of their own mood cycle o lacking in matured cognitive capabilities, such as self-reflection, reasoning, processing new information, perspectivetaking, and language and memory skills
- 12. Family-Focused Therapy (FFT) • Psychoeducation, communication skills training, and problemsolving skills for managing symptoms of depression • Adjunct to medication for decreasing risk of relapse and hospitalization
- 13. Psychotropic Medication • Lithium is the only FDA approved medication for treating acute mania and bipolar disorder in adolescents (ages 12-18 years) o Response rate of bipolar children using lithium was 65% o Relapse rate was seen in 37.5% of adolescents with bipolar disorder • 60% take less than a third of their prescribed medication
- 14. Selective Serotonin ReuptakeInhibitors (SSRIs) • Adverse effects: stimulation, increased anxiety, and sleep impairment • Clinically significant suicidal ideation was present in 29% of the sample population o Attempters more likely to have co-morbid substance abuse, panic disorder, non-suicidal self-injurious behavior, family history of suicide attempts, history of hospitalizations, and history of physical and sexual abuse than nonattempters
- 15. Clinicians Must Assess! • • • • • • • • • etiology family history precipitating factors child’s temperament parent-child relationships attachment styles and parenting styles co-morbid conditions cognitions child’s response to limit testing
- 16. References • • • • • • • • • • • • • American Academy of Child and Adolescent Psychiatry. (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder J. Am. Acad. Child Adolesc. Psychiatry, 46(1): 107125. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: American Psychiatric Association. Chang, K., Howe, M., Gallelli, K., and Miklowitz, D. (2006). Prevention of pediatric bipolar disorder: Integration of neurobiological and psychosocial processes. Annalas New York Academy of Sciences, 1094: 235-247. Fristad, M.A., Davidson, K.H., and Leffler, J.M. (2007). Thinking-feeling-doing: A therapeutic technique for children with bipolar disorder and their parents. Journal of Family Psychotherapy; 18(4): 81-103. Geller B, Tillman R, Craney JL, 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(5): 459-67. Hamrin, V., and Pachler, M. (2007). Pediatric bipolar disorder: Evidence-based psychopharmacological treatments. Journal of Child and Adolescent Psychiatric Nursing; 20(1): 40-58. Lofthouse, N., and Fristad, M.A. (2004). Psychosocial interventions for children with early-onset bipolar spectrum disorder. Clinical Child and Family Psychology Review; 7(2): 71-88. National Institute of Mental Health. (2000). Child and adolescent bipolar disorder: An update from the national institute of mental health. National Institute of Mental Health, US Department of Health and Human Services; [cited 2010 January 26]. (NIH Publication Number: NIH 00-4778). 4 pages available from: http://www.nimh.nih.gov/publicat/index.cfm Silva, R.R., Matzner, F., Diaz, J., Singh, S., and Dummit III, E.S. (1999). Bipolar disorder in children and adolescents: A guide to diagnosis and treatment. CNS Drugs; 12(6): 437-450. Steinkuller, A., and Rheineck, J.E. (2009). A review of evidence-based therapeutic interventions for bipolar disorder. Journal of Mental Health Counseling; 31(4): 338-350. Sylvia, L.G., Tilley, C.A., Lund, H.G., and Sachs, G.S. (2008). Psychosocial interventions: Empirically-derived treatments for bipolar disorder. Current Psychiatry Reviews; 4: 108-113. Wong, I.C.K., Besag, F.M.C., Santosh, P.J., and Murray, M.L. (2004). Use of selective serotonin reuptake inhibitors in children and adolescents. Drug Safety; 27(13): 991-1000. Zaretsky, A.E., Rizvi, S., and Parikh, S.V. (2007). How well do psychosocial interventions work in bipolar disorder? The Canadian Journal of Psychiatry; 52(1): 14-21.
Editor's Notes
- One percent of the population aged 14-18 years has met criteria for bipolar disorder, and have also shown greater functional impairment, higher rates of co-morbidity and suicide attempts (NIMH, 2000; Hamrin & Pachler, 2007). Silva and colleagues (1999) found that approximately 0.3-0.5% of adults with bipolar disorder reported the onset of symptoms before the age of 10 years. Similarly, Chang and colleagues (2006) discovered that 15-28% of bipolar adults experienced onset before the age of 13 years, whereas 50-66% experienced onset before the age of 19 years. A psychosocial consequence of PBPD is that children and adolescents may struggle with academics and interpersonal relationships (Hamrin & Pachler, 2007) during critical stages of emotional development.
- Studies have found that the risk for children of parents with bipolar disorder to develop a mood disorder is quadrupled (Hamrin & Pachler, 2007) compared to children of parents without bipolar disorder. Researchers indentify that the rates of these offspring for developing bipolar disorder is 14-50% (Hamrin & Pachler, 2007). Additionally, children and adolescents are at a higher risk for legal problems, substance abuse, increased suicidal behavior, and hospitalizations (Hamrin & Pachler, 2007).
- few children meet the criteria defined by the DSM-IV-TR for bipolar I or II, and instead get placed in the category of bipolar NOS (not otherwise specified). Research has found that a child’s developmental stage has an influence on how mania is presented differently in children than in adults
- bipolar I, the person must have had at least one manic or mixed episode, characterized by irritable mood, in at least one week duration (or less if they are hospitalized). For children and adolescents, a manic episode is characterized by functional impairment, and by 3 or 4 additional symptoms: grandiosity, decreased need for sleep, flight of ideas, distractibility, pressured speech, increased activity, and risk-taking behavior (Preston et al., 2006). However, for a diagnosis of a mixed episode, the person must have met both criteria for a manic and depressive episode within a one-week period. Symptoms of a mixed episode include functional impairment, hospitalization or psychotic features, dysphoria, disorganized thinking or behavior (Preston et al., 2006; Hamrin & Pachler, 2007). On the opposite end of the bipolar spectrum, symptoms of a depressive episode include persistent sad or irritable mood, loss of interest in activities once enjoyed, significant change in appetite or body weight, difficulty sleeping or oversleeping, physical agitation or slowing, loss of energy, feelings of worthlessness or inappropriate guilt, difficulty concentrating, and recurrent thoughts of death or suicide
- the person must have had at least one hypomanic and one depressive episode (American Psychiatric Association, 2000). It is important to note that no functional impairment or hospitalization is a characteristic of hypomania (Preston et al., 2006). However, a diagnosis of bipolar NOS is when the person has recurrent hypomanic episodes without intercurrent depressive symptoms, as well as experiencing rapid shifts between manic and depressive symptoms that meet the threshold criteria but not duration criteria for manic, hypomanic, or major depressive episodes (American Psychiatric Association, 2000)
- Clinicians often have a difficult time discerning between bipolar disorder and attention-deficit/hyperactivity disorder (ADHD), unipolar depression, conduct disorder or oppositional defiant disorder (Silva et al., 1999; Lofthouse & Fristad, 2004; Fristad et al., 2007; Hamrin & Pachler, 2007), substance abuse and dependence, post-traumatic stress disorder, schizophrenia (Silva et al., 1999; Hamrin & Pachler, 2007), bulimia nervosa, Tourette syndrome, and borderline personality disorder (Hamrin & Pachler, 2007).
- The three common symptoms that are not found in ADHD but that are found in bipolar disorder are elevated mood, grandiosity, and flight of ideas (Lofthouse & Fristad, 2004; Hamrin & Pachler, 2007). Hamrin & Pachler (2007) researched that 60-90% of adolescents who are bipolar also have ADHD. Silva and colleagues (1999) agree that the overlapping symptoms in both diagnoses include “excessive talking, increased activity, and distractibility” (pg. 43). Just as vital to note, researchers found a 69% co-morbidity rate of conduct disorder in children with bipolar disorder (Silva et al., 1999; Hamrin & Pachler, 2007). Substance abuse disorders in older adolescents are more common in patients with co-occurring bipolar disorder (Silva et al., 1999), except no relationship is found for conduct/antisocial personality disorders (Fristad et al., 2007).
- Cognitive-Behavioral Therapy (CBT) indicates that children may have cognitive distortions that contribute to the maintenance of an impaired mood state.This approach focuses on monitoring negative automatic thoughts (Fristad et al., 2007). Sylvia and colleagues (2008) found that 77% of their clients who received CBT had a significant reduction in the number of episodes they had experienced. This study reported that clients had exhibited significantly better social functioning, and less depressive symptoms, but there was no evidence of a reduction in manic symptoms (Sylvia et al, 2008). experience difficulty recognizing the pattern of their own mood cycle, most likely due to the unpredictable nature of these cycles, as well as lacking an understanding of their cycles (Fristad et al., 2007). More importantly, it is essential for a clinician to keep in mind that children are often lacking in matured cognitive capabilities, such as self-reflection, reasoning, processing new information, perspective-taking, and language and memory skills (Fristad et al., 2007).
- FFT consists of psychoeducation, communication skills training, and problem-solving skills for managing symptoms (Stienkuller & Rheineck, 2009) of depression. FFT is known to be an adjunct to medication for decreasing the risk of relapse and hospitalization in children with bipolar disorder (Stienkuller & Rheineck, 2009). Sylvia and colleagues (2008) found that FFT resulted in fewer relapses and longer delays between relapses, however there was no evidence that there was a reduction in manic symptoms for clients with bipolar disorder. A limitation to taking the FFT approach when treating PBPD is that the gains are only fully realized at the end of treatment after one year since most families require that time to execute the new skills that were learned in counseling. This also implies that there is a need for a larger number of sessions (Zaretsky et al., 2007; Stienkuller & Rheineck, 2009) in order to reach the desired therapeutic goals.
- research has found that the first line of treatment for children with bipolar disorder is lithium, and that the response rate of bipolar children using lithium was 65% (Silva et al., 1999). Lithium is the only FDA approved medication for treating acute mania and bipolar disorder in adolescents, specifically ages 12-18 years (Hamrin & Pachler, 2007). On the other hand, they found that the relapse rate was seen in 37.5% of adolescents with bipolar disorder (Silva et al., 1999), perhaps due to the prime treatment challenge of noncompliance to medication. Roughly 60% of adolescents with bipolar disorder take less than 30% of their prescribed medication (Stienkuller & Rheineck, 2009). However, research has supported the efficacy of psychoeducation in improving a person’s attitude to and compliance with lithium treatment (Zaretsky et al., 2007).
- selective serotonin reuptake-inhibitors (SSRIs), cause mania in children and adolescents who are predisposed to bipolar disorder (Lofthouse & Fristad, 2004). The SSRIs’ adverse effects of stimulation, increased anxiety, and sleep impairment in the early phase of treatment (Wong et al., 2004) have become a concern for clinicians who try to monitor the safety of their clients. A study determining the relationship and efficacy of SSRIs in children and adolescents with bipolar disorder reported that clinically significant suicidal ideation was present in 29% of the sample population, which was significantly reduced when implementing a combination of CBT and Prozac (Wong et al., 2004). Researchers found that a quarter of bipolar children and adolescents attempted suicide, especially during a depressive episode (Hamrin & Pachler, 2007). The same researchers additionally found that attempters were more likely to have “comorbid substance abuse, panic disorder, non-suicidal self-injurious behavior, family history of suicide attempts, history of hospitalizations, and history of physical and sexual abuse than non-attempters” (pg. 42). The greatest risk of an integrated treatment using psychotherapy and psychopharmacology is that the previously anergic patient may experience just enough energy to actually carry out their plans and successfully commit suicide (Silva et al., 1999; Wong et al., 2004).